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Home My WebLink About0065 ELLIOTT ROAD - Health r 65 Elliott Road Centerville P A = 248 283 No. 4210 1/3 ORA ESSELTE 10%U& ® o 0 0 �. I� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes -, ftplItAtIOn for ZISp08aY 6pstPnt COttstCUttIOn 3pPr1rilt Application for a Permit to Construct( ) Repaiir,-Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components 1 Location Address or Lot No. J = !io Owner's Name,Address,and Tel.No. �' G qc Assessor's Map/Parcel ,�f ✓ ( Jah Gl� �7� "j'lns,�ersdes`d T��. �� Designer's Name,Address,and Tel.No.Lai Q lsC� k ► / Type of B ilding: 246` 2-T1 Tog- 3(0`(' (38 91 PO Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(� Other Type of Building C,.r ',kA No.of Person Showers( � ) Cafeteria( ) Other Fixtures /�_ ass �.s Design Flow(min.required) gpd Design flow provided G gpd Plan Date / Z�1� �Q� Number of sheets I Revision Date Title Size of Septic Tank 0 v T pe of S.A.S. Description of Soil ('\ - (� t.. ,`�g � �y ;-,/-M C "J"1 i s s —�—.•��-r(® l t..� r Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the EnvironmMtalode and not to (ace the system in operation until a Certificate of ' B Compliance has been issued by oard o cn^-�`'(�� bei 4 d Date / Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes I . 4plICatIOn for DI8p08aY 6psteln COnBtrULt10I1 3perUllt �! Application for a Permit to Construct( ) Repai Upgrade( ) Abandon( ) ❑Complete`System ❑Individual Components Location Address or Lot No. G-,, t//r ra 711 1- Owner's Name,Address,and Tel.No. �I Assessor's Map/Parcel j-, J I 1, (—� 0 l 3 .fin �(�nr 1 P?n� Q 4 (s J,/(`��,�� u 26 Z �� Ins�a1 er's Name,Address,and Tel.No. ,p Designer's Name Address and Tel.No. l'T\��<-�Co'%3& ' 7 91 y;�~ r V t6�.aldJ,a /L 62&) C CU- (4 At J0 Wu,, L. oA 6 ,Type of Building: 2- 6- Z j f e 6`'1 ' P 0 i Dwelling No.of Bedrooms Lot Size QN sq.ft. Garbage Grinder( � r Other Type of Building S c �, �,-� ;1 No.of Persons Showers( � ) Cafeteria( ") Other Fixtures �� f s �_ , J S t-�LAI Design Flow(min.required) 3.;t h ! gpd Design flow provided O 1 gpd Plan Date w 2 :5- Ao? - Number of sheets r! Revision Date -- c Title Size of Septic Tank 1 (�y C,A-I Type 1 of S.A.S. + v-Description of Soil a. 4 �� I v+t Itr r t�A e taut >A .0 Nature of Repairs or Alterations(Answer when applicable) /u�,�� f ( ,,; _ r3 x L,-� (N i ivG S r Date.last inspected: Agreement: c The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i accordance with the provisions of Title 5 of the Environrd'�ode and not to place the system in operation until a Certificate of Compliance has been issued b this Board of;Heal`th� Seed(� . fin, Ae Date Application Approved by /i,�� ;/l/g 1 / U Date, Application Disapproved by / / Date for the following reasons U Permit No. v y �(/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Dispo al system Constructed``( ) Repaired( ) Upgraded( ) Abandoned( �y ` , -•i I (,i 4\Z- Lev Ob&i at [/;t_ / has been constructed'nAo,,, nce with the provisiomns of Title 5 and the for 'sposal System Construction Permit No (�{/ ' ted Installer Designer � r��•""��';� � #bedrooms Approved design flow tJ�:11/>9! > gpd The issuance of this permit Jshall of be construed as a guarantee that the system ill ction as designed?`) Date Inspector 'I No.---------- -------------------------------------------------------- ----_---------------------_--=--=----Fee-:= �/L1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Disposal *pet In Construction ,Vermit Permission is hereby granted to onstruct( )�k� Repair( Upgrade( ) bandon System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructiodmust be om leted within three years of the date of this permit. Date �// ( �/ Approved by ✓ /r / ` I 3, y Town of Barnstable Regulatory Services Thomas F. Geiler,Director • RAMWAsl.e, • 9�PMAS& � $ Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 2- S oe Designer: �Zvi p n u�,N t�D�1 i2 ��s Installer• Address: 4-3 T Y-I/W6 LC C IQ Address: �19 On IP41 e 14.1 Leovo-q— was issued a permit to install a (date) (installer) septic system at �o S �� 6 �� D based on a design drawn by (address) �t101p 6006000VZ, iZ5 dated Qe_4 2S, ?�D6 (designer) __,11_A certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. 