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0106 FOXGLOVE ROAD - Health
106 FOXGLOVE ROAD Marstons Mills - - - - - --- A = 149 - 130 - 022 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments to Property Address , a� es �� See ve : Owner Owner's Name ..,_s information is l required for every 2��2lrt%i6 .e 0d-6-?d Ll c�°y page. City/Town State Zip Code Date of Inspect on Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when A. General Information filling out forms on the computer, f� oK✓ use only the tab 1. Inspector: key to move your / cursor- not ✓ / / D /�� // use the return J/� key. Name of Inspector — "L� Tao- Company Name AM FAIR �02 Company Address -- --- —— - City/Town /_0 e / — State Zip Code 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 an a CEP approved systemi inspector pursuant'to Section 15.340 of Title 5(310 C 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspectore Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 � VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M Property Address �eev� s information is Owner Owner's Name / / l„ / /�f required for every (�0-4�v, Ile / 'A 0.1 G,Td- j �� page. City/Town State Zip Code Date okfirispection Bo Certification (coot.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System asses: 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `M / 0 G Property Address Owner Owner's Name c,4T1v, `l information is required for every page. City/Town State Zip Code Dat f I soe nn pection Be Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(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.doc-rev.6/16 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 P 9 P Y Commonwealth of Massachusetts N Title 5 Official m a _ Inspect'®n F®r a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name �eS information is required for every G2 H �Eo'v/Ile �� ad page. City/Town State Zip Code Date of In pection B. Certification (coat.) 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. [IThe system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup pf 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 ❑ 21-� 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `M 106 two� /o— �. Property Address Owner ve Owner's Name information is required for every 294 ✓�/d I-� / � 0� 3 �° �� page. Uty/I own State Zip Code Date of I pection Bo Certification (coot.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ny 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 ributary to a surface water supply. El Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ly 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- ❑ L—�/ 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 16,000 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M �O �Ov� fed Property Address s Owner Owner's Name information is required for every ✓� ` �/4 o� 3O2 `j /��� page. City/Town State Zip Code Date of Co Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes o ❑ ping information was provided by the owner, occupant, or Board of Health El 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? 21111- ❑ 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)] Do System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Pro r� a Ad ress p rty d Owner Ow y ner s Name information is Ao_ required for every ��� y` i� (�� 1 / page. Clty/Town State Zip Code Date of In pecti n D. System Information Description: // /QOO625 IL4 c / �� 7:: Number of current residents: J Does residence have a garbage grinder? ❑ Yes Jo Is laundry on a separate sewage system? (Include laundry system inspection El Yes No information in this report.) Laundry system inspected? ❑ Yes XNo Seasonaluse? El Yes Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑l Yes No Last date of occupancy: '� 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 1 //,, TOWN OF BARNSTABLE jLOCATION C/6� rOX Vf/_ 'k2 S1=E#=-ei VILLAGE.,. tom; $ M,1u I USSESSOR'S MAP&PARCEL IN-3W99URPS NAME&PHONE NO. 060v1x4 l f t 4�TI-1-7 SEPTIC.TANK CAPACITY 100b LEACHING FACILITY: (type) eQ Chcvw\btr'=) (size) :500 NO.OF BED OOMS OWNER ,a r 11 Qc PERMIT DATE: C ATE 1-,P 1 0as lic) Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) _ ___ _ Feet Edge of Wetland and Leaching Facility(If any w sexist within 300 feet of leaching facility) Feet FURNISHED BY �n" 4.4 t t t•t h�\ t�t 4 t 4 ♦ \��4 ♦ 4'.'1 4 A'\'\�4 h•\ \ ♦ ♦ t \•t \ h \ t fY \ \ \ 4 \ 4 4 \ 4 4 \ 4 4 \ 4 4 ♦ \ 4 4 46-, f JL! f r f 4 ♦i f ! f\ 4 \f f f J J f ? f : fr t 4 \ \ t \ t - 4 h t ♦ 4 \ \ \ t t t t \ 4 k 4 ♦ \ t \ ♦ \ \ \ 4 4 h h \ \ k 4 4 h t t \ ♦ 4 t h h h \ t \ \ \ 4 \ \ 4 4 t \ \ t t 4 4 4 \ \ k h 4 26 27 18 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ��vrf Owner Owners Name 1 / information is '*/Ga.