Loading...
HomeMy WebLinkAbout0035 BUCKWOOD DRIVE - Health 4PO-.Go`os 'Puiht ' oad n Hyani s o r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is required for Centerville MA 02632 10/15/09 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out }-"'/� forms on the J computer,use 1. Inspector. ���//J 35 only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspections Company Name P.O. Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that-tthe information reported below is true, accurate and complete as of the time of the inspection. Tt'i�insp—'ection was performed based on my training and experience in the proper function and rnaintenancOof or4e sewage disposal systems. I am a DEP approved system inspector pursuant'to Section ;>h.340M Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Falls " ❑ � rn Needs Further Evaluation by the Local Approving Authority o0 10/20/09 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the 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. iL 6 ADJUST•08= Title!OfBdel Inspection Forth:Subsurfa Sawage Disposal System•Page 1 of iS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is Centerville MA 02632 10/15/09 required for ' every 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: � a 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. 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. *Ametal 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: 0 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 ❑ obstruction is removed ADJUST•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is required for Centerville MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed r e s . The Y q P P 9 Y P�P O � system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 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. ADJUST•08M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is required for Centerville MA 02632 10/15/09 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. ADJUST•08106 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °y 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is required for Centerville MA 02632 10/15/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 ❑ El Area 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 shalt upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ADJUST-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is required for Centerville MA 02632 10/15/09 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® '❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] ADJUST-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 40 Goosepoint Road Property Address Anna Faria Owner owner's Name information is required for Centerville MA 02632 10/15/09 every page. Cityrrown State Zip Code Date of Inspection 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 Number of current residents: 1 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date CommerciaUlndustrial 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: Last date of occupancy/use: Date Other(describe): ADJUST•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is required for Centerville MA '02632 10/15/09 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. , . i ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: ' 10/13/00 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No ADJUST•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is required for Centerville MA 02632 10/15/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.7 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2.1 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: * 1000 gallons 4" Sludge depth: Distance from.top of sludge to bottom of outlet tee or baffle 30" ' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 511 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured ADJUST-08= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Fana Owner Owner's Name information is required for Centerville MA 02632 10/15/09 every page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. R Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: _ Scum thickness e . Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): ADJUST•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is required for Centerville MA 02632 10/15/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even _ 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No ADJUST•08106 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 or 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is required for Centerville MA 02632 10/15/09 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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: Type. ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: s ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: Elinnovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): This system has two five hundred gallon drywells surrounded by three feet of stone, there was no sign of ponding or failure, ADJUST-08M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name information is required for Centerville MA 02632 10/15/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 i Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): ADJUST•08106 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Faria Owner Owner's Name Information is required for Centerville MA 02632 10/15/09 every page. CityRo state Zip code Date of Inspection D. System Information(cont.) 