HomeMy WebLinkAbout0073 DOLAR DAVIS ROAD - Health 73 Dolar Davis Road
Centerville
A= 171 - 279
---------------
I
move
Olt
UPC 12534
2-153L3LO-
� V
No. 1 Fee01—
?�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1111IIII
PUBLIC HEALTH DIVISION ;OWN OF BARNSTABLE, MASSACHUSETTS ''es
ZippliCotiott for TDigpoga1 *pgtem Cottgtructtott Permit
Application for a Permit to Construct( ) Repair Grade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. 173 r oo u-. Rd Owner's Name,Ad ress,and Tel.No. 6 -&V5-
�r->��I i� rmt Alssef-ts.
Assessor'sMap/Parcel Ir)1 -) /`t1 ;V
l taper's N meAddr ss,and T 1.No. / Designer's Nap Address and Tel.No. 6rV 36--- 5- r
(1s�v PJ dUrstno-,
S� Gir O_Y
Type of Building: a
Dwelling No.No.of Bedrooms �/ Lot Size �`�o sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 330 gpd Design flow provided 3 A, 3 gpd
Plan Date 'l. r(S' ml/ Number of sheets Revision Date
Title ' Lvz Cc it t
Size of Septic Tank V_'Ki' IQ Type of S.A.S. /�o1p ?X15-0 I(1 � �p�✓
Description of Soil 01.
Nature of Repairs or Alterations(Answer h n ap licable)
0
Date last inspected:
Agreement:
The undersigned agrees to ensure the constructio aintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the E ironm al Code and not to place the system in operation until a ertificate of
,Compliance has been issued by this Board o ealth.
tgned Date
Application Approved Date
Application Disapproved by: Date
for the following reasons -
Permit No. I —3 Date Issued '.)Z 1
6
rJ...s' tr 1
j ..^^" f 19
No. I ! Fee
THE COMMO WEALT r s H OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE; MASSACHUSETTS YES
2pplication for Migool i&p!5tem Cow5truction Permit
Application for a Permit to Construct Repair <91ade Abandon I�
pp ( ) p ( ( ) ( ) � Complete System Individual Components
�13h r
Location Address or Lot No. �o V Owner's Name,Address,and Tel.No.
Q-&n kro i i l E? rti rt A sse.r�
IQAssessor's Map/Parcel -) n <IanQ �.fvllle ��3a
'I staller's Nam�e,/�ddress,and T 1.N-o_. Designer's Nam a- Vo/e Address and Tel.No. �V 3��-
ICJ/v7T/ �/Err
&r s T�
Type of Building:
Dwelling No.of Bedrooms `3 Lot Size 1j;/tTc r sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 330 gpd Design flow provided `3��� 3 gpd
Plan Date , (S_ "mi/ Number of she Revision Date
Title !i me I/ S /f AP c,-1 7,5 [JCJ/e,r Ui S � C '/�),I fdilk Size of Septic Tank I/Yri aalA 14-10 Type of S.A.S. a(, �U i U 1�l4�i/
mAors f
Description of Soil
Nature of Re airs or Alterations(Answer/w'hen applicable) Gn
Date last inspected:
Agreement:
The undersigned agrees to ensure the con structand-maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
S'g end` r `�...., Date
Application Approved by, Date r
Application Disapproved by: Date
for the following reasons
Permit No. �;_ , Date Issued 7 -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that th On-site Se age Dze.--t—
at sal Sys em Cons.t.rrzu-c�t-e)d C
Repaired (v) Upgraded
Abandoned b
( )
73 Lllnn t); , ¢, Cen,. -iI,►I4 has been constructed in accordance } �
with the provisions of Title 5 and the for Disposal System Construction Permit No. � o i dated
Installer ( {i, tC�77�4CctC j�� 1-r�C. Designer ilit)n(1
.f4-F
#bedrooms 7j Approved design flow 3 J gpd
The issuance of this permit shall not be co strued as a guarantee that the syste will func designed.