� l required for every �� V` � 11,114 page. City/Town State Zip Code Date of I pecti n D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: j � 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 Sy m: 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F0 X led Property Address �fe�ve Owner Owner's Name information is 0.l � K� 5/nspq/Uion2 required for every 'ems 7"�✓6 �i /� ' o�-+opage. Clty[Town State Zip Code Date of D. System Information (coat.) Approximate- : `age of all components, date installed (if known) and source of information 4 l G✓ �, DQI SthAl— — IL-L° h/ 4� o2J0/ Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 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): 10 Depth below grade: feet Materia 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: X Sludge depth: / t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner O wner s Name information is /,, required for every C-4,'K Ile page. Cityfrown State Zip Code Date o(InspeEtiofi D. System Information (coot.) Septic Tank (cont.) l� Distance from top of sludge to bottom of outlet tee or baffle b� 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 How were dimensions determined? -- /`e /`cr cli2 L/C•e Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): O w1 d'?.Prn cj�PC/ 'good C""cr,7A0 P1, �-G 1-r 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 106 o x low I Property Address Owner Owner's Name information is 1p ` / required for every r � page. City/Town State Zip Code Date of l4specti n 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 roust 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.doc-rev.6/16 Title 6 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 "M �L FG /oke /e Property Address V�f Owner Owner's Name information is /n/ Ile— required for every e page. City/Town State Zip Code Date of I specti n D. System Information (coat.) Distribution Box(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.): 60 7� I t/- _ Pump Chamber(locate on site plan): Pumps i��working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): ' If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is /4 required for every L2h4Vt/6 / /7 Qd 3�- V page. City/Town State Zip Code Date of In pection D. System Information (cost.) Type ;L) So C) U �1 i7✓► (/ H I ` �-j a� j7' , ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: --- --- ❑ overflow cesspool number: ❑ innovative/alternative system I ypeiname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 01- �' V V ' ✓�f ©74" 41ldl-r1wL G i 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Mas sachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is C // /�� �a �01 t5� required for every �"" (/L page. City/Town State Zip Code Date of 14pectiefin 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.doc-rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .Property Address Owner O wners Name information is /_ G // a 6 / required for every 'e"' page. CitylTown State Zip Code Date of Inspection Do System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two pe nent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately FQ /v T Q f ybilov o2 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M /06 o Property Address / ��22veS Owner Owner's Name information is G� // �( f/d 6 �hs required for every e� ✓✓a ✓J` yh7 page. CitylTown State Zip Code Dao D. System Information (coot) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / Itio t"' Estimated depth to high ground water: feet T 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: pate ❑ erved site (abutting property/observation hole within 150 feet of SAS) Checked with PI Board of Health -explain: -..1s -{— ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how y established the high ground water elevation: o4a M r a ,e `�o hoc — /�/� /'O u H O a 2 L - n9.06,17 C/ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Mas sachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments love° � Property Address � Owner Owner's Name / / j1pection information is / / G required for every (mot° � 'epage. Clty/Town State Zip Code Date of E. Report Completeness Checklist ff-Inspection Summary:A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Ss m Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 .• it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o 106 Foxglove Road Property Address Ruth Correia Owner wner's Name information is Ce erville ,nn- .) MA 02632 November 23, 2010 _ required for State Zip Code Date of Inspection o every page. City/T i 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: A. General Information When filling out forms on the 3W computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell — cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. — Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508.428.1779 SI 12855 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 j Title 5(310 CMR 15.000). The system: j CD ® Passes ❑ Conditionally Passes ❑ Fails; 7 ❑ Needs Further Evaluation by the Local Approving Authority UZI cn November 23, 2010 Job# 10-2839 1 IAA 00 I pector's ignature Date 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. ****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 Official Inspection Form'.Subsurface Sewage Disposal stem•Page 1 of 17 tins•09101 . I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 106 Foxglove Road — Property Address Ruth Correia — Owner Owner's Name information is Centerville MA 02632 November 23, 2010 required for State Zip Code Date of Inspection j every page. Cityrrown 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: Tank is not in need of pumping at this time leaching chambers had no standing water. ; I o - i 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. I 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): i i I f i Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pag J 2 of 17 t5ins-09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Foxglove Road — Property Address Ruth Correia — Owner Owner's Name information is Centerville MA 02632 November 23, 2010 ! — required for Date of Inspection every page. Cityrrown State Zip Code p 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): I