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. L k?AL a a . ADJUST-08M life 5 FOM&62NO a SM98 OWPO9 l SYMM•page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Goosepoint Road Property Address Anna Faria - Owner Owners Name information is required for Centerville MA 02632 10/15/09 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 20 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: USGS maps show an elevation of over 20 feet. ADJUST•08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 _ Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 611512000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: .2 / Ou forms on the computer,use 40 Goosepoint Rd, Centerville, MA 02632 only the tab key Property Address to move your Ana Lucia Faria cursor-do not use the return Owner's Name key. 9 Suffolk Ave Owner's Address Hyannis MA 02601 City/Town State Zip Code Date of Inspection: 01/30/07 Date 2. Inspector: Mike Hudson Name of Inspector ' Septic-wiz Environmental Services -77 = = Company Name `.�# CU F' 31 Midway Drive °r Company Address ; Centerville MA C-D102632 City/Town State Zip Code` 508-367-5669 a� Telephone Number C:) rn Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310,CMR 15.000).The system: , ® Passes ❑ Conditionally Passes ❑ Fails i ❑ Needs Further Evaluation by the Local Approving Authority '01/31/07 Inspector's SignAturCY Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or ` has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. E ****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. 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 40 Goosepoint Rd Property Address Centerville ; MA 02632 Cityrrown State Zip Code Faria 01/30/07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: • i ® 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: I 4 . T I i B) System Conditionally Passes: r I ❑ 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. 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 i 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. i 1 - ND Explain- i f I - I - I 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Y Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 City/Town State Zip Code Faria 01/30/07 Owner's Name Date of Inspection F In B) System Conditionally Passes(cont.): 1 ❑ 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 ❑ 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: i C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine If the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 Cityrrown State Zip Code Faria 01/30/07 Owner's Name Date of Inspection IC) Further Evaluation is Required by the Board of Health (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. f ❑ 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: I '=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. I Other: 40 Goosepoint Rd-T5 Inspection.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 City/Town State ZipCode Faria 01/30/07 Owner's Name Date of Inspection 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 ❑ ® 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 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. 1 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. 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 City/Town State Zip Code Faria 01/30/07 Owner's Name Date of Inspection I' E) Large Systems: To be considered a large system the system must serve a facility with a N 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 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. 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 40 Goosepoint Rd Property Address Centerville MA 02632 Cityrrown State Zip Code Faria 01/30/07 Owner's Name 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? ® ❑ 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(3)(b)] 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information 40 Goosepoint Rd Property Address Centerville Ma 02632 City/Town State Zip Code Faria 01/30/07 Owner's Name Date of Inspection 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 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2005-302 GPD g ( y g (gpd)): 2006-265 GPD Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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: Last date of occupancy/use: Date Other(describe): 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 E Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 CitylTown State Zip Code Faria 01/30/07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Water Pollution Control Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Leaching system installed 10/13/00 via sewage permit, age of older components uknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form. M C. System Information (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 Cityrrown State Zip Code I Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 32.5" feet Material of construction: ' ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 100' + feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints not visible, vented thru roof, no sign of leakage Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) - I - . r If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ® No , certificate) Dimensions: 8'6"Lx4'10'Wx5'8"H - 1000 gallon i 4'4" (6"thickness) Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured stick w/rag, tape, mirror, floodlight 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 Cityrrown State Zip Code Faria 01/30/07 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping every 3 years, no records found on pumping, levels in compliance but recommend pumping, no tees, concrete baffles appear in good condition, tank structurally sound, liquid levels were level at outlet, no signs of over capacity or leakage. I _ Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ITight 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): 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 City/Town State Zip Code Faria 01/30/07 Owner's Name Date of Inspection I - Tight or Holding Tank(cont.) 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.