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HomeMy WebLinkAbout0356 BAY LANE - Health 355 tau Lane Centerville - P A = 186 018 s t 4 l� No. 4210 1/3 ORA t Pendaflex . 10% L=;Oo-CAT ION j� / SEWAGE P/ERMIT NO. 'Y!-LLAGE tl I N S T A LLER'S NAME & ADDRESS Z-lz� S UILDER OR OWNER DATE PERMIT ISSUED f f i DATE COMPLIANCE ISSUED , r�` �� � -�----•1. B��'. �� / �� ' r i '-- - - - -- �t�o�?�` Fi .,� -- .� f �. LOI '„i:�- ARN�S/TA GX �' � TION 354 �.e� SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 3 OWNER nflicANO-e-1 q 00"no- &L'ka6YL PERMIT DATE: 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 Fie F 4 0 00 r -Pram f 2.�n ao'ne� 3,56 Bays Lanz 02632 Sy,3tem 'con,6i,3-t-6 o/. 1- 1000 yajion zap.tic tank, 1-Diz; 2-igu.tion Sox, 614 o� AC e i� `y v 411 6 o 17� � v I fe Asslss� �s°; �oT WTALL EWS NAi &PY OAtE Y iO SEPWC TA iK CAPACITY �Q� /y LEACfIIl�tG E�ACi[;TI'lt.{rypr}. 1`tO. OF8El3�t?C}}PhS �'. �tTIIQER OR{)Wi�II~R - PERMFFi�ATE C{)IvIPT.IAPIC$ DATE: Separation l?cAM; Betvieen Ehc Maxinwm Adjusted Caoundwater Table to tie Bottomof Leaching Fac.�ility Food Pnvate stater Supply deli and Leac2iingacility (ti`assy urt�s exist an�sita er anttun�feet of leashing fac�ity} - fit.: Edge of wletland and Leaelung£acity(If any wetlands exist vnthin w feet o =leaeluttg f 3 F Feet Furnished by' �. � � L r l ROW, a O O -30, I • /8w- 018 „< Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 356 Bay Ln r° Property Addressy Johanna Shaw Owner Owner's Name information is Centerville t/ MA 02632 7-28-17 Is" required for every + 't page. City/Town State Zip Code Date of InspectioQE 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 t e Local Approving Authority 7-28-17 I ector'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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �0�7j VS , Commonwealth of Massachusetts f Title 5 Official Inspection Form ��i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �_ 1,_:✓ 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 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: System is in good working order with no sign of failure. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts fZ Title 5 Official Inspection Form � I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) ❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts �aa Title 5 Official Inspection Form fI1 ' �I Subsurface Sewage Disposal System Form Not for Voluntary Assessments a% 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 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 than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts ^+ f Title 5 Official Inspection Form I I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-1.7 page. City/Town 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form f. ' N Subsurface Sewage Disposal System Form Not for Voluntary Assessments 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is Centerville MA 02632 7-28-17 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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: 7-2017 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form f� ' A Subsurface Sewage Disposal System Form Not for Voluntary Assessments 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 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: Previous inspection pumped 2012 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form ;,II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 48"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 40"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 gal Sludge depth: 12" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts :a=1 fJJ. Title 5 Official Inspection Form ' ,14 Subsurface Sewage Disposal System Form Not for Voluntary Assessments s!ai 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 page. City/Town 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 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape 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 good condition with baffles installed and no sign of leakage. 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 � s -ems! 356 Bay Ln r- Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 page. City/Town 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 :a=1 Title 5 Official Inspection Form �A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 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.): Good condition with water at working level and no sign of back-up from field. 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 i Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form ,�� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-flodiffusers ❑ 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.): Flodiffuser field in good working order with no sign of back-up into d-box or surrounding stone. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts gal Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Bay Ln L J' Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 page. City/Town 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 i., „f�-! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W. 1 356 Bay Ln . Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 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 ----------------- FOT,� (7) 1�1 A - 1 - X7 .3 301 c -3 93 - d t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts ,a=1 Title 5 Official Inspection Form :y.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 page. City/Town 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: 10 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at 10'. 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 a=1 G Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 356 Bay Ln Property Address Johanna Shaw Owner Owner's Name information is required for every Centerville MA 02632 7-28-17 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 I Commonwealth of Massachusetts 'l� d� Title 5 Official Inspection Form C , r _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "tom S ;M 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. 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 Scott Campbell use the return Name of Inspector key. Cardinal Construction Company Name 32 Ridgetop Rd. Company Address Cotuit Ma 02635 Cityrrown State Zip Code 508-420-1295 S1388 '© Telephone Number License Number 1 B. Certification u� 1 I certify that I have personally inspected the sewage disposal system at this address"and that the m ii r information reported below is true, accurate and complete as of the time of the inspection. The,inspedon was performed based on my training and experience in the proper function and maintenance df'on slte 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 urther Evaluation by the Local Approving Authority 9/23/14 Ins ect is Signatur 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. f IL �y t5ins•3/13 i e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. Citylrown 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: Installed riser on distribution box and new cover on inlet side of septic tank. 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-3113 Title 5 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 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. Cityfrown 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•3/13 Tide 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 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. CitylTown 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 El ® 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 Title 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 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. Citylrown 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 ❑ ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 356 Bay Lane 'JM Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) - ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)) 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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: 2al 3 z- 1MV-9 Sump pump? ❑ Yes ❑ No Last date of occupancy: current Date CommerciallIndustrial 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•3/13 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 4'M 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: current 2014 Date Other(describe below): General Information Pumping Records: Source of information: system pumped directly after completion of inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? By size of septic tank. Reason for pumping: Maint. 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 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 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: 1.5 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: Sludge depth: 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 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 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 0 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle 0 How were dimensions determined? Visual 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 was pumped directly after inspection was completed. Both inlet and outlet tees in place at time of inspection. Structural integrity of tank is good. Liquid level at proper working height at time of inspection. No evidence of leakage into or out of 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 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 Forth:Subsurface Sewage Disposal System-Page 11 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. Cityrrown 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.): Biox is set level. Has equal distribution. No evidence of solids carryover. No evidence of leakage into or out of box. 