Date Inspector
No Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
aigonl *p,5tem Cony ruction Permit
Permission is hereby granted-lto Construe.,,( ) Repair (4,,-) ��grade ( ) AbandonSystem located at � t(�J , ( )� v�
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
l to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.'
Date , Approved by..
. W.,
OCT-12-2011 09:29 From:BORTOLOTTI CONST 50B4289399 To:15087906304 P.1f1
FROM :down cape enQireering inc FAX NO. '15OW6298W Oct. .2 2011 0720AM P2
a 7�M►mpu If. a'.a+il!�°�•, Rpia°ra:ilt�r
�hri�f'r6rnnt�.
Mx�t�. /� �4,U�3inG 9'1gi.Q,tiJJlr�in �7b��ROd1'lla
:00 mAll, 1tlla rule,MLA 01661
Qi:w r. �Q}S- fig 4�i49 pox° 302-740-6101
X11W1IkY�iP : liB4`aI r7P LAG �' t �l]L!jlQ
P oTte.
i�.I�If�Ill•{.'��S ��f.� ��" ' +._�..�.. ._ �.0.{tAA���: / 'V' //r/r- I `.
1 'MtjkT' 9'v� �G.f�r�D �iGCJ'
oil„� � / �rr�ala�/�5�� .�rns;�ucr���l,r:.ittr,;►,�,tnll�
sPnfic 5y-%xm rat 73 j A,✓U /S hased nn a Jaip.,o 3r:twig.by
datd
T a;tti{y LtUttJIac jmCj(- $ygt=r(,,'*ze-ticed abovo wiq ins{,+11.�d �ub�tr+t,ti,�:lly tk4rarcli�� W
tho dr,S.im WhdC-h TnaY U CUT, Tl Wr �.�Ijy,rnv�:,�� �:�ri��,ee sutl► as :�li.rttl a�Ir,CuCit7lt Of (ttr
dk Tib-ofion hux arl.dh i-;;c Via tank.
_ T 4xTAi ► Nat lb. n 'tic; sy'RfCTll.TtiL4'1l`:u�c.i �.IscrvC ,gas u� lkt1lcci wirl, Ty a r,�a�in��s ;.i..c
+re,ilar t a.n 10, Istaxal re-io(I.A ..0n.of le SAS or any vat c8l MIUCA*Inn Of EiTztY crli`P uvnt
(it dlm svytr.r.zystcr�} hut'irx ac ngrdance wi,Llt$gate� Loan, Q-09-0alinna. i'�lau lCvi!�r.)u,nr
cr�°1.af o.,A ea by del-W..UITT 60 follow
C7ANIfiLA�
_ OJItl.F1
(.LrJ�{ttll1,1,� �yitT3cCl GIVII, r^
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tir.�,fc�la C4^i.
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a:�►1, 'Zl� :`DI" li i�,v°� 1 i "''ff: t}�p( �.TrTE mil,( 1111!( 17 A4- I I i�p r,�TAn
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TOWN OF BARNSTABLE
LOCATION PS- SEWAGE# .-Oil-atdy
'VILLAGE (_,t:T1T!:---9Z.o,J t LL tc ASSESSOR'S MAP&PARCEL 1-7 l -J-39
INSTALLER'S NAME&PHONE NO. J�eA=—a-t,5TII J�C'wL',: S30'-77 1
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type2�7.t�.k� (size)30•4.K-14• 1��
NO.OF BEDROOMS TUSd
OWNER
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) A4 Ac Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
,FURNISHED BY
ti
�7.� ,
. 6�J��'
.e �-�
�, ��'
30'
y/`
O
a / N
Town of Barnstable >ln#Z,�
�IRE7
iDepartznot of Regulatory Services
� �rA3 Public Health DiviSioli Date
MAS& 200 Main Street,Hyannis MA 02601
Date Scheduled /�` / Time ! CJ u ce
Foil Suitability .��ssess����ent for Pc e ispos Il
Pcrfanned D �Gtt1 I GL I� Witnessed Y.
