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0285 SHOOTFLYING HILL RD - Health
ol 285 SH®®TFLYING HILL IRS West Barnstable Y �4 = 214 - 014 - 001 1, 77 TOWN OF BARNSTABL LOCATION hP4 WAGE # VILLAGE ASSESSOR'S MAP INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY,: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum-Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any w ds exist within 300 feet ofg cili w ` �/� i ,n(�/} Feet. Furnished by �� JI�X., V�" ", t� Y Ui� 14 AA OIL AC �a �C 3a tz /5 ...................... -.--.../- -- -1-T-... -- ..[,0e i W.K. . �. -- -.... '7 - V/ - � n Fr r Vwn of P4 Department of Health,Safety,and Environmental Services 12-221 Public Health Division Date 367 Main Street,Hyannis MA 02601 BAmfrrABLK MAM 16 9. 3> Date Scheduled Time lb-AM Fee Pd. /oo, Soil Suitability Assessment for Se ispos r Performed By: Witnessed Y.B C.4 .............. .............. .. ...... ............. ... . .......... ........................ ........ .0 I .......... .. ... ........ ........ . ... Location Address Owner's Name CW S k q 0 kqty;�J. 1'� Ic ce&&-e-V I(k / - 64-4414 Address Assessor's Map/Parcel: (A /04/10'a/ Engineer's Name WK CAf e- NEW CONSTRUCTION REPAIR Telephone J�a — ft Land Use I LQA 5cc(A-ed Slopes(1/6) 0 -S.— . Surface Stones./4/0/)e Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well >/00 ft Drainage Way ft Property Line 11 Other SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) C-1 2, 12-' Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water In Hole: Weeping from Pit Face A//-A7. Estimated Seasonal High Groundwater AIM— ............... .............. Method Used: V"'T Depth Observed standing in obs.hole: In. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. index Well# -Reading Date: Index Well level.-- Ad).factor Adj.Groundwater Level . ... ...... .. .. Observation Hole 9 Time at 9" Depth of Perc 7V Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./inch /7C Site Suitability Assessment: Site Passed Site Failed: Additional Testi ng Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back Copy: Applicant ........... ------------- ....... _.........____.........._......... ___�____ -pif� Soil Horizon 0 be'. .. Soil Texture �ii�oi T Soil Other Consistency,%Gravel) Depth fl-T), Soil Horizon. Soil Texture Soil Color Soil I - - I Surfaci (USDA) (Munscll) Mottling (Structure,Stones,Boulderes. Soil goil Texture Depth from Horizon Soil Color Soil 01her Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.%Gravel) Depth from §oil'[lo'lZ:::ori Soil Texture Soil Color Sol Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. � ^ � . . ' � � - ~ � � � ' � - � � � � � �. Above 500 year flo od boundary No Yes u/ Within--year-_—boundary No es . '— Within 100 year flood boundary � � co n co F I I i S -,(6 u t cp Postage $ ru Certified Fee /� N C] Retum Receipt Fee fury c7!Postma Q O (Endorsement Required) `< Here U) 0 Restricted Delivery Fee J (Endorsement Required)rq C, p Total Postage&Fees �7 r-I S nt To , ru -/'� G�' ra - mb - ------------ Sire Apt No.; N --PO Box No. Ctty,State, P+4 Certified Mail Provides: o A mailing receipt o A unique identifier for yourtnailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: p Certified Mail may ONLY be combined with First-Class Maile or Niority Mail®. a Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". n If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office-for postmarking. If a postmark on the Certified Mail receipt is not needed',detach and affix label with postage'and mail.. IMPORTANT,Save this receipt'and present it when making an inquiry. PS Form 3800,August 2606(Reverse)PSN 7530-02-000-9047 COMPLETE • . ON DELIVERY ■ Complete iteins,l,2,and 3.APO complete tat A Si item 4 if Restricted Delivery iesire .JAPd y - Agent ■ Print your name and addressi th& everse _ ❑Addressee so that we can return the card to:you. i i sit B. Received by(P' ted Name) C. Date of Delivery ■ Attach this card to the back,of themailpiece, �� C "oJ'T �c p or qn the front if space permits. '1 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes A If YES,enter delivery address below: ❑No � /3eah �a�aan �d, Apf a�. �f�yj � � SC a99 a8 3. Service Type �ertifled WWI ❑ s'"Priority Mail Expres ❑Registered Return Receipt for Merchandise ❑ Insured Mail ❑Collect on Delivery f 4. Restricted Delivery?(Extra Fee) ❑Yes 7012 101 000 2847. 8414 PS Form 3811,July 2013 Domestic Return Receipt UNITED 8iWWiRdsYAm8 &Ili1lI(1fill#fll ll I 1 111,1- First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4®in this box* Y Town of Barnstable O Health Division 200 Main Street Hyannis,MA 02601 I i i lIll'l'l,ilillll1llllllll1, i'fl'�ll�ll�Illflllllll�lllllllllll, �TME r� Town of Barnstable arn��ab'e . �° Regulatory Services Department 1 edeaC j BA"SCABM I 9 "�: ,� Public Health Division m �D Mays 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012 1010. 0000 2847 8414 January 19, 2017 WEYMOUTH, ELIZABETH H & JOHN A TRS 1 BEACH LAGOON RD, APT 27 HILTON HEAD, SC 29928 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 Wt&-t Barn&kbcc The septic system located at 285 Shootflying Hill Road, `-en4etw4l] ,MA was inspected on 12/29/2016 by Sean M. Jones, certified Title V.Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of.1995 TITLE V (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH cKean, R.S., fl----_._ Agent of the Board of Health QASEPTICU.etters Septic Inspecticn Failures or Future Evl\285 Shootflying Hill Road Centerville.doc T �. Town of Barnstable • swftrrsreare, : . 6 9. ,�� Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA*02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ondin of effluent g p g to the surface of the ground a ❑ Pumping more than 4 times during the last year not due to clogged or obstructed Pipe ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool 1 YEAR DEADLINE CR ITERIA Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h OTHER ❑ Repair deadline. Q:\SEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc dL6 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cs 285 Shoot Flying Hill Rd Property Address a-� John & Elizabeth Weymouth °o Owner Owner's Name information is required for every Ma- 02632 1-2/2912016 s page. City/Town' State Zip Code Date of Inspection tJ1 MD 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. ICI Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 12/29/2016 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 /of Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is required for every Centerville Ma- 02632 12/29/2016 Zi City/Town/Town State page. Y p Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. 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•3/13 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 286 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is Centerville Ma 02632 12/29/20-16- required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chainber 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 approva[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-otder.