HomeMy WebLinkAbout0095 ANNABLE POINT ROAD - Health 95 Annabelle Point Road Me
Centerville
A=210-040
i
�I
No. 42101/3 ORA
ESSELT E
10%
9 0 0 0
:,
A
F
/T�J\
V
T
O
A
e IWa
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your I
cursor-do not Mike Hudson
use the return Name of Inspector
key.
Septic-wiz Environmental Services
vf,�Ai
Company Name
31 Midway Dr
Company Address
Centerville MA 02632
City/Town State Zip Code
508-367-5669 DEP SI#4254
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 andqrrt4intenance-of on.sile a
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 13-340
Title 5(310 CMR 15.000).The system: C73
V) f )
® Passes a;'_�' - '
❑ Conditionally Passes ❑ ,F:ai s
❑ Needs Further Evaluation by the Local Approving Authority ;? ;.
10/10/13 - £
Inspector
nspecto Sig-na)KrN 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.
d®/16/'�
t5ins•11110 Title 5 Official Inspection Fo I S rface Sewage Disposal System•Page 1 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM , 95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11/10 Title 6 Official Inspection Form: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
95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
N IB) System Conditionally Passes(cunt.):
�-
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
jj C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 95 Annabelle Point Rd
Property Address
Frank Kennedy .
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
page. Citylrown 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:
1
Yes No
0 ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool 1
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
mns•11M0 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owners.Name
information is required for every Centerville MA 02632 09/27/13
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.
E] ® 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.
Lf E) Large Systems: To be considered a large system the system must serve a facility with a
1 design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
page. Cityrrown State Zip Code Date of Inspection
C. C.hecklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
.Residential-Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owners Name
information is Centerville MA 02632 09/27/13
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
3 bedroom ranch
Number of.current.residents:
Does residence have a garbage grinder? ❑ Yes ®. No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundryinspected?
s stem
YEl Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2011 - 27 GPD
9 ( Y 9 (9Pd)) 2012- 60 GPD
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied for sale
..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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
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: Home owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
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:
16 years old via permit and as-built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 26"feet
Material of construction_
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
joints ok, vented thru the roof, no leaks
Septic Tank(locate on site plan):
Depth below grade: 10"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No
Dimensions: 5'8"Wx10'6"Lx5'8"H - 1500 gallon
Sludge depth:
4'8" (4"thick)
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
22"
Scum thickness
6"
Distance from top P of scum to to of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 19„
How were dimensions determined? LED Snake camera/probe, sludge
probe, tape measure and floodlight
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Recomment pumping 1X every 36 months, inlet and outlet PVC tees in good conditon, tank level and
sctructurally sound, liquid depth normal to outlet invert, no evidence of leaks in or out of septic tank.
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•11110 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
95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
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.):
I 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
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 level w/(4)outlets
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box level, recommend riser, liquid even with (4) outlet elevations, no solids or leaks.
I
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
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: (1)25'Lx18'W
❑ 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.):
Med sands, no sign of hydraulic failure, no ponding, damp soil or lush vegetation. 25'Lx18'W leach
field (4) pcv pipes in stone. Bottom of SAS 4.63' below grade.
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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
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.):
�I 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•11110 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
�M s 95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
page. Cityrrown 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope 3 ;
® Surface water I
® Check cellar \�
® Shallow wells
Estimated depth to high ground water: 132156"
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:
Reviewed permit and as-built
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Reviewed USGS topo and water resource maps
You must describe how you established the high ground water elevation:
Bottom SAS 4.63' below grade. Perc test 8/20/96 by Bennett&O'Reilly indicates no groundwater
encountered at 156" below grade. SAS not to be found In ground water seperation violation ----,--.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 95 Annabelle Point Rd
Property Address
Frank Kennedy
Owner Owner's Name
information is required for every Centerville MA 02632 09/27/13
page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Driveway
95 Annabelle Point Rd
Centerville, MA 02632
A B
1500 gallon 2
septic tank
i O O
D-Box T-�
Al - 52' B1 - 30' — - - - - � - - - - - - . � - - - -- -
i 3
A2 - 57' B2 - 25' !