Y
& qENT
Location Address 73 O/Q/� avl J Owner's Name
CAddress vl
Assessor's Map/Parcel: -/7 Mngiucer's Namc
NEW CONSTRUC710N REPAIR Telephone It(Sve
Land Use Slopes(%) C�0^ S Surface Stones
Distance's frorn: Open Water Dody ft Possible Wei Area ft Drinking Water Well ft
F �
Draiha.ge Way ft Property Line (7 ft Other Jt
SEETCH' (Street came,dimensions of lot,exact locations of lest holes 8c pert tests,locate wetlands 7n pro)rintily to Boles)
Q \ r Drs
Ns�
C:) M.
'v
3�TN2•
o°
�s
Parent material(geologic) ��0.C.�ot� ����`Sr Depth IQ Deciroelx
Depth to Oroundwatcr: Standing Water in Hole: //T. Wecplllg ID'anl flit Fflce I /
Estimated Seasonal High Oicundwawr
DE T EI[NHIaTATJ[ON FOR SEASONAL HIGH WATER TABLE
lYlelhod UsccL -1r
Depot Observed standing in obs.hole: Na/� NGIn, Deli l�l IU 5gil Ikl 011l.58:. �' III,
Depth to weeping•,from side of obs.bolt: _� in. Oround wit ler Adjusihlent m�ft.
Index Well Y Reading Dale: Index Well level Ad�j.!niter T Adl,CJrounclwater Level e
]PE RCO LATIIOz'41, ' +�S'r ItDatk �fl 'Abim �G po 4M
Observation w
Hole ff ' Time at 7"
Depth of Pcrc �1 b /l Tlutp ul 61,
Start Pre-soak Time @ Time(9"•6")
End Prc-soak °`
Rate Min./Inch G',�!L! {'�Inch
Site Suitability Assessment: Site Messed_K SiIG-Failed: Additional Testing Needed(Y/N) /V
Original; Pubiic Fieallh Division Observation Hole Data To Be Compteted on Back-----------
***If pex'colaticia test is to be couiducted vvcLiihi 100' of wedand, you must first uaotalry tllne, ff
t
Mirnstable Conservation➢ ivision at Yeast olrze (I) week pricir to Ibeghitu.uh.1g.
QnS EPTICMICRCFORM.DoC
DEEP.OBSEj jiVATION elf®L + LOG --___
Depth from Soil Horizon S 17101E # "f "�
Surface(in.) oil Texture Sdil Color
• (USDA). Soil• �~Other
(Munsell) Mottling i/ g (Structure,Stones;Boulders,
\ >i; Con istene a' ravel
3 - 9
�- AL/- g Y� lz
3y-13 z /flA
Depth from
DERP OBS-F-RVA HOLE'LOG
Soil Horizon
Surface(in.) Soil Texture Soil Color -----
(USDA) Soil
(; ) (Munsell) Mottling (Structure,Stories, Boulders.
er
v F, Consjs enc %Cravel
L 5
S G�/R �12
DEEP®BSERVA� ®�
Depth from Soil Fiorim y �n�®��
n Hole Si,rface(in.a Soil Texture Sall Color
(USDA) Soil
(Munsell) her
Mottling (Structure,Stones,Boulders.
Consistency.�o t7nvell
f
Depth fiom Soil.Horizon a Hole#_
Surface(in.) Soil Textnre -.soil Color Sall
(USDA) „ 1 e Other
�(Muri's ]I)=-. Mottling (Structure,StoneS', Boulders,
Consi�encv�-_?,6 Orp�eil
_. ,
*J• , .",.� �a.�a i 'i „fig E t�;4Jla
Flood rnsurance](g to� ap.,
Above 500 year flood boundary No Yes
Within 500 year boundary No Yes _
Within 100 year flood boundary No
'Yes
D M Of Nfltu rally_cmrfng ]EbG�vaous lV�`aterla➢
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? e-
„ If not, what is the depth of naturally occurring pervious mararial7
ce? tif_ gcatson ,
I certify that on —'Nov -16 (date)I have passed the soil evaluator examination approved by the
]Department of Environmental.Protection and that the above anal}�xi ^was„prf�,rt��d b'y me consistent with
the required train' x.ertise and experience described in �10 CMR 15.0I7.