9 DAVID cy10 (Installer's Signature)Signature) COUG ANOWR No. 1093 GIST0L (144 �o SgNiTARkNN (Designer's Signature) (Affix Designer's Stamp Here) r PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. TOWN OF BARNSTABLE ,n,(/�/ LOCATION 3r AVI o 7r � SEWAGE# a Of� / VILLAGE aenreryo& ASSESSOR'S MAP&PARCEL rA.141?i Q ;143 INSTALLER'S NAME&PHONE NO. �� SEPTIC TANK CAPACITY j!000 LEACHING FACILITY: (type) $aD ��, u,�[( S (size) 13- Zb LEACHING BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between e: 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) 1 Feet FURNISHED BY W I� '7 SOILTEST LOG SOIL EVALUATOR: DAVIID DR COUGHANOWR. R.S. WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. PERC NUMBER: 12400 NO R TEST PIT 1 PARENT MGROUNADTEREAL EPROGLAC IA OUTWASH '1 PERC AT 80 in - 2 MIN/INCH IN C SOILS ' ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 48 25 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING - 0-6 AR SANDY LOAM 10 YR 2/2 NONE FRIABLE 45.42 6-34' B LOAMY SAND 10 YR 5/6 NONE FRIABLE 34-138 C MEDUIM SAND 10 YR 6/3 NONE LOOSE 36.75 -- - NO TEST PIT 2 PAARENTU MATERIAL: PROGLAC ALD OUTWASH 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR .SOIL OTHER 48.00 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 0-8 AR SANDY LOAM 10 YR 2/2 NONE FRIABLE B-32 B LOAMY SAND 10 YR 5/6 NONE FRIABLE 4S3;i 32-120 C MEDUIM SAND 10 YR 6/3 NONE LOOSE 319 00 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi to c Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 yearboundary No-A—/ Yes Within 100 year flood boundary No l! Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perv'tpus material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on l 6 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me cons' to th . the required training,expertise and experience described in 310 CMR 15.017. �ySH 0 Signature ICJ C LSD 4" Date o DADVID " COUGHANOWR s0 �10ENS�� Q 0 Q:\SEpTIC1PSRCFORM.DOC /� VA LV PL oF� Town of Barnstable (/ P# Department of Regulatory Services nARIVBTABIE, Public Health Division Date OCt '3 1 2-00`6 MASS 200 Main Street,Hyannis MA 02601 � Date Scheduled O Time Fee Pd. //W Soil Suitability Assessment for Se ge ' posal v Performed By: Witnessed B 7A �D LOCATION& GENERAL INFORMATI%T Es Location Address 6 S ELLIOTT- P—D Owner's Name q 4,4 KOv+'LeA q l,LV 1 LLL Address `O S C u l O'f'T 12D a JTer_�Vl LLE Assessor's Map/Parcel: 2-44-/2-f 3 Engineer's Name I)jI ut p CDvGh l-Npwi NEW CONSTRUCTION j REPAIR oT�elephone# SD t �6� 6 4_. Land Use %142 Slopes(R'o) <� Surface Stones D �' Distances from: Open Water Body 100 t ft Possible Wet Area (oU� ft Drinking Water Well LUb+ ft Drainage Way 5 0 t ft Property Line L V + ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,`locate wetlands in proximity to holes) ® TP-1 TP-2® I GROUNDWATER ADJUSTMENT 1 EXISTING GROUNDWATER LEVEL NI BASED ON TOWN OF BARNSTABLE l ' GIS DEPARTMENT RECORDS. f A I INDICATED GW 20.0 b, + INDEX WELL MIW-29 ZONE D I I O READING DATESEPT. ...E 2008 J READING . 8.7 ADJUSTMENT 5.0 ADJUSTED GW 25.0 /8 Parent material(geologic) V" ' Depth to Bedrock N 0 ne Depth to Groundwater. Standing Water in Hole: 140 V Weeping from Pit Face K0 AC Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH[WATER TABLE _ Method Used: See aOov'e, Depth Observed standing in oi;S.hole: in: .Depth to loll mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj,factor— Adj.Groundwater Level PERCOLATION TEST bete Tme ►t M Observation Hole# I Time at 4" Depth of Penc 60 I h Time at 6'. Start Pre-soak Time @ I " Time(9"-6") End Pre-soak 24 Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- .* If:percolation test is-to be conducted within 1001 of wetland,you must first notify the Barnstable"Conservation Division at least one (1) week prior to beginning. Q:XS EPTICIPERCFO RM.DOC TOWN OF BARNS /� r 7 T 77T LOCATION �(�� u SEWAGE # VILLAGE `--Q—ETE EV VE ASSESSOR'S MAP& LOT<J INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / LEACHING FACIL=: (type) (size) /a I< Z-^: NO.OF BEDROOMS a BUILDER O`�O :) PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by • f I 4 x I G� i VE r Town of Barnstable * Regulatory Services * BARNSTABLE, + Q MASS. Thomas F. Geiler, Director vp i6gq. �0 lfo 39. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 18, 2008 Nancy D. Komenda Jeffrey F. Komenda P.O. Box 160 Centerville, MA 02632 NOTICE OF VIOLATIONS OF BARNSTABLE CODE CHAPTER 360 ARTICLE VII 060-16, ARTICLE I 053.1. VIOLATION OF 105 CMR 410.354 STATE SANITARY CODE The property owned by you located at '65 Elliott Road, Centerville;-was inspected on September 17, 2008 by Donnna Z. Miorandi, R.S., Health Inspector for the Town of Barnstable, because of a complaint. The following violations were observed. 