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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is required fcr every Genterville Ma 0.2632 12129/2016- page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)-and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less Q ® than '/day flow ,,ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is required`or every Centerville Ma 02632 12/29/201.6 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified . laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking-water-supply ❑ El 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of_Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is required for every Centerville Ma 02632 12/29/2016 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ -® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ 2 Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or.as part of this inspection? ® ❑ Were-as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is required for every Centerville Ma- 02632 12129/201.6 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown 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•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Witte 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,..°� 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is required forevery Centerville Ma 02632 12/2912016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Witte 5 Officiat Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owners Name information is required for every Centerville Ma 02632 12/29/2016 page. Cityrrown State . Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron JZ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 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 Sludge depth: 10" t5ins•3/13 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 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information every is required'fo.r Centerville Ma 02632 1-2/2912016 page. Cityr'rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 1" Scum thickness ' 8" Distance from top of scum to top of outlet tee or baffle 1" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? opened covers, took. measurements Comments(on-pumping recommendations, inlet and outlet tee-or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is overdue for pumping, heavy buildup of solids. Water level was ok, tank was strucrturally sound. Needs risers. Signs of past overloading include toilet paper on top of otlet pipe and black stained soil above cover. 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•3/13 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 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name informatics is required for every Centerville Ma 02632 12/29/2016 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): 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is required for every Centerville Ma 02632 12/29/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found to be full of standing water all the way from tank outlet pipe into box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (ncte condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information,is required for every Centerville Ma 02632 12/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leaching facility consists of Infiltrators or similar. System fails inspection due to d-box being overloaded. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is Centerville Ma 02632 12/29/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is required for every Centerville Ma 02632 12/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: '® hand-sketch in the:area below ❑ drawing attached separately t 4�cv, O t]_ _ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 L TOWN OF BARNSTABLE LOCATION—MYS;4coi rug1N4. L=k _ !�d SEWAGE# C.-VILLAGE (J_Ztet,�, ASSESSOR'S MAP&PARCEL :4-14.01'+—06 INSTALLER'S NAME&PHONE NO. .( • l�� '77t—�3�i�j SEPTIC TANK CAPACITY 4..r t e�hiG 16Cn 4 4t_ hl-f® LEACHING FACILITY: (type) uZ..L7,(Ch9 (size) NO.OF BEDROOMS �- Soo�at Cks� OWNER PERMIT DATE: `—i"7 COMPLIANCE DATE: 3 ( -7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility $ Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Qgx,/;/ Zg� 151j,--Y--,-,, .�2 8�r ��. ��i yz, ��a�S s�' ,:����¢-Ry�h �:11 �� No. cp/'? Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye ftplication for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repairk,/ Upgrade( ) Abandon( ) ❑Complete System 2 Individual Components Location Address or Lot No. "(iwner's Name,Address,and Tel.No.Y V,�3 3g- 6(f')/ M"n Uje�inn ofia20,,14gcon V, Ajo�3� Assessor's Map/Parcel aJ / (-fhb Installer's Name,Address,anti Tel.No. Designer's Name,Address,and Tel.No. `s' '✓�+ —ys / r+olo Cvns��:x 'a» c nl5u,h��� u.T7�c�p e C,--n 'r)e�4"�'✓��' ,1—'yac• � r/-lQii�S�• D DGlfo`7 1. Type of Building: v Dwelling No.of Bedrooms Lot Size 7 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) , 3,Y) gpd Design flow provided 3 y 9 gpd Plan Date Z I. (a,c j Number of sheets Revision Date Title T' �� N a9 Size of Septic Tank C/8 n Type o S.A.Sb)14jo i oZ /a,& Description of Soil lie- Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. / Signed Date / Application Approved by Date Application Disapproved..by --- Date for the following reasons Permit No. _00// — 0 V Date Issued '�`� 1-2 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is required for every Centerville Ma 02632 12/29/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,a yt 285 Shoot Flying Hill Rd Property Address John & Elizabeth Weymouth Owner Owner's Name information is required for every Centerville Ma 02632 12/29/2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 �r`"3., r• roy t ,. ri ..r.,> ..... ,,..,..r _...^. .. ... ,.r.. �..... .. - ., .,-�. • ..�F ram* .ti �: . .,. . No. C/," 17 r Q Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yer 01pplication for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair,( Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No� ~r •5 " Y ;tiv er's Name,Address,and Tel.No.,?VS 3 3�. 6 C/�/ �'"Q'" ►►D � SAW ^e� c.t1e�vh Assessor's Map/Parcel a/� / dv. G�/�I�: +t.9 / j , SL' Installer's Name,Address,anA Tel.No. `tfZZ3-y.Pfr 2a C- Designer's Name,Address,and Tel.No. JDS• 3Lo;--y5 V1 �wr wt�� C�rrsl-ruc�r'an,=L:nc. �/5�rrfushz� � ,t,�tc.3���p � ',l�p�•;,�3 ,`irx• 93'r�/�tio-r Sf eW ► 'l D1 rF / An f aCn"� TI pe of Building: ,- Dwelling No.of Bedrooms 3 Lot Size 7 1�< < 1 sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtur--s Design Flow(min.rj!ecuired) J-30 gpd Design flow provided 3 Y� gpd Plan Date Ck1 yy,tyA t, (o.Cx)I r) Number of sheets Revision Date 41 '9-0� Title 1 c ` � c ��IlkVr e f r Size of Septic Tank Typer of'S.A.S(2)/4J/a aiL. : X/.