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert .10, even w/oputlet Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box level and liquid flowing even with plastic outlets, no solids or carryoiver, stain line even with outlet, no evidence of leakage in or out. IQ - Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 40 Goosepoint Rd-T5 Inspection.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 City/Town State Zip Code Faria 01/30/07 Owner's Name Date of Inspection 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: Type: ® leaching pits number: (1)6' Radius est3' stone ® leaching chambers number: (2) 500 gallon ❑ 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.): Soil conditions normal, no signs of hydraulic failure, ponding, damp soil or abnormally lush vegetation. 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 Cityrrown State Zip Code Faria 01/30/07 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction` Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .{ c IPrivy (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.): 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System �' Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 40 Goosepoint Rd Property Address Centerville MA 02632 Citylrown State Zip Code Faria 01/30/07 Owner's Name Date of Inspection 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. W Goosepoint Rd 40 Goosepoint Rd Centerville, MA 02632 3 Bedroom House Rear of House A B A 1-25' B 1-33' 1000 Gallon 2-32' 2-36' Septic Tank 3-38' 3-39' O 1 4-25' 4-25' D-Bto p 4 (2) 500 Gallon Chambers 3 6' (R=6') Leach Pit w/ 3' stone T5-Inspection Fonn.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 40 Goosepoint Rd Property Address Centerville MA 02632 City/Town State Zip Code Faria 01/30/07 Owner's Name Date of Inspection Site Exam: Slope 3: Surface water N 4 )c°' `i- ' Check cellar S Shallow wells Ij 1 Estimated depth to ground water: Z o 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: Reviewed as-built from upgrade and prior system inspection ❑ Checked with local excavators, installers- (attach documentation) ; ®. Accessed USGS database-explain: reviewed USGS topographic and water resource maps You must describe how you established the high ground water elevation: Reviewed prior inspection on file, reviewed elevations on USGS topographic and water resource maps. Reviewed nearest open waiter elevation w/Google Earth. i i i 7 40 Goosepoint Rd-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 RECEIVED OCT 0 6 2004 TOWN OF BARNSTABLE HEALTH DEPT. DATE 10/5/04 PROPERTY ADDRESS 40 Goosepoint Road Centerville PARCEL MA, 02632 C7 On the above date, theAeptic system at the address above was Inspected. This system consists of the following: 1.- 1-1000 gaiion zept is .tank. 2. 1-Dizbtigution fox 3. 1- �(k00' g�i2�on ep-acking pit. 4, 2-5100-�Y'2ion eiach-ing chamPeas. ,j, Based 'on inspection, I certify the following conditions: 5. 7h.i3 .i6, a t.Zt.fe dive zej2tic zyztem(95 code) 6.. The 3e12;Uc,rzystem .iz .in paopea woak.ing oadea :at the /22ezent time. 7. The eeaching chamgenz we.¢e d1ty at time o?e �o SIGNATUREi 2-1 Name: Robert A. Paolinll 1 � s Company: Joseph P. Macomber & Son Inc --i C 4> Address: P. O. Box 66 `-) Centerville, Mass 02632 5- Phone: 508-775-3338 or 508-775-6412 � ►� Imam Amvm JOSEPH P. MACOMBER & SON;: INC.. Tan ks-Cesspools-Leachf fields Pumped &.Installed Town Sewer Connections P.O. Box 66 Centerville, MA.02632-0066 775-3338 775-6412 • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRO WNTAL AFFAIRS a DEPARTMENT DF'9NVAAQNMENTAL RAMCTION s • rTITLE 5 OFFICIAL INSPECTION FORM—.1�103`:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICATION Property Address: 40 goo.se12oint '-Road Cente zv.iia lea Owner's Name:Richaad Tino2y Owner's Address: .3ame Date of Inspection: 1014104 Name of inspector: (please print) Rae.ent ao..ein,� Company Name:_ 1 .ma c oingelt L c. Mailing.Address: • en e2v:t e, cz a. 026 32 . Telephone Number: 5 0 8—7 7 :3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system.at this address and that the.information reported below is true;accurate and complete as of the.time of the inspection.The inspection-was performed based on my training and experience in-the proper function and maintenance of on.4ite sewage disposal systems.I am a DEP approved system inspector pursuant to=Section.15340.of-Title 5(31.6 CMR,i5:a00). The system: xxx Passes -Conditionally Passes Needs Further Evaluation,by the Local Approving.Authority F Is Inspector, Sig AgWre: Date:' The system inspector shall submit a copy of this inspection reporr-to the-Approving Authority(Board of Health or DEP)within.30 days of completing this inspection.If the system:i .ashated system or has a design flow of 10,000 gpd or,greater,the inspector and the systerit•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. Page 2 of 11 OFFICIAL INSPECTIONYORM—NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION:FORM. � PARYA CERTIFICATION (continued) Property Address: 40 Goosepoint Road Centerville, MA Owner: Ri shard Ti nory Date of Inspection: 1 n/d/6 a Inspection Summary: Check.A;B;C;D or.E/ALWAY&completetall of Section;D A. System Passes: NO I.have not found any information.which indicates that and+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. C me ts: Te/Z.�.ec ZyateM "is .ia /z2opea woak.ing. padea at .the /zee entime.- B. System Conditionally Passes: NO One or more system components as described in the"Conditional:Pass"!section.need to be replaced:o.r 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. NO • The septic tank is metal and over.20 years old*or the septic tank(w:hether metal.ornot):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:appr©yed 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: NO. 