4360-16; Town of Barnstable Code: The septic system is in hydraulic failure. Raw sewage was observed at ground level. Sewage odors were detected. Your leach pit is also on the neighboring property. 1) You are directed to hire a licensed septage hauler to pump the overflowing septic system within twenty-four(24) hours of receipt of this letter. 2) You are also directed to keep the on-site sewage disposal system pumped as many times as necessary(daily if need be) to keep it from overflowing onto the ground. 3) You are further directed to contact and hire a professional engineer to design a septic system which meets local and state regulation requirements within twenty one (21) days of receipt of this letter in order to repair this system or connect to town sewer. 4) The newly installed septic system or town hookup shall be completed on or before Novemberl5, 2008. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance may result in the issuance of a $100.00 non-criminal ticket citation. Each day's failure to comply with an order of the Board of Health shall constitute as a separate violation. I X ,L PER ORDER OF E BOARD OF HEALTH Th mas A. McKean Director of Public Health Certified letter: #7006 2150 0002 1042 0804 i COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PROTECTION y b��y A350 MAIN STREET �a WEST YARMOUTH,MA _ �O 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM RECEIVED PART A MAP 248 PAR 283 CERTIFICATION JUN 1 2 2002 Property Address: 65 ELLIOT ROAD CENTERVILLE.MA 02632 TOWN OF BARNSTABLE HEALTH DEPT. Owner's Name: HOWARD, KEN Owne(s Address: 65 ELLIOT ROAD CENTERVILLE.MA 02632 Date of Inspection MAY 30,2002 Name of Inspector: (please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth.MA 02673 Telephone Number: 508-775-2800 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 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: Z— 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 tot he 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 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 65 ELLIOT ROAD CENTERVILLE,MA 02632 Owner: HOWARD,KEN Date of Inspection: MAY 30,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ 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 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: _ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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)" E broken pipe(s)are replaced obstruction is removed ND explain: LLTitle 5 Inspection Form 6/15/2000 2 Page 3 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 65 ELLIOT ROAD CENTERVILLE,MA 02632 b Owner: HOWARD,KEN Date of Inspection: MAY 30,2002 C. Further Evaluation is Required by the Board of Health: N/A _ 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 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: 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 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 xx 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. t 3. Other: t i Title 5 Inspection Form 6/15/2000 3 Page 4 of 1 1 a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 65 ELLIOT ROAD CENTERVILLE,MA 02632 Owner: HOWARD,KEN + Date of Inspection: MAY 30,2002 D. System Failure Criteria applicable to all systems: N/A 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 pit is less than 6"below invert or available volume is less than 1/2 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a a surface water supply N/A Any portion of a cesspool or privy is within a Zone I of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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. 1 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 65 ELLIOT ROAD CENTERVILLE,MA 02632 Owner: HOWARD,KEN Date of Inspection: MAY 30,2002 Check if the following have been done. You must indicate"yes"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 out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 i Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 65 ELLIOT ROAD CENTERVILLE,MA 02632 Owner: HOWARD,KEN Date of Inspection: MAY 30,2002 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): N/A [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2000 52,000/2001 73,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,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 Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,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) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 ELLIOT ROAD CENTERVILLE,MA 02632 Owner: HOWARD,KEN Date of Inspection: MAY 30,2002 BUILDING SEWER(locate on site plan): X Depth below grade: 3" Materials of construction: Cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 6" Material of construction: X concrete o 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: 1,000 GALLON PRE CAST Sludge depth: 4" Distance from top of sludge to the bottom of outlet tee or baffle: 26" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 181, How were dimensions determined: ASBUILT AND 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 AT WORKING LEVEL.INLET BAFFLE,OUTLET BAFFLE.TANK AND COVERS 6"BELOW GRADE. NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal s 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 i Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 ELLIOT ROAD P Y CENTERVILLE,MA 02632 Owner: HOWARD,KEN Date of Inspection: MAY 30,2002 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspecti on)(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 float switches,etc.): DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.,): PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 ELLIOT ROAD CENTERVILLE,MA 02632 Owner: HOWARD,KEN Date of Inspection: MAY 30,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER 12"BELOW GRADE.3' WATER IN PIT. STAIN LINE 2"ABOVE WATER.NO SIGN OF OVERLOADING OR SOLID CARRY OVER. CESSPOOLS: N/A (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.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 ELLIOT ROAD CENTERVILLE,MA 02632 Owner: HOWARD,KEN — Date of Inspection: MAY 30,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ail, L' 0 Title 5 Inspection Form 6/15/2000 10 . i Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 ELLIOT ROAD _ CENTERVILLE,MA 02632 Owner: HOWARD,KEN Date of Inspection: MAY 30,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 28 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation X Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS AND GIS 28'. BOTTOM OF PIT 7' BELOW GRADE. �.r�'A s� 7 P,r Title 5 Inspection Form 6/15/2000 11 " s TOWN OF BARNSTABLE LOCATION �� U-1-0 621 SEWAGE # VILLAGE £ T ASSESSOR'S MAP & LOT "� c NAME&PHONE NO. � �o so P• SEPTIC TANK CAPACITY £��7 /A, C l!o LEACHING FACEUTY: (type) (size) NO.OF BEDROOMS �� BU LDER ORrOWNER MIT Separation 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 F/4t a, ** s Ix0 COMMONN�'EALTH OF MASSACHUSETTS (7P, EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMEI\TAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02108 61 i-292-5500 WILLIA\1 F.WELD Govemo: TRUDY CORE qq Secretary ARGEO PAUL CELLUCCIG UHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM $ Co i r PART A CERTIFICATION 'I,r Property Address: 6s 'm '�� o RV CPn-T"ry>>/t REcEivEO tD Date of Inspection: '!—9 Address of Owner: AUG 7 1997(if different) N Name of Inspector: JUhn /7 go Ao TOWN OF HBARNSTABLE . I am a DEP approved system inspector p/!,ursuant to Section 15.340 of Title 5 (310 CMR 15.000) S HEAITHDEPT. Company Name: 70�►rt /✓uCkyiO�' a' VJC+, ,�, Mailing Address: /.S��J �/tr riu 9 S7 Al o•�S /�/�� /MMk. Telephone Number: S� - 9s E 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: (/Passes _, Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: s�7 The System Inspectors/allsubmit a copy of this inspection report.to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: A] SYSTEM PASSES: _ I have not found any information which indicates that the system violates any of the failure criteria a. defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank,-whether or not metal, is cracked, structurally unsound, shows substantial Infiltration or exfiltration, or tank failure is imminent. The system will pass inspection. if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 20 DEP on the World Wide Web: http://www.magnet.state.ma.us/dep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A �,y f CERTIFICATION (continued) Property Address: Owner: hle40-1 PeTr/�IS Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) .-------,.� Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed Q j k x tj pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: ry-y' r broken pipe(s).are replaced i * obstruction is removed I}a�ti � distribution box is levelled or replaced a _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass t inspection if(with approval of the Board of Health): `vT _ ' *`k3r•T,'�:� ; broken pipe(s) are replaced Xp d. obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT SHE SYSTEM IS NOT FUNCTIONING IN A MANNER .6 WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation,not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddress: {r p/ / -�- Owner: aJ �i��i o�� /'A CrPi7/t'l�l� i��t� Ma Hurh� �e rr Date of Inspection: D) SYSTEM FAILS: g 7 You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 clewed 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. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ Any portion of a 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 I 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 suppty well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well wader analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200.feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater tream ent program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 17-/4d Cp h`fi�iv,'lI i, Lr Property Address: 6�� r ! S Owner: ltla j-y Date of Inspection: / Check if the following have been done: You must indicate either "Yes"or"No"as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ Nl As built plans have been obtained and:examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, exe�vdrng tKe Soil Absorption System, have been located on the site. ✓. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) Page 4 o! 10 } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: S" Owner: �f��,f•� Ae 7rid,s Date of Inspection: S-q-97 RESIDENTIAL: FLOW CONDITIONS Design flow: e.p.d./bedroom for S.A.S. Number of bedrooms:_ l Number of current residents: 4 Cwoe h✓rs�% Garbage grinder (yes or no): A/c Laundry connected to system (yes or no):185 Seasonal use (yes or no): Alb Water meter readings, if available (last two (2) year usage (gpd):Sump Pump (yes or no): Alp Last date of occupancy: r�e�k�h�(f ot, N�'o,r•� COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: �t System pumped as part of inspection: ( es of no)_ If yes, volume pumped: __LW_Q gal ns Reason for pumping A//G;H 1411 1 TYPE OF SYSTEM Septic tan k/c14"4ntiea-60z/soiI absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other I/A Technology etc. Copy of up to date contract? APPROXIMATE AGE of all components,.date installed (if known) and source of information: _ /ti21s�`p jc, 2 7 r � Sewage odors detected when arriving at the site: (yes or no)_kV (revised 04/25/97) Pays 5 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: IVw e o-;7 Peril(X..s Date of Inspection: //� —9 BUILDING SEWER: (5JC (Locate on site plan) Depth below grade: Material of construction: _cast iron r/40 PVC_other (explain) Distance from private water supply well or suction Imp• r Diameter 4_ Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Ya Material of construction: concret _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: /r Scum thickness: -;� Distance from top of scum to top of outlet tee or baffle: r Distance from bottom of scum to botiom'of outlet tee or baffle: 12 How dimensions were determined: tN lei- Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, de th of liquid level in relation to outlet invert, structura integrity, evidence of leakage, etc.) foak was dhs gov, Coitctere 22-Y s ern /hlr'J" a-OF GREASE TRAP: (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revioad 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �lr�-yti Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/da� Alarm level: Alarm in working order_.Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: {/c,, (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (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.) (zevis*d 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 1 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic llic failure, level of onding, congiti n of vegetation, etc.) 8 y /Cj P Sat j ��c 0; vP�sd( o CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) 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.) (revised 04/25/97) Page a of 10 0 v ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 11i vv �, / ,� Owner: /yy �p P, Date of Inspection: � " q-°12 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) fJ I To Cv(, {i 7, Cvv�r (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Ha'- C11 S Date of Inspection._ Depth to Groundwater f6 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record j/Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) grade 6 '7rc"ef" :1' Y, VIA1 J ti�a ,er-1 14/.1 /1• Hv �•t/u��Y VI.S /��f' (revised 04/25/97) Pago 10 of 10. TOWN OF BARNST.,4B,LE �`C� /9�7 Ili LCX'ATION (CE E O�T e—u SEWAGE # VILLAGE Q�TF-Q-V O1E ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. _I SEPTIC TANK CAPACITY` / LEACHING FACILITY: (type) LLA (size) NO. OF BEDROOMS BUILDER PERMITDATE: COMPLIANCE DATE: t 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 ro e'wrr Map Page 1 of 1 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ; rr � . Zoom Out��I ��IIn r R f t ® )PG Map: 248 2482$7 248172 Location: N 20 # t150 Owner: Location In s t Map &Parce N 60052 Location Acreage Current Ow x �* Mailing Addi 65283 E 264$285 ; , Appraised Extra Featur �e, y. 248054 v Out Building Land u► ' Buildings Total Apprai 248291 ;� Assessed V q 87a� 248284 Extra Featur 076 rt + r 248251 q 80 Out Building s� Land Buildings Total Assess Set Scale 1" = 61 I April 2001 Hi Res I MAP DISCLAIMER Copyright 2005-2008 Town of Barnstable,MA All rights reserved.Send questions or comm( BarnstableMA v1.2.3083 [Production] http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=248283&map... 9/17/2008 + SOIL TEST LOG DATE EVALUATOR: OCTODAVID . COUGH08 DESIGN CALCULATIONS SOIL EVALUATOR: DAVID D. COUGHANOWR. R.S. WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. ' PERC NUMBER: 12400 • DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS TEST PIT 1 PARENT MATERIAL: PROGLACIAL OUTWASH USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL PERC AT 80 In - 2 MIN/INCH IN C SOILS CONDITION. IF NOT, INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 3 OUTLET D-BOX. 48.25 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING SOIL ABSORBTION SYSTEM: A 24 ft. x 12.5 ft x 2 Ft LEACHING GALLERY CAN LEACH 0-6 Ap SANDY LOAM 10 YR 2/2 NONE FRIABLE i Abot_ = ( 24 x 12.5 ) = 300 sf 6-34 B LOAMY SAND 10 YR 5/6 NONE FRIABLE Asdw = ( 24 + 24 + 12.5 + 12.5 l x 2 = 146 sf At of = 446 sf 45.42 34-13B C MEDUIM SAND 10 YR 6/3 NONE LOOSE Vt 0.74 x 446 = 330.04 GPD 35.75 i' USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt 330.04 GPD > 330 GPD REQUIRED NO GROUNDWATER ENCOUNTERED 4. TEST PIT PARENT MATERIAL: PROGLACIAL OUTWASH } 2 MIN/INCH IN C SOILS LEACHING GALLERY 10 M GALLON SEPTIC TANK DIMENSIONS AND DETAIL NOT TO ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER USE SHOREY PRECAST 500 GALLON NOT TO USE EXISTING H-10 UNIT SCALE (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING LEACHING DRYWELL (H-10 LOADING) SCALE 48.00 SEPTIC TANK IS TO BE PUMPED DRY 0-8 Ap SANDY LOAM 10 YR 2/2 NONE FRIABLE CONSTRUCTION DETAIL AT TIME OF INSTALLATION AND IS TO 13E 8-32 B LOAMY SAND 10 YR 5/6 NONE FRIABLE IN EXAMINED FOR STRUCTURAL TEGRITY. INSTALL PVC 45.33 DRYWELL UNIT STON TEE EQUIPPED WITH AEGAS BAFFLE 32-120 C MEDUIM SAND 10 YR 6/3 NONE LOOSE 24.0 Ft- 36.00 TAPER Ln GROUNDWATER ADJUSTMENT � 1E§:11E�::11 �� C) co N �4 N � 0 � m � EXISTING GROUNDWATER LEVEL m _ BASED ON TOWN OF BARNSTABLE ri GIS DEPARTMENT RECORDS. Ln 3.5 Ft 6.5 ft B.5 ft .5 ft INDICATED GW 20.0 { 24.0 f t INDEX WELL MIW-29 1 ZONE EADING O+DATE SEPT, 2008 6 1n A R k READING' ".c B.7 500 GALLON DRYWELL ADJUSTMENT .'5.0 ` INLET OUTLET ADJUSTED',G W= 25.0 DIMENSIONS AND DETAIL COVER COVER A USE H-10 LAVIT INSTA L ONE s - + RISERLTO WITHIN THREE —> �3 IN DROP VFLOW LINEy > INCHES OF FINAL GRADE FROM AL r ;k TO AND INDICATE LOCATION BUILDING 10 ir, �� D_BOX .. J ON AS-BUILT PLAN 48 in - t LIQUID GAS LEVEL BAFFLE N O TE S �3 r a oo �� { �000�000�o0 000�� . ll INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. � a00000000 CROSS SECTION VIEW00 2) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. 5g 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS 1021n OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES ) CROSS SECTION VIEW BEFORE EXCAVATING FOR SYSTEM. I SEWAGE DISPOSAL SYSTEM PLAN 5) EXISTING LEACH PIT TO BE PUMPED. FILLED. AND ABANDONED IN PLACE. t 2 in PEASTONE 2 in PEASTONE 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE. o o TO SERVE EXISTING DWELLING 2B 314 u, TO EFFECTIVE 3/4 TO 26 7) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES _I�,,,�,,,� pEpTFi I-I/2,n GRAVEL In NANCY & JEF,FREY KOMENDA AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. In 8) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT t� 65 ELLIOTT ROAD CENTERVILLE, MA PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. Y 46 In 58 In 46 In 9) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL k�k 1501n ECO-TECH ENVIRONMENTAL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH t INSTALLER MAY SUBSTITUTE AN APPROVED GEOTEXTILE 43 TRIANGLE FABRIC IN PLACE OF THE 2 in. PEASTONE LAYER SPECIFIED. 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