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.): *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•3113 Title 5 Official Inspection Forth: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 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 3 ❑ 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.): Course dry soil inspected during excavation.No signs of hydraulic failure. No ponding. No vegetation system in driveway. 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 •''c 356 Bay Lane Property Address Michael B. Gaspard Owner owner's Name information is required for every Centerville Ma 02632 9/23/14 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 356 Bay Lane Property Address Michael B.Gaspard Owner owner's Name information is required for every Centerville Ma 02632 9/23/14 page. cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 69 5� ql 31 (Sins•3(13 Title 5 Official.bspedion Fo m:Subsuifaoe-Sewage Disposal.System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is Centerville Ma 02632 9/23/14 required for 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: 9.5+ 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: 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: Excavation at time of inspection. 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 356 Bay Lane Property Address Michael B. Gaspard Owner Owner's Name information is required for every Centerville Ma 02632 9/23/14 page. Cityfrown 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•3113 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal System•Page 17 or 17 Y CA.PF COD,ENGINEERING, INC. Robert M. Perry, P.E. 50 Leland Road Brewster,MA 02631 Tel./Fax 508-8964861 bo erry(akayecod.net October 10, 2005 Secretary Stephen R. Pritchard Executive Office of Environmental Affairs Attn: MEPA Office 100 Cambridge Street, Suite 900 Boston, MA 02114 Re: MEPA Compliance; DEP File No. SE 3-4391; 356 Bay Lane, Centerville, MA; Applicant Mr. Michael Gaspard Dear Mr. Pritchard, Enclosed please find an Environmental Notification Form for a single-family home addition project. The project, more fully detailed in the narrative accompanying the ENF, was approved by the Barnstable Conservation Commission and appealed by an abutter. Due to the fact that a portion of a proposed porch will alter an area defined as a coastal bank segment this MEPA filing is required. The applicable agencies and reviewers have been provided with copies of the ENF. Please feel free to contact out office should you have questions. Sincerely, Cape Cod Engineering,Inc. y Zrterry,P.E. Ear � Cc: Distribution list } v For Office Use Only Commonwealth of Massachusetts Executive Office of Enviro,imentalAffairs Executive Office of Environmental Affairs ■MEPA Office EOEA No.: Environmental MEPA Analyst: ENFNotification Form Phone: 617-626- The information requested on this form must be completed to begin MEPA Review in accordance with the provisions of the Massachusetts Environmental Policy Act, 301 CMR 11.00. Project Name: Michael Gaspard Home addition Street: ' 356 Bay Lane Municipality: Centerville Watershed: Cape Cod UBiversal Tranverse Mercator Coordinates: Latitude:N 41° 38 , 28 Longitude: Estimated commencement date: Jan. 106 Estimated completion date:June 106 Approximate cost: $8C ,000 Status of project design: complete %complete Pro onent:Michael Gaspard Street: 225 Gosnoid St. Municipality: State: MA ZipCode: 02601 Name of Contact Person From Whom Copies of this ENF May Be Obtained: Robert Perry Firm/Agency: cape Cod Engineering, I $tjeet: 50 Leland Rd Municipality: Brewster State: MA I Zip Code: 02631 Phone: 508-896-4861 Fax: 508-896-4861 1 E-mail:bobperryCcapecq .net Does this project meet or exceed a mandatory EIR threshold (see 301 CMR 11.03)? ❑Yes fiNo Has this project been filed with MEPA before? ❑Yes (EOEA No. ) )MNo Has any project on this site been filed with MEPA before? ❑Yes (EOEA No. ) )x No Is this an Expanded ENF (see 301 CMR 11.05(7)) requesting: a Single EIR? (see 301 CMR 11.06(8)) ❑Yes �No a Special Review Procedure? (see 301 CMR 11.09) ❑Yes ) No a Waiver of mandatory EIR? (see 301 CMR 11.11) ❑Yes )f No a Phase I Waiver? (see 301 CMR 11.11) ❑Yes )MNo Identify any financial assistance or land transfer from an agency of the Commonwealth, including the agency name and the amount of funding or land area (in acres): none Are you requesting coordinated review with any other federal, state, regional, or local agency? ❑Yes(Specify . ) nNo List Local or Federal Permits and Approvals: Barnstable Conservation Order of Cond. Mass DEP Superseding Order of Conditions Town of Barnstable Building permit Revised 10/99 Conurnent period is limited. For intionuation call 617-626-1020 Which ENF or EIR review threshold(s) does the project meet or exceed (see 301 CMR 11.03): ❑ Land ❑ Rare Species x© Wetlands, Waterways, & Tidelands ❑ Water ❑ Wastewater ❑ Transportation ❑ Energy ❑ Air ❑ Solid & Hazardous Waste ❑ ACEC ❑ Regulations ❑ Historical &Archaeological Resources Summary of Project Size ;4.5 ng Change Total State Permits & & Environmental Impacts Approvals © Order of Conditions Total site acreage c. ❑ Superseding Order of Conditions New acres of land altered 0. 1 ac ❑ Chapter 91 License Acres of impervious area 0. 1 0 ❑ 401 Water Quality Square feet of new bordering Certification vegetated wetlands alteration 0 ❑ MHD or MDC Access Permit Square feet of new other 0 ❑ Water Management wetland alteration Act Permit Acres of new non-water 0 ❑ New Source dependent use of tidelands or Approval waterways ❑ DEP or MWRA Sewer Connection/ Extension Permit Gross square footage * * El Other Permits Number of housing units (including Legislative Approvals) — Specify: Maximum height (in feet) 124 g 33 TRANSPORTATION - * All floors w/in house plus Vehicle trips per day garage Parking spaces WATER/WASTEWATER Gallons/day (GPD) of water use 330 0! 330 * Design GPD water withdrawal GPD wastewater generation/ treatment 330 _.~; 0 330 Design Length of water/sewer mains (in miles) CONSERVATION LAND: Will the project involve the conversion of public parkland or other Article 97 public natural resources to any purpose not in accordance with Article 97? ❑Yes (Specify ) ®No Will it involve the release of any conservation restriction, preservation restriction, agricultural preservation restriction, or watershed preservation restriction? ❑Yes (Specify ) [�No RARE SPECIES: Does the project site include Estimated Habitat of Rare Species, Vernal Pools, Priority Sites of -2- Rare Species, or Exemplary Natural Communities? ���� Near, not within. ❑Yes (Specify ) 9c�c�0 See attached HISTORICAL/ARCHAEOLOGICAL RESOURCES: Does the project site include any structure, site or district listed in the State Register of Historic Place or the inventory of Historic and Archaeological Assets of the Commonwealth? []Yes (Specify ) No If yes, does the project involve any demolition or destruction of any listed or inventoried historic or archaeological resources? ❑Yes(Specify ) ❑No AREAS OF CRITICAL ENVIRONMENTAL CONCERN: Is the project in or adjacent to an Area of Critical Environmental Concern? ❑Yes (Specify ) )UNo PROJECT DESCRIPTION: The project description should include (a) a description of the project site, (b) a description of both on-site and off-site alternatives and the impacts associated with each alternative, and (c) potential on-site and off-site mitigation measures for each alternative (You may attach one additional page, if necessary.) Please see attached . PROJECT NARRATIVE(NA-1) The area subject to this notice is land in Centerville,MA off of Bay Lane. Please see the locus maps for the exact location. The specific site is directly adjacent to an extensive marsh system that was formerly a cranberry growing land area now overgrown with a thick common reed community. The work site is a residential dwelling site with open lawn areas and semi-formal landscaping. The driveway is partially paved and otherwise stone surfaced. The old ditches within this wetland are still visible and appear on the USGS map for the area but are not rivers due to the straight line manmade appearance,historical agricultural function and low—to—nil flow characteristics. No flow was observed in the ditches during the very wet .spring of 2005. Tidal flow is severely restricted from passing beneath Bay Lane from the Bumps River into the embayment south of locus. The 100 year coastal flood plain with base flood elev.