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Home My WebLink About17A & 17B ELLIOTT ROAD - Health 17A & 17B Elliot Road Centerville A= 248 -004 - 002 SMEAD KEEPING YOU ORGANIZE[ No. 12534 2-153L©R �SUSTAINABLE FORESTRY UN.RECYCLED INmAnvE CONTENTIOV CuGfiad Fiber sourcing POST-CONSUMER® wwwj4ro0wm.orp 1"12W WADE IN USA QV OiiGAN17FD AT SMEADaM r 2�f � NO. ' J` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye 2ppliLation for Mispo8al *pstem Cunstruttiun permit Application for a Permit to Construct(�epair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Add ess or Lot o. 0 I• V)0 Rt i�'' Owner's Name,Address,and Tel.No. �•; T. t_ Assessor's Map/Parcel $ Ins ller's Name,Address,and Te.No. Ton 4. o Designer's Name,Address,and Tel.No. �� L l h `/C� GG 69 1=l S�rc(,C b13 ii� t' L/Lrk t Type of Building: Dwelling No.of Bedrooms If Lot Size 17114E o �'sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required)` �}�0 gpd Design flow provided S S gpd Plan Date �'m ®)\1 Number of sheets Revision Date Title Size of Septic Tank $ 1✓Lf✓ 0&?t Type of S.A.S.r3� ,$- L tau sC-.t- Description of Soil su, Nature of Repairs --or Alterations(Answer when applicable) J�p G se Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental -to-.place the system in operation until a Certificate of Compliance has been issued by this Bo Healt Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. O!,p4 37 V Date Issued _- ---- ---- ------- --1a��3x- -- - - - - - ---�— No. o { �� Fee i ice^ THE"',OMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for ]Disposal Epstein Construction 3permit Application-for a Permit to Cons c��e air Upgrade Abandon ❑Complete System I.ndividual Components Location Add or Lott o I A Owner's Name,Address,and Tel.No. �sessor Map/Parcel si Installer''sWametAddrdss;!and T : I`l Designer's Name Address and Tel.No. y Jul C. /'y��Oy CCU `A�'" iS Ukqf,.l� (p Type of Building: Dwelling No.of Bedrooms # F Lot Size 7 °—Sq.ft. Garbage Grinder Other Type of Building. No.of Persso s i t r Showers( ) Cafeteria( ) t ltf Other Fixtures Design Flow(min.required)` 440 gpd Design flow provided �� ,� gpd Plan Date A I %N4 Number of sheets Revision Date ff4S G Title : Size of Septic Tank Ann lkltv1 Type of S.A.S.( 3 \ Y—Q1ITj (" ,, Description of Soil i Nature of Repairs or Alterations(Answer when applicable) L ,f Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code andnot-to place the system in operation until a Certificate of Compliance has been issued by this Bo d Health X Signe Date t _ Application roved PP PP b Y Date 1 2 J Application Disapproved by Date l for the following reasons Permit No. Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( _- Repaired( ) Upgraded( ) Abandoned( at q , ! a t �, has been constructed' accordance I. 4r t � dated / 3 with the provisidns(of it4etiS and the for 1�isposdl System, onstruction Permit No, r Installer Designer #bedrooms y Approved design flow' L / gpd The issuance of this pe it hall not be construed as a guarantee that the system w 1 ion as designed Date q Inspector d IV No. Ll Fee or) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS mtspo� pstem (Construction 3permit Permission is hereby granted to Construct( Repair( ) Upgrade( ) Abandon( ) 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:Construction must be completed within three years of the date of this permit. Date Q ` (� Approved by Town of Barnstable Inspectional Services s ,,,�,,, Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,n's,MA 02601 Office: SOa-862-4644 Fax: 50&740-6304 Installer&Designer Certification Form Date: Sewage Permit# �T Assessor's Map\Pareel LY 0q%1 Designer: Installer: Installer: Address: l�vrl! l7r- 1 Address: On f A 3_ �q �C> SU�cam— was issued a permit to install a (date) (installer). septic system at , 44 (1,jj tAf> based on a design,drawn by (address) S�titra dated Or, (designer) I 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. Strip out (if required) was inspected and the soils were found satisfactory. 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. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed_ o ce with the to rms of e I1A approval letters(if applicable) ..,-1 f M r oass�� (Installer's Signature) E ° A' I�cGa a, (Desig` 'is Signature) A ) ( � • ere PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH' N. 