Signature /
.vl , Date
Q:IS,EMC\PERCrORM.DOC
t
DATE 5/26/06
PROPERTY ADDRESS 73 Dolan Davis Road
Centerville
MA 02632
On the above date, the septic system at they address above was
Inspected.
This system consists of the following:
�. 1-1000 gaiion .6ept.ic tank.,
2., 1-Dizta.igut.ion Box.,
3., 1-1000 gai eon .2each.ing 12.it o
Based on inspection, I certify the following conditions:
r a i_7
cr
t
SIGNATURE
Name: Robert A. Paolini
6_.
[ €n
Company: Joseph P. Macomber & Son Inc_.
Address: P. O. Box 66
Centerville, Mass 02632
Phone: 508-775-3338 or 508-775-6412
0W.WavvM
IJOSEP. MACOMBER & SON, INC.
anks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
66 Centervilie, MA 02632-0066
775=3338 775-6412
r
�\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
d
s. •
TITLE 5
OFFICIAL INSPECTION FORM-.NOT:FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART.A
CERTIFICATION -
Property Address: .. 73 .Dolar Davis Road
Centerville MA 02632
Owner's Name: Mildred Cohen
Owner's Address: . 67 Noanett Road
Needham MA. 02494
Date of Inspection: 5/2 106
Name of Inspector:(please print Rob rt :A Pam„ o.ilni
Company Name:„. P. lea c o m Le 2
Mailing Address:
en eavc e, ¢.s.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 15340 of-Title 5(310 CMR M000). The system:
XXX Passes —
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fai
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection reportto the.Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or hasa 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 toe system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This'repot't 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
i
conditions of use.
Title 5 Inspection form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL INSPECTION,.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOIE
PART A
CERTIFICATION (continued)
Property Address: 73 Dolar Davis Road
Centerville MA 02632
Owner: Mildred Cohen
Date of Inspection: 5/2 6/0 6
Inspection Summary: .Check A,B;C,D or B/ALWATVtomplete,all of Section.D
A. System Passes:i/ES
NO I have not found any information which indiCates`that any of the failure criteria described in 3.10 CMR
15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below:
Comments:
SeI2tic ayz�tem i,3 is paopge t wo zk-ing.:.Oade/t ut the /2/tezent t ime.l
B. System Conditionally Passes:
NO One or more system components as described in the"Conditional Pass",:section need to..bp,replaced.or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or hot determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
NO 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:
NO Observation of sewage backup'or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a.broken;settled or uneven distribution box.System will pass inspection.if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distriliutiori box is leveled or replaced
ND explain:
NO 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: 73 Dolar Davis Road
Centerville MA 02632._
Owner: Mildred Cohen
Date of Inspection: 5/2 6/0 6
C. Further Evaluation is Required by the Board of Health:
No 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:
No Cesspool or privy is within 50 feet of'a surface water
No 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:
No 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.
No The system has.a.septic tank and SAS and the:SAS is within a Zone 1 of a public water supply.
.No The system has a septic tank and.SAS,and the SAS is within 50 feet of a private water supply well.
No 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 visual
"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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 73 Dolar Davis Road
Centerville MA 02632
Owner: Mildred Cohen
Date of Inspection: 5/2 6/0 6
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following;for all inspections:
Yes No
_ X Backup of sewage;into facility or system component due:to overloaded.or clogged SAS.or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ X Liquid depth in"cesspool is less than 6"below invert or available-volume is less than'/S,.day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface
water supply.