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)` NA broken.pipe(s)are replaced. N A obstruction is removed N A distribution box is leveled or replaced ND explain: NO 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): NA broken pipe(s)are replaced NA obstruction is removed ND explain: Page 3 of I 1 O)ETfiCIAL WSP-ECTION FORM-NOT VOR VOLUNTARY ASSESSMENTS SUBStWACE SEWAGE DISPOSAL SYSTEM INSPECTWN FORM PART A . . CERTIHICAT•ION`(eoritinued) : Property Address:40 roozeooint Road onfon»i1�Pv Owner:./2ccha2d 7inoau Date of Inspection: C. Further Evaluation-is.Required by'the Board of Health: no Conditions.exist which require further.e.valuation,by.the Bow:d:of-Heaith:in-order:to:deterthine ifthe system is failing to protect public,health,.safety or the environment. OO 1, System will pass unless Board of.Health determines-iu accordance with 310.CMR 15:303 ] b that the matttter-which public health,safety ano t4e..environment: system is not functioning in.a na Cesspool or privy is within:50 feet of asurface water na 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;ii any),determines:that the system is functioning in a mariner that proteets the:public health,safety and environment: no The system has aseptic tank and soil absorption system{SAS).and the SAS is within 100 fe.et.ofa surface water supply or-tributary to a.surface water supply. no The system-has-a.sepiic tank and SAS and thefSAS is:within a Zone 1 of a--public watensupply. n o The system has a septic tank and.SAS and•the-SAS is within,50 fEet of a private water supply well. no The system has aseptic tank and SAS and the-SAS is less than 100 feet..but 50 feet or.3riore fiorAa private water supply well**.Method used to determine distance- mea�u2ed "This system passes if the well water analysis,performed at a DEP certified laboratory,for coli€orm 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-tis form. 3. Other: Page 4 of 11 OFFICIAL•-INSPECTLUN FORM-NOT TOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS*-L SYSTEM INSPECTION:FORM PART.A CERTIFICATION(continued) Property Address: 40 Goosepoint Road r ntPrvi._l_1_P, MA Owner: lei r•hard Ti nary Date of Inspection: 1 Q.1 21_1 A— D. System Failure Criteria applicable to all systems:. You must indicate."yes"or"no"to.each.ofthe:following:for all:inspections: Yes No _ . X Backup.of sewage:into Adlityor system component•due._to overloaded.or clogged SAS..or.cesspool _ X Discharge:or ponding of effluent to the.surface of tht.ound or..surface:waters due to:an,overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due:to an overloaded or clogged SAS or cesspool _ X hiquid depth in cesspool is less thank"below invert or.available volume is less than'fr.day flow -7 Required pumping more-than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of-the SAS,cesspool or privy is below High ground water elevation. Any.portion of cesspool or privy is within i00 feet of a surface water supply.or tributary to a surface water supply. X Any portion:of la cesspool ror.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. i _ X Any portion of.a-cesspool or-privy is less than 100 feet but greater..titan SU.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 organi.e.compounds indicates:that the well is free from pollutiow.from::.Ibat,facility and.the presenceof ammonia nitrogen and nitrate nitrogen is equal to or less than -ppm,provided that no other failure criteria are•triggered.A copy of the analysis must be attached.to this form@.4 .A10. (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:systtm must.serve.a4aeility with a design-flow of 1,0100.0 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 the-system is within 400 feet of a surface drinking water supply _ X the system.is within 200 feet of a tributary to a surface drinking water supply X. 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 Page 5ofll OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �— MJBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B -CIECIMIST Property Address: 40 ar)nsc;e ^i nt Rc�ad Owner Date of Inspection: ^1^Q l 4"V 4 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No X pumping information was prpvided'by the uwner,occupant, or Board-of Health X Were any of the system components pumped out in the previous two weeks? X _ 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? X X _ 'Were as built plans of-he system'obtained and examined?of they were not availablelhote as N/A) X Was the facility.or.dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X — W ere all system components,excluding the SAS,located on site.? X _ Were theseptic tank manholes uncovered;,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS).on the site.has been determined based on: Yes no x Existing information:For example,.a plan at the Board of.Health. " v Determined in the field(if any of the failure criteria related to Part C is at issue appro?dn%tionof distance is unacceptable)[310 CMR 15.302(3)(b)'] Page 6 of 11 OFFI?CIAL..•f�SPECTI-O'1::]F'ORM%-NOTFOR'V�3�UN'I';�lRY ASfiESSNNIEN`�S SUBSU9FACE SEWAGE BISROSAL SYSTMINSPEMONFORM PARTT.0 SYSTEM JNFORMATIOAI Property Address: 40 Goosepoint Road Centerville, MA Owner: Richard Tinory Date of Inspection: 10/41r0 d FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):• ,3 Number ofbedrooms•-(actual): 3 DESIGNflow•based on'310 C1VITt 15.�0�(for exariiplec•I ID gpd z#•oi°•bedroiims)3 z 17 0=31 D gad Number of current residents-_2 r Does-residence have a garbage gr, der(yes br no): n o Is laundry on a separate sewage.system(yes or.no):.n oo [if yes sepa.te ans.*tion required] Laundry system inspected(yes or no):_Q Seasonaluse:(yes orno): •ao 200.2=35, 550gaieonz gl2d=97.. 