=11 surrounds and includes portions of the project area. The Request for Departmental Action(Superseding Order of Conditions)for which the ENF is required relates heavily to the appellants declaration that the project site lies within a Riverfront Area. As mentioned above,the old,straight-line irrigation ditches were not found to be rivers by this office nor by the Barnstable Conservation Commission due to the uniform shape,former agricultural function and no observed flow during the spring of 2005. The larger water body to the south was not found to be a river by the Barnstable Conservation Commission nor by this office during the formulation and review of the Notice of Intent primarily due to shape and flow characteristics. Due to the appellant's declaration that the subject waterbody is a river we undertook a study of the mean high water line along the shore along the property boundary with this main waterbody that more resembles an embayment or pond. Rather than debate the identity of the resource area that may or may not have relevant jurisdiction to the project area,we conclude that the presumed 200 ft. Riverfront Area(RA) does not intersect with the land area proposed for the dwelling addition construction. The proposed mitigation program will lie within the RA but the proposed mitigation activity is exempt from Rivers Act performance standards: planting of native shrubs in an existing lawn area greater than 50 ft.from the riverbank(MIS. The presumed RA is delineated on the site plan and stems from the observed MHW line of the embayment. The bog and ditch wetland is distinctly defined and also incorporates a minor coastal bank(below the BFE) formation along the marsh edge on the lawn. The general land area of this neighborhood portion includes what may be considered discontinuous coastal bank segments nearer to the dwelling due to the past alterations relating to the driveway and house construction. The primary resource areas of note are the expansive,pbragmites—populated bog(BVW)area to the south and west,the 100 year flood plain and the minor coastal bank near the existing lawn edge. A series of flagged stations, 1 thru 7,delineate the edge of the top of the bank of a small edge ditch and the minor coastal bank adjacent to and within the existing lawn area. With exception of the flood plain and any perceived,discontinuous coastal bank segments,the bog and the minor coastal bank represents the closest clearly defined wetland resources to the dwelling. The proposed project involves work on the dwelling. The Proposed Project. The specific work on the dwelling is listed on the plan and involves minimum excavation. The excavation is required for post support footings for the porch and the added deck supports. The support locations are shown on the plan. A short foundation wall is proposed on the driveway side of the existing garage. Minimal equipment is needed and,if necessary the post supports on the work limit side of the project can be dug by hand. The bulk of the project-related activity occurring at the site will be foot traffic and related construction efforts around the building. Minimal vegetation will be disturbed in the course of the activity. All areas disturbed shall be restored to a pre-construction condition. An approximate 170 st aluminum framed greenhouse adjacent to the existing dwelling is proposed for removal with the resulting land area restored with native shrubs and ground cover. A work limit is shown on the plan. The work limit is designated and established with a silt fence or other guard as dictated by the Conservation Commission. We propose a properly dug in,staked,woven vinyl sheet silt fence. Straw bales are a suggested buttress for the fabric. Our conclusion is that with work limits in place and properly maintained,the work proposed at the property as outlined in this notice will have no adverse impact upon the relevant wetland interests. Alternatives discussion follows: • Alternatives discussion is limited to the prospect of adding to the existing dwelling in a practical manner. Upland is limited on the lot,restricting the alteration of the dwelling to the area of the dwelling itself as well as the subject lot. • Alternatives considered are`substantially equivalent economic alternatives'involving approximately equal floor area improvement for the existing dwelling. 1. Expand the dwelling footprint to gain the additional space. Primary impact would be the direct disruption and occupation of land area within the wetland buffer zone. Construction impact will be outward of the newly occupied footprint further expanding the temporary ground alteration. The consequential impact would be a loss of buffer zone ground area outward from the dwelling. Building addition portions within the flood zone area of the lot will require post supports or other elevated type of foundation to be elevated sufficiently.to become habitable space. 2. Expand the`walkout' portions of the existing dwelling. No habitable space is permitted for residential dwellings below the base flood elevation within which lies the existing cellar walkout area. Additional space at this walkout level will not meet Mass.Building Code regulations for habitable space. I Add the second floor to the dwelling. This alternative offered a practical way of gaining useable space within the dwelling footprint without the accompanying permanent land alteration within the buffer. The associated deck and porch supports are of a minimum size,proposed within currently altered land areas. The alternative results in a means of getting the older,non-code,habitable space out of the older,flood susceptible dwelling portions(walkout cellar)and replacing it on the proposed second floor. LAND SECTION - all proponents must fill out this section I. Thresholds/Permits A. Does the project meet or exceed any review thresholds related to land (see 301 CMR 11.03(1) _Yes Xy No; if yes, specify each threshold: II. Impacts and Permits A. Describe, in acres, the current and proposed character of the project site, as follows: Existing Change Total Footprint of buildings n_ 1 p_ p , Roadways, parking, and other paved areas Other altered areas (describe) 0.5 0 n _ yard Undeveloped areas 4 0 4 B. Has any part of the project site been in active agricultural use in the last three years? Yes _ No; if yes, how many acres of.land in agricultural use (with agricultural soils) will be converted to nonagricultural use? C. Is any part of the project site currently or proposed to be in active forestry use? —Yes X� No; if yes, please describe current and proposed forestry activities and indicate whether any part of the site is the subject of a DEM-approved forest management plan: D. Does any part of the project involve conversion of land held for natural resources purposes in accordance with Article 97 of the Amendments to the Constitution of the Commonwealth to any purpose not in accordance with Article 97?_Yes xx No; if yes, describe: E. Is any part of the project site currently subject to a conservation restriction, preservation restriction, agricultural preservation restriction or watershed preservation restriction? —Yes ___X_ No; if yes, does the project involve the release or modification of such restriction? _Yes X No; if yes, describe: F. Does the project require approval of a new urban redevelopment project or a fundamental change in an existing urban redevelopment project under M.G.L.c.121A? _Yes y_ No; if yes, describe: G. Does the project require approval of a new urban renewal plan or a major modification of an ?xisting urban renewal plan under M.G.L.c.121 B?Yes _No X— ; if yes, describe: H. Describe the project's stormwater impacts and, if applicable, measures that the project will take to comply with the standards found in DEP's Stormwater Management Policy: No change in drainage caused or proposed . I. Is the project site currently being regulated under M.G.L.c.21 E or the Massachusetts Contingency Plan? Yes _No X ; if yes, what is the Release Tracking Number(RTN)? J. If the project is site is within the Chicopee or Nashua watershed, is it within the Quabbin, Ware, or Wachusett subwatershed?_Yes X No; if yes, is the project site subject to regulation under the Watershed Protection Act? Yes X No K. Describe the project's other impacts on land: Temporary construction impact to be restordd. Several permanent post supports are proposed . Meaningful ( 1000 s .f) native area restoration. III.. Consistency A. Identify the current municipal comprehensive land use plan and the open space plan and -4- describe the consistency of the project and its impacts with that plan(s): Single family dwellings are not applicable B. Identify the current Regional Policy Plan of the applicable Regional Planning Agency and describe the consistency of the project and its impacts with that plan: C. Will the project require any approvals under the local zoning by-law or ordinance (i.e. text or map amendment, special permit, or variance)? Yes _No _XX; if yes, describe: D. Will the project require local site plan or project impact review? _Yes XX No; if yes, describe: RARE SPECIES SECTION I. Thresholds/Permits A. Will the project meet or exceed any review thresholds related to rare species or habitat (see 301 CMR 11.03(2))? _Yes _X_X No; if yes, specify, in quantitative terms: B. Does the project require any state permits related to rare species or habitat? _Yes XX_No C. If you answered "No"to both questions A and B, proceed to the Wetlands, Waterways, and Tidelands Section. If you answered "Yes"to either question A or question B, fill out the remainder of the Rare Species section below. II. Impacts and Permits A. Does the project site fall within Priority or Estimated Habitat in the current Massachusetts Natural Heritage Atlas (attach relevant page)? _Yes No. If yes, 1. Which rare species are known to occur within the Priority or Estimated Habitat (contact: Environmental Review, Natural Heritage and Endangered Species Program, Route 135, Westborough, MA 01581, allowing 30 days for receipt of information): 2. Have you surveyed the site for rare species? _Yes_No; if yes, please include the results of your survey. 