I — I ❑ 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): I i i - i C) Further Evaluation is Required by the Board of Health: i ❑ 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. I 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 j ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pagel3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 106 Foxglove Road — Property Address Ruth Correia — Owner Owner's Name information is Centerville MA 02632 November 23, 2010 — required for State Zip Code Date of inspection every page. Cityrrown — 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: — I I **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: i I I — 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_day flow — I t5ins•09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•PageJ4 of 17 I I I . I f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 106 Foxglove Road Property Address Ruth Correia — Owner Owner's Name information is Centerville MA 02632 November 23, 2010 _ required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged orb obstructed pipe(s). Number of times pumped: El ® 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. j ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. i El ® 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be j 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. I 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t5ins•09108 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I ,,. 106 Foxglove Road Property Address Ruth Correia — Owner Owner's Name information is required for Centerville MA 02632 November 23, 2010 ; - every 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 I ❑ ® 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 El ® 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? I ® ❑ Was the site inspected for signs of break out? I ® ❑ 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? i ® ElWas 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: i ® ❑ 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® El approximation of distance is unacceptable) [310 CMR 15.302(5)] i - D. System Information j 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 I i i t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 cf 17 I i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments I 01 106 Foxglove Road — Property Address Ruth Correia — Owner Owner's Name information is required for Centerville MA 02632 November 23, 2010 — eve page. City/Town State Zip Code Date of Inspection ry D. System Information Description: I i i 0 _ Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No I 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)): — Detail: i I _ i Sump pump? ❑ Yes ®I No Unknown _ Last date of occupancy: Date i Commerciallindustrial Flow Conditions: Type of Establishment: I 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 ❑I No I Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑l No i Water meter readings, if available: i t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i w 106 Foxglove Road — Property Address Ruth Correia ' — Owner Owner's Name information is Centerville MA 02632 November 23, 2010 — required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): I i i - General Information i Pumping Records: i None available. Source of information: Was system pumped as part of the inspection? ❑ Yes ® No i 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 i ❑ Tight tank. Attach a copy of the DEP approval. I ❑ Other(describe): i I _ i l5ins-09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts 9.3 Title 5 Official Inspection Form PM Subsurface Sewage Disposal System Form - Not for Voluntary Assessmentssk j M 106 Foxglove Road Property Address Ruth Correia Owner Owner's Name information is required for Centerville MA 02632 November 23, 2010 every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Leaching system installed 11/26/01 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): i i Septic Tank(locate on site plan): Depth below grade: feet i Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 8.5' long x 5.2'wide- 1000 gall Dimensions: 3" Sludge depth: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f I ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Foxglove Road _ Property Address Ruth Correia _ Owner Owner's Name information is MA 02632 November 23, 2010 required for Centerville every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" j 2 Scum thickness 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured _ i Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank is not in need of pumping at this time. I I i i { Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): I 1 i Dimensions: I — Scum thickness — I 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 j t5ins-09108 Title_5 Official Inspection form:Subsurface Sewage Disposal System-Page 10,of 17 i i . i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Foxglove Road Property Address Ruth Correia _ Owner Owner's Name information is Centerville MA 02632 November 23, 2010 required for � — every page. Cityrrown 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): i — i Dimensions: Capacity: — gallons i 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.): i i I I Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins•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 106 Foxglove Road Property Address Ruth Correia _ Owner Owner's Name information