_ X Any portion of a cesspool or privy is within a Zone 1.of a:public welt.
X Any portion of a cesspool or privy is within.50 feet of a private water supply well. �..
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.[This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free 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.]
No (Yes/No)The system fails.I have determined that one or.morefof 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 1.0,000 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
_ . X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located'in a nitrogen sensitive area(Lnterim 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: 73 Dolar Davis Road
Centerville MA 02632
Owner: Mildred Cohen
Date of Inspection: 5/2 6/o 6
Check if the following have been done.You must indicate"}Fes"or"no"as to each.of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped outin.the previous two weeks
X _ Has the system received normal flows in the previous,two week period?
X Have large volumes of water been introduced to the system recently or as part of th;s inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?.
X Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ 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.
X _ 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
f
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM;INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 73 Dolar Davis Road
Centerville MA 02632
Owner: Mildred Cohen
Date of Inspection: 5 2 6 0 6
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4 4 4 0
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd z#of bedrooms):
Number of current residents: 2
Does residence have a garbage grinder(yes or no):yes
Is laundry on a separate sewage.system(yes or no):n o . [if yes separate inspection required]
Laundry system inspected(yes or no):n o
Seasonal use-(yes or no): no .2 0 0 4=15, 0 0.0. ga e i o n %D 41. 10
Water meter readings,if available(last 2 years usage(gpd))'..-2 0 0 5=2, 0 0 0 ga i i o n.6[7=5 4 8
Sump pump(yes or no):
Last date of occupancy:
COMMERCIAL/I14bUSTRIAL N
IA
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design.flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use: .
OTHER(describe):
GENERAL.INFORMATION
Pumping Records NI R —
Source of information:
Was system pumped as part of the inspection(yes or no): n o
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM.
X 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
ob_tained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
20+
Were sewage odors detected when arriving at the site(yes or no): n o
6
'Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 73 Dolar Davis Road
Centerville MA 02632
Owner: Mildred Cohen
Date of Inspection: 5[2 610 6
BUILDING SEWER(locate on site plan)
Depth below grade:2 4"
Materials of construction:_cast iron X_40 PVC other(explain):
Distance from private water supply well or suction line: 20=
Comments(on condition of joints,venting,evidence of leakage,etc.):
Jo.intz aRReaa Light,, No .Qeakage i Vlva.lp-d. 1hanuyh
SEPTIC TANK:ILES(locate on site plan)10 0 0 gci.2 e o n,6
Depth below grade: I
Material of construction:X_concrete metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8' 6"X5 ' 8"X4' 10"
Sludge depth:_..tz a c e
Distance.from top of sludge to bottom of outlet tee or baffle:t2 a c e
Scum thickness: t a a c e
Distance from top of scum to top of outlet tee or baffle: t 2a ce
Distance from bottom of scum to bottom of outlet tee or baffle: I./?-a re
How were dimensions determined: mea-6u2ed
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.): —
l um tank ev 2 I 7ank .ih
.s 2uc u2a y 60undoL-iau.id ieiveiz ate aoama. ,l
GREASE TRAPkQ (locate on site plan)
Depth below grade:
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:
Comments(bn pumping recommendations,inlet and outlet tee or baffle'condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
2eaze taa .ia not pltezaerit
7
r
Page 8 of 11
.OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 73 Dolar Davis Road
rent:erville MA .02632
Owner: Mi 1 drPd enhen
Date of Inspection:_5_12.6_10.6
TIGHT or HOLDING TANKNO (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass__polyethylene. -other(explain):
Dimensions:
Capacity: gallons
Design Flow:. gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes.or no):
Date of last pumping:
Comments(condition of alarm and flo t switches,etc. :
7.ight oa hoiding tankh ate not RaeZent
DISTRIBUTION BOX: 6 S (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, tc.
Box iz .2eve.2. f a� 1 .eateaai.1 No iso eid caaayovea oa iekage in oa
out 07 rox.,
PUMP CHAMBER: NO (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump eham&ea .is not 1211eseat
8
Page 9 of 11
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION(continued).