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. WoMdeptsiHEALTIASEWERconnecASEPTIODesiperCertification Form Rev 8-14-13.DOC e. d-IC J TOWN OF BARNSTABLE LOCATION �� —LID tw a SEWAGE# VILLAGE 0_ta14"V/1k_ ASSESSOR'S MAP&PARCEL;yg- 0 Y-001 INSTALLER'S NAME&PHONE NO. 9 If LAC— SEPTIC TANK CAPACITY %!AD - 1000 G LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: 0-1 o 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 i r n, _ ►co �5 (76 1� 3 k �S Z - 301 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. Citylrown 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 David B. Mason use the return Name of Inspector key. David B. Mason Company Name 4 Glacier Path Company Address 'c' East Sandwich MA 02537 City/Town State Zip CodeF 508-367-1617 S1287 1 _ Telephone Number License Number ; B. Certification C.) M I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority. June 30, 2014 Inspector'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. a , j .�71% t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins•3/13 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 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 ears usage d Yes 9 ( Y 9 (gP ))� Detail: Water District indicated that 15 Elliott Road is ties into another buildings water service. No use records available. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27 2014 page. Cityrrown 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: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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: August 2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 typical Sludge depth: 2" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °,M a 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is Centerville MA 02632 June 27 2014 required for every , page. CityTrown 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 41" . Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. PVC Tees. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 Level with 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.): Dbox is 17 inches below grade. No indication of solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 15 Elliott Road, Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 1-500 gal unit ❑ 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.): Unit access is 15" below grade. no indication of hydraulic failure no ponding 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Elliott Road 1M Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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: 20 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: Town groundwater contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used Town groundwater contour map 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Elliott Road Property Address Robin Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 Assessing As-Built Cards Page 1 of 2 Y J.E. TOWN OFBARNSTABLE nYir UAAON SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL e-pu INSTALLER'S NAME&PHONE NO. Geea,-VF 77 1- SEPTIC TANK CAPACITY-1T0c LEACHING FACILITY:(type)/ (size) NO.OF BEDROOMS o , OWNER Ze s�4 PERMITDATE: COMPLIANCEDATE: Separation Distance Between the: o 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) t / Feet FURNISHED BY CLEAR.ovT A I� .0AF 0 0 1 .7 p _ DIVAA,ee- I http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=248004002&seq=1 7/3/2014 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town(which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE:05 O 0Z2 Fill in please: APPLICANT'S YOUR NAME/S: i4® / ram l>l S'ctJ S.4 2 BUSINESS YOUR HOME ADDRESS: ;ZPi . l'/_Z.Or ,&Z2 TELEPHONE # Home Telephone Number NAME OF CORPORATION: NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YE NO (ro I' n ADDRESS OF BUSINESS - % MAP/PARCEL NUMBER 1 D A 1 11 (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main !,,- (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. 'BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual hastb/n��--"Vhe permit requirements that pertain.to this type of business. MUST�:OMPLY WITH ALL (( �1//II KAZARDOUS MATERIALS REGULATIOM!S Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS [ ENSING AU ORITY) This individual has e n informe the li easing requirements that pertain to this type of business. Authorized S6natu,re dr , COMMENTS: i I TOWN OF BARNSTABLE Dater / O I 00lZ TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: C,L 3/ 1;,,� �,o,Y-s��p„,� BUSINESS LOCATION: .f�r3, 6/Zzorl 419 INVENTORY MAILING ADDRESS: Y;;;;�C""elo; "?.D -, /) TOTAL AMOUNT: TELEPHONE NUMBER: 5o�s- 3�4 3yy5 CONTACT PERSON: �d/J�,� EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: l"��sL��t/ter-Usa^-2✓ INFORMATION/RECOMMENDATIONS: J Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW FUSED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible ®� Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison"labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's ig t Staff's Initials 77 Commonwealth of Massachusettsr u Title 5 Official Inspection Form _ p Q� Subsurface Sewage Disposal System Form;Not for Voluntary Assesrs/m ents 17A&B Elliott Road t ' `e`er' X 5 U i Property Address CQ �., Robin and James Maddalena _ Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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:out forms A. General Information filling out forms on the computer, 6 V use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason r� Company Name "- O 4 Glacier Path Company Address y r— East Sandwich MA 02537 t MM City/Town State r Zip Code -'b. 508-367-1617 S1287 za Telephone Number License Number .