is required for Centerville MA 02632 November 23, 2010 - every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): i 011 Depth of liquid level above outlet invert t 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.): No solids or high stains present. Liquid level was found at bottom outlet pipes. _ i I i i Pump Chamber(locate on site plan): i Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No I i Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I I i i I i i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I i I i l5ins•09/08 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 12 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Foxglove Road — Property Address . Ruth Correia Owner Owner's Name information is required for Centerville MA 02632 November 23, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Type: ❑ leaching pits number: — ® leaching chambers number: Two 500 galdrywells. ❑ leaching galleries number: — i ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions: — i i ❑ overflow cesspool number: — i ❑ innovative/alternative system i i Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching chambers had no standing water or evidence of surcharge. i i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): i Number and configuration — i Depth—top of liquid to inlet invert — Depth of solids layer — Depth of scum layer Dimensions of cesspool — I Materials of construction i Indication of groundwater inflow ❑ Yes ❑ No i f5ins•09l08 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 13 of 17 i i f , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Foxglove Road Property Address Ruth Correia _ Owner Owner's Name information is required for Centerville MA 02632 November 23, 2010 every page. Cityrrowh State Zip Code Date of Inspection D. System Information (cont.) Comments (vote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I Privy (locate on site plan): Materials of construction: — I Dimensions — Depth of solids — i Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I i i t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 106 Foxglove Road __- Property Address Ruth Correia Owner Owner's Name ------------------------ information is Centerville MA _02632 November 23, 2010 required for ------ ---------- — - — - -- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 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 i f / / ••/•/ / . \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 26 27 18 18 i i Foxglove Road i i i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 4 N 106 Foxglove Road _ Property Address Ruth Correia Owner Owner's Name information is Centerville MA 02632 November 23, 2010 required for — every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: i ® Check Slope i ® Surface water i ® Check cellar ® Shallow wells Estimated depth to high ground water: feet — Please indicate all methods used to determine the high ground water elevation: i l ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) i ❑ Checked with local Board of Health -explain: i I _ ❑ Checked with local excavators, installers -(attach documentation) i ® Accessed USGS database-explain: USGS topo map and town GIS. j You must describe how you established the high ground water elevation: I i i Before filing this Inspection Report, please see Report Completeness Checklist on next page. i !Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i I .� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 106 Foxglove Road Property Address Ruth Correia Owner Owner's Name information is Centerville MA 02632 November 23, 2010 required for — every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked i ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I i I i i i I i I I i j i i t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i i TOWN OF BARNSTABLE LOCATION 1' ` 3d �v v._�� Xd- SEWAGE # VILLAGE 0 1,. I ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 4&� -mom rF 7 7 SEPTIC TANK CAPACITY LEACHING FACILITY:.(type) 9L u 1-2- 4 'e--; (size)`3`-2 NO. OF BEDROOMS 3 ' BUILDER OR OWNER /6,0A T,r.l PERMITDATE: /0`1 l/ ® / _ COMPLIANCE DATE:,//-"" G a Separation Distance B/of h Maximum Adjusted Gle to the Bottom of Leaching Facility Feet Private Water Supplyaching Facility (If any wells exist on site or within 2ching facility) Feet Edge of Wetland and cility(If any wetlands exist within 300 feet oflity) Feet Furnished by dA/- <. ar.fl y°A � Z � d o -V e �f /p No. 6 p Fee $5 0 �n / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Miopooal Opotem Conotruction Permit Application for a Permit to Construct( . )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 106 Foxglove Rd. , n ervi� George Bartlett Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service Daniel Johnson P O Box 1089, Centerville 804 Main St. , Osterville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other T�pe of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 340.4 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets 1 Revision Date Title $13bssurface Sewage Disposal System - Size of Septic Tank Type of S.A.S. Description of Soil; gravely loamy sand Nature of Repairs or Alterations(Answer when applicable) rep lace failed SAS with 2 leaching drywells ( 24 'L X 13 W X 2' overall) 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 issued by this_Poar4Af Health. Signed /� ° Date �—Q Application Approved by 4p- Date /U —a 1/—O L Application Disapproved for the following reasons Permit No. 2001 0 Date Issued ---- No. / t * y Fee $5 0 / _ -� .