39 Water meter readings,if available(last 2 years usage(gpd)V 0 0 3=4 2. 9 7 5 g.Q o n,3 gl2 d=1/7 7 3 Sump pum (yes.or no): R Oo Last date of occupancy: &n e_e n.t COMMERCIM USTRIAL Type of estab .Wilt: �. Design flaw. on•310 CN M 15.203)% N.4 gpd- Basis.of aigii0show(seats/persons/sgft,etc.):, NA Grease trap•present(yes or no): NA Industrial waste holding tank present•(yes or no):d$ Non-sanitary waste discharged to the Title 5 system•(yes or no): NA Water•.meter readings,if available: NA Lastdate of occupancy/use: . NA OTHER(describe):. NR . 'GENERAL INFQWATION Pumping Records " Sourceofinformation. Not ava.i-eagee Was system pumped as part of the inspection(yes or no)20 If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for.p..umping: A1,4 , TYPE OF SYSTEM X Septic tank,distribution box,soil absorption•systeM _Single.cesspool _.Overflow cesspool _)ynvy _Shared system.('yes or no)(if yes,attach previdus inspection recbrds,if airy) _Innovative/Alternative-technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank. Attach a.copy-of the DEP.approval Other(describe): Approximate age of all components,date installed(if known)and.source of information: Su,3tem .inztaL9PrJ Ry L2i (Incorn a 9ni� 3,/nn Were sewage odors detected when arriving at the site(yes or no):a Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Goos -point Road Centerv; llP,- MA Owner: Richard Tinory Date of Inspection: 1o1 4/'6 4 A N BUILDING SEWER(locate on site plan) Depth below grade:ZZ" Materials of construction:_cast-iron X_40 PVC—other(explain): Distance from private water pupply weor suction line: 0 f Comments(on condition of joints,venting,evidence of leakage,etc.): —7ninf.t nonon.n fi ihf Nn O))l l70I7/ /J e)4 Ppryk7 q/� le .Ven _/• th2ough house vent. J [ (G SEPTIC TANK: qe4locate on site plan) 10 00 ga—Le o n Depth below grade: 18" Material of construction:X 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: 4 , Sludge depth: t 2 a c e Distance from top of sludge to bottom of outlet tee or baffle: Zit Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle:6" How were dimensions determined. ,n p a.6 u n p d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): —Pump frank o»onii iionnti Tne'of n�/fOnf f� Task ;,A Af"1irf„ran 00, ate .in 2.Qace iniind GREASE TRAP: NC(locate on site plan) Depth below grade: NA Material of construction:—concrete metal fiberglass_polyethylene—other (explain): NA Dimensions: — Dimensions: N4 Scum thickness: NA Distance from top of scum to top of outlet tee or baffle: NA - . Distance from bottom of scum to bottom of outlet tee or-baffle: /� Date of last pumping: NA Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 2eahe taaR i.6 not R2e.6ent.• T41a G Tnanarfinn T+nrm Ail winnn 7 Page 8 of I I : O#FICIAE INS•PEC']l''ION FORM—NOT FOR VOLUNTARY ASSESSMENTS t� llk':ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: 40 Gooseyoint Road Owner. Date of spection: 10 4 04 „r TIGHT or HOLDING TA14K: no (tank must be pumped at time of inspcction)(locate on site plan) Depth below grade:na Material of construction: na concrete na metalna fiberglass na polyethylene na other(explain). Dimensions: na Capacity:'-- na gallons ` • Design Flow: na. gallons/day Alarm present(yes or no): as Alarm level: n r2 Alarm in working-order(yes or no):ri Date of last pumping: na Comments(condition of alarm and float-switches,etc.): ;Ught o2 hQ ed1ag .t_ank,3 not R/tezeat DISTRIBUTION BOX:yeh (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: no Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D-9ox ha,6 .two .2atena.2,6. No ev-idence o)e .so eid ca/z2yove2.- &ox 43 'eeve.e No,evi erzce o eedkage into_ Oa 0-at OZ &Ox-' PUMP CHAMBER:na (locate on sife.plan) Pumps in working order(yes or.no): rza Alarms in working order(yes or no):/za Comments(note condition of pump.chamber,condition of pumps and appurtenances, etc.): PumI2 chamgelt not ste,6ent. 8 • Page 9 of 1 I OFFICIAL INSPECTION]FORM—NOT-FOR VOLUNTARY ASSESSMENTS SUgSUgF.ACE-SEWAGE.DISPOSAL.SYS'I'EM Ii`1SPECTIONYORM PART:C SYSTEM INFORMATION(continued). Property Address: 40 Goosep nt Road Centerville, MA Owner:. Richard Tinory Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): L"-gocate on site plan,excavation not required) If SAS not-located explain why! Type fey leaching pits,number:ye 1 leaching chambers,number:.L 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.): Medium eared. No .6 ns o h daaatic a-ieuae. Vegetation afzpea2e no zma . CESSPOOLS: no (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: nw Depth—top of liquid to inlet invert: as - Depth of solids layer: na Depth of scum.layer: na Dimensions of cesspool: n�z Materials of construction: na Indication of groundwater.inflow(yes or no): na Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ceee12oo e,6 aae no.t 12 aeeen.t.- PRIVY: n o (locate on site plan) Materials of construction: na Dimensions: na — Depth of solids:. . na'. Comments(note condition of soil,signs of hydraulic failure,level of'ponding,condition of vegetation,etc.): 9 Page 10 Of 1T OFFS INSRM PFJ 'T?TQN:FARM»NOT ,PORV4LIJ1!ITARY. OE TS SII S RFACE SEWAGEMISP.OSAL SYS-M'1NSLEC'T PART:0 SYSTEM TNF•ORMAT'I.ON(continued)`' Property Address: 40 Goosepoint Road C n r Owner; Ri c-hard- Tinory Date of Inspection: SKETCH OF SEWAGjE•DI$POSAL SYSTEM ties to a supply enters.the building. t least two perinanertt reference landmarks or ovide a sketch of the sewage disposal system including bTovidearks.Locate all wells within 100 feet.Locate where public water 3 9• i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 -Goosepoint Rd. Centprv; 11P, MA Owner: Richard Tinory Date of Inspection: 1 0/4/0 4 SITE EXAM Slope Surface water Check cellar, Shallow wells Estimated depth to ground water 7o feet Please indicate(check)all methods used to determine the high ground water elevation: n o Obtained from system design plans on record-If checked,date of design plan rgviewed: o Observed site(abutting property/observation hole within 150 feet of.SAS) no Checked with local Board of Health-explain: �o Checked:with local excavators,installers-(attach documentation) ��4ccessed tJSGS,database=explain:h t t g •7o wn ga2nh t o&.ee. ma•`u s �--. You must describe how you established the high ground water elevation: IL and N j e 2ea mode.9 12/16/9 4. 