-1.8 Description of Soil .J Nature of Repairs or Alterations(Answer when applicable) Date last inspected: '; Agreement: . � i The undersigned agrees to ensure the construction and maintenance of the afore described onsite sewage-d.-tsposal system in accordance with the previsions of Title 5 of the Environmental Code and not to place the system in"operation until'a Certificate of Compliance has been issued by this Board of Health. Signed _ Date Application Approved by Date �-/Cp Application Disapproved by " Date for the following reasons Permit No. 01�)O/O " G L/ Date Issued `q�'� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(4) Upgraded( ) n Abandoned( )by ///. S�,'1x 7�,.oC9 . -FY,c at has been'coiistrucied iri accordance` with the provisions of Title 5and the for Disposal System Construction Permit No,�? 1/hated Installer_i}i f �-v�r �. t��y� di rr[a .1ra� `'� Designer_�r)Cry #bedrooms " + J J Approved design flow 1A 3tf 9 gpd The issuance of this pe,6it shall not be construed as a guarantee that the system will functi.%as designed. K Date vV - - - - ----- --- ----- ----------- -------------------------------------------------------------=------- t No.cI Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstrm Construction Permit Permission is hereby granted to Construct( ) Repair( '}o Upgrade( ) Abandon( ) System located at � � }� h—��i�7er �`><-!�/ -�j J and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be/�/npleted/wit in three years of the date of this p-rmit. " Date �- /GJ �6 Approved by - �,/ Town of Barnstable 4��+E t Regulatory Services Thomas F. Geiler,Director �0� Public Health Division ArF1639. 'Thomas Mclean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form 1 Date: °l 17 Sewage Permit# °�I?-0�� Assessor's Map\Parcel any Designer, U�NJ�` i e fy) eerl Installer: 601' l� Address: Mar n Address: l Al< 7L � On o�l �1 �es/o ,e: �,�Sywas issued a permit to install a ( ate) n (installer) septic system at °� U A0a based on a design drawn by ( d ess a-v,4 e'1 ��q P,Xf dated d (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic syst t in accordance with State&Local Regulations. Plan revision or certified t esigner to follow. O A of&ftiSs�s �o DANIELA. �s o OJALA (Installer's Signature) CIVIL N No.46502 G sTOt<1 NAL (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLLANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc / 2 — 500 GAL. CHAMB. WITH 4' STONE AROUND LOT 18 44,491 t S.F. �o O TH1 Y DECK �^i V SHED EXISTING DWELLING TOP OF FNDN EL. 75.6 a 0 i� 111a \ GRAVEL `�V DRIVE \\ / 1 \N.OF/d�ss9 DARIIEL A. N \ / 001 OJALA / c CIVIL � \ \/ 7 o No.46502 Scale:1"= 20' s, ,AL 0 10 20 30 40 50 FEET SEPTIC AS-BUILT 3'1'z"17 off 508-362-4541 IN I fox 508-362-9880 CENTERVILLE downcape.com #285 SHOOTFLYING HILL RD. Civil engineers PREPARED FOR land surveyors BORTOLOTTI CONST. 939 Main Street ( Rte 6A) YARMOUTHPORT MA 02675 SCALE: 1' = 20' MARCH 22, 2017 17-017 I 1 1 l .2 �► ,s S (,� sr7��( a��r.�i /-riLL /� Zitl� f-'L/f o M TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE tl: MINIMUM STANDARDS FOR HUMAN HABITATION Date 0 U Time: In ( &D-� Out Owner Tenant Address Address S tv , Com liagee Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal r Gj 17.Temporary Housing IV 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition c I Number of Bedrooms _ Number of Vehicles Allowed (max) Number of Persons Allowed (max) f� Persons Interviewed Inspector Y` If Public Building such as Store or Hotel/Motel specify here ( i TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date I Time: In Out Owner �O v V l Tenant Address l =it' Address Compliance Remarks or Regulation # Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities Ilk %,p J O - —V Eb 7. Lighting and Electrical Facilities &!!f PAS P 'f t 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal — 3� 17.Temporary Housing N► 7 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Ilow ) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here FORM 30 H&W HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H9ALTH CIT /TOWN Z E fJ a {� DEPARTA� NT 4 11 r ADDRESS M y0y`0 TELEPHONE Address rJ 1 Occupant 4- Floor Apartment o. No.of Occupants No.of Habitable Rooms No.Sleeping Rooms— No.dwelling or rooming units_ No.Stories------. Name and address of owner ( RctAlaw-cZ Re arks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: L I a T_,_ Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: 2L �Q Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 _ I Bedroom 2 b l Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: S-tacks, Flues Vants,Safeties: Kitchen Facilities in ve Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: General Building Posted Locks on Doors:::�+ &,- — ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REP S SIGNED AND CERTIFIED UND HE PAINS AND PENALTIES OF PERJUR ." .�- r INSPECTOR TITLE DATE � TIME •' A.M. Ili THE NEXT SCHEDULED REINSPECTION P.M. '. _ _ ._ .., v.is ply*":SJM;'t+)�. f. .^• t' r �: _.a,a, �,... i, _. . -y Y ✓ ., 1. ... .3 r , .. . ..Y p. 410.750: Conditions Deemed to Endanger or Impair'Health or Safety The following conditions, when found to exist in residential premises,shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not'be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs ofthe occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. I f ill i re uired b 105 CMR 410.250 B 410.251 A 410.253 and the li htin in com- (D) Failure to provide the electrica ac t es q y ( ), ( ), g g mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result,in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. FORM 30� H&w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' + ._ r. CITY/TOWN, W ° DEPARTMENT 'o ADDRESS dd TELEPHONE Address -- _ Occupant ' + Floor Apartment N No.of Occupants No.of Habitable Rooms No.Sleeping Rooms_3 No. dwelling or rooming units_ No.Stories_ Name and address of owner h -- ^ram jwsti �t7►r� 4y AjL,;V—`1 Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish ' Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: i ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: V V Walls: Foundation: Chimney: �-- BASEMENT Gen.Sanitation: �Q � . J A Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: r Hall Lighting: Hall Windows.- HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: - Stacks, Flues,Vents: - 1y PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: r Gen. Basement Wiring... - ` DWELLING UNIT - Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 t Bedroom 2 b 1 {[ Bedroom 3 2 oy j E Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,V nts,Safeties: Kitchen Facilities ;Sink t IC 0 "Stye Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: n y! General Building Posted Locks on Doors: v ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT`IS SIGNED AND CERTIFIED UNDER THE PAINS AND y PENALTIES OF PERJUR ." INSPECTOR �^ ! '� -- TITLE— DATE TIME A.M. THE NEXT SCHEDULED REINSPECTION 1` P.M. s 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. F . t• i y1 I �� 1/ �L � � �� �� �� � y COMMONWEALTH OF MASSACHUSETTS H EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS � a DEPARTMENT OF ENVIRONMENTAL PROTECTION /G TITLE OFFICIAL INSPECTION FORM-NOT FOR VOL UNTARY ASSES SUBSURFACE SEWAGE DISPOSALSYSTEM FORM NIENTS PART A CERTIFICATION Property Address:� S�JOo7'�o/, Owner's.Name: 63,Z :z Owner's Address: S/ ./ Date of Inspection: 00 ^:a Name of Inspector: lease print) e�S P�� Company Name: �y ;Mailing Address: 1 Get 'eig , Telephone NumberrS�a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the info below is trt:e,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function a ration reported and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Sect' S.340 of Title 5(310 CbIR 19.00o). The system: _ Passes Conditionally Passes Needs Further Evaluation by the Local Appr Fails oving Authority Inspector's Signature: Date: a o 6 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 t?ow of gpd or greater, the inspector and the system owner shall submit the report to the annro ,iat 10,000 DEP. The orilginal should be sent to the system owner and copies sent o:�the 1;uy r, if applicable, and the authority, r` P- regional office of the approving Votes and Comments *This report only de scribes conditions at the time of inspection ;1rd under the condition time. This inspection does not address how the system will Perl'arm in the tutus: s use at that under the same or ' conditions of use. different Title Inspection Form 6/15/20ro page r Page 2 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ��S s�00 �.� Owner: t -e 6 J� Date of Inspection: Inspection Summary: Check A,B,C,D or E/AL_ WAyS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 Orin 310 CMR 15.304 exist,Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: y One or more system components as described in the"Conditional Pass"section repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,ewd or ill a p ss. Answer yes, no or not determined(Y,N,ND in the explain. ) for the following statements. If"not determined"please The.septic tank is metal and over 20 years old* or the septic tank(whether metal or not is strut unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection ifth existing tank is replaced with a complying septic tank as approved by the Board of Health. ) structurally .*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance e indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if wit approval.of Board of Health): box due to broken or (with broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a y ear due to broken or obstructed pi , Pass inspection if(with approval of the Board of Health): pe(s). The system will —.-- broken pipe(s) are replaced obstruction is removed +D explain: Page 3 of 11 OFFICIAL INSPECTION FOR11rI._ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: eo Owner: t Date of Inspection: L C. Further Evaluation is Required by the Board of Health: /" Conditions exist which require further evaluation by is failing to protect public health, safety or the environment the Board of Health in order to determine if the system 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 ?. 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**. Nfethod used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacte_-ia and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other, 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: t�Ss S`i00� th H1 /1 Q� 1 �' ei�'1 tt�—� �4�d3� Owner: T1 C� 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 ckup of sewage into facility or system component due to overloaded or clo ed SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or -e3ogged SAS or cesspool _✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or 11 cesspool _. �,iquid depth in cesspool is less than 6"below invert or available volume is less than %Z day flow �i!/Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number mes pumped ARV 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 �er supply. �y portion of a cesspool or privy is within a Zone 1 of a public well. 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 forma (Yes/No)The system fails. I have deter �mined 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 ;;Pd. You must indicate either"yes"or"no"to each of the following: (The followi_-rg criteria apply to large systems in addition to the criteria above) y s no — the system is within 400 feet of a surface drinking water supply the system is within 200 teet of a tributary to a surface drinking water supply _ — e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a manned 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 s 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. Page 5 of 1 I OFFICIAL IN SPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F PART B ORtti7 CHECKLIST .QQ Property Address: � S Rd, Owner: T1 Chill / Dalb/3'� Date of Inspection: col 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 ? v Has the system received nor mal flows in the previous two week period? Have large volumes of water been in troduced 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 dwellin ins ec g p ted for signs of sewage back up? Was the site inspected for signs o g f break out? ✓ — ',Here all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered,opened,and the interior of thee baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth o the condition ✓ p f scum Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? 2 Ye no 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 Feld(if any of the failure criteria related to Part C is at issue approximation is unacceptable) Q 10 CNIR 15.302(3)(b)) PP hori of distance Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1LNI PART C SYSTEM INFORMATION Property Address: (;1�5 Ao FJ n� Owner: tio tC t✓ - od-6 3-L Date of Inspn: RESIDENTIAL, FL W CONDITIONS Number of bedrooms (design): Number of bedrooms(actual): 3 DESIGN low based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3�0 Number of current residents: 0 Does residence have a garbage grinder (yes or no): /1/0 Is laundry on a separate sewage s stem or no): /1YO [if yes separate inspection required] Laundry system inspected(yes or o):fE� Seasonal use:(yes or no): � Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): ,K 0 Last date of occupancy:_��r/-e C OMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CTMR 15.203): Basis of design flow(seats/persons/sgft,etc.):-mod Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL, INFOI.MATION Source of information: Was system pumped as part of the inspection( •es or no): If yes, volume pumped: gallons--How was uanti Reason for pumping: q ty pumped determined'? TytkOF 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) _ Iru)ovativ;/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 inforr tion: Wee sc:vage ociers detected :vhcn arriving at the site(yes or n o)rid, i Incn Minn �,vm 9/1 ii`)11(1(1 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR,tiI PART C SYSTEM INFOXVIATION(continued) Property Address: CZ OS sdj0 0� fie'^ ,,,�•,'1,��- � � �'//� �� Owner: S�1 t� Cd-6 Date of Inspection: .t 06 BliILDING SEWER(locate on site plan) Depth below grade: Materials of constructio —cast iron _4 PPVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage, etc.); SEPTIC TAINK: (locate on site plan) Depth below grade:---L_ � Material of construction: concrete metal fiberglass__polyethylene —other(explain) _ — If tank is metal list age:— Is age confirmed by a Certificate of comp liance certificate) P (yes or no);_(attach a copy of Dimensions: Sludge depth.' 