� C:7) r~— W rn B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority June 30, 2014 Inspector's Signature7 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. G Q �I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. Cityrrown 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is Centerville MA 02632 June 27 2014 required for every , 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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.] 11 ❑ ® 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M s 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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): 2 Each Number of bedrooms (actual): 4 Total Unit DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: d Number of current residents: 0 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 ears usage d Yes 9 ( Y 9 �9P ))� Detail: 2012; 28,000 gallons and 2013; 27,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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-3113 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 c,M 17A&B Elliott Road Property Address Robin and James Magdalena Owner Owner's Name information is Centerville MA 02632 June 27 2014 required for every , 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: Board of Health Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is Centerville MA 02632 June 27 2014 required for every , 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: Installed 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3'feet Material of construction: ❑ cast iron E 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No observable issues. Septic Tank(locate on site plan): Depth below grade: 26"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Typical Sludge depth: 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is Centerville MA 02632 June 27 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 44" Scum thickness 211 Distance from top of scum to top of outlet tee or baffle 311 Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Scour Stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Observable components appear in adequate condition 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 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 17A&B Elliott Road M Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27 2014 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 Effluent level with 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.): No evidence of solids carry-over. D-Box is 37 inches below grade 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: SAS located but viiewed with camera t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is Centerville MA 02632 June 27 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 5 Infiltrators ❑ 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.): Viewed with camera. No signs of hydraulic failure or pondin . 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 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 M ey'�t 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c, 17A&B Elliott Road M Property Address Robin and James Maddalena Owner Owner's Name information is required for every Centerville MA 02632 June 27, 2014 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: 20 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: Ground water contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used Town Groundwater Contour Map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 17A&B Elliott Road Property Address Robin and James Maddalena Owner Owner's Name information is Centerville MA 02632 June 27 2014 required for every , page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTAABBL�EE LOCATIONt fyf/ /�/I1�SEV✓ YiE# OA VII LAGE R'a IP ASSESSOR'S MAP&LOT DO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACr[T 4 a o y 1 LEACHING FACMM:(type S- (size) .9"��, _ NO.OF BEDROOMS BUILDER OR OWNER PERMrrDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Fumished by i a � J w �t jw ti � ? C,4 t J http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=248004003&seq=1 7/3/2014 No. 0 10 ' ` Ad Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Migogal *pgtem Congtruction Permit