A3 - 61' B3 - 30'
2 Stone Leach Field
18'Wx25'L
i
TOWN OF BARNSTABLE q
LOCATION gS ►a�,.�w�>L�-�c. �y`~'�' a"), SEWAGE # / 7-
VILLAGE Cal, 'A1042, _ASSESSOR'S MAP & LOT o118- Q Vb
INSTALLER'S NAME&PHONE NO. sub
SEPTIC TANK CAPACITY 1 SVp (rl.
LEACHING FACILITY: (type) S�"-� Fc.�l� (size)
N0.OF BEDROOMS 3
BUILDER OR OWNER 0400�- Norsk C a /<,tn
PERMITDATE: - J 0 -y`�' COMPLIANCE DATE: .' "y
Separatiorr Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 5�< D�``� ' Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) St% R&A Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Sc a�a t^- Feet
Furnished by it O'/Ze: I I•�, �,��- �.�;��uc'►�
T°fi b ,�
all
-9 oi'b " t h 13 Est+
0 .sZ G'tw
os.7 0-1 Ll
,moo
Vo
No. /— Fee VOO
s'[ THE COMMONWEALTH OF mASSACHUSETTS Entered in computer: t'
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[pphratiou for Oisspoear 6petem Conotruction Permit
Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. RS bra- 11. VOU44 Owner's Name,Address and Tel.No.
dAP v Qte -vs.
Assessor'sMap/Parcel 41eN..Qe•�C Vkc-
y'4N4 P., a o�". C v��swillt �h
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
VUGAt&ft34' C.&%•4. 8+.,.... �it o'tLt.\�y�t,.4..
S.t�. T3ox.SS"1- $A %w—.X..a'p—*.s 0.N.
t'.1_0- o z c 3 ww•. 0 3%
'!ape of Building:
Dwelling No.of Bedrooms —3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Sa\off. . N` ter} L. L.
CAA j:FA11f- - CjX
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date 1 f—� 2
Application Disapproved for the following reasons
Permit No. Date Issued 9�,
/ Pit V
No. '" J eY(� .., Fee U 0
e - ,
' THE COMMONWEALTH OF M�SSACHUSETTS Entered in computer:
i f Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS
11pprication for Misspogaf *pgtem Congtruction Permit
Application form Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. q S Owner's Name,Address and Tel.No.
Assessor's Map/Parcel P 1 �30.`� 1 t f��_�� E c
0. E +; k 1 1C P C �`, f::✓�Ile
Installer's Name,Address,and Tel.No. 5-0 s 8 ti Designer's Name,Address and Tel.No.
''�Vor4l-.c..yl• Co..S�-.
U.
pe of Building:
4,4 Dwelling No.of Bedroom_— Lot Size sq.ft. Garbage Grinder,( )
Other Type of Building No.of Persons Showers( ) Ca feteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets . Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
t
S
Nature of Repairs or Alterations(Answer when applicable) 14o,,NF
Q
Date last inspected: ' L'
w
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
tee.
Signed v'— 1--- Date /'�1�r '`f
Application Approved by r t Date.Q? - —
Application Disapproved for the following reasons v
Permit No. ` �— Date Issued 92
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BAR-NSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired Upgraded( )
Abandoned( )by
at I . a i— U has been constructed in accordance
J with the provisions of Title 5 and the for Disposal System Constructi n Permit No.�� �dated 7 7 .
Installer Designer )
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date ��. , ! Inspector.
—— —— —�;———————————————— ——————————— ——
No. 7'— ll Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migponl &pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair(X)-U grade( )Abandon( )
System located at lie ��,/�.P I //2r 4,14,E y/ILIZ
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years
7 of the date of this permit.
ar
Date: 1 Approved by � f \
1
-BENNETT' X O'REILLY, Inc.
