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Home My WebLink About0202 ANNABLE POINT ROAD - Health 202 ANNA.BELLE POINT RD. CENTERVILLE A = 211012 ti r i �. i7.11ll � UPC 12534 A No.21_OR �' HASTINGB.tlN d � a FEE CO�00NWEALTII OF MASSACHUSETTS board of Health, BAR" 5T91 B LE , MA. •-�� APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(V) Abandon( - Od Complete System ❑Individual Components ' Location 202 AWVJA51t L1,Z ?01V4 r KV Owner's Name IlAkM 4AeSW Map/Parcel# .O Address Lot# Telephone# Installer's Name Designer's Name CR VyptL L?r"ID 1A Yl14 Address o20 �- Address 3o6 OLID Mom-* Rp 1 Telephone# Telephone# Type of Building * Lot Size 2 IWO sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder (h)o Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) 130 gpd Calculated design flow Design flow provided gpd Plan: Date S• 2 3 Q 0 Number of sheets Revision Date Title 9LPJ 1.S ,,yPQ. PaQ EQ K�57k0 R �O -A&nA IdIX) ,1 IV49 Description of Soil(s) � BS U Rol 'C ?0Sff L 6G!� 9T-RYV1 Soil Evaluator Form No. Name of Soil Evaluator A. �- N%�.��Date of Evaluation 50 . 00 DESIGNING ENGINEER MUST SUPERVISE DESCRIPTION OF REPAIRS OR ALTERATIONS INSTALLATION AND CERTIEy IN WRIT:N- G- E SYSTEM WAS INSTALLED IN STRICT nnr•GA The undersigned a ees to ins a abo escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees t to pla to operation until a Certificate of Compliance has been issued by the Board of Health. Si ed D In c ns • t N f. t__ FE ' Board of Health; 1J�r,A L rMA. � x ' r r1✓ APPLICATION FOP DISC A��YS1 NSTRUCTION PERMIT-, /v+ 4 N Application for a Permit to Construct( ) Repair( ) Upgrafle,(%� Al a#nO _ U/Complete System ❑Individual Components Location Qtwi__, AN3e L),V-- PO) �� Ow e'shame Map/Parcel# _ Address r Lot# P -Telephone# Installer's Name y �''( #f Designer's Name CP) ;h L L✓V)►_S® UR VM5 Address ^_rr ? ` Address` O6 OLt) PL MoVf4i RD #4 Telephone# _ " L+ 'elephone# f.,�� Type pf Building Lot Size sq.ft. D,A11'in 3 NOAf Bedroi ins A f GarbagA�ri 1 ( 4jo Other-Type of Buildin �No. ,f f YP g� % `' �bl p�rsbns Showers ( ),Cafeteria ( ) Other Fixtures U Design Flow (min.requ�ed) gpd Calc lated des4iifi Design flow provided gpd Plan: Date C;, 3' ' !� Number of sheets ,.4 ; &vision Pace s Title 1 r Description of Soil(s) q tip Soil E a at�or Form No. Name of Soil Eval r e of Evaluation 0 O DESCRIPTION OF REPAIRS OR ALTERATIONS '' The un& signed a` ees to instoll3he abov escribed Individual Sewage,Disposal System in accordance with the provisions of TITLE 5 and further agrees t to pla s to operation until a Certificate of Compliance has been issued b the Board of Health. Si ned Data K�V-QQ bee xv Insp c` ns No COMMONWEALTH OF MASSAC14USETTS FEE Board of Health, CERTIFICATE OF COMPLIANCE Ito t%_ Description of Work: ❑Individual Component(s) ❑Complete System x The undersigrwd hereby certify that the Sewage Disposal System; Constructed ( ),Repaired �Upgraded ( ),Abandoned ( ) by: at G f I has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) an the approved design plans/as-built plans relating to application NoO dated Approved Design Flow I: (gpd) Installer Designer: Inspector: �. `' , The issuance of this permit shall not be construed as a guarantee that the syste�will function as designed. No. FEE COMMONWEALTH OF MASSAC , ENGINEER MAST SUPERVISE 7I,E S STEM WAS INSTAN AND LLED IN WRITING Board of Health, AC�ar.��p AILED IN STRICT_ ANCE TO PLAN. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(1/<Upgrade( ) Abandon(,Y,,).ariindividual sewage disposal system at as described in the application for Disposal System Construction Permit No. T lam/ Provided: Construction shall be completed wit 'n tlyree years of the date of t p rmit. All local condi ' n must be met. ` Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health c f A t TOWN OF BARNSTABLE �' C'" LOCATION Q�Z k�� - A` /gg40 SEWAGE # �d " VILLAGE C-6&76A r.1-46 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 131I// 4Yar7L4 E SEPTIC TANK CAPACITY /500 LEACHING FACILITY: (type) 4- 0Xff6VA5 (size)X 3ZX 6, !i NO.OF BEDROOMS BUILDER OR OWNE C� PERMITDATE: Od 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 wetlands exist within 300 feet of leaching facility) Feet Furnished by -{l0 br--9liaR5 4`STaver e - Sewer Information 5/17/00 s0#'su(a < 211icr 012 �SiT1$SSz .... «< dClf@33€ ANNARELLEpoiNT CENTERVILLE Et s;;,`0i James M.Ford ......:.:...�..::...... «<trtisp f d tlk ' S/2/00 .......... _...-_. ........................ ........................ ........................ =`Cp.m..men# ........................ Pe tri a 01 # f MijSr SUPERVISE DETAAT ENGINEER , INSTALLATION AND CERTIFY N lITINC THE SYSTEM WAS INSTALLED IN STRICT ACCORDANCE TO PS r 10/16/2000 07:33 5083627606 R.P. MICHNIEWIC_ PAGE 01 October 14. .1000 Roger P. A ichnle,viez, P. E P. (). 13rtx ,t07 East Sandwich, AI.A 02537 Town of Barnsthble Board of Health 367 Main.Street Hyannis, MA 01601 Attn: Donna Moran di RE:Septic.S vstiOn Repair 202 Annah�lle Point Raid Barnstable,AAA I have inspected theseptic system repair work at the above referenced site as recently performed hi,Ayirtte Construction, and certify the work to be performed in compliance with the design plans. last revised.Septe►nber M8, 2000 Respectfully cubmitte , �,, ja 4/ •q�� ROGER PAUL / iCHN1EWICZ M a' v No.30420 l f CIVIL er P Michnitnvicz, E. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 202 Annabelle Point RD Property Address NOI P.,a Bakalars Owner Owner's Namex information is �7 required for centerville MA 02632 5-22-17 8 every page. Cityrrown State Zip Code Date of Inspection 00 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When f5 # 42390 filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 rein Cityrrown State Zip Code 508-420-4534 S14297 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 5-22-17 spe o gnature 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. US t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,••� 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: At time of inspection system met all minimum passing requirements. Property has been mostly seasonal. The septic tank is located in the front yard under a large juniper bush ( I recommend removing the bush for easier access and root intrusion. At time of inspection there were alot of fibrous roots in the flow diffusers that we removed.( something to keep an eye on in the future.) have seen this several times with flow diffusers) 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 Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. Cityrrown 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 than Y2 day flow t5ins•3113 Tide 5 Official Inspection Form: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 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. City(rown 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. [Phis 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- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•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 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ❑ ® Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ❑ ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3per plan Number of bedrooms(actual): 2Per plan DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: According to design plan system consists of a 1500 gallon septic tank d box and a 3 bedroom s.a.s Number of current residents: 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 Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: System not designed for disposal. water readings were not available at time I typed this report. Sump pump? ❑ Yes ❑ No Last date of occupancy: seasonal 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts AM. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 202 Annabelle Point RD Property Address Bakalars Owner Owners Name information is required for centerville MA 02632 5-22-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: seasonal 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 10-13-2000 per permit Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: . .5 ft 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: 1500 Sludge depth: light to moderate t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every 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 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 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 in the front yard under a large juniper bush. I recommend pumping at time of transfer and every 2-3 yrs there after for maintenance. I also recommend removing the juniper bush for access and to lessen root intrusion. 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'a 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. Citylrown 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 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): box was level with no signs of failure or leakage. there were no roots in the d-box. 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.): *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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number:-' ® leaching chambers number: 4 flowdiffusers ❑ 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.): flow diffusers were working properly at time of inspection there was some root intrusion that I have seen before in flow diffusers but we were able to remove them from the diffuser that we opened. I ran water into the diffuser and could hear it flowing and dropping into the soils in the bottom. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for Centerville MA 02632 5-22-17 every page. CityrFown 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-3113 rifle 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 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,.•''r 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every page. Cityrrown 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: 5 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: 5-22-17 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: l design plan �i�'Fn �itn�Gdr ��9��r'�A 'f �` � Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 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 202 Annabelle Point RD Property Address Bakalars Owner Owner's Name information is required for centerville MA 02632 5-22-17 every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION _ a 0�Z P21H't 1QW SEWAGE # 60 VILLAGE ASSESSOR'S MAP & LOT- — INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 7 (} (/i!Jles (size) fl x g�Zx 6 it NO.•OF BEDROOMS_ BUILDER OR OVINE 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 wetlands exist within 300 feet of leaching facility) Feet Furnished by ............ 21 f�< , ...... 7 , S ' w : j / \ ° A p 211------------ " 12 :# 202 - AP 2�1T Al Ap � 43 # 7rt 39° r � _ - h:\BARN\BASEMAP.dgn Aug. 31,, 2000 14:19:13 MAP 211 SCALE V-60' TOWN OF BARNSTABLE f - t LOCATION ;Zoo z P01H' ZQW SEWAGE # VILLAGE ASSESSOR'S MAP & LOT (� INSTALLER'S NAME&PHONE NO. i�.. i I SEPTIC TANK CAPACITY �SaO LEACHING FACILITY: (type) _7 R(?aAi�vt9- size 1 3a./X C NO:-OF BEDROOMS BUILDER OR OVINE PERMITDATE: 106 COMPLIANCE DATE: 10 Separation Distance Between the: I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1 `7C 9t I 203' 498 925 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for`Intemaf nal Mail Se reverse