Application for a Permit to Construct(IO) Repair( ) Upgrade( ) Abandon( ) A Complete System Wridividual Components Location Address or Lot No ��/�O/ /who Owner's Name,Address,and Tel.No. Assessor's Map/Parcel.Z. p .0®j;:P ((/- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Spa �cr�m�`Lj� ��s Type of Building: n�,,,p i Dwelling No.of Bedrooms A�e Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building 4~�• No.of Persons Showers( ) Cafeteria( ) Other Fixtures yy Design Flow(min.required) gpd Design flow provided `t gpd Plan Date 7.:L�� Number of sheets Revision Date Title Size of Septic Tank -0 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) V Date last inspected: IAgreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B rd of Health. Signed Date I Application Approved by q„i Date Application Disapproved by: Date for the following reasons Permit No. o& �3 Date Issued -3 w ` N7-7 4t o., tFee Ud p A \ THE COMMONWEAL H OF MASSACzHU ETT�'S_ Entered incomputer: 'PUBLIC HEALTH DIVISION', TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for XDi�po�al � ip�tem CCow5truction Permit t Application for a Permit to Construct 4 Re air a pp ( )� p ( ) Upgrad'e:(�`) Abandon( ) U Complete System individual Components Location Address or Lot Nov,�,:- %: /w�- Owner's Name,Address,and Tel.No. Assessor's Map/ParcelAs;,P QU Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: f' a� `�`^ � �`P4-,�"v Dwelling No.of Bedrooms r Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures t r Design Flow(min.required) gpd Design flow provided '� gpd Plan Date Number of sheets Revision Date `Title Size of Septic Tank Description of Soil 29, ,X Nature of Repairs or Alterations(Answer when applicable) x Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B rd of Health. Signe Date � Application Approved by W 20 Date F—3 'Application Disapproved by: Date for the following reasons Permit No. o p Date Issued E—"3-l0 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( O�Repaired ( ) Upgraded ( ) Abandoned( )by �iil7 LCC"�d�"r/f"�f 'O�T/C S at �S �G�/o, �L� G E'/'�.T has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a Q/6 V dated L,3- p Installer�� G�.��y�� Designer m9P,4 y-'.0 .�%/,�v4 t'd �'✓'• #bedrooms Approved design flow 1�= gpd The issuance of this ermit shall not be construed as a guarantee that the system wil cti as de: ed. Date tv Inspector (rfi! No. � i .- . Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Th5pofsal *p5tem CCow5trUction Vermit Permission is hereby granted to Construct ( t-< Repair ( ) Upgrade ( ) Abandon ( ) System located at " :l- <:!5 L- o?' G and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions Provided: Constructi n must be completed within three years of the date of is permit. Date �A Approved by (11 '`� Town of Barnstable Regulatory Services Thomas F.Geiler,Director • 01 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: Designer: l� j. ,Y lll� Installer: I_ Address: . Address: On was issued a permit to install a (date) (Installer) septic system at � ,�� based on a design drawn by (a dre s) dated / �' 9'"✓® (designer) I_certify that-the septic system referenced above was in substantially according to ie design, which may include minor approved-changes such as later'as relocation of the distribution box and/or septic tank. .. r. I certif} that the septic system:referenced above was ins+aiRed with"'m- greater thm l0' lateral relocation"of the SAS or-any.vertical telocatign of any component of the.sepfi system)but in accordance with State&Local:Itegiflat ons. Plan revis oza or certified as btby designer tb follow. _-----_ tiOFF." s DAv�D y (installer's S gnature) �• n hIASON n, i57P�fr sq ITAR�P� (D er s Signature) (Affix er' .Starnp Here) PLEBE R TiTRN TO BAitr4,kT_ABUj PUBLICREALTH.PI SfO i CAM O]ti'" COMPLIANCE U:L= NO ;:SE: D B03$°3' SFEIJ[` DUIj;CARD ARE RECMED WEITURR j TABLE PIJBLl[C 3[DIViSIOAT THANK YOU Q:Health/Septic/DesignerCertificatiou"Form - _ Town of.Barnstable P# - �y�' "`l'� Department of Regulatory Services Public Health Division Date -7 4NAM ' 206 Main Street,Hyannis MA 02601 Date Scheduled f T Time e 0 Fee Pd. IUD D, � w Soil Suitability As essment for Sewage epos,al Performed By: Witnessed LOCATION & GENERAL INFORMATION Location Address~- Owner's Namee,� I Address �{ I t Assessor's Map/Parcel: Lngineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use slopes MI I SurfaceMohes Distances from: Open Water Body ft 'o9sil 'Wet Area ft Drinking Water Well ft Drainage Way_� ftperty line ft Other ft ' SKETCH:(Street name;dimensions lof 19C exact locations of test holes&perc tests,locate wetlands in proximity to holes) Paietial(geologi� ,"b� - �1 I Depth to Bedrock 1 �Q -be pth-4o- Standing-Water in Hole: Weeping from Pit R&Ce , • + EA#ik a�S Groundwater 2 ` DETER-IM[INATION FOR SEASONAL HIGH WATERTABLE Method User] .. u V, depth Ot scrYed standittg�x obs:hole "in a l;*h t9 sail mottles: i . •Depth•to-weeping from side of ohs,hole: in. at'oundwiiter Adjustment Index Well#-° Reading Date: Index Well level Adj,*Ctor Adj.droundwater level a; :YERCOLATION oiue :'Tl D+► :. 