-- _ � ' •' THE COMMONWEALTH OF MASSACHUSETTS - Entered.in.coppntekl- _ Yes - PUBL1C gfALTH DIVISION-TOWN OF BARNSTABLE MASSACHUSETTS _ �� - -- 0[pprication' for 0i000zar *pztem Construction Permit M / Application for a Permit to Construct( , )Repair(X)Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. ` i� 106 Foxglove Rd. , Centerville George Bartlett ' Assessor's Map/Parcel j t A �- 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel:No. Wm. , E. Robinson Septic Service Daniel Johnson P 0 Box 1089, Centerville 804 Main St. , Osterville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 340.4 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets 1 Revision Date Title St]hatirface Sewage Disposal System Size of Septic Tank Type of S.A.S. Description of Soil gravely loamy sand Nature of Repairs or Alterations(Answer when applicable) replace failed @XS with 2 leaching drywells ( 24 'L X 13 W X 2' overall) a 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-t Cate of Compliance has been issued by this oar of Health. } . s Signed Date Application Approved by jp Date /0 O Application Disapproved for the following reasons Permit No.�2001` Date Issued 0-a e/-01 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Barlett Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( X)Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at 106 Foxglove Rd. , Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ),00 dated /U-d y-0/ Installer Wm. E. Robinson Sr. Designer Dan Johnson ` The issuance o�j t s permit shall not be construed as a guarantee that the sy m willflfunction as de gned. Date 1? I1�DU Inspector ISM,,rV 1 f --__. No, )Do(J 6 gO———— Fee THE COMMONWEALTH OF MASSACHUSETTS Bartlett PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS , 1wigo0ar *potem Construction Permit Permission is hereby ranted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at �106 Foxglove Rd. , Centerville 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. r Provided:Construction must be completed within three years of the date of this permit. f Date: 0( Approved by r �- { G � ..- �_ ea.a-_.•...... ,-� :. :r, SJr���Kwt'�'. ae y"�a s��5... -. - ,,..� r � a a•i,w:.. " t°SrtX �{ +71` i r 1 K5 r d`-"F m�* �1fY ��� �(F4 yam. `y c ? MRS �'('a kj� am$'a'rcr � C;`'fFa-'#1 �. yz„rr-^•-...��. ..-%mom .ate•, r � t k , t.,d J.. 'Z t '-T y.. ��� � �� ��`�� �•� ���� � - �.�LO�AT30NM'-'1��•���o �T �o�ii'�� J�c� k SEWAGE #t - " LAGS; Lr^' ) R x- yx:•i{ v ASSESS0 S.MAP INSTALLER'S NAME&PHONE NO. _&b it ,p SEPTIC..TANK CAPACITY LEACHING FACILITY: (type) `� (size) :3 Y NO:OF'BEDROOMS T. . f - BUILDER OR OWNER_ ,eiC / t l►` PERIv1TTDATE /�`Z.4/ a:/ COMPLIANCE DATE. {S .Y.d�Yt n h{(q.'t'9,t� '�.�':.h 1 �Y.!{'-�,'l�i(jr�'3�t�l t.}ti'}ddr !!f.. � t. •.' -.:. ,. ..,.,i-, i. i, :Separation Distance Between the. } 4� Maximutn Adjusted Groundwater le tot the Bottom of,Leaching Pac�lity fleet r Private Water Supply Well an actung EaciLty (If any`wells east xfr f on site:or within 200 fe of leaching•faciLty ge of,Wetland:and dhi ung Facility(If any wet}ands exist Ed ' within•3:00 feet'of eachiig I'acTity) -" Furnished by Gtr 'Z � t >N 9,.i1'a 7 y ,Si 1r Y T-f r, .t .. .. ,. ,. .. i ' i� i'fr: t Yd.. t�+t c J .,,,.a.�•..c-'r u r •a: Y 6.t ii 1 ` ty t1 Y� z ^2R x :t f f Sa } S r i� c lMq S.trt.vt yxt� iy�i Y . , 1 ... ., .. .i , .. 'i , :. d nti - - - _ , LOCATION SEWAGE PERMIT NO. -i- aq �e-f-29 9 VILLAGE I N S T A LLER'S NAME i ADDRESS I e U 1 L D E R OR OWN ER u PROP, DATE PERMIT ISSUED 4 DAT E COMPLIANCE ISSUED i0 �S 1$i+�,c�► �_ t . _ �� °�� �� 33 Y/ t� �,.� 4 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ,7A ' Lti ...`......._.. ................OF...,. -—-- i w .....�/Y - Appliration for Disposal Workii Tnnitrnr#inn Prruat Application is hereby made for a Permit to Construct (4'<6r Repair ( ) an Individual Sewage Disposal System at: ................_........-.................................................................. ........ ......................................... t Location-Address or'Lot ................................... ...... _...... ..................................... Owner Address Installer Address d Type of Building Size Lot-_ -Sq. feet U Dwelling-1;*11o. of Bedrooms........... ...........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ....... No. of persons............................ Showers — Cafeteria Q' Other fixtures ------•-•---•-- ••-------=----•--•----••-••-..... W Design Flow....... � .....................gallons per person per day. Total daily flow__..z .........................gallons. WSeptic Tank—Liquid capacity, � .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.............._..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....../---------- Diameter... ..... Depth below inlet.................... Total leaching area..Z,,1,1'::::~_sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed ....................... Date....�"j4r?__• ..... a Test Pit No. 1----- -----minutes per inch Depth of Test Pit.... ....... Depth to ground water/.eA_11,1__-__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ................. •-•-•••••••••-••-•---•••-----••----•----•-•-•-••-••--------------------j------•------......................................................... 0 Description of Soil.. = - �� �'S�� — Q��- �- •�� � V -- W --•--•-•--•.................••--•••--•-••--•----•-....