3. If your project is within Estimated Habitat, have you filed a Notice of Intent or received an Order of Conditions for this project? _Yes_ No; if yes, did you send a copy of the Notice of Intent to the Natural Heritage and Endangered Species Program; in accordance ' with the Wetlands Protection Act regulations? _Yes_No B. Will the project"take" an endangered, threatened, and/or species of special concern in accordance with M.G.L. c.131A (see also 321 CMR 10.04)? _Yes _No; if yes, describe: C. Will the project alter"significant habitat" as designated by the Massachusetts Division of Fisheries and Wildlife in accordance with M.G.L. c.131A (see also 321 CMR 10.30)? _Yes No; if yes, describe: D. Describe the project's other impacts on rare species including indirect impacts (for example, stormwater runoff into a wetland known to contain rare species or lighting impacts on rare moth habitat): WETLANDS, WATERWAYS, AND TIDELANDS SECTION I. Thresholds/Permits Coastal Bank alterations' Superceding Order of Conditions A. Will th a project meet or exceed any review thresholds related to wetlands, waterways, and tidelands (see 301 CMR 11.03(3))? X_Yes _ No; if yes, specify, in quantitative terms: One foundation post support on a coastal bank ( alteration) B. Does the project require any state permits (or a local Order of Conditions) related to wetlands, waterways, or tidelands? X Yes _ No; if yes, specify which permit: Local Order of Conditions; Superceding Order of Conditions C. If you answered "No"to both questions A and B, proceed to the Water Supply Section. If you answered "Yes"to either question A or question B, fill out the remainder of the Wetlands, Waterways, and Tidelands Section below. ll. Wetlands Impacts and Permits A. Describe any wetland resource areas currently existing on the project site and indicate them on the site plan: BVW, Coastal Bank, Coastal Flood Plain Presumed Riverfront Area B. Estimate the extent and type of impact that the project will have on wetland resources, and indicate whether the impacts are temporary or permanent: Coastal Wetlands Area (in square feet) or Length (in linear feet) Land Under the Ocean Designated Port Areas Coastal Beaches Coastal Dunes Barrier Beaches Coastal Banks 0.5 s=. yd - Parmanant. Rocky Intertidal Shores Salt Marshes Land Under Salt Ponds Land Containing Shellfish Fish Runs Land Subject to Coastal Storm Flowage net rastoratinn of 125 sc=. ft . w/in Flood plain (permanent) Inland Wetlands Bank Bordering Vegetated Wetlands Land under Water Isolated Land Subject to Flooding Bordering Land Subject to Flooding RiverfrontArea (coastal) restorat; nn of apprnx- 10nQ sq ft. RA C. Is any part of the project 1. a limited project? —Yes X No 2. the construction or alteration of a dam? Yes X:L No; if yes, describe: 3. fill or structure in a velocity zone or regulatory floodway? _Yes X No 4. dredging or disposal of dredged material? _Yes X No; if yes, describe the volume of dredged material and the proposed disposal site: 5. a discharge to Outstanding Resource Waters? _Yes X No 6. subject to a wetlands restriction order? _Yes X No; if yes, identify the area (in square feet): D. Does the project require a new or amended Order of Conditions under the Wetlands Protection Act (M.G.L. c.131A)? X Yes _No; if yes, has a Notice of Intent been filed or a local Order of Conditions issued? _y_Yes _ No; if yes, list the date and DEP file number: SE3— 4391 5/05 Was the Order of Conditions appealed? yy Yes _ No. Will the project require a variance from the Wetlands regulations?_Yes _XX No. -6- E. Will the project: 1. be subject to a local wetlands ordinance or bylaw? XX Yes _No 2. alter any federally-protected wetlands not regulated under state or local law? _Yes X No; if yes, what is the area (in s.f.)? F. Describe the project's other impacts on wetlands (including new shading of wetland areas or removal of tree canopy from forested wetlands): None significant Ill. Waterways and Tidelands Impacts and Permits A. Is any part of the project site waterways or tidelands (including filled former tidelands)that are subject to the Waterways Act, M.G.L.c.91? _Yes XX No; if yes, is there a current Chapter 91 license or permit affecting the project site? Yes _ No; if yes, list the date and number: B. Does the project require a new or modified license under M.G.L.c.91? _Yes X No No; if yes, how many acres of the project site subject to M.G.L.c.91 will be for non-water dependent use? Current _ Change _ Total _ C. Is any part of the project 1. a roadway, bridge, or utility line to or on a barrier beach? _Yes XX No; if yes, describe: 2. dredging or disposal of dredged material? _Yes XX No; if yes, volume of dredged material 3. a solid fill, pile-supported, or bottom-anchored structure in flowed tidelands or other waterways? _Yes XX No; if yes, what is the base area? 4. within a Designated Port Area? _Yes XX No D. Describe the project's other impacts on waterways and tidelands: IV. Consistency: A. Is the project located within the Coastal Zone?xX_Yes _No; if yes, describe the.project's consistency with policies of the Office of Coastal Zone Management: Consistent w/ flood pla i constr cUon . code. B.�s the protect located within an area subject to a Municipal Harbor Plan? _Yes XX No; if yes, identify the Municipal Harbor Plan and describe the project's consistency with that plan: WATER SUPPLY SECTION I. Thresholds/Permits A. Will the project meet or exceed any review thresholds related to water supply (see 301 CMR 11.03(4))? _Yes _.XXNo; if yes, specify, in quantitative terms: B. Does the project require any state permits related to water supply? _Yes Xg No; if yes, specify which permit: C. If you answered "No"to both questions A and B, proceed to the Wastewater Section. If you answered "Yes"to either question A or question B, fill out the remainder of the Water Supply Section below. II. Impacts and Permits A. Describe, in gallons/day, the volume and source of water use for existing and proposed activities at the project site: Existing Change Total Withdrawal from groundwater Withdrawal from surface water Interbasin transfer Municipal or regional water supply -7- b. If the source is a municipal or regional supply, has the municipality or region indicated that there is adequate capacity in the system to accommodate the project?_Yes _ No C. If the project involves a new or expanded withdrawal from a groundwater or surface water source, 1. have you submitted a permit application? _Yes _No; if yes, attach the application 2. have you conducted a pump test? _Yes No; if yes, attach the pump test report D. What is the currently permitted withdrawal at the proposed water supply source (in gallons/day)? Will the project require an increase in that withdrawal?_Yes _No E. Does the project site currently contain a water supply well, a drinking water treatment facility, water main, or other water supply facility, or will the project involve construction of a new facility? Yes _No. If yes, describe existing and proposed water supply facilities at the project site: Existing Change Total Water supply well(s) (capacity, in gpd) Drinking water treatment plant (capacity, in gpd) Water mains (length, in miles) F. If the project involves any interbasin transfer of water, which basins are involved, what is the direction of the transfer, and is the interbasin transfer existing or proposed? G. Does the project involve 1. new water service by a state agency to a municipality or water district? _Yes _No 2. a Watershed Protection Act variance? _Yes _ No; if yes, how many acres of alteration? 3. a non-bridged stream crossing 1,000 or less feet upstream of a public surface drinking water supply for purpose of forest harvesting activities? _Yes _No H. Describe the project's other impacts (including indirect impacts) on water resources, quality, facilities and services: III. Consistency-- Describe the project's consistency with water conservation plans or other plans to enhance water resources, quality, facilities and services: WASTEWATER SECTION I. Thresholds/Permits A. Will the project meet or exceed any review thresholds related to wastewater (see 301 CMR 11.03(5))? _Yes -X_y No; if yes, specify, in quantitative terms: B. Does the project require any state permits related to wastewater? _Yes No; if yes, specify which permit: C. If you answered "No"to both questions A and B, proceed to the Transportation --Traffic Generation Section. If you answered "Yes"to either question A or question B, fill out the remainder of the Wastewater Section below. II. Impacts and Permits A. Describe, in gallons/day, the volume and disposal of wastewater generation for existing and proposed activities at the project site (calculate according to 310 CMR 15.00): -x- Existing Change Total Discharge to groundwater(Title 5) Discharge to groundwater(non-Title 5) Discharge to outstanding resource water Discharge to surface water Municipal or regional wastewater facility TOTAL B. Is there sufficient capacity in the existing collection system to accommodate the project? Yes _ No; if no, describe where capacity will be found: C. Is there sufficient existing capacity at the proposed wastewater disposal facility?