Engineering&Environmental Services
MATTHEW T.FARRELL,EIT
Civil Engineer
84 Underpass Road,P.O.Box 1667,Brewster,MA 0263j
(508)896-6630 Fax(508)896-4687
� � q����
1 A
TOWN OF BARNSTABLE
` 3 THE r o` DATE
OFFICE of FEE
S EP ;
TAnt jy` BOARD OF HEALTH RECEIVED BY
XAXL
i7 MAIN STREET
,. 140'IA NYPNNIS, MASS. 02605
S
d F.R 7,ANC'E REQUII d T FGR
ALL VARIANCES MUST PE SUBMITTED FIFTZRN (151 t),'r'IS_ PRIOR TO
THE SCHEDULED BOARD OF HEALTH MEETING
NAME OF APPLICANT Florence Subacs TEL. NO. --
ADDRESS OF APPLICANT__g_9 gnnahPl 1 P Pni nt _Raad,,_.,CentPrvi 1 1 P
NAME OF OWNER OF PROPERTY_ Same
SUBDIVISION NAME Opeechee Heights DATE -APPROVED 3-5-56
ASSESSORS MAP AND PARCEL NUMBER KAP Z C) A-0
LOCATION OF REQUEST 95 Annabelle Point Road, Centerville
-SIZE OF LOT 13 ,900 SQ.FT WETLANDS WITHIN 200 FT.YES x
NO
VARIANCE FROM RE .=ULATION List Regulation)
Well setback: Existing well not 150, feet from proposed
SAS
REASON FOR VARIANCE(May attach if more. spr.^e is needed)
Prnt:jerty is rurrPntl v nerved by r)rivate WP11 . ( Rxi sti ng
90 ' ± from cesspools ) . It is proposed to increase setback
to 103 ' ; the existing well is upgradient from SAS and town water*
PLAN - FOUR COPIP.S C.- PLAN MUST BE SUBMITTED CLEARLY
OUTLINING VARIANCE REQU'-ST.
VARIANCE APPROVED
NOT APPROVED _
REASON FOR DISAPPROVAL
BRIAN R. OlRADY, R.S. t CHAIRMAN
* is financially unfeasible .
SUSAN G. RASR, R.S.
JOSEPH C. SNOW, M.D.
BOARD OF RRA,LTH
TOWN OF BARNSTABLE
a
t(
BENNETT A O' REILLY Inc.
Engineering, Environmental & Surveying Services 84 Underpass Road
Sanitary 21E/Site Remediation Property Line P.O. Box 1667
Site Development Hydrogeologic Survey Subdivision Brewster, MA 02631
Waste Water Treatment Water Quality Monitoring Land Court 508-896-6630
Water Supply Consulting Trial Court Witness 508-896-4687 Fax
B096-1280
September 16, 1996
To: Abutters
RE: Map 210, Parcel 41
95 Annabelle Point Road, Centerville
Ms. Florence Subacs has requested the Board of Health grant the following variance for a
proposed upgrade from existing cesspools to a Title 5 sewage system at the above referenced
property.
The requested variance is as follows:
1). WELL SETBACK: Existing well serving locus property is not 150 feet from
proposed Soil Absorption System. (47 variance requested).
The meeting has been'sched—uledland will be held at the Barnstable Town Offices on October 1,
199 at 7:40 pm. If you have any questions or comments, please feel free to attend the public
hearing.
Very truly yours,
BENNETT & O'REILLY, INC.
cc: Ms. Florence Subacs & Barnstable Board of Health
TOWN OF BARNSTABLE g �j
LOCATION 'C�5; !�dti�.Ia @. t�� a A- SEWAGE #
. VILLAGE Ca-" ��, ASSESSOR'S MAP & LOT Q c
INSTALLER'S NAME&PHONE NO. a�m -s �o -s - SSUB-(ac\(1
SEPTIC TANK CAPACITY 1 SUC7 6-L o
LEACHING FACILITY: (type) N�,.'ilek (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: - J 0,�`� COMPLIANCE DATE: d�"I�"C'I�
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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) St Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) S4 e ink P Feet
Furnished by f3 G nh e� �' O /l e: r•�, ���a �""�;�'^ ►``�
b
I n I
a
I
.s
September 23, 1996
Mr. Thomas McKean
Town Of Barnstable
Board of Health
Post Office Box 534
Hyannis,MA 06201
RE: Septic System variance for 95 Annabelle Point Road,Centerville
Dear Mr. McKean,
We are writing to request attendance to the next evening Board of Health meeting,
planned we understand for Wednesday October 3, 1996, in which the Town will
consider granting a set-back variance for the required Title V septic installation at the
above listed address.
We are the owners of the property,having closed in August, and have an interest in
the system, its impact on the property and potential conflicts with the abutting
properties. Funds for the improvement are presently held in escrow with our
attorney,and we are anticipating the work to commence with either vote.
If the Town denies the variance,the new septic system will be installed in the
location of the existing cesspool,a hookup will be made with the Town Water
Department. All properties in the area are presently on n water.