02 Distance from top of sludge to bOttOr_ tee or baffle:i of outlet r Scum thickness: c2 Distance from top of scum to top of outlet tee or baffle: Distance.from bottom of scum to bott How were dimensions determined: da le f outlet tee nor bafflebaffle' Comments(on pumping recommendations, inlet and ttet tee or b�e—condi-on strucr;;al inteo-ri liquid t as xelated to Outlet invert,evidence of le a e, etc.): // o. ty, quid levels h r7 I n /7d7� ne6 A74- 4-v1 ! � fIQ f%ON,�/ !O h Q N Qh GREASE TRAP:/ (locate on site plan) Depth below grade:i1 faterial of constructio_n:—'concrete (explain): — -- _ metal fiberglass po.lyethylene _ other � Dimensions: Scum thickness:--- - Distance frorn top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffl Date of last pimping: — Comments(or.pumping recommendations, inlet and outlet tee or baffle condition,structural inter? ty as related to outlet invert, evidence of leakage, etc.): , liquid levels ti Tirl:. incn,:.,•nnn G,,rry „I C >li/lll Page ti of 11 OFFICIAL INSPECTION FOR1tiI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR,)/1 PART C QQ SYSTEM INFORMATION(continued) Property Address: -C; Q ,S`j00bt:41.1.1-1 -It Q� Owner: Ackq 63Z Date of Inspection 196 TIGHT or HOLDING TANK:(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow; gallons/day Alarm present(yes or no): Alarm level: Alarm in workingorder Date of last pumping; (Yes or no): Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:zif r Present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 00/-Vn e_(__ Comments(note if box is level and distribution to outlets equal,any evidence , any evidence o leakage i to or out of box,et .): of solids carryover, f /-'o PUMP CHAMBER: A-/(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): e • eage 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property address: At C/' a aS SNJO Owner: G CeN �E'✓v��r�� Date of Inspection: � / SOIL ABSORPTION SYSTENI(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number._ � LH� leaching chambers,number: teaching galleries, number: o� t S 710�qt leaching trenches, number, length: leaching fields,number, dimensions: / overflow cesspool, number: 1'3 U �N ev innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level ofponding, damp soil, condition of vegetation, i O/Ai etc.); vie �n d 7� CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of'groundwater inflow(yes or no): _ Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): a PRIVY: (locate on site plan) Materials of construction: _ Dimensions: Depth of solids: Comments (not,--condition of soil, signs of hydraulic failure, !eves of ponding,condition of vex-� station; ::tc.): I':rl,., fncr.,,•�ii•n f'n.-m !.;1 G,�II(lll 9 Page 1,)of 11 OFFICIAL INSPECTION FORM—NOT FOR ASSESSMENTS VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INS ARY PART C PECON FORM SYSTEM INFORMATION(continued) Property Address: dvJ SXOvl Owner: S�( c tv � vi � ' ✓ l�( l/ �� ©a,c 3i Date of Inspection: Ok 10 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 buildin , g 1 � 0 A y C� 3 ill I� .,, rvu l:iv-m ri I C7ii Page l l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (�? Owner: Date of Inspection: /d SITE E!AM Slope �O Surface water Check cella_ .� 0 — ? Shallow we:.ls 0� 3 J / _ 3YEstimated depth to ground water ,3�f feet Co y Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Obsen•ed site(abutting property/observation hole within 150 feet of SAS) --- Checked with local Board of Health-explain: — P I A V1 Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: 00 You must dzscri e howy u established the high ground water elevation: / Se D0^7 MT/ I'�q NV s ,f A/I �'11'100 COMMONWEALTH OF MASSACHUSETTS , EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAI. PROTECTION a F a.. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM d �+ PART A . _ CERTIFICATION ILL RD CENTERVILLE,MA Property Address: 285 SHOOT FLYING H 02632 M214 P014 LO1 5 Owner's Name: AMY STANLEY ENTERVILLE,10'lA 02632 Owner's Address: 285 SHOOT FLYING HILL RD CINJED a T� Date of Inspection: 11/26/01 DEC 0 6 2001 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS P.O.BOX 2119 TEATICKET,MA.02536 OF BA RNSTgB�E Mailing Address: T�WHEgLThI DEPT. Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I have personally inspected the sewage disposal system at this address and that the information reported below I certify that P true,accurate and complete as of the time of the inspection.The inspection was performed based on p training and s f t experience in the proper function and maintenance of on site sewage disposal systems.J am a DEP approved system n 15.340 of Title 5(310 CMR 15.000). The system: inspector pursuant to Sectio h� X Passes- _ Conditionaily P ses ' Needs Furth valuation by the Local Approving Authority Fails ,;w, Date: 11/26/01 Inspector's Signature: . 3,-w of this inspection report to the Approving Authority(Board of Health or DEP)wtthtn ` The system inspector shall submit copy P designg d or eater,the i 30 days of completing this inspection.If the system is a shared systemate regional or has a offi a of the DERThe original should bevX inspector and the system owner shall submit the report to the appropapproving authority. *i sent to the system owner and copies sent to the buyer, if applicable,and the app' g i Notes and Comments 'Al y THE S YSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG T. SYSTEM'S USEFULL. l y ****This re ort only describes conditions at the time of inspeCtlon under thd under e same or l different conditions tof use. p .,iati inspection does not address how the system will perform in the future A 1�, J1I, Page 2,of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' .s CERTIFICATION (continued) 1 Property Address: 285 SHOOT FLYING HILL RD CENTERVILLE,MA 02632 M214 P014 L018 a € Owner: AMY STANLEY Date of Inspection: 11/26/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D e � A. System Passes: ; X 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 t CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL. 