_Yes No; if no, describe how capacity will be increased: D. Does the project site currently contain a wastewater treatment facility, sewer main, or other wastewater disposal facility, or will the project involve construction of a new facility? _Yes _ No. If yes, describe as follows: Existing Change Total Wastewater treatment plant (capacity, in gpd) Sewer mains (length, in miles) Title 5 systems (capacity, in gpd) E. If the project involves any interbasin transfer of wastewater, which basins are involved, what is the direction of the transfer, and is the interbasin transfer existing or proposed? F. Does the project involve new sewer service by an Agency of the Commonwealth to a municipality or sewer district? _Yes _No G. Is there any current or proposed facility at the project site for the storage, treatment, processing, combustion or disposal of sewage sludge, sludge ash, grit, screenings, or other sewage residual materials? _Yes _No; if yes, what is the capacity (in tons per day): Existin Change Total Storage Treatment, processing Combustion Disposal H. Describe the project's other impacts (including indirect impacts) on wastewater generation and treatment facilities: 111. Consistency-- Describe measures that the proponent will take to comply with federal, state, regional, and local plans and policies related to wastewater management: A. If the project requires a sewer extension permit, is that extension included in a comprehensive wastewater management plan? _Yes _No; if yes, indicate the EOEA number for the plan and describe the relationship of the project to the plan TRANSPORTATION -- TRAFFIC GENERATION SECTION 9 I. Thresholds/Permits A. Will the project meet or exceed any review thresholds related to traffic generation (see 301 CMR 11.03(6))? _Yes *--No; if yes, specify, in quantitative terms: B. Does the project require any state permits related to state-controlled roadways? _Yes X No; if yes, specify which permit: C. If you answered "No"to both questions A and B, proceed to the Roadways and Other Transportation Facilities Section. If you answered "Yes"to either question A or question B, fill out the remainder of the Traffic Generation Section below. II. Traffic Impacts and Permits A. Describe existing and proposed vehicular traffic generated by activities at the project site: Existing Change Total Number of parking spaces Number of vehicle trips per day ITE Land Use Code(s): B. What is the estimated average daily traffic on roadways serving the site? Roadway Existinq Change Total 1. 2. 3. C. Describe how the project will affect transit, pedestrian and bicycle transportation facilities and services: .III.•Consistency-- Describe measures that the proponent will take to comply with municipal, regional, state, and federal plans and policies related to traffic, transit, pedestrian and bicycle transportation facilities and services: ROADWAYS AND OTHER TRANSPORTATION FACILITIES SECTION I. Thresholds A. Will the project meet or exceed any review thresholds related to roadways or other transportation facilities (see 301 CMR 11.03(6))? _Yes _X_No; if yes, specify, in quantitative terms: B. Does the project require any state permits related to roadways or other transportation facilities? _Yes _X_No; if yes, specify which permit: C. If you answered "No"to both questions A and B, proceed to the Energy Section. If you answered "Yes"to either question A or question B, fill out the remainder of the Roadways Section below. II. Transportation Facility Impacts A. Describe existing and proposed transportation facilities at the project site: Existing Change Total Length (in linear feet) of new or widened roadway Width (in feet) of new or widened roadway Other transportation facilities: B. Will the project involve any - 10- r 1. Alteration of bank or terrain (in linear feet)? 2. Cutting of living public shade trees (number)? 3. Elimination of stone wall (in linear feet)? III. Consistency--Describe the project's consistency with other federal, state, regional, and local plans and policies related to traffic, transit, pedestrian and bicycle transportation facilities and services, including consistency with the applicable regional transportation plan and the Transportation Improvements Plan (TIP), the State Bicycle Plan, and the State Pedestrian Plan: ENERGY SECTION I. Thresholds/ Permits A. Will the project meet or exceed any review thresholds related to energy (see 301 CMR 11.03(7))? _Yes XX_No; if yes, specify, in quantitative terms: B. Does the project require any state permits related to energy? _Yes -XX No; if yes, specify which permit: C. If you answered "No"to both questions A and B, proceed to the Air Quality Section. If you answered "Yes"to either question A or question B, fill out the remainder of the Energy Section below. 11. Impacts and Permits A. Describe existing and proposed energy generation and transmission facilities at the project site: Existing Change Total Capacity of electric generating facility (megawatts) Length of fuel line (in miles) Length of transmission lines (in miles) Capacity of transmission lines (in kilovolts) B. If the project involves construction or expansion of an electric generating facility, what are 1. the facility's current and proposed fuel source(s)? 2. the facility's current and proposed cooling source(s)? C. If the project involves construction of an electrical transmission line, will it be located on a new, unused, or abandoned right of way?_Yes _No; if yes, please describe: D. Describe the project's other impacts on energy facilities and services: III. Consistency-- Describe the project's consistency with state, municipal, regional, and federal plans and policies for enhancing energy facilities and services: AIR QUALITY SECTION I. Thresholds A. Will the project meet or exceed any review thresholds related to air quality (see 301 CMR 11.03(8))? _Yes y_X_ No; if yes, specify, in quantitative terms: B. Does the project require any state permits related to air quality? _Yes X-X No; if yes, specify which permit: C. If you answered "No"to both questions A and B, proceed to the Solid and Hazardous Waste - 11 - Section. If you answered "Yes"to either question A or question B, fill out the remainder of the Air Quality Section below. II. Impacts and Permits A. Does the project involve construction or modification of a major stationary source (see 310 CMR 7.00, Appendix A)?_Yesy No; if yes, describe existing and proposed emissions (in tons per day) of: Existing Change Total Particulate matter Carhon monoxide Sulfur dioxide Volatile organic compounds Oxides of nitrogen Lead Any hazardous air pollutant Carbon dioxide B. Describe the project's other impacts on air resources and air quality, including noise impacts: III. Consistency A. Describe the project's consistency with the State Implementation Plan: B. Describe measures that the proponent will take to comply with other federal, state, regional, and local plans and policies related to air resources and air quality: SOLID AND HAZARDOUS WASTE SECTION I. Thresholds/ Permits A. Will the project meet or exceed any review thresholds related to solid or hazardous waste (see 301 CMR 11.03(9))? _Yes _)=No; if yes, specify, in quantitative terms: B. Does the project require any state permits related to solid and hazardous waste? _Yes LIX No; if yes, specify which permit: C. If you answered "No"to both questions A and B, proceed to the Historical and Archaeological Resources Section. If you answered "Yes"to either question A or question B, fill out the remainder of the Solid and Hazardous Waste Section below. 11. Impacts and Permits A. Is there any current or proposed facility at the project site for the storage, treatment, processing, combustion or disposal of solid waste?_Yes _No; if yes, what is the volume (in tons per day) of the capacity: Existing Change Total Storage Treatment, processing Combustion Disposal B. Is there any current or proposed facility at the project site for the storage, recycling, treatment or disposal of hazardous waste?