-•••-•---•----------------------•-------•-•-----...-----••••-•-••----•••••---••--•---•-•-••••:.....••••-•••--•--•--•-......•-••-•-----•----•------ U Nature 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 iITiE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operat' unti Certificate of Compliance has bee ed by the oard of health. '`�a"^^ Sign .. ...................•-----••----•• --"/-t f! / (D Application Approved By.......... --••- .................. /(O _•------••-f•----Date.............. Application Disapproved for the following reasons:-- .......................................---•-----_------••----•---- --•--•--•-•-----•---•--------•----•-----•----•--•-- •—-----•- -----------•-------•----•--•-•---.._•-...----.---••--------------------------------------•------:-------------•--------------•--- Permit No........- - .... Issued..----..... 4 Date ate ......- No....4!y--... .9 Fps...:.. :Q......_......_ THE COMMONWEALTH OF MASSACHUSETTS c� .. BOARD OF HEALTH �r A rlir t ion for is n al Works Cfonstrnrtinn rrntit Application is hereby made for a Permit to Construct Q,,,, br Repair ( ) an Individual Sewage Disposal System at: .....---•-------.......................••-.........----•--•----.........------•---.......--••---- .............. _ .......... f �. ......-------- �r Location-Address or LoNo. + : e°: ". -•-`.....l''--....-•.........................._..... --------------------•--------------- Owner Address _ •____...... ... 3....._ ....................................................... ..ws..._........__....--Y..... ... Installer Address Q Type of Building Size LotA;442----Sq. feet U Dwelling '.,��o. of Bedrooms....... -------------------..........Expansion Attic ( ) Garbage Grinder ( ) aOther—Type,of Building ............................ No. of persons......._____--..-__---_-___- Showers ( ) — Cafeteria ( ) Otherfutures -•--•---------- •------•--•--•-----••-•-•-------•-•••.-•---._.....-•--•---- •-•-•-••••--•--------•---------------------------•-------•--....--------- W Design Flow...... .....................gallons per person per day. Total daily flow_., ..........................gallons. WSeptic Tank—Liquid capacitv/z,&%2z 'gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No_____ ___________ Diameter...,!."...... Depth below inlet.................... Total leaching area. ..sq. ft. Z Other Distribution boxes'" Dosing tank ( ) Percolation Test Results/ Performed by,/ "f L �. ......................... Date...-.1 Test Pit No. i...`l/----.---minutes per inch Depth of Test Pit.. f Depth to ground water s 1-.f1�-_-_-_. LJ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground ,water........................ a -•----------•-••--••-•...------"•-1 ------------ ---------------------•---------•---•---••......•-•••••.......................................................... O Description of Soil.__ 2_:__? ��;�q ✓�� _ Vim.f J� °�� �rw?.»lt. .�. t!.w! Vic. ° r ,; ` —' - W ----•------•---------•---------------------------------•---•--•--•---------••------•------------••------•----------------------------------•--------•---•--------------------•------------------------- VNature of Repairs or Alterations—Answer when applicable................................................................................................ d r Agreement: ! The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLij 7 of the"State Sa tary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -------•-------•--........--r---------------------------------------------------- -•-•----•-•--•------------- �t Date ;Application Approved By-•------- : .........:.......... Date Application Disapproved for the following reasons:. �\ -----------------------------•---•--•----•--•----------------...---...------------------•-----------...--•------------••--•----------••-------------•-•--•--•-------•-----•••----••-•-------••-------... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tntifiratr of Tompliaurr THI,�IS TO CFRTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by_,T .. :..M.0 --............................I........................................ .............................................................................................. �1 Installer has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._ __ f�. ............. dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUED A A G RANTEEr THAT THE SYSTEM WILL FU TIC)N SATISFACTORY. DATE.................. .�Q�...........-------------------•-•...... Inspector--....---_.. .._ .......----•--••...•---....---- .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j ...........................................OF..................................................................................... Disposal sal(�Works Tnns#rudion rrntit Permission is hereby granted_.. h1..---------•-•--.....-•-••---•-•--•--••--•-•--•---------•---•-•---•--••...................................... to Construct ( ) or Repair ( ) an Individua Sewage Disposal System atNo...�,1�. ?� - G� �41 n ............���1;U&ta.E.................................................................................................. Street q tf as shown on the application for,Disposal Works Construction Perm' o.................... Dated:..___.. :�lt!t.l mac_�_............ � l �!'� ---•----•---......-•------------------•----•- ..........._._ Board of Health DATE---- la .......................................... -----,-L..=�---•---•---------•- FORM 1255 A. 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