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. n/a The septic tank is metal and over 2'0 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits a . substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced � s with a complying septic tank as approved by the Board of Health. s *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating '" p 5 that the tank is less than 20 years old is available. ND explain: n/a n/a 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: n/a ? n/a 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 r ND explain: n/a itS Page 3,of 11 4,` OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ; PART A ti CERTIFICATION(continued) f d Property Address: 285 SHOOT FLYING HILL RD CENTERVILLE,MA 02632 M214 P014 L018 ' Owner: AMY STANLEY 2n fit Date of Inspection: 11/26/01 s C. Further Evaluation is Required by the Board of Health: r , 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 A4 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 1, Si 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the ,,Y` system is functioning in a manner that protects the public health,safety and environment: Y t _ 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. l _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well �V F• _ 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 � k; supply well".Method used to determine distance n/a ` "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 P , nitrogen and nitrate nitrogen is';equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy � r of the analysis must be.attached to this form. a�a 3. Other: n/8 t-w Ew 4.A i �eq Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 285 SHOOT FLYING HILL RD CENTERVILLE,MA 02632 M214 P014 L018 r } 3 x Owner: AMY STANLEY Date of Inspection: 11/26/01 D. System Failure Criteria applicable to all systems: y You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground 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 :I X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/Z day flow ; X Required pumping more than 4 times in the last year NnT due to clogged or obstructed pipe(s).Number of times fill pumped nLa. ,¢� �5,, X Any portion of the SAS,cesspool or privy is below high ground water elevation. E � X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. x; _ X 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 tea ; 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.] 1 _ (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. � ti. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"toS each of the following: (The following criteria apply to large systems in addition to the criteria above) " . ra . yes no sr _ X 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 It 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. N f Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B � CHECKLIST �5 Property Address: 285 SHOOT FLYING HILL RD CENTERVILLE,MA 02632 M214 P014 L018 �'r Owner: AMY STANLEY _ . Date of Inspection: 11/26/01 ?; Check if the following have been done.You must indicate"yes"or"no"as to each of the following: A `4 h1 Yes No r X _ Pumping information was provided by the owner,occupant,or Board of Health Ni 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? X Have large volumes of water been introduced to the system recently or as part of this inspection? li }q-P�E X Were as built plans of the system obtained and examined?(If they were not available note as N/A) xrx X _ Was the facility or dwelling inspected for signs of sewage back up? '? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS located on site? X _ 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? Ya X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? g The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 3 x � Yes no X Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is W " unacceptable)[310 CMR 15.302(3)(b)] *'pia {K�•Ye.i� 14�. Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS € SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION : ';` Property Address: 285 SHOOT FLYING HILL RD CENTERVILLE,MA 02632 M214 P014 L018 Owner: AMY STANLEY Date of Inspection: 11/26/01 FLOW CONDITIONS r x RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 2 `` 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 or no):NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO r Water meter readings, if available(last 2 years usage(gpd)): n/a Sum um es or no : NO y PP pump ) Last date of occupancy: n/a M � COMMERCIAL/INDUSTRIAL xi Type of establishment: n/a , Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no):NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a F OTHER(describe): n/a GENERAL INFORMATION 'S Pumping Records f Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system x', _Single cesspools _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) ;f *, _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): n/a ``f P '� Approximate age of all components,date installed(if known)and source of information: R. , {„ 1996 BY OWNER ; Were sewage odors detected when arriving at the site(yes or no): NO �a a Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS #R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM fi° +xx PART C `'s SYSTEM INFORMATION(continued) q Property Address: 285 SHOOT.FLYING HILL RD CENTERVILLE,MA 02632 M214 P014 L018 ; Owner: AMY STANLEY Date of Inspection: 11/26/01 BUILDING SEWER(locate on site plan) + ' . Depth below grade: 18" i �%. Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a k Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATERY SEPTIC TANK: X(locate on site plan) =�t Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass polyethylene other(explain)n/a ac If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) r Dimensions: 1000G L 8' 6" H 5'47" W 4' 1011" Sludge depth: 1" '. Distance from top of sludge to bottom of outlet tee or baffle:33" L'.µ Scum thickness: 0" ` Distance from top of scum to top Sof outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a E ` How were dimensions determined: MEASUREDh` Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 4 " THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING , Np PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE4t k,, GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction: concrete metal fiberglass_polyethylene_other(explain): n/a — — — Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a r Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related ,' € : , to outlet invert,evidence of leakage,etc.): n/a Jam. 