Sent St et&Number Po ce, ZIP Coder r ostage t P Is Certified Fee Special Delivery Fee Restricted Delivery Fee Ln Return Receipt Showing to Whom&Date Delivered a Rehm Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ co) Postmark or Date LL rn a Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). t 1.If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the d return address of the article,date,detach,and retain the receipt,and mail the article. CIC uO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article n RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the 0 ; addressee,endorse RESTRICTED DELIVERY on the front of the article. 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. 6. Save this receipt and present it if you make an inquiry. 102595-97-t3-0145 d Town of Barnstable t� Regulatory Services °�`T"E tO'yti Thomas F. Geiler, Director t • Public Health Division = BAMSTABLF, �cbA ' �,� Thomas McKean, Director 'FD"APB a 367 Main Street, Hyannis, MA 02601 . Office: 508-862-464 Fax: August 21, 2000 Mr. Harold Larson 202 Annabelle Point Road Centerville, MA 02632 Dear Mr. Larson: Your disposal works construction permit#2000-353 for replacement of a septic system at 202 Annabelle Point Road, Centerville, is hereby revoked. The engineered plan does not show the highest adjusted groundwater table elevation as required in accordance with Title 5, the State Environmental Code. On August 1, 2000, I telephoned the designing engineer Roger Michniewicz and the land surveyor Paul Ryll. Mr. Ryll informed me that he will revise the plans. However, no revised plans were received as of this date. I also informed the installer, Brian Ayotte, of the request for revised plans on August 1, 2000. The disposal works construction permit #2000-353, for 202 Annabelle Point Road is hereby revoked. You may request a hearing if written petition requesting same is received by the Board of Health within seven days. Once the revised plans meeting Title 5 are submitted to the Health Division Office, we will be le to issue you a new disposal works construction permit. Sincerely yours, Thomas A. McKean Director of Public Health cc: Roger Michiewicz Paul Ryll Brian Ayotte larson/wp/g/11s McKean.Thomas To: Miorandi Donna Subject: RE: Lake Wequaquet/High Groundwater Elevation As of this date, a revised plan was not received. Therefore, Brian Ayotte was again notified by telephone NOT to begin construction of the system at this site. From: McKean Thomas To: Miorandi Donna; Harrington Glen; Barry Ed; Dunning Jerry Cc: Saad Dale Subject: Lake Wequaquet/High Groundwater Elevation Date: Tuesday, August 01, 2000 4:17PM REMINDER Please ensure that elevation 34.8 is shown as the adjusted high groundwater table elevation on plans for proposed soil absorption systems at properties adjacent to Lake Wequaquet. I am presently in the process of attempting to reach the engineer to correct a plan recently accepted by this office. In the meantime, disposal works construction permit#2000-353 is on hold until the plan is revised. Page 1 ..�� -- - -- _ - 1 i I S GENERAL NO TE. YoP o� �ouivlc� ►so`r' � t+�9ouTL�-r LE SOIL TEST PIT DATA _ 'J`L. 4`t w A rC T.P. -1 T.P. -2 1. THIS PLAN IS FOR THE DESIGN AND INVERT ELEVATIONS* ? CONSTRUCTION OF THE SEWAGE DISPOLSAL � GRND. ELEV. �•� GRND. ELEK FACILITY ONLY. INVERT AT BUILDING .. •R: 6.W. ELEY, G.W. ELEV. 2. ALL CONSTRUCTION METHODS MATERIALS AND INVERT IN AT SEPTIC TANK ��• MAINTENANCE FOR THE SEP710 SYSTEM SHALL INVERT OUT AT SEPTIC TANK `10• � Z=-O'O ACCESS COVERS MUST BE hr7,HIN 6 ' OF FINISH GRADE. CONFORM TO MASS. D.E.0.E. TITLE 5 AND LOCAL F l u I G RA' V- INDICA TES BOARD OF HEAL TH REGULA TIONS, INYERT IN A T DIST. BOX �' ' p*, O v F� S A- 9 � INVERT OUT.AT DIST. BOX 0•t} , i_ PEAC. TEST 3. ALL SEPTIC SYSTEM COMPONENTS SUBJECT TO - !'