Property Address: 73 Dolar Davis Road
Centerville MA 02632
Owner: klAY49c
Date of Inspection: 5 2 6/0 6
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Loca.i<ed .ee 12age 10.
Xype leaching pits,number:
leaching chambers,number:
leaching galleries,number: `
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
Loamy .to medium zando No 3ign,6 o� ;ea.iiaze., So.iez a/te day., Vege.ta;lion
._a no2ma
CESSPOOLS: NO (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer: _
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):.
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Ces.61zoo.e�s a/te not /2/tehent
PRIVY: NO (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.):
l,T ivy 1.6 not /Me-Zen.t
9
Page 10 of 11
OTFWIAL INSPECTION FORM-.NOT FOR VOLUNTARY.ASSESSMENTS
SiJ"ACE SEWAGE DISPOSALSYSTEM INSPECTION FORM
l PART C
\ .SYSTEM INFORMATION(continued)
Property Address: 73 Dolar Davis Road
Centerville MA 02632
Owner: Mildred Cohen
Date of Inspection: 5/2 6/0 6
SKETCH OF SEWAGE DISPOSAL SYSTEM `
Pr\%ide a sketch of the sewage disposal system including ties to at least two permanent refere fe 'landmarks or
benchmarks.Locate all wells within 100 feet.Locate where.public water supply enters the.building.
Qlar S. R�
301
o to
10
r
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: . 73 Dolar Davis Road .
Centerville MA 02632
Owner: Mildred Cohen
Date of Inspection: 5/2 6/0 6
SITE EXAM .
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate check all methods used to determine the high ground water,elevation:
•N 0 Obtained from system design plans on record-If checked,date of design plan reviewed:
y es Observed site(abutting property/observation hole within 150 feet of SAS)
ue�sCheckedwithlocal-Board.ofHealth-explaimez l 'U a2d
a Checkedwith local excavators,installers-(attach documentation)
l,[e_.s�ccessedUSESdatabase-explain:httR town.�2aanista&ia,'ma..,u¢
a4
You must describe how you established the high groundwater elevation:
Used : Cape Cod C.omm.is•ion ldatea 7ag•2e Cohtoultz Aad P ugtic Glatea Supply
b ii head paoteet.ion aaeaz map.- Sept 1995
Vat ea ae souace s oO;&.ice cape cod commzz ion.,
Top of Ground
Vx
Leaching
Pit Feet
GroundwatA Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is �
feet:
V
' 11
r
•.III+,,,..-,.f•f+.•,�,-..ter-,I.I,f,.lf..•,.....�I...r ,....v ate:.-••1;
TOWN OF BARNSTABLE BOARD QF HEALTH
SUASURFACK SEWA08 DISPOSAL SYSTRM INUPRCTIQN lydRM.- PART D CERTIFICATION
•••TMI-T•Yfft•*T1M'V6TT1111lMI'R �� � �' �••�I•' '•
-TYPE 01 PAINT CLEWY•-
P1i0.PERTY MSPI<;CTE10
STREET ADDRESS 73 ;Dolar Davis Road Centerville • 02632'
.._,
A•SS•ESSORS MAP, BLOSK AND 'PARCEL
owNER's NAME Mildred..,99hen
PART' D QSRTIFICATXON
NAME OF INSPECTOR Ro l ii tt P.a.0VA-1
COMPANY NAME ,=ph .P., 17acoxielt. Son Inc
r I I li^•, f i 111��1 ■Ild��w�.r.�,r�y...
COMPANY ADDRUS.
Box 66 '• ,Czn�eay.UZz Na.�b' 02632 '
str• �' Toxn-or City. tita • Lip
COMPANY TELZPHONE ( 508. J /75 - 3338 FAX (' 508'11790 1578 .