_Yes _ No; if yes, what is the volume (in tons or gallons per day) of the capacity: -12- Existin Change Total Storage Recycling Treatment Disposal C. If the project will generate solid waste (for example, during demolition or construction), describe alternatives considered for re-use recycling, and disposal: D. If the project involves demolition, do any buildings to be demolished contain asbestos? Yes No E. Describe the project's other solid and hazardous waste impacts (including indirect impacts): III. Consistency--Describe measures that the proponent will take to comply with the State Solid Waste Master Plan: HISTORICAL AND ARCHAEOLOGICAL RESOURCES SECTION I. Thresholds / Impacts A. Is any part of the project site a historic structure, or a structure within a historic district, in either case listed in the State Register of Historic Places or the Inventory of Historic and Archaeological Assets of the Commonwealth? _Yes XXL No; if yes, does the project involve the demolition of all or any exterior part of such historic structure? _Yes _No; if yes, please describe: B. Is any part of the project site an archaeological site listed in the State Register of Historic Places or the Inventory of Historic and Archaeological Assets of the Commonwealth? _Yes xX_No; if yes, does the project involve the destruction of all or any part of such archaeological site? _Yes _ No; if yes, please describe: C. If you answered "No"to all parts of both questions A and B, proceed to the Attachments and Certifications Sections. If you answered "Yes"to any part of either question A or question B, fill out the remainder of the Historical and Archaeological Resources Section below. D. Have you consulted with the Massachusetts Historical Commission? _Yes Xy No; if yes, attach correspondence E. Describe and assess the project's other impacts, direct and indirect, on listed or inventoried historical and archaeological resources: II. Consistency-- Describe measures that the proponent will take to comply with federal, state, regional, and local plans and policies related to preserving historical and archaeological resources: ATTACHMENTS: 1. Plan, at an appropriate scale, of existing conditions of the project site and its immediate context, showing all known structures, roadways and parking lots, rail rights-of-way, wetlands and water bodies, wooded areas, farmland, steep slopes, public open spaces, and major utilities. 2. Plan of proposed conditions upon completion of project (if construction of the project is proposed to be phased, there should be a site plan showing conditions upon the completion - 1;- f of each phase). 3. Original U.S.G.S. map or good quality color copy (8-'h x 11 inches or larger) indicating the project location and boundaries 4 List of all agencies and persons to whom the proponent circulated the ENF, in accordance with 301 CMR 11.16(2). 5. Other: Aerial. GIS photograph ( 2001 ) of locus , Plans CERTIFICATIONS: 1. The Public Notice of Environmental Review has been/will be published in the following newspapers in accordance with 301 CMR 11.15(1): (Name) (Date) Cape Cod Times October 13, 2005 2. This form has been circulated to Agencies and Persons in accordance with 301 CMR 11.16 7Es. Date Signature of Responsible Officer ate Signature of pe on preparing or Proponent ENF (if different from above) Name (print or type) Name (print or type) Robert M. Perry Firm/Agency Cape Cod Engineering, fgpp Agency. 50 Leland Rd . Street Street Municipality/State/Zip Brewster, MA Municipality/State/Zip 02631 Phone Phone 508-896-4861 - 14- ` l i--'` � �'�•.• a '`� ,.Gooseberry ���� J�O�:'��• ,. rop LewisPt 0 •�o�/ // rim o I f �5}�/ ° lug N Pt� ,l/O♦�h.: 1 ."#w J. 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I :' East Bay :`'.. /e p I Hyarfl�s r� � a . Bead ) 14 13 rf oo •9 d 1' ;! Gannet •',rysta •°♦ 4 a Rocks 9 ^' - � ♦ j I /9 20 /3 el N A 1V T Ul C K E T '•.•2 ! OGannet i12 Ledge I e 3. 2� 9 i. �. . i / 10I 1��1v/"� •.�_Cr �4��? I� k ..tom y �.xJ'� � ,+�_��h. q k��. Y►..: la�sY�V � �"r.,l,s1'�"1° C_ tr` ::_ 1 � -a ts�� °x � §s!$'°, � r:<.. � � � 'r."` -4^ - r- ram" _ ,� '�. :�. a •'� r l I l MM �p n ) >oyy ✓ ti. - s 1. �41 1�� e• y <A4`u'�+t,r�- ti+'{_,,� � ;�.', e' � �'� � `"� r•� ,{t. •e4 '"r: '"'�Ly A - - a .- i 4 �'' r � r3� rZ: y ea � � t $ e �_, h•a qS',�a �§ � ` FCC, r ti�a~• k.,��1�"�`s t, `''°��SR TIN AA , rpw V r 4� ��. �,i'�c`��':�`+ d'�1 ° a. i2 } �tY� r » t.,i�} .�L•r i ti�-1 "� � °'da .; +bra� r isg^F P r�✓i, a�x• > .. X d 1. `: r t < a/^�' _-<3ayr��yl-ve.� � `• r ., e f n �; ._t "fr Y ty max}�y 1 f 5 •s } y g=i 4, f•- °J"i✓ t .s`A�"�. rr" 'i. � ,.-a'�� r ( C a 1u t T Ye `� z. r A 1 � - < � d 3 r �sy C u •fa., �' �tE. !a � ei?i Z'' r s > --,} is t ,�?? Via: �, 7i'f .<�dd�;� �� � �,£ ".� ! •1� f >. t�``t, '�`(��P` , _ �; ,�gr I Commonwealth of Massachusetts Division of FmsheriesWildh � Mass Wi/d/ife Wayne F. MacCallum,Director May 24, 2005 Barnstable Conservation Commission 367 Main Street Hyannis,MA 02601 RE: Applicant: Michael Gaspard Project Location: 356 Bay Lane Project Description: Alteration &Addition to existing dwelling NHESP File No. 05-17869 Dear Commissioners: The applicant listed above has submitted a Notice of Intent with site plans (dated 3/23/05)to the Natural Heritage&Endangered Species Program (NHESP) of the Massachusetts Division of Fisheries & Wildlife, in compliance with the rare wildlife species section of the Massachusetts Wetlands Protection Act Regulations (310 CMR 10.37), for the subject project. Based on a review of the information that was provided and the information that is currently contained in our database, the NHESP has determined that this project occurs near but not within the actual habitat of state-protected rare wildlife species. It is our opinion that this project, as currently proposed, will not adversely affect the actual habitat of state-protected rare wildlife species provided that silt fencing is located prior to all site work along the limit of work on the site plan (dated 3/25/05)and promptly removed when disturbed areas are stabilized. Please note that this determination addresses only the matter of rare wildlife habitat and does not pertain to other wildlife habitat issues that may be pertinent to the proposed project. Sincerely, Thomas W. French, Ph.D. Assistant Director cc: Michael Gaspard Robert Perry, Cape Cod Engineering, Inc. DEP Southeastern Regional Office, Wetlands Program www masswildli e org Division of Fisheries and Wildlife Field Headquarters, One Rabbit Hill Road, Westborough, MA 01581 (508) 792-7270 Fax(508) 792-7275 An Agency of the Department of Fisheries. Wildlife& Environmental Lam Enforcement EX, Z 3 O A Shee� 53r 8 '11 1 Ole. a ��. . L A/VE 50 ft•�vida� . ..«.�o.e. 9y. /�� ., S 68• P6'OO E 26G.08 owl r/Fl•00 f•�, u lo.es aey t!b ��� \ L«LINT• � •:p•A� ,r c � N �� LANE� . 106.sr ev \ � use''- i +� Gv(.{/S 0 i e N r o o NU !P®•B 10 7 + A o iw �• \ • �.. Iy o, w, w 91 P �s.'fi,, N� •r a 3 's• �� ,� o • F' 6� eow o �2 J tlis7a�2�c,.9 � , 6eall e/•lbla�e/oir/OD/iit Le en Ina* Ze 3 ENF Distribution List EOEA—Mr. James Stergios DEP Boston Office DEP—SERO Attn: MEPA Coordinator EOT Attn: Environmental Reviewer Massachusetts Highway Department Public/Private Development Unit MHD—District#5 Attn: MEPA Coordinator Massachusetts Aeronautics Commission Attn: MEPA Coordinator Massachusetts Historical Commission Cape Cod Commission Southeastern Regional Planning& Economic Development District Barnstable Town Council Barnstable Planning Board Barnstable Board of Health Barnstable Conservation Commission CZM Attn: Project Review Coordinator DMF Attn: Environmental Reviewer r ZVI: ` `T) o OATE :_12/1/03____ PROPERTY A00RESS : 356__[.ay- Lane ---__ -___ -- -02�32----------------- On the above date, I inspected the septic systerrv--a the above address. Tnis system consists of the loll,owlng: MAP 1. 1- 1000 gai-Ron zep.t-ic .tank. PARCEL 2. 1-Diz;tItiflut.ion fox, LOT 3. 3-r.Qow Di�luzzoit,5 -in zeziez. - Baseo on my inspection, I certily the Iollowing conditions: jAN 0 9004 4. 7hiz .i.6 a Live zeyz.t.ic hyztem (78 Code) 5, The �,gow d.i/�uzoaz ate paezen.Uy day. TOJ�HEALTH DEPT. 6LE 6. 7iow d.i��uzho2h ate 120' o�4 .the wet.2aadz. 7. The 3e/?tjc 6y,3;tem ih in p/Lo.pe2 woak.ing oade2 at the paezen.t time. SIGNATUR Fame ' . P . Macomber Jr . z- C o rh p a n y : 9 1 Q p hs.�ggTop b_ Son, Inc . ^ Odr25S L --------- C LLrr -_ 1a . -Q-Z632-0066 axone : 508 . 775-- ) ) 38 ThiS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. T inks-CesspooIi-LeachlleIds Pumped & Installed Town Sewer Connactlons P 0 Box 66 Centerville, MA 02632-0066 775.3338 775-6412 i ` lT�.T�I':T.-T..'I+T�TITZT..`TR.T.1•:•.T•�'JrT:�TTTr.TTI TTT�l4:1".L•TILT.fi"t'Z ... i,owN OF B.unnzt-A&�e BOARD OF HEALTH SUI)SURFAU SFWAOE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION .•••-••:-r••.-•.: —-.i i-^.-.--n.r rm•rt:rri ra..•.r.-r+rrT-m-.—•.��vrn-i x�rnr'r�i�b r+s'mrrt*srs+►•rra - nnnn�rerrnrasv*n-r�rire•.—rrr•r--�- —.. -TYPO OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 356 /any Lane Centeav�QQe, �ln�s�. ASSESSORS MAP , BLOCK AND PARCEL # 186-018 OWNER' s NAME 72an Ionez PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P. Macomber Jr COMPANY NAME Joseph P. Macomber &''ton Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Street Town or Clty Stat♦ LIP COMPANY TELEPHONE ( 508 ) 775-3338 FAX ( 508 ) 790-1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at this address and that the information reported is true , accurate , and omplete as of the time of :inspection , The inspection was performed and a-ny recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function And maintenance of on- site sewage disposal systems , Chec one : System -PASSED. The inspection tihich I have conducted has not found any information which indicates that the system fails to adequately protect public health or' Che environment as defined in 310 CMR 16 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* \ The inspection which I have con 'Licted has found that the system fails to Protect the Public health and the environment in accordance with Title 5 , 3.10 CMR -15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , ,r Inspector Signature o r.; �. bate ne copy of this c reification must be provided to the OWNER, the BUYER ( Where applicable ) and the DOARD OF ItEALTII, * If the inspection FAILED , th'e owner or"" `P'arator Shall upgrade ' the eyatem within one ,year of the elate of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 16 , 305 , partd , doc COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �r V. TITLE 5 OFFICIAL INSPECTION FORM—NOT.FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 35 6 L3a y Lane Cen.tenviiie, Nazz. Owner's Name: ;tan Gone-s Owner's Address.: Same Date of Inspection: 1211103 Name of Inspector: (please print)a o z e R h %. Ng c o m f,e 2 a/z. Company Name: �. P.,Macomie2 9 Son Inc. Mailing Address: Cen Eeay.i Lee, q,6-6. 