2ound wat eaagov nnuae 2ange�,ve.e. u d7echncca2 �u22et�n 92- 00-01 2ate12 an. ound waken eieua.tionz. . � n r Leaching Pit : Beet �ec:c:.>tiiv�gd e:S1sNt � , , W I Gr undwater: Feet Below.Bottom of Pit High Groundwater Adjustment 1.8 ft per FrfNpter Method Therefore,the vertical-separation distance between the bottom of the leaching pit and the adjusted groundwater table is s feet: G1- ' la•.n:nr.^n,'f7^TrTrt.—rtR'ITre.R+T.T.rrtttrr+Trvn/TnRT�lT ter�7Jf+o�Tti•.� 'TOWN OF Barnstable WARD OF HEAVII SUIISbUFACE SEWAGE I)ISfOarA{, SYSTEM IbIShECTION FORM - PART D •- CERTIFICATION.._ _] " �n n•nnr�nnnTTTnrrnnt.+rrr •••Tl'1 T"•' �T.IIT•�•�7T��A•� �T *rn �•. —TIP6 OR PRINT GLCAA7 PROPERTY INSPECTED STREET ADDRESS 40 GooseoQixtt_R^ad, Centerville... MA ASSESSORS MAP , DI OCK AND PARCEL # OWNER•' s NAME , Richard TT.inory PART D - CEliTIF.TCATX0N NAME OF INSPECTOR Robert Paolini COMPANY NAME Joseph P. Macomber &` 'Son Inc COMPANY ADDRESS ^ Box 60 Centerville- Mass 02b32 Street 'form or C1Ly State CIP COMPANY TELEPHONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1.578 n, CUTIFICAT•ION• STATEMENT I certify that I .. have personally inspected the sewage • disposal system at '.this nddr.ess and that the information reported is true., accurate, and -complete as of the time of ,inspection, The inspection was performed and any 'recommendations regard"ilig uporade-, maintenance , and repair are consistent witli my' training and experience in the proper function and maintenance of on- site sewage disposal - systems , Check one ; Y Systeoi .PASSED The inspection which I have condu-gted has not found any information which indicates that th.e system fails to adequately protect public• health-or' the environment as defined i.-n 310 CMR 16 , 303 . Any . failure criteria .•not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con_a-titted has found that the system fails 'tc protect the E-)ub•li.c health and the environment in accordance with Tittle 5 , 310 CMR 15 . 3Q3 , and as specifically noted on PART J - FAILURE CRITERIA of this in P cto r fo Inspector Signature . Date LO - F• TrT.c•.�Ts:nT— -�:easr�� .• ;ne copy of this 9.prc.i'fication• must be provided to the OWNER, the -BUYER ..'( wh'ere appllcable'j and the 1301A1113 OF )t3AI,,TIi, * .If the inspection FAILED , th,e• ow-nor or op.erator. shall ljpgrade ' the eyetem- within one year of the date of the inspection, unless allowed or required otherwise as provided in 3,10 CMR 15 . 3.06 , partd , do( TOWN OF BARNSTABLE LOCATION 5'D G D a S Ply 4) /^/f _ SEWAGE VILLAGE C NT2R // ASSESSOR'S MAP & LOT �- - ( . INSTALLER'S NAME&PHONE NO. e P t. SGN SEPTIC TANK CAPACITY G D e. 11�1/' n/Q LEACHIlYC.FACILITY: (t5'Pe) C//�H�3CPR'S (size) 'o a 6 a� N0. OF BEDROOMS NBUILDER OR OWNER Q PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: I. - Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist : . on site or within 200 feet of leaching facility.) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by TOWN OF BARNSTABLE 'G• LOCATION O O S0 IAI% RQ SEWAGE #Z moo ` VILLAGE C e Al re A d//11 f ASSESSOR'S MAP & LOT —gAM 24STALLER'S NAME&PHONE NO. A4 A C O A4 9 e P. P SON SEPTIC TANK CAPACITY A G O Q. -- A0 LEACHING FACILITY: (type)I—Al ow Cf/�,A1tSfR'5 (size) 6'00 6-AZ NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: ' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r i s y�' / T No.- Fee $ 5 0. 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migpogar bpgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. 40 G o o s e po i n t Road Owner's Name,Address and Tel.No. Mrs. Douglas R. Salter Centerville,Mass. 02632 Assessor's Map/Parcel Centerville,Mass. 02632 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son Inc. - J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 - Box 66 Centerville Mass. 02 Type of Building: Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons 1 Showers( ) Cafeteria( ) Other Fixtures- Design Flow 355 gallons per day. Calculated daily flow 3 X 1 1 0=3 3 0 gallons' Plan Date Number of sheets Revision Date Title Size of Septic Tank Existing 1 000 Type of S.A.S)Existing 1 —LP 1 000 Description of Soil:Loamy boney sand to coarse sand. Nature of Repairs or Alterations(Answer when applicable) Adding two 500 gallon leaching chambers packed in 4 ' of packed in 4 ' of 11" stone, 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 nd not to place the system in operation until a Certifi- cate of Compliance has been iss d by thi d f ealth. 1 0/1 1 /00 Signgorthe ate Application Approved by ate Application Disapproved following reasons Permit No. Date Issued W. J7 No. i �' Fee $ 5 0.0 0 4 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for Zi000ar bpotem Conotruction Permit Application for a Permit to Constrict( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components �. Location Address or Lot No. 40 Goosepoint Road Owner's Name,Address and Tel.No. Mrs. Douglas R. Salter Centerville Mass. 02632 Assessor'sMap/Parcel G c y oo Centerville,Mass. 02632 Installer's Name,Address,and Tel.No. 5 Q 8—7 7 5 �3 3 3 8 Designer's Name,Address and Tel.No. 5 Q 8—7 7 5—3 3 3 8. J.P.Macomber & Son Inc. . ~�. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 026�32, Box 66 Centerville Mass.02632 Type of;Building: t Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons 1 Showers( ) Cafeteria( ) Other Fixtures g Design Flow 355 gallons per day. Calculated daily flow 3 X 1uj 0=3 3 0 gallons. Plan Date Number of sheets Revision'Date����-, Title f ,. Size of Septic Tank Existing 1 000 Type of S.A.SExisting 1 —LP 1 000 Loam bone sand to coarse sand., Description of SOB; �' Y ` Nature of Repairs or Alterations(Answer when applicable) Adding two 500 gallon leaching Chambers packed in 4 ' of 1;" stone. + ' 3 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 Certifi- cate of Compliance has been i7md by thi o d f ealth. Signed ate 10/11 /0 0 Application Approved by D ate Application Disapproved or the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliatiq THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired�X )Upgraded( ) Abandoned( )by J.P.Macomber & Son Inc. =N-f., at 40 Goosepoint Road Centerville,Mass. :ate; as�rxn constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated ,, Installer J.P.Macomber & Son Inc. J P acomber & $on Inc,,,� Designer '� A, �' / C !r The issuance of this permit shall be cons�ued,-a guarantee that the system, will unction ndesiggned. � Date _ < < i (J Inspector 'Y /v i � / 0�/0—T/i No. Fee $ 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mwiopooal &p.5tem (Conwtruction Permit Permission is hereby granted to Construct( )Repair(XX)Upgrade( )Abandon( ) System located at 40 Goosepoint Road Centerville,Mass. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust be c.mpleted within three years of-the-date-of this,p� tl Date: V Approved b PP Y /E_ S l/&99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, Joseph P.Macomber Jr., hereby certify that the application for disposal works construction permit signed by me dated ' 10/11 /0 0 concerning the property located at 40 Goosepoint Road Centerville,Massmeets all of the following criteria: /7he failed system is connected to a residential dwellingonly. There are no commercial r in Y o business uses associated with the dwelling. / ✓ The soil is classified as-CLASS I and the percolation rate is less than or equal to 5 minutes per inch. •E✓There are no wetlands within 100 feet of the proposed septic system •r//There are no private wells within 150 feet of the proposed septic system ✓' There is no increase in flow and/or change in use proposed •/There are no variances requested or needed. •c! The bottom of the'proposed leaching facility will not located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimotor Jmethod when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will M be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, , Please complete the following: A) Top of Ground Surface Elevation(using GIS information) Y °.r 4 B) G.W. Elevation jz +the MAX. High G.W. Adjustment A f7, � `t DIFFERENCE BETWEEN A and B y, SIGNED : DATE: 1 0/1 1 /00 (Sketc pr sed plan of system on back). q:health folder.eert l f .� 't I `-----, _', Q � � �[�� ,, ��;, � , . '- ;.; �b J f_. � .�✓ �' 11�1-ST—A — R- - — �► - -A.D D R-E S.S a 5,UIL tJ-Q1.Il- =A D`D R E-SS' DtA.-E—RE RM1T i �- i �. I � o cy— .� o �, A �. L � r+} '7 _ � f F'S . No......07......... a U FER'.Ao................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALT OF....... ... .. .. ........ ............................... App iratiun -fur BiupuuFal Works Cnuaa,itrur-tivaa Prrutil Application is hereby made for a ermit to Construct ( ) or Repair ( ) an Individual Sewage Disposal l System at: AM Location-Address or Lot No. rt� f� � ---- ------------------ 'rPavAR r SP Ir ✓vQ ,.hers, _ Owner Address a •••... --• -- = -------------------------------------- ------ Installer Address ; U Type of Building Size Lot-/_7j?!�7-----Sq. feet . Dwelling-4 No. of Bedrooms---..I...................................Expansion Attic ( ) Garbage Grinder (�' Other—Type of Building ............................ No. of persons.-________________._-_--_--- Showers ( ) — Cafeteria ( ) a' Other fixtures ...................................................... ................••.------................------•---------------•--•---..... ......_... -------------- W Design Flow. ..............� .................gallons per person per day. Total daily flow--------—30.a......................gallons. W Septic '1':�rtk Liquid capacity-/0_09-_gallons Length................ Width................ Diameter____---._.-_____ Depth_-_............. � •, I x Disposal Trench—No--•------------------ Width..._.....TotaI Len ...----- Total leaching area--------------------sq. ft. Seepage Pit No...... Diameter. e t e __._______ Tot 1;leach I trea__________________sc it. Z Other Distribution box ( ) Dosing tank '� Percolation Test Results Performed by.......................................................................... Date--------------------------------------- �e. Test Pit No. 1................minutes per inch Depth of 'Pest Pit_-______•___--____-- Depth to ground water..................... 44 Test Pit No. 2................minutes per i ch Depth of Test Pit.................... Depth to ground water........................ s t x...............f.. t . Description of Soil - ----= -- --------------•-••- ... �:.. - ... x _... - - - ---- -- - - -- - U W _----_---•-•----------------•---••------•--------------------------•---•-- .....-•-•------•--••---......---............_..._..---...--•--........._...._........_.......-------•---------------•-------- UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ------•------------•--••---•-•------•--------------•--------------------------••----•--•--•---•---•---•----•---•--------------------------------------------------------------------•----•-------••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the d of health. - Sig = . ---•------------------------- l Date Application Approved By........