Thank you for your attention to this matter. Please call 08) 935-1630 the date of
the meeting is rescheduled
Sincerely,
Frank M. Kennedy P.O.A for
Raymond J. Kennedy
95 Annabelle Point Road
Centerville,MA
DEEP OBSERVATION HOLE LOG SYSTEM DESIGN CALCULATIONS GENERAL NOTES LEGEND �' L
Test Hole Depth From Soil Horizon Soil Texture Soil Color Soil Mottling Other A) Neither driveway nor parking areas are allowed _ 3; <
Existing Contour
Number Surface(inches) (USDA) (munselI (Structure,
over septic system unless H 20 components are used. 32 .y0
Stones,consis- SYSTEM DESIGN CALCULATIONS ,� ---T Proposed contour i KMr. p
tency,°',,Gravel I B) The designer will not be responsible for the system 24x5 Existing Spot Grade
_ A _,"" as designed unless constructed as shown_An changes n
Ii :L= O- I A Lt4mY �4�1u )Oye ��1 I p F� � I I G Y g Proposed Spot Grade ( �
'�G --...... ... ........ . _. . . 11 ) Basis Of Design shall be approved In writing. J J, °
Z r, G C)Contractor shall he responsible for verifying the ohu-- Wvae 8heode Utility Line(s)
s)
R Number of Bedrooms
.... .... .
-. 3 ... ... ._.... V.- - .', ��rtY SQ,.I. �oyl2 /c. o /R,4vEt_. — y (
Other' location of all underground and overhead utilities — u Underground Utility Lines) ��' f-- ALLlAA"tL_5 Fir,
�Z ( C ���� ! I°��� ` " 6Cdti/EL �? w/ 2.)Design Daily Sewage Flow ?jam G p D.
prior to commencement of work. g -- Gas s Line
a r Location ?FQT to tLD•
_.. ._ . .. .. .. . . . . . .. .. .. .. . .. .. .. . . ...... .. t6 PIA
TH Test Hole and/or Boring Loc t 0
1 3.)Septic Tank Capacity Required: Gal.
... .. .. .. .... ... . .... ... . . . .. . ........ S.T. Septic Tank
... . ... . .. ..
fProvided7 1. .. Gal.
i
D.B. Distribution Box
�._... .. . .. ...... . . . ... . .._. . . . . ; _. ._ ... .. . _ . . .. 4)Soil Absorption System Capacity S.AS 9cil Absorption System
Required. l,�'� GPD (44� ✓ Res Reserved for System KEY MAP no scale
Provided . / r , -
•a- P ovded � '���� CPU.. �•-� o Utility Pole
I ZS k I� 'LFAC►•�1 , zE�l if}{ __sti( d�L,4 t ® Catch Bann Plan Book Page
16; .� Fire Hydrant need Book �7 �� Page
VT
K lam} x . r� ,�>l.h ►� ' � ���
L L Well
).) A Garbage Disposal is tk'r permitted w/this design, �,, Assessors Map Parcel
Date of TeSt Q.Zo -�� Use Soil Class . ' Witt) o
Percolation Rate L ti Mtn/i►3W i►1 pert. rate of less than �
\ I
Min./in. for o loading rate of
/4 .GPD /s t � \�`�'• -
Witnessed by 0'Kt 1ir1.Y f L(CY
Nay
FLOW PROF 1 L E WQTFR t t►J �`
Top of Foundation
6L
Elevation= <,.'p,4+ •
F nish Grade __ 9':`'.t Finish Grade : '44 F�_ ��p.c� r 'TOf o{ f1AjLIl�p '� .t, T°•� `�
- --— J4
36"max. I '
3
9"min. 36" max. I MAX 1
��- 47`
�. L4Y� OF
flow line ; ya` Tb
' 10„min 14" ri l - —' __ _ - ,/4" 1') ! /z �� L,•� - - \
r
gas baffle
1.5od ti
. Go I. Se c Tank Distribution BoxcACY IEU, __.._>L ' �__ _' ! ~\ YQ �vv
- - 1
l2656,M Ci,:6oaPobtf' �1 ' �I / d = I �oi� k;r-
600
0 Zip"
CONSTRUCTION NOTES
L) All construction shall conform to the State 10.) Base aggregate for leaching facility shall i�0� Ex(�'TI►.lG GE�iPoGt_� �L} Tv RE1dVkt� ,f( L; • Nt t '
Environmental Code Title 5 and the requirements of 1 ';y �J'
q consist of 3/4 to 1 1/2" double washed stone tree `� Mi �01r)
the local Board of Health. of iron, fines and dust and sholl be installed from w(� CCWT'AKWATFU ��011. A".) PC f4i*i .�Lf✓ vV .).Qi.. t ` 0 - ram AQ
below the crown of th,, distribution line ;n the bottom �� +� 24)MPnc..{ E.(J lam' MIki, � yXR.�z:M�1.tT, t
2.) Septic tonk(s),greose trop(s),dosing chamber(s), �
and distribution box(es) shall be set on a level stable of the soil absorption system Base aggregate shall -
base which has been mechanically compacted, or on a be covered with a 2" layer of !/8" to 1/2"double A16