02632 Telephone Number: 5 0 8-7 7 5=3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15:340 of Title 5(310 CMR 15000). The system: 6//Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Dater 0 The system inspector shal ubmit 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. Notes and Comments ****This report only describes conditions at the time of inspection and:under the conditions of-use at that time..This inspection does not address how the system will perform.in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 . page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 356 Bat/ Lane Cente2vUeg, mass. Owner: 7/can aznez Date of Inspection: 7 2/7/ 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 3,10 CMR 15.304 exist. ny failure criteria not evaluated are indicated below. Comments: 7h o ,s.o of i n A Z eM .iZ Zh Zn /220/2e2 wo,,z .cng 02 e2 at the pzezent time. B. System Conditionally Passes: X 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 b the P PP y Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: VP 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 Hof Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: gyp( The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 356 Bay Lane . en e2v4 e, ass 6 owner:. 7aan Date of Inspection: 7217103 C. Further Evaluation is Required by the Board of Health: /)P Conditions exist which.require further evaluation by the Board.of Heaith.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(l)(b)that the system is not functioning in.a manner,which:will protect public health,safety and the environment: Ak) Cesspool or privy is within 50 feet of a surface water . Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: � I 00 The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet ofa surface water supply or-tributary to a-surface water.supply. ,!�,b The system has a.septic tank and SAS and the SAS is within a Zone 1 of a-public water supply. ,CJV The system has a septic tank and.SAS and the SAS is within.50 feet of a private water supply well. ,00 The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well". Method used to determine distance "This system passes if the well water analysis.,performed at a DEP certified laboratory,for coliform bacteria 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 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,A CERTIFICATION(continued-) Property Address: 3 5 6 Bay Lane Cent eav'i-tee, Naz..s. Owner: Flan lonez Date of Inspection: 1211103 D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to.each ofthe followingfor 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 �esspool Ag���; . iquid depth in.&sspwAis less than 6"below invert or available,:volume is less than'h•day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /of times pumped _ cs y portion of the SAS,cesspool or privy is below high ground water elevation. _ s/.Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. y portion of-a-cesspool or.privy lis 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 5.0: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 foam.] . _(Yes/No)The system fails.I have determined that one or:more:o€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 10j000 gpd to 15,000. gpd• You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply Xt.e system is within 206 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. 4 Page 5 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE" DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3 5 6 !3a y Lane Cen.te2vi,eie, maz,3. Owner: Taan cone s Date of Inspection: 7211103 Check if the following have been done. You must indicate"yes"or"no"as to each..of the:following: Yes No -Z Pumping information was provided by the owner, occupant,orBoard 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 thisinspection? _ -,Z 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,&4eluding 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: Yes no'/Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C lot SYSTEM INFORMATION Property Address: 356 13au Lang. Owoer: l?r �nn n w Date of Inspection: FLOW CONDITIONS ,... RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN now bucd on 310 CMR 15.203 (for example: 110 gpd x M of bedrooms): Number o(current residenu: _I Does residence have a garbage grinder(yes or no):44 Is laundry on a separate sewage system(yes or no);4p_ (If yes separate Inspectlon.requ'ired) Laundry system inspected (ycs or no): Seasonal use:(yes or no): � ZOOZ= 19, 000 ga e 2on�=304. 9 1 Ch[7 Water meter readings, if available (last 2 years usage(gpd)): Sump pump(yes or no): -60 9a.CLon.6= 106, 85 Last date of occupancy: . COMM ERCLkL 1KDUSTRIAL Type of esublisbment: Design now(bucd on 310 CMR 15.203): d Buis of design now(seats/persons/sgft,ete.): Grease atp present (ycs or no):,&g Industrial waste holding tank present (yes or no):,I�# Non•saniury waste discharged to the Title 5 system (yes or no):40 ) Water meter readings, if available: Last date of occupancy/use: X4 OTHER(describe): GENERAL INFORMATION Pumping Records Sourcc of information: Was system pumped as pan of the inspection(yes or no): _ If yes, volume pumped: _gallons — How was quantity pumped determined? Rcason (or pumping: ZTYP OF SYSTEM Scptic tank, disvibution box, soil absorption system Singlc cesspool Overflow cesspool sL Privy /E Sharcd system (yes or no) (if yes, attach previous inspection records, if any) . Innovativc/AItem&Iive technology, Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank 1jeAtucb a copy of the DEP approval .(� Other(describe): ,/� Approximate aee of all components, date Installed (if known)and source of information: Were sewage odors detected when arriving at the site (yes or no):,-a 6 Page7orl1 OFFICIAL INSPECTION-FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Pro:pertyA.ddress: 356 l3ay Lane 0wacr: Tnnn. �nn0A c Date of i-nsp"dott:' 12,14-10.�_ r•' BUILDINC SEWER(locate on site plan) Depth below.grade: 9 - Lite w.ieght 4" _PVC gil2e Mstcrials o.f constsvctioh:Aw iron 0 PVC.�other(cxplgn):9- f i t t in gz t h2 o u gh o u t Distance from.privale water supply well or suction line: /.A`7- Vie �3el2 zc zyzteffl. Comments(on condition of joint;, vcrtt ng, c.vidcce of Fcsikage,etc.): Lintz agaea2 .L.iaht. No ev.iclenee o-1 .eeakae The h � em i.6 vented th zough the 2oo� vent,3. " a u t� SEPTIC TANK: Zlocate on site plain) DVth bclow grade: Materizlofconsurvction: e'concreternctal fib crglasspolyethylcne .,VO ocher(explain) 44 If tulle is metal list is age egnfirmcd by a Certificate of ComplanE0(yos or no) (attach a copy of certificate) 6'' pimcnsions: •� •�- Stud.gc depth. Distance from top of fudge to bottom o outlet lac or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle '. , Distance from bottom of scum to botto of outlet to orbaffle: H.ow were dimensions:detcrmined: Comments.(on pumping recortunendataons, inlet and otttiet tee or baffle condition, structural integrity, liquid levels as rclated.to outlet invcn, .ovidcnce of•leakage, cte,),. The tank i.1 � 2nctr�2a� , �orx�Ycl an zhow.s no evidence o,Z leakage, Qaste wa't-ea 'eevei u.t the '9utiet ;�nv•elLt iz 51 CREASE TRAB (locate on site plar.� r'' ; Depth b:ctow.grad;: Material of construc rglass�olyethylcneWOother (explain): Dimension Scum thickness: Distance from top of scum to top of outlet fee or baffle:', Distance from bottom of scum to bottom of outlet tee or baffle: Date of Iast:pumpinj: Comments(on pumping rccomm;ndaiions, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outict invert, evidence of leakage, etc,): nn# blzaAazzL 7 f Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:3 5 6 Bay Lane en t e2vi.C.ee. l'?a,3,3. Owner:-7/lan aonez Date of Inspection: 1211103 TIGHT or HOLDING TANK4&,—P'--(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete 0 metal fiberglass L polyethylene,0�rl? other(explain): Dimensions: 'OU Capacity: A4 gallons Design Flow: IM gallons/day Alarm present(yes or no): AM Alarm level: Alarm in working order(yes or no): .14 Date of last pumping: VA Comments(condition of alarm and float switches,etc.): Tight o z hoid ina tankz ate not /22ezent DISTRIBUTION BOX: t/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 4)14 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No ev.c epee . o zo .e z ca22y oven. No ev.idence o-�e eeakage .in o oa out o)e e 9ox. PUMP CHAMBERif,�jI (locate on site plan) Pumps in working order(yes or no): V14 Alarms in working order(yes or no): ZA Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): l itm� rhamPon !A nol pno,son1 8 i Page 9 of I 1 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C: SYSTEM INFORMATION(continued) Property Address: 356 day Lane en e,zv.i.PQe, Na. 3. OwnerF2an 7onez Date of Inspection: 1217103 SOIL ABSORPTION SYSTEM(SAS): /(locate on site plan,excavation not required) 3-7-Pow DiZ1u.6.6o A J.n. A0/Jlo A. If SAS not located explain why: Lcaf ec! • S496 Q99e 10 Type leaching pits,number: 6 leaching chambers-,number: J- Qow d i��u 02 Wc` leaching galleries,number: 0 WO leaching.trenches,number, length: Q &)L6 leaching fields,number,dimensions: n 470 overflow cesspool,number: O 11��-- C� �� � Xb innovative/alternative system Type/name of technology:'? /�iL �. Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Loamy band to P-ine coat.6e 3arzd No A ynu o e hl�d4au eZr. & 4 gE64-e op 1?ondi.nG So.i.e-6 ate dAil. Veqeta.t ion to nQ17MOP CESSPOOLS��9e,(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: VV Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): A1,4 Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): CAA A, ciao 120E 12�G64�fib � PRIVW�L/6(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.): 9 i Page 10 of.11 OFFICIAL INSPECTION FORM>--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 5 6 day Lane en e2v i fie. Ma-6.6 Owner: 'tan 70ae s Date of Inspection:12 1/0 3 SKETCH OF SEWAGUDISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters.the building. -7 f -9— , al . L-F, 10 Page l l of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued), Property Address: 356 Bay Lane en t eavT e ai13, Owoer: ;'.zan 7one,3 Date or inspection: 1,211103 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water %d, 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: NA Observed site (abutting property/observation hole within 150 feet of SAS) NO' Checked with local Board of Health-explain: N4 6e ,6 S Checked with local excavators, installers- (arach documentation) -s Accessed USGS database-explain: hj .12://I'own. ka,?az ag e, ma, uh. You must describe how you established the high ground water elevation: Ll,3ed: gahlte_t_U R Nill/vn Nadei 1,2116194 q1tound wa.te2 e2eva.tionz agove .sea .teve-e. 11-6ed: USgS • OFUP/waLion we-P-P da -a. zunr. 1992 11,6ed: CISgS - - l ¢ e 12 finizuale4ange s o e g2ou Prz.3. Januazy 1992 3-7iow Di.,Iu,3zoa s. Aii th/tee ate p,zebentiy day, v� Groundwater.//Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical.separation distance between the bonofj�n of the leaching pit and the adjusted groundwater table is feet. y 11 ' L AprU 30, 2005 RE: 356,gain L-C101e 2flU HA`( -3 28 cev tewULe, MA Pet�tiow to the garv"Stclble cowsewat�ovu Covv ,n ssiovv,.._,. ..�.-®DIVISION To whom Lt vv 2 concern, MU hu.sbavLJ and I are abutters to the northeast of the propertU formerLU b6ongLng to :Fravx jov,,es. MrJones had a habLt of appLULng forperwLLts for One thing and &Ucld ng Whatever he Wanted. 1 tKv0z Uou WUL find that the garage Ls bLgger thaw shown and Ln VLOLatLon Of the SUdeUv e rec(uirewLent on the MacponaLd's. Sideline. The septic sUstewA. exists as shown on the encLosed s�Zetoh. This s�Zetah aLso shows various encroachwLents ALong our sideLLne as weLL as a proposed triangLe swap of equaL area to straighten Lt out. Mr Jones never c(uite got around to resoMv"o this. TKs Lot was ovtgLnaLLU smnUer before MrJones fUed the wetLands. The ov'bq,naL wetlands were Located as shown on the Land Court Decree Plan. The house was permitted due to the fact Lt was onLu goLng to be for two people to LLve LvA,for 4 months. I c[uestion weather this smnU, Low, Lot wUL support an en0rgement, with a septic sustem Ln confoymL to with TLtLe 5. `ours truLU, Joanne McMahon a j 300 ga!J. Lane cevktervULe, MA 02&32 sog-��s z9o3 �'I G.C. garnstabLe Gonservatl,On CowtmUssS On c.G. Barnstable Board of tteaLth c.c. Barnstable guLLdLng inspector l c.c. Robert n�. perm, �.E. . � . 1. 3 Yl RA Y R--3556 AP (F R=; 4. 1 t L=33.64 APROX LIMIT OF CBDX (FND) DITCY PER L. C.. PLAN 35308A �. LOB"` 3 R-& SPLIM LOT 5 LC ASPHALT DRi'IVE �Q� \ T O.F- a 12.5' X G. YD. i LOT 4 V, AREA 27790--t-S F � �� LOT Imp s- GRAPHIC an o zo O Y inch EDGE. OF UPLANDS � h LOT J jl / CN ExsT - SH 2 _DWELLING LOT 5 �a 61 sq.ft. �. _= LOT . � F Y � y LOT 7 Q) 454 sq STEpS R - exist V , LOT 4 GREEN HOUSE All o F , 356 BAY LANE 3J16 'I - 11 SCALE CENTERV► LLE MA =RoNT C�AVA��oeJ -- Y (a Qt%41 � r G�I571Nis RcoF LI E M, 71 �o tJrW DoW ERS - 0 12. 4L 8 CEUAr� SNAk� 1 I I i ,O i-Y i STyvlr &AAoS 356 SigY SANE. �� AR C\-AVAT 1 oN C Rv ILL E MA. 311 _ ScALC WeW 9,OOF LIME RcH1 cCc"C Qoo.F7 cb F`F%STIW, ?,ccF LIVE- (-Fri SN�'c� rrI ;r EX tST�N(r I5+ FlvoF2 0 t - I z` iz.X�S'�1Nlr DEC4c i FY�iS�IN Cr ltJALi:OvT n Ll Ev�s-��N(� GRADE 356 BAY LANE SIDE ELAVATION C E N T E R V I L L E MA. r" _ SCALE I�R1CK CN 1 MNEJ 12. �D t2 y 1 1 F1t2CN2'TEC-i RAF S4 L.,LES N'C\d DORM", =. N EW_ 2 ra F LooRno ;T GEaAR sNAkE Fti�o, NeNPoRcN k EifS-riW& L5A- Pcbc , _o ��IbTINIr DEcK F�oN T -�` -- - r' FA is-T►Nb Z SIDE c` Y �,,/,31.KOVT gASE(+rIENT FX15T1Ntr STONE WfAoilti � WAt.i - _ - �XhTLN(s &RARE _ _ — a� An First floor plan 42=10" =7" 911 6=9" 8=8" Ir Gauge ra=ra 1'-0=Y6' 1-0rrb dYraH ra=r ra=6=f' ra=a•r N 0 4 09 n\ Smoke!Heat M'ot x aet av Kitchen Dining - i 13R x 10.00"T ?P ® Smoke 4 N Ilk ■ `" o" living b r f � b ® o N Library N a• t , lv4r Covered porch w Fi N ■ rrr=taco ' ra=rr IN 11 IN .{�---7'48" lk T-2" 3=1" 9'-0' 4" .r 37=10" Covered porch try=taco +r-+=raoo tnr=taco - - 37'-6 Second floor plan 43'-0" 9'-11" 6=8" 6=5" 11=8" 3=1" 3'-0" 2'-3" 7-0 7d'x Y-e, "x 3d'' 3'.Xx 5'S' 3,-o x5'-1' 7-0•x 5'-f^ ,7-0'x5'.1• N Closet F � x Garage � � u 00'Ot xWt M.Zb CD Q, Master suite y .5b 42"W 13R x 10.004 13'-6" b ' ® Smoke 4 N © Smoke 4 13'-V/fi �r�•x Q'e' V. 4.0.Q'.8-BF 2-6" Smoke ch ? 2-6"-� Bedroom 2-6" N 1'- y ______ 3-6CO . r-0•x B'A'8F p NT - N N to 2'--3" 2=6" 2'-3" 2'-3" 2'�" T-0" b Basement floor plan 44-0" 3=9" 101-0" 13'-8" Ir111-9" 440" rm.ro rp .•a N ao=sr da.raso Exercise/Game Room ® o 4 • � 'oc x ae1 moke a � Smoke '^ AUPI + 1_r 6 b Bedroom �o = F 1-9?11-9" Smoke m ----- 42"W 13Rx 10.00 ,I1��1�12-4"� Den/video room b 14=7" _ 14'-8" -�_"� =r Smoke b- Utility room Smoke a ublSho~ k ry 601Lx30"W + 38'-0" Prl' ¢ s<voof 9^Y S <fn+TEQY/Llf NARL-OR PROPOSED PROJECT COMPONENTS L REMOVAL OF EXISTING GREENHOUSE OF APPROX. 155 S.F., RESTORE GROUND TO STABLE VEGETATED CONDITION. 2. PROVIDE IMPROVED POST SUPPORTS ALONG REAR DECK.ALL SUPPORTS CONSISTING OF 2 FT.X 2 FT.MAX.FORMED CONCRETE FOOTING PADS APPROX.3 FT.DEPTH. ALSO TO SUPPORT ADDED DECK ON REAR. 3. ADDED DECK ON REAR APPROX. 12 FT.X 20 FT.APPROX.7 FT. CLEAR OF GROUND. . 4. 2 FT. EXTENSION OF REAR OF HOUSE ALSO SUPPORTED BY ADDED DECK SUPPORTS. APPROX.7 FT.CLEAR OF GROUND. 5. POST-SUPPORTED"FARMER'S"PORCH ALONG FRONT OF EXISTING DWELLING;7 FT.W.X 37.5 FT.L; 2 FT.X 2 FT.MAX. FOO Q� L �� E 6. 4 Fr.W.W 14 6 L COVERED PORCH BETWEEN EXISTING HOUSE AND GARAGE. ---.._ 7. SECOND FLOOR ADDITION AND ACCOMPANYING ROOF CHANGES. CONSERVATION AND GENERAL NOTES 1. THE WORK LIMIT SHOWN CONTAINING CONSTRUCTION RELATED ACTIVITY SHALL BE FITTED WTTHA SILT FENCE. THE FENCE SHALL CONSIST OF A CONTINUOUS LINE OF STAKED FABRIC SILT FENCE OR OTHER ARRANGEMENT AS DETERMINED BY THE CONSERVATION COMMISSION. THE SILT FENCE SHALL REMAIN IN PLACE UNTIL THE WORK IS COMPLETE AND ANY f GROUND DISTURBANCE HAS BEEN RESTORED.. 2. NO CONSTRUCTION-RELATED ACTIVITY SHALL OCCUR OUTSIDE OF THE WORK LIMIT. 3. ALL TREE,ROOT,SLASH OR OTHER DEBRIS RESULTING FROM THE WORK SHALL BE REMOVED FROM THE SITE- 4. REFER TO ANY RDER OF CONDITIONS ISSUED FOR THE PERFORMED WORKX ACTIVTTY BY THE BARNSTABLE CONSERVATION COMMISSION. 5. PLAN REFERENCE:SITE PLAN LOCATED IN BARNSTABLE,MA PREPARED FOR FRANCIS AND SUSAN JONES BY YANKEE SURVEY I CONSULTANTS,PAUL A MERITHEW,PLS.DATED SEPT.25,1991; ADDITIONAL SITE DATA PROVIDED BY CAPE COD ENGINEERING, INC. 6- ELEVATIONS REFER TO NGVD 1929. CONTACT CAPE COD ENGINEERING,INC.FOR BENCHMARK INFORMATION- S 6 7. THE PROPOSED ADDITIONS'DIMENSIONS ARE TAKEN FROM DRAWINGS PREPARED BY MICHAEL GASPARD,APPLICANT.AND b ARE AVAILABLE UPON REQUEST. 8. NO CONCLUSIONS ARE INTENDED OR INFERENCED WITH \� p RESPECT TO ZONING COMPLIANCE. 9. THE SITE IS LOCATED WITHIN THE 100 YEAR COASTAL FLOOD a o PLAIN ZONE A10 WITH BASE FLOOD ELEVATION-I NGVD- h CONSTRUCTION SHALL COMPLY WITH APPLICABLE FLOOD PROTECTION PROVISIONS OF THE MASS STATE BUILDING CODE- . � 7 8 -�.. rn 2 � L�o� / 1t S r P ll po PP L / p �rAn/aGE / PSI" L1N � 01 N f QSE p D G p p ��g P 0 S Q zoo- "9. J ,,��j E K P OLK-Po /s X E �� a b Z �. \ O EX/S/'• X v \ •c.. ErREE Y 'moo NvvsE Lim/r• of top' A,_-e- /dESTO�E G90vly �L, , �,�, �sEE tiorE) REVISED 9/29/05-SHOW PRESUMED R.A.AND COASTAL BANK NEAR DRIVEWAY o r�oEl o raFt< sT,,�,v� C TOPOGRAPHIC PLAN SHOWING PROPOSED \ 6 \\s ADDITIONS TO AN EXISTING DWELLING RT AT O L D 80 �� M, 356 BAY LANE, CENTERVILLE, MA CR ASSESSORS' MAP 186;PARCEL 1$ µ/. 35880 PREPARED FOR MICHAEL GASPARD 225 GOSNOLD STREET, HYANNIS, MA 02601 MARCH 23,2005 SCALE-AS NOTED d PREPARED BY NOTE:THE PRESUMED 200 FT. RIVERFRONT AREA IS'SHOS'V '.,,t A PLAN SC/q L E /"= 20 ' CAPE COD ENGINEERING, INC- -' ­ SCALED _ MEASUREMENT FROM THE LOCATION OF MEAN 1�Idfl-W TER . ROBERT M.PERRY,PE AS OBSERVED DURING SEPTEMBER 2005 IN THE EMBAYMENT TO THE - 50 LELAND ROAD SOUTH OF LOCUS USING THE TOWN OF BARNSTABLE GIS AERIAL BREWSTER,MA 02631 PHOTOGRAPH ml86plg.dgn AT A SCALE OF I IN.- 100 FT. TEL-508-896-4861 a