� .... .. .. ..... o•:-- ------ --- ------ Da e Application Disapproved for the following reasons___________ V' 4--- - ---•--•---------•-•----••----•---------------•---------.------ Permit No.................................................. - �D Issued..--- Date No........... Fizz............................. " THE COMMONWEALTH OF MASSACHUSETTS ; BOARD O HE :,T Appliration 1pr: ilqipiial Worka Crnn #rn tnn rrn�i# -Application•is hereby made fora Permit'to Construct,( ) or` Repair: ( ) any Individual Sewage Disposal > System at , - Location-Address ................or Lot No. ! rr� --- . •_...- - o d '• re Owner Ad ss ,�• .............. ---••-••• . ----•-. -------• --•..................................................... 'Installer Add f Q Type of Building Size rLo nstaller •..—� y a. U •• Dwellin ' No:'of Bedrooms__t ` :_.Ex ansion'Attic ' Garbage Grinder as Other.—Type of Building No.. of .persons .. Show Cafeteria l a Other Pfi '.' ATM. ) - �. i - 5 ................................................. W Des gn Flow__._ j � °t� g11 ons,per per son er �s Total daily flow ., 4 ._gallons..,' '.' Septic,1 an,, Lliquid capacity gill h"s ' Len"gthL__'. Width. W Disposal Trench=No ____..:_ VVidtli.. nth / otalaclun 1re1-.: _:. ems ft. : % w e, g q' .. Seepage Pit-,No F ....... Diameter Plepth" 'be�w inlet Total rg�trea_. sq: :. ,z Other=Distribufion•'boz :(' ) "k.Dosing tank'(': Percolation Test'Results Performed.by M...... ...,_ _.__ _____._. ......Date. ......:..::..:............. .. i Test Pit 1, o. l________________minutes per inch Depth of lest Pit __i_'_'.Depth to ground water ---------------------- Test Pit No: 2._.__ __.__._minutes per.inch Depth of Test Pit ._._ Depth to ground water---------------------- --- -- j - --------- ¢' 0 .- - O �, -�l//ia�dGa' it d7.s'I-•t -� V �d."1�✓ • , •Y+J-•---� ^' •`! Descripfion of.Soil .... t - -- /��y:e� - -- . .................. ---•-•-----...__. --- ------- ---- ------- ----- ---------------------------- ---- -- - --- V Nature of Repairs or Alterations—Answer when'applicable................................... ................................... .. .............. .. --•---------'--------------'-•- ----------------- --- ----- --- .... - • ` • � i .......................:..........'.r Agreement- a A The undersigned agrees to° install the aforede'scribed Individual Sewage Disposal.System in accordance with the provisions•of Article XI of the State Sanitary Code The signed further agrees not,to,place t e.sy, tem�in operation until a=Certificate of`Com liaric'e`lias b�� Et�'b ,s P P y iOb6 altli._ ed .. , , t -I •• ._Wit__ _ _________ A lication.A roved B /1 ' PP PP Y • ... Date., Application Disapproved for the ollowin reasons:--.__= -- ----.............. ............................. - - ............................................ I Date r Permit No t . ,M ` yiF ssued:P .. .. o ss n. t a..•.y t ry 4 c it .i i�' f <"r -1 ;t - F � 1. � ' ? r �r i 3 ♦xP+ � 'Je�Y �f*�l'. 1?E�a..a �s�r'�l'�",e A.h,w<-v•t q.`• x...tr,�.� �..{:. ''7. ;. a r Nk4 sh �.: :a'�4'• �"�r• ,t _X ��# '9' '� :i THE COMMONWEALTH OF MASSACHUSETTS< '• , . •, - � t. �. i _. - art. ...� r _k ♦-_ - '. 'BOA R-1) W Of ': EALT-71 H y t ti >' 7. ......... J... ... ................... .................................... ....... - . THI IS T6' '- R I B , That�the Individual Sewage Disposal.System-constructed_(, ) or Repaired ( ) �J by Y� '-i.r� t .................. n . u 16stall " . -- . . has been installed in acc rdance with the provisions of Articl �I ofs�e State Sanitary Cdde s 4e3_cri e jii4he `�) application for Disposal Works Construction Permit No....... :....__... dated. ................................ THE. ISSUANCE OF THIS .,CERTIFICATE SHALL NOT;BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION .SATISFACTORY. DATE:..................................... =---........-- Inspector --;-.. , 17900 5 r=T /OT.`17 19 � Fo�worior✓ . 371 18 /O S.'00' PR N V OO SE po,N 7 ROA,D. ¢o' wioE CER T. i i iED PLoT -PGoN • LoCAT/o/v —• CEN'TERV/LLE � MASS. Sc4t6 ��40' 047i� I99RCN 2$ 1975-. . EiN� LoT • on/ A �qN FoR . WAGCo7T- -•9.iy.ES - ; $s .9�!D 2ECo,20E0. IN Ae 4N OBK. /98 - . • �.-t•}k�1�i1':.i JZ�7� ''?�i^yeti `a"Yf e (_"`i ?• CERTiOY 7/1.9T Tl/E` Fv u/vO•gTioN �"`� ..."a� ' s►' � 1 !�• -. Sf/owN o� THiS PL%9N /S �ocgrEO on/ 7W GRou/v0 195 So"WAV T/E Tro R,F P/:92Z,4 - PE. T10 ivE,42 /97s . . IZEG• L�9N0 SuavE�i2 /05 04 / 10 l7 90 o sq /�ow�w9riaaj PRIV, &OoSE poiN7 RoAD ¢o' WID ' "` • CER T i i iE0• Per= .P�.q.�. . : - •.CoCAT/o.iv - C'EN TE12 v��GE � CIA-S5: SCALE /��'40-' OWE �•9RCN 2? /9 75 Li9N. RE/? - BEiiV� Lo"T �/8 SMo Nam/ .9• /q44N Fn,e WAt e o7T A�"!E$ .9ND 2ECo90ED` /N Pl AN 0,<, /98 ,,J `'i• '�,+;~ PG /,s/ Bi9�2ivs .Gvvivry REC= of cos z cERT�FY 'r.�.vr rNE tJN D9T/ON 61V 7fVAS PLAN i5 .4 c 9rEd GRouwO 95- Sf/oWN ETToR. P/92Z.9 — PETir/on/Ex /97S G r� £'- IZEG• L�9N0 SuRyE oR TOWN OF BARNSTABLE LOCATION qO Gooirove r .t?D SEWAGE# VILLAGE SSESSOR'S MAP&PARCEL 252 0491.'o0 NAME&PH NO. 4t he 91AUc k S bj6 -36 7 SEPTIC TANK-CAPACITY /000 5?QdO f LEACHING FACILITY:(type)1 6 12 .2 dl:�WPf size 0-t 2 c,hc,.,et✓S NO.OF BEDROOMS 3 F OWE. R AN 4 L✓e., p' t - 4WDATE: 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 2? .9 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet.of leaching facility) \0 o' +' Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) 101)1 + Feet FURNISHED BY '� W Goosepoint Rd ! 40 Goosepoint Rd 1 Centerville, MA 02632 j 3 Bedroom House Y t Rear of House A B i e A l=25' B 1-33" 1000 Gallon 2;32' 2-36' L2 - 4c Tank 3-38' r 3-39'4-25' 4-25' D-B (2) 500 Gallon Chambers 6 (R=6') Leach Pit �,•_ _ w/-3'-stone__ -- ,--