9�
6 Inch crushed stone base.
washed stone free of iron, fines and dust. LAQ__
3.) Septic tanks) shall meet ASTM standard G !, ) Vent soil absorption system when distnbution
1127-93 and shall have at least three 20"diameter lines exceed 50 feet, whey, located either in whole I "s '30'
or in part under driveways, parkin turnip areas
manholes. The minimum depth from the bottom of y g, 9 ,
or other impervious material, ar when dosed. v Tke� kcA I5 ern p5y -row" teA4 nE C
septic tank to the flow line shall be 48��.
4.) Schedule 40 PVC inlet and outlet tees shad
!2 )Soil absorption system steal', be covered with o CIO WtaZ_-i WIT(-k!!.j 11;6. or PW0A'W_A �i•A•S.�
extend a minimum of 6"above the flow line of the minimum of 9"of clean medium sand (excluding
septic tank and shall be installed on the centerline
topsoil ) * EY15T tigjEU_ FOtZ LZ-CL1--, Fsz6'Ee_TV 14,
of the tank directly under the cleanout manholes. ;3 ) Finish grade shall be o maximum of 36" over the
'Zara
5.) Raise covers of the septic tank and distribution top of oIJ system components, including the septic tank, F/ PcX5-1_15)
box with pre-cast concrete water tight risers over
distribution box,dosing chamber and soil absorption
mum cover
inlet and outlet tees to within 6"of finish grade. system Septic tonks shall have a mini ,
of 9 `� PROJECT ► �/ t c-,{ `t _fit _ ,�i �j
6.) Piping shall consist of 4" schedule 40 PVC or .z,< < _. V< ._U j�� Q 1,,� ! &�IEAiS �F�`JI i�� l 1� /6UrlA -�
equivalent. Pipe shall be laid on o minimum 14 ) From the dote of installation of file soil
t`
aborption system until receipt of a Certificate of i_G��� �,�'•'� .. ;.�1 �, _ ^iL ,�►�1�,( f't i� I (►(T F( CF114iVJZviU
continuous grade of not less than 1 0/0.
Compliance, the perimeter of the soil absorption Tu ( '' � . TITLE
7.) Distribution lines for sail absorption system system shall be staked and flagged to prevent the SEWAGE DISPOSAL SYSTEM
(as req'd) shall be 4" diameter schedule 40 FV use of such area for ail activities which might ,':�K L!r
laid of 0.005 ft /ft. Line shall be capped at �� �� Itt' '• v1:"6
damage the system /��/'` �f:- M ��
and or ds noted. ALSION
15.) The Board of Health shall require inspection of R t
v 8A Outlet pipes from D-box shall remain level forat H�' ''�` ,:` , BEN NETT_A 0 REILLY, Inc.
all construction by on ogentot the Board of Healih f�MS 3?NPJM. G�•
least 2 feet before pitching to soil absorption system. (or the designer if this system requires a vat once) and - RLsLLYEngineering & n ironmental ervice C
E S
_ ..r & t `��r
Water test D-box to assure even distribution. 1 *% Ct3 W
may require such person to certify in writing that all kr� i N0.36270 G
9.) D-box shall have a minimum sump of 6"measured work has been completed in accordance with the terms 4 + tt� Underpa« Rord
of the permit and approved r
7 below the outlet invert. pp oved plans 48 hours advance �rS �6�?� P.O. Box 1667
Q notice requested rOtMA►E 508-896-6630 Office Brrwater, MA 02631 46S, fix
s
3 � DATE SCALE BY CHECK JOB NUMBER.
r
Rfa ,n 17o