�• + VEHICLE LOADING (I.E. UNDER DRIVEWAYS, ETC.) INVERT IN AT S.A.S, 40.30.�_ '4` ( "MIN. 2" OF _ 1 ° N� � 1/3 -1/2 DIA. j SHALL BE DESIGNED TO WITHSTAND H-20 LOADING, BOTTOM OF_S,�4,S, Q. ._ 4 MIN. a 1 �ja h'ASHED STONE INDICA TES 4. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR OBSERVED GROUNDMATE4 3 -0 Q SSA o LIO✓IO 1064 " OBSERVED S�, APPROVED EQUAL. ,-r�0 - '17. 00) 10 ti DEPTH DIST GROUNDWA TER �Ld AD✓USTED GROUNDNA TER ._, 80X u; W W i 314 -1 1/2 DIA. p � �00 GAL. p MASHED STONE 5. BEFORE STARTING CONSTRUCTION CALL DIG SAFE `�''�' 0 0 - 1-800-322-4844 FOR L OCA TION.OF SEPTIC TANK 3 G�,�G INDICA TES UNDERGROUND UTILITIES. �}-1� TEST PIT SEPTIC TAW 6 D-BOX TO BE SET ON A' NoI( � -10 \ 6 BED OF C0W.ACTED CRUSHED STONE.' � 6. DATUM IS �J 6Y = OY MOTOR TO WATER TEST D-Bl1X TO " BS-r trL oDWV)r-u55o PROP. S.A.S, 7. NO DETERMINA TION HAS BEEN MADE AS TO COWL LANCE �- ' R'� t�"� - - ..}. ._ 5A Wt �)t„1„ TO C 2.F%,A"T�. 11�CH 5 WITH DEED RESTRICTIONS OR ZONING REGULATIONS. - --- - (A TL&Cfev__) - IT SHALL REMAIN THE OWNER'S RESPONSIBILITY TO ti4RIGG Briggs Engineering & Testing t�� .C..T1v *mv,-'}•� "� —" -- z RATE- � • 17. 0e� _ OBTAIN ALL REOUIRED PERMITS, SPECIAL PERMITS, G ,t�� s c� .'�� >s�cialos,Inc V -� VARIANCES, ETC. FOR THIS PROJECT. _—.--.,r..� �_^,.."''`'� C p►-o - !� �.� 5 U B. IT SHALL REMAIN THE OWNER'S RESPONSIBILITY Pro'ect: Annebelle Road - Barn st -ble 1 TEST BY.� N�• 't��,� .5 _, Sn1L OVAL { TO HA VE THE PROPOSED DWELLING FOUNDATION Sample p to n o. , 100 .1) WITNESSED BY. O u�A 1� R A Dom, a G � DESIGNED TO ACCOUNT FOR THE EXISTING GRADE M-6 1 0 5 Date:5 3 1 AND SOIL CONDITIONS AT THE LOCATION OF THE Title N' Particle Size Anal}si � �` . PERC. RATE e— � MIN./ IN. PROPOSED DWELLING. L.;) 13 ANAt.1TS15 — �o1L 1 S cL�S9 Z Depth from Surface Soil Horizon Soil Texture Soil color t°o ' DESIG/'J CRITERIA.' ^� (Inches) (USDA) (Mun:ell) yp 15 0.71-�< DE516N FL OW- so _ BEDROOM XELL ING �. 110 GALIDA Y PER BEV,7009 wfi .fJq)vD 4*r' 3 ,I0 k 301 �o EQUALS ?JtoD GALS PER DAY. W• � . - :� — _�. . _ 1.�0 Cz fL��c 6�. faF.1►-ice f 64) — _ - _ SEPTIC TANK RED!/InED. �D l �il! Jn�TeaiL R :y _ _ 3�0 GrO�C I y ,j rPD Xt0a; - (i6O GAL. SEPTIC TANK PA}MJVI[IED.- _ 1500 GAL. l f �a SIZE Gr LEACHI.�t'G f ACILI TY REOUIRED . DES16N PEAC. RA TE 5 MINUTES/INCH I° 6ALLONS PER DAY _ +- -- 5 f •5 SIZE OF LEACHING FACILITY P VIDED.• ° Y- - ou a�'xs FLOIib »u 55 009 5!LT SAND GRAVEL r /1 R�✓D d�� _.. .. j SIDEWALL S.F. X� _37 Fw- GPD _.�.__ I�,oa( n.ul °TI 1^ ro 100 BOTTOM S.F. X O• -• •GPD TOTALS S.F. GPD P <✓ :f , lnti`` SIEVE n M A"` hE; illustrated graph re resents the sand 'raction only as y' ICNtirc.ti a E F� Y l N"' defined by . .P• Pcllcv# 6RP/UWM/PeP-Pi�0-1 , Appendix 2. C►viI O/ G 13 DATE PR ESSIONAL REIN .: IL DA TE PROFS SION ND RV R flx)�71-� �P�tN 'IS�Pq�' a REMOVE,UNSU(TABI,F,SOIL BFNF.ATH AND IN A S Fr.\57DF.7. F p PAUL y I`r �+` AROUND THE PROPOSED S.A.S.DOWN TO THE CI STRATA,AND C(�S�QOdL S�CiLL �%.F+ Q R. N '� •� REPLACE WITH CLEAN SAND PER TITLES � „ �+� .t t ' s 1�U1 ' D Gl.3GAcu -' RYLL `"+ �� % j - B.M.. TOP OF FO NDAT ON BprG�G�LL � W I<'r tAk_�V No.12149 E V 4 • --- D o a' --- . r ,' �D IT m° CIO 0 ;I 250 0 7 it,-r 2g Nx 0 . PLAN SHOWING A PROPOSED REPAIR TO AN pa' o EXISTING SUBSURFACE SEPTIC DISPOSAL SYSTEM � z �`` LOT 1 ANNABELLE POINT ROAD,* BA •9� -o ,�o u �� Q �, �- RNSTABLE, MA 0 SCALE 1 ' = 40 ' MAY 23, 2000 t)ESIGNING ENGINEER MUST S �, v Vtl'Lhl�I.3�p '.. D.i Q V a � INSTALLATION AND CERTIFY IN E,;;1T as-, CANAL LAND SURVEYING THE SYSTEM WAS INSTALLED IN STRF T� 16o f s.F. 306 OLD PL YMOUTH ROAD SAGAJ�90RE BEACH ADRDANCE TO PLAN. 133. 0 LE_ GF�NI) ' -1;4 , ---40- . MSI'INCCONTOUR PROJECT NUMBER 00-067 .____Pal PROPOSED CONTO(TTt K�V 1 SE1 D $ 2'.i. .�� . ✓� Z 5� �0 � ZlJ �d