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ; ,-_��,. Property Address: 285 SHOOT FLYING HILL RD CENTERVILLE MA 02632 M214 P014 L018 Owner: AMY STANLEY § `` Date of Inspection: 11/26/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade:n/a Material of construction: concrete metal fiberglass _other ex lain : n/a — — — g _polyethylene ( P ) Dimensions: n/a Capacity: n/a gallons ; ,,V Design Flow: n/a gallons/day y ` Alarm present(yes or no): N/A '�' Alarm level: N/A Alarm in working order(yes or no):NO Date of last pumping: n/a # Comments(condition of alarm and float switches,etc.): k DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) , Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE : `•, 4 s: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into il" ` or out of box,etc.): , •- s, :' BOX IS STRUCTURALLY SOUND-SYSTEM IS FUNCTIONING PROPERLY. ,S PUMP CHAMBER:_(locate on site plan) r Pumps in working order(yes or no): NO . Alarms in working order(yes or no):NOa ' Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): ` b. n/a � s r 'VY# S � � 1 x Q Page 9 of I I '' ,0 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ;W Property Address: 285 SHOOT FLYING HILL RD CENTERVILLE,MA 02632 M214 P014 L018 ' Owner: AMY STANLEY Date of Inspection: 11/26/01 SOIL ABSORPTION SYSTEM(SAS): _ (locate on site plan,excavation not required) If SAS not located explain why: t ; n/a E �E Type 1000 GAL 6'X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: nla n/a leaching trenches, number, length: nla n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a � n/a s• innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,'signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY-SOIL PROBED DRY-SHOWS NO SIGNS OF FAILURE-BOTTOM AT 10' ' vN" a i. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a 1`r nRl Depth—top of liquid to inlet invert: n/a + Depth of solids layer: n/a Depth of scum laver: n/a ° Dimensions of cesspool: n/a Materials of construction: n/aw4 Indication of groundwater inflow(yes or no):NO � F Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): } r; n/a PRIVY: (locate on site plan) ' s, Materials of construction: n/a Dimensions: n/a "h ` Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): r� 5 n/a ( , , 4 Page 10 of 11 ` Y ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :a PART C SYSTEM INFORMATION(continued) Property Address: 285 SHOOT FLYING HILL RD CENTERVILLE,MA 02632 M214 P014 L018 ; N Owner: AMY STANLEY Date of Inspection: 11/26/01 SKETCH OF SEWAGE DISPOSAL SYSTEM t Provide a sketch of sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. j t: Locate all wells within 100 feet. Locate where public water supply enters the building. �q Nc F ; g s� *� Q act w {#. a r ee f0 x a � L e r 4 30 r r c� Y 5 �f sue, x in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 285 SHOOT FLYING HILL RD CENTERVILLE,MA 02632 M214 P014 L018 Owner: AMY STANLEY t, Date of Inspection: 11/26/01 SITE EXAM _Slope Surface water .; _Check cellar : Shallow wells .?; Estimated depth to:ground water 13+feet '` Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: { . GROUNDWATER DETERMINED BY AUGER ON SITE-NO WATER AT 13'-BOTTOM OF PIT AT 10' # Y �4 • a`J � 3 t •S F.' J z r } 1 eap.. TOWNN' OF BARNSTABLE a P 11 COCATIO_ ��®f� /g �/ / SEWAGE # —357/ VILLAGE ® AS S R'S MAP & LOTS INSTALLER'S NAME&PHONE NO. &,•41-elk 6aws/ar,7,oN V TOO,/ SEPTIC TANK CAPACITY LEACHING FACILITY: (type), �� rzfi.�dJ f� —(size) A.2 NO.OF BEDROOMS B DER OWNER PERMIT DATE: ✓��`— COMPLIANCE DATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S 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 chin ility) Feet Furnished by Rene 33' .31 1W p �9 r No. !M, _�35/ Id11K,, L0 Fee I� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIPpffcatfon for Diopool *pgtem Con!5truction Permit Application is hereby made for a Permit to Construct( Xor Repair( )an On-site Sewage Disposal System at: Location Address or Lot o. i F;r / Owner's Name,Address d Tel.No< OA,C . . Assessor's Map/Parcel y ✓✓ -771_ �p3 Installer's Name,Address,and Tel.No. t Designer's Name,Address and Tel.No. '7�:7"�—_��80, Type of Building: Dwelling No.of Bedrooms Garbage Grinder(AA) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //® gallons per day. Calculated daily flow 3 3 6 gallons. Plan Date y/73 9{ Number of sheets Revision Date Title Description of Soil " Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation untp a Crert fi- cate of Compliance has been issued by s oaz of He th �/,T Signed Date Application Approved by Date �d Application Disapproved for the following reasons l(�Permit No. �� Date Issued -7 3 v v No. gro � £ tt # f / '/] �' / "''!�/y ,,.,�f1 `Fee _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS r ' r Z(ppricatiotl4or ;Digpogar 60gtem Congtructfon Permit Application is hereby made for a Permit to Construct( /')or Repair( )an On-site Sewage Disposal System at: " Locatibn Address or Lot No. r 'f 9 owner's Name,Address d Tel.No. C. Assessor;s Map/Parcel G�'c E �`/ ' F Cc�dP. lL, j -77/_ 60b3 Installer's Name,Add es�s,and Tel.No. e /� Designer's Name,Address and/Tel.No. Type of Building: Dwelling No.of Bedrooms 3 V)l Garbage Grinder.O Other Type of Building Noof Persons Showers( ) Cafeteria( ) Other Fixtures R r,'� P Design Flow gallons per day. Calculated daily flow 3 3 gallons. Plan Date ,17 I C Number of sheets f " / Revision Date Title P` Description of Soil s ,OF Nature of Repairs or Alterations(Answer when applicable) ' ( Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a rtifi- cate of Compliance has been issued by s oar of He th. �,� Signedmg �� Date Application Approved by<� Date Application Disapproved for the following reasons A Permit No. 1 (o _ �� Date Issued v --- ` -------_ -.. ------ -- ------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS .,, Certificate of Cbmpfiance THIS IS TO CERTIFY,that the On-site Sewage Disposa System installed(600)or repaired/replaced( )on by -joinstaller G'J'�L�7f 11 �eAa/- at /l/_ 5 Oo�� ✓ �'N /v has been constructed in accordance with the provisions of Title 5 Ad tire for Disposal System Constructiogfe t No.37.4' :X 57, dated O!P .�1^�` 3' Date 's l-0 ��?' Inspector THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. — �� r ---------------------------- i V(] — �- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLE: MASSACHUSETTS Digpont *pgtem Congtruction Permit Permission is here'6y granted to _ -- �G��l4 ` 1,11111X Alelll* to construct(repair( )an On- Ite-Sewage System}located at No.# — simat and as described in the above Application for Disposal System Construction Permit. 