CERT•I•FICATION. STATEMENT
I certify that I have pereotiaily .inspected ..the oewage 'digposa`i. system at
this nddress and that. .tli:e' information reported ,is tale,. aoc Ura•te•, slid
omplete as of the time .of#inspeetiony The insgevti&n was per•Foxaed and any
recommendations regard.ing upgrade., -maintenance,- abd repair .are• eon$is'tent
with my trainip,9 and experience in th@ proper function- avid maintenance of on-
site sewage disposal systems,
Check one;
Systeul PASS D
The inspection whiah •I have .-conducted has .,n-ot' found any information .
which indicateq that the system fails to ' adequately, protect .publi•e
health or the envi.ropment as defined in. .310 CMR. 1C30.3•, *ny failure
criteria a6t evaluated are as stated in the FAILURE' CRI'i'RR,IA .section o•f
this . form.
System FAILED*
I The inspection which I have -has .found that *the oystem fails to
protect the public Health rind the enV4rortment • in a000rdemce with Title
61 310 CMR 15 . 303, and ecificali.y noted -on .Pk.T 0 •. FAILURE
CRITERIA of this inabec' ion orms /
! Date Jai ��o
Inspector Signature
,um
ne copy of this aertifioAt•i:ar must berovi'ded 'to =the .QWNR, the BUYER•
where appikca•ble) and the DPARD OV KEA TEt.
4•
* If the inspection FAIG'Eb,, 'thb .cwne'r'.*'r"'operator •n:K4Lll, . upg-r:e►de'•the eyetem.
within one year of the aat•e of the inopection, unless. ai'lowed Qr, required
EhArw4ae as Provided in' s,lU CMR 16 , 305 ,,
TOWrNI OF BARNSTABLE
LOCATION SEWAGE#
VILLAGE ASSESSOR'S/ ��MAP&PARCEL /71
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS OWNER kz1kce
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
-7:3 polar DCWIS AN
100,
G/ASSESSOR'S MAP NO. PARCEL
",-4O CAT ION
!'.. -r`�EE PERMIT
ERMIT N o.
L�
VILLAGE
r INSTA LLER'S AME i ADDRESS
� G�
e UILDE R OR OWNER
DATE PERMIT ISSUED42 /
C�
DAT E COMPL,I.ANCE ISSUED D/ V-7 �
b B
oI All p e iS
SYSTEM PROFILE----------
ALL SYSTEM COMPONENTS SHALL BE
MARKED WITH MAGNETIC TAPE OR NOTES
TOP FNDN. AT EL. 60.1' COMPARABLE MEANS FOR FUTJRE LOCATION. a rodACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE)
1. DATUM IS ASSUMED
ACCESS COVER (WATERTIGHT) TO
PROVIDE INSPECTION PORT To WITHIN 3" OF FINAL GRADE
WITHIN 6" OF FIN. GRADE 2. MUNICIPAL WATER IS AVAILABLE 0
MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM
�
3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
RUN PIPE*EXISTING 57.9' FOR FIRST 2'LEVEL
18" MIN. COVER
10" EXISTING 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO
TEE 1000 GAL H-10 2" DOUBLE PEASTONE Q
SEPTIC TANK \56.5±*' TEE OR GEOTEXTILL FABRIC H-_1 0
EXISTING 55.2 Locus
G/ \ r
(RE -USE) GAS Z�5 4.7' C�_
ml 74 741
R 54.7' 5. PIPE JOINTS TO BE MADE WATERTIGHT.
4' LIQ. LEVEL (ACME 0 BAFFLE 54.87r' ml
C> 54.7'
\_6- CRUSHED STONE OR MECHANICAL 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH e orn
c=,
COMPACTION. (15.221 [2]) S 1.8 5' 52 8 MASS. ENVIRONMENTAL CODE TITLE V.
.
DEPTH OF FLOW
TEE' SIZES: 4'
H-20 3050 INFILTRATORS 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
q3
BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE.