'II'itntr�,_ Tinto at qn t_.: DcpttJ 3bft'enc '9Rme at6" St�rt#'re sink me @ - - t ' 7 lime(9,6„) j ch SiteUitability Assessment Site Passed Sue Failed. ' Additional Testing Needed(Y/N)._.� t trrL.Pullltcl TtFt�visron 'obset•vation,Hoj Data To Be Completed on Back--- €pMolatioa test is'to be conducted wit Wit 11 of wctlt�nd,'you must first notify+tllte tiarole"Consemtul,n.Diviston atleast one(1)week prior to`.beginrung.,. Q:1SW'6VERCP0RM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) ;,.,.;;.Mottling' - (Structure,Stones,Boulders. Consistency, Gravel) I.{ lV° Ytq S Y F , DEEP OBSERVATION HOLE LOG Hole# Depth from• Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders." Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Moidtng '(Structure,Stones,Boulders. Consiste c Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon SoiI Texture Soil Color Soil, Other Surface(in.) (USDA] (Munsell) Mottling.._ (Structure'.Stones,Boulders. " Consistency,%!0ra i 1 9 Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No_Ie /Yes,m Within 100 yea rflood boundary No Yes. a.. .. ...._ ._ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi u erial exist in all areas observed throughout the area proposed for the soil absorption system? If not,.what is the depth o naf rally occurring pervl us material Certification. � ! ' .-I"certify that on. (date)I-have passed the soil evaluator examination approved by the Department of Environmental Protection and that,the above analysis was performed by me consistent th the requir training,e , erfi npprience described in 3,10 CMR 15.017 Signatur Date .. i Q NSBPT10PERCFORM.DOC F-k 24727 Ps224 �W33643 DEED RESTRICTION The Barnstable Board of Health requires that the following restriction; that the dwelling be restricted to two (2) bedrooms as defined by the Massachusetts Department of Environmental Protection and interpreted by the Barnstable Board of Health due to the need for a mandated Title V Deed Restriction for septic systems that have a capacity of 220 gallons per day, be placed on the property at: 15 Elliott Road, Centerville, Massachusetts, Map 248, Parcel 004/002, as currently owned by Maddalena Manor Realty Trust, 43 Sail-A-Way, Centerville, MA 02632, as property referenced in the Barnstable Registry of Deeds as Book 12626, Page 217_ as the owner of the property/trustee referenced above acknowledge the deed restriction(s) being placed on the property. Owners/Trustee Signature Date The person named above: /d6 /, iU IN/"g- /)/)/0, acknowledges the foregoing instrument to be his/her free act and deed, before me. Notary Public My Commission Expires: SARA ELLEN WHELDEN Ndaly Pub it; COMMONWEALTH Of MASSACHUSETTS My Commission Expires Seplember 17,2010 T N.E. TOWN OF BARNSTABLE ®OZ A)J��LOCAT�ON r ��oT �,d SEWAGE# VILLAGE M jJJ ASSESSOR'S MAP&PARCEL-2,3 c&—o ost-Uo,Z INSTALLER'S NAME&PHONE NO. 77 S— o�l3J SEPTIC TANK CAPACITY LEACHING FACILITY. (type) J (size) NO.OF BEDROOMS lid ruirm�� OWNER PERMIT DATE: COMPLIANCE DATE: J_ So- Separation Distance Between the: >v®�� 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 A o F 0 EF �/I'L-'GL f G•� O� CC O � i CENTERVILLE, MA j CONSTRUCTION NOTES Barnstable High School Existing / -,-z 1.) ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE, TITLE 5 (310 CMR 15.000): House #17B C.O. EXISTING 20" DIAMETER COVER EL=49.3± Existing WITH 12" RISER Vent STANDARD REQUIREMENTS FOR THE SITING, CONSTRUCTION, INSPECTION, UPGRADE, AND House #17A EXISTING 20" DIAMETER COVER 41Q• EXPANSION OF ON-SITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOR THE TRANSPORT EL=48.4± WITH 12" RISER AND DISPOSAL OF SEPTAGE, AND THE LOCAL BOARD OF HEALTH REGULATIONS. 47.8 EL=48.0± Sire 2.) ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE IS POTENTIAL FOR \N��\�� r VEHICLES OR HEAVY EQUIPMENT TO PASS OVER IT SHALL BE DESIGNED TO WITHSTAND AN H-20 � �/� /� �/� /��/� � LOADING. IF UNDER AN IMPERVIOUS SURFACE, SYSTEM SHALL BE VENTED TO THE ATMOSPHERE, Pine Street 3.) TO MINIMIZE UNEVEN SETTLING, SEPTIC TANKS AND D-BOX SHALL BE INSTALLED ON A STABLE 45.9± a' o MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE. 45.5± GEOTEXTILE >. * o > 4.) COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK, THE DISTRIBUTION BOX, AND ` 43.5 FABRIC Proposed �_ a�v THE SOIL ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN 6" OF FINAL GRADE