76 a G No. Mate- The applicant recognizes his/her duty to comply with Title 5 and the following to p visions or special cond' 'ons. All construction must be co �lete three years of the date below. c Date: Approved by Board of Health ALL SYSTEM COMPONENTS3 SHALL BE NOTES SYSTEM PROFILE MARKED WITH MAGNETIC TAPE OR (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS NAVD 88 ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2' PEAST❑NE OR GE❑TEXTILE CONCRETE COVERS TO WITHIN 3" GRADE 2. MUNICIPAL WATER IS EXISTING TOP FOUND. EL. 75.6 FILTER FABRIC OVER STONE \ 73.5 MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER;SYSTEM 73.0-74.0' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. Service Rd H-10 WATERTEST D'BOX FOR LEVELNESS BLOCKS OR 4. DESIGN LOADING FOR ALL PROPOSED PRECAST PRECAST RISERS H-1 MIN. 2 WALL THICKNESS PRECAST RISERS UNITS TO BE AASHO H-M 4'OSCH40 PVC MORTAR ALL INVERT IN 70.17' 72.6 COMPONENTS Locus PIPES LEVEL 1ST 2 (TYP.) 4' 5. PIPE JOINTS TO BE MADE WATERTIGHT. �4'S ND SIDES 71.0 �` oo° 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE EXISTING " 'ooaoo°°° p p p TEE- SEPTIC TANK** TEE 71.2t'* ®® ® WITH 310 CMR 15.000 (TITLE 5.) 0 0 0 , , 6' MIN. SUMP o00000000000O°°° ,000000°000? 12' MIN. INT. DIM. °°°°°°°° ®® ®®®®® ®®®®� ,°°°°°°o° GAS BAFFLE 0-0- ®®®®®®®®®®® ®®®®� ®®®® 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND ;ogog000° ° ° ° ° 68.17 NOT TO BE USED FOR LOT LINE STAKING OR ANY a°°°°°°°° •.,. �... Wequaquet 70.44 0.27 - OTHER PURPOSE. �_ ••77 7,77.... H 10 500 GAL. LEACHING CHAMI'ERS BY ACME PRECAST OR EQUAL. Z Lake 3/4'-1-1/2' DOUBLE WASHED STONE 4' MIN. (2) UNIT:3 REQUIRED 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. ALL AROUND PRECAST STRUCTURES 12 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSI❑NS TO ❑UTSIDE OF STONE: 25,00, X 12.83' 9. COMPONENTS NOT TO BE BACKFILLED OR COMPACTION. (15.221 [2]) CONCEALED WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD ` t (3.3% SLOPE) ( 1 % SLOPE) Ln OF HEALTH. FOUNDATION- EXIST. SEPTIC TANK 23' D' BOX 12' LEACHING 10. CONTRACTOR SHALL BE RESPONSIBLE FOR FACILITY CALLING DIGSAFE (1-888-344-7233) AND **INSTALLER SHALL CONFIRM MINIMUM VERIFYING THE LOCATION OF ALL UNDERGROUND & *THE INSTALLER SHALL VERIFY THE SEPTIC TANK SIZE AT 1000 GALLONS 62.8' BOTTOM TH-2 OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF LOCATIONS OF ALL UTILITIES AND ALL AND ITS SUITABILITY FOR RE-USE. NO GROUNDWATER FOUND WORK. LOCUS MAP BUILDING SEWER OUTLETS AND REPLACE WITH 1500 GALLON SEPTIC ELEVATIONS PRIOR TO INSTALLING ANY TANK APPROPRIATE TO SITE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED NOT TO SCALE SHALL BE REMOVED 5' BENEATH AND AROUND THE PORTION OF SEPTIC SYSTEM CONDITIONS IF NOT SUITABLE PROPOSED LEACHING FACILITY. �g� ASSESSORS MAP 214 PARCEL 14 12. EXISTING LEACHING FACILITY SHALL BE PUMPED a> AND REMOVED OR PUMPED AND FILLED WITH CLEAN SITE IS LOCATED WITHIN A ZONE II 10T O. SAND. LEGEND 99- EXISTING CONTOUR SYSTEM DESIGN: X 99.1 EXIST, SPOT ELEV. CAP AN VIN YARD / ELEC IC ASE ENT GARBAGE DISPOSER IS NOT ALLOWED -[99]- PROPOSED CONTOUR (210. 0' E) _ EXISTING 3 BEDROOM DWELLING (98.4] PROPOSED SPOT EL. �6 DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD TH1 - / w USE A 330 GPD DESIGN FLOW } TEST HOLE co Y N_ 2% SLOPE OF GR❑UND o SEPTIC TANK: 330 GPD (2) = 660 COL) UTILITY POLE / '� � � **RE-USE EXISTING 1000 GAL. SEPTIC TANK N FIRE HYDRANT NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING �O SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD BOTTOM 25 x 12.83 (.74) = 237 GPD M TEST HOLE LOGS / / �o LpT+18 TOTAL: 472 S.F. 349 GPD 44,491_ S.F. / �� USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) DANIEL E. GONSALVES, SE #13587 / ENGINEER: WITH 4' STONE: ALL AROUND 57.9' DAVID STANTON, RS / o = a WITNESS: e H2 -DATE. 2/6/17 �, � 1 MA PERC. RATE _ < 2 MIN/LNCH �,I, a� 71 p ti TH ^� APPROVED DATE BOARD OF HEALTH CLASS I SOILS p# 15258 74 ELEV. I I ELEV. TITLE 5 SITE PLAN o» 4 73.9' 0" 73.8' DECK OF A A / SHED 285 SHOOTFLYING HILL ROAD LS LS EXISTING 6g WEST BARNSTABLE MA 10YR 4/2 10YR 4/2 DOPLOF FNDN �2 8 10 � EL. 75.6 73 B B PREPARED FOR LS LS BORTOLOTTI CONSTRUCTION/ „ 10YR 5/6 „ 10YR 5/6 �o- � i 32 71 .2 36 70.s WEYMOUTH DATE: FEBRUARY 6, 2017 C C 72 0 BENCHMARK PERc \ �� p`L COR BULKHEAD Scale: 1"= 20' M/CS M/CS \ \�� \ \ / 69 0 10 20 30 40 50 FEET I \ GRAVEL i 2.5Y 6/6 2.5Y 6/6 1 I DRIVE \ / 0� r �;N of MAs off 508-362-4541 1 \ \ 0 Q ���tH o�M s ���g sq yam, fax 508-362-9880 1 / ` - �y o DANIEL G \\ ,� �° DANIELA. N gA. downcope.com CIVIL " OJALA down Cape en ineefin , MC. » � » � 46502 .o No.40980„ 132 62.9 132 62..$ S/ I \ / ro �F 4 ea ,p�P civil engineers WATER ENCOUNTERED '2.,40-1� �Fs/o STAR G.� ND s v - land Surveyors NO GROUND I // 71 00 939 Main Street ( Rte 6A) / DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 D CE > 7-0 > 7 I // 17-017 BORTO-WEYMOUTH.DWG a y • SEPTIC PROFILE ---� TEST HOLE LOGS T.O.F. AT EL t., (NOT TO SGIf)JT ACCESS COVER TO WITHIN C OF. FIN. GRADE t�^ r'-AccEss COVER (wATER1IGHT) TO ENGINEER: :-�. - •�- ,�- r �� .�" '' fu, L MINIMUM .75' OF COVER OVER PR PE REQUIRED OVER SYSTEM f -- WITHIN 6' OF FIN, GRADE ECAST 2% SLOPE, WITNESS ram' .; { -� ---"'.., - " IS 771 RUN PIPE LEVEL (D ) FOR FIRS 2 f E_G,_>< V t — .__ DATE: I PROPOSED It GALLON sePTlc - - P E RC. RATE - I f I , ', -• N -a M c TANK (H 1 ( ,= o �� P��CLASS •�'' SOILS if (_7G SLOPE) 6' CRUSHEC STONE OR MECHANICAL DEPTH OF FLOW' _ `{ COMPACTION. (15.221 [21) TEE SIZES: SLOPE) LX SLOPE) L - M�. - ,'(Z (70-+f� �r1 11 7'Tv � Cr V !0 1. C.• (r INLET DEPTH OUTI£T DEPTH <oi. Z•9 LOCATION MAP ASSESSORS MAP Z( PARCEL FOUNDATION— SEPTIC TANK _--- D' BOX ` --.— LEACHING -- FACILITY FLOOD ZONE A _41 - --- --- `" BUILDING ZONE '- -- SETBACKS: FRONT - i SIDE _ I �, -7 2 `r¢- REAR. — i 5 i PLAN REFERENCE: i i t j Izv IsI !o j,w ! S3 4— loll - + --- v �"f SZ,ZZ-�, +� U_---, 1 f `i• Z� pc. � ' . DATUM IS SEPTIC DESIGN: (GARBAGE DISPOSER IS tom .' ) 2. MUNICIPAL WATER IS a- -1>k• _-_- _ ;�,• 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. ©f � DES"N FLOW: BEDROOMS � = GPD GPD I Z, 4. DES �IGN , OADING FOR ALL, PRECAST UNITS TO BE AASHC-H � 'USE A 2 G P D DESIGN FLOW 5. PIPE JOINTS TO BE MADE WATERTIGHT. - 0� SEPTIC TANK: "'` GPD ( ) _ � GALLONS �T t, - 6. CONSTRUE;ION DETAILS TO BE IN ACCORDANCE WITH MASS. USE A -` = GALLON SEPTIC TANK ENVIRONMENTAL CODE TITLE V. LEACHING: _ %. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE -- USED FOR LOT LINE STAKING`, +2)-2" ^ :. __ 0-4 ) = I4 `-' GPD BOTT yM: S. PIPE FOR SEPTIC SYSTEM TO SCH. 4C-4° PVC. GPD i �'I,� x'? `�'�- _ 2 i 5�' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALELD WiTHOU? ` TOTAL: S.F. GPD !NSPECTIOt� SY BOARC OF HEALTH AND PERM'SSION OBTAINED FROM BOARD OF HEALTH. Le * eI,;{ , f1. Y^�k✓!/ 1'�x X' 3r"i t+IR(i't= IY", r. p o w f fo OeTe,* SITE AND SEWAGE PLAN OF ,7` � ``" k. (✓Y--t t� -�N �4�`r-.` .;.fit*, `•,..../ � ,,. -...._,_...�r' ',,,1� � _- � �,,r-�, .fit`/ `�L... (' " e.. y� / . " -� ..r^'.' " � � �f✓ y ' .L— '� '�� Yam__- ? }•-�,Jr p+� ! ' '�'n, � ` 1 LN THE TOWN' OF: �m BOARD OF FEF_A_LTf? MA PREPARED FOR: APPROVED DATE A-» / �0 0 ftc ?ice, 4 Feet .. � ✓ I SCALE: DATE, L down cape engineering, ine. CIVIL ENGINEEIRS /o� AIx>�� `� ' LAND SURVEYORS ,� 11 is a l� MtrL-x. `c.a � PHONE 508-362-454' �4r 4c'lc FAX 508-362-14880 --- ' � `" L Z i JQB 9 9 IT�alll St. y''aI'mouth, ma H. 4 ^ ' DATE