INLET DEPTH = 1 on. 3/4" TO 1 1/2" DOUBLEp WASHED STONE
OUTLET DEPTH = 1409 SLOPE) (-L-% SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. ou
OVERALL DIMENSIONS TO OUTSIDE OF STONE: 30.4' X 10.E5'
LEACHING 5.85' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
FOUNDATION- EXIST. - SEPTIC TAN K 26' D' BOX 20
FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION LOCUS MAP
OBTAINED FROM BOARD OF HEALTH.
NOT TO SCALE
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON H-10 SEPTIC TANK IF NOT SUITABLE. DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION ASSESSORS MAP 171 PARCEL 279
B)TTOM TH-2 EL. 47.0'
OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO
ENCOUNTERED
8ROY&ESATER COMMENCEMENT OF WORK.
UN
LEGEND 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
100.0 PROPOSED SPOT ELEVATION
12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
REMOVED 5' BENEATH AND AROUND THE PROPOSED�
+100.00 EXISTING SPOT ELEVATION LEACHING FACILITY.
SYSTEM DESIGN:
Flo 01 0 PROPOSED CONTOUR
0
100 EXISTING CONTOUR GARBAGE DISPOSER IS NOT ALLOWED
DESIGN FLOW: 3 BEDROOMS 0 110 GPD 330 GPD
400
4& USE A 330 GPD DESIGN FLOW
SEPTIC TANK: 330 GPD (2) = 660
RE-USE EXISTING 1000 GAL. SEPTIC TANK**
1 \
LEACHING:
SIDES:' 2(30.4 +10.25) 1.85 (.74) 111.3 GPD
Q/TEST HOLE LOGS BOTTOM 30.4 x 10.25 .74 = 230 GPD
UNDERGROUND / s' \\
DANIEL A. OJALA PE ELECTRIC, TEL.
ENGINEER.. AND CTV. IN
TOTAL: 461 S.F. 341.3 GPD
,
THIS AREA. m LOT 12
WITNESS. DON DESMARIS 15,156 SF USE (4) H-20 3050 INFILTRATORS,
WITH STONE AT ENDS AND 3' AT SIDES
DATE:-9/15/11
Z
PERC. RATE < 2 MIN/INCH ^ryh /
I p# 1,3403 BENCH MARK CORNER OF rn
CLASS SOILS CONC. BULKHEAD EL. = 59.3
ELEV. ELEV. EXIST. DWELL. MA
C�iTOP FNDN. 60.1' APPROVED DATE BOARD OF HEALTH
off
58.0' -0 58.0' GRAVEL DRIVE
FILL FILL TITLE 5 SITE PLAN
39p 57.75 9 .391 57.75' 39 OF
0
A A i 0 DECK
58
LS LS
8"
H 73� DOLAR DAVIS RD
1 OYR 3/2 819 1 OYR 3/2 Cn
, . 57.33' 57.33' CP CENTERVILLE, MA
58 58 PREPARED FOR
B B
r
PERC LS LS o A
�� �\�A OF AU4,4 DANIEI
G�34" 10YR 6/8 55.16' 3491 10YR 6/8 55.16' A. BORTOLOTTUNASSERY
D NNIEL A. OJALA E
VILE
DJALA No.A
DATE: SEPTEMBER 15, 2011
CP
C No.465 SS\
c
off 508-362-4541
Pa
C5 -ki fax 508 362-9880
M CS M/CS ONAL c
DANIEL yG
ip
OJA A.
2.5Y 7/4
2.5Y 7/4
IVY
IL OJALA down cope engineering, Inc.
132" 1 47.0' 132" 1 47.0' 2 No,40980
Scale: 1 2V 0\\ CIVIL ENGINEERS
NO GROUNDWATER ENCOUNTERED ��Ss ir- LAND SURVEYORS
/ON L SU
939 Main Street YARMOUTHPORT, MASS.
0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S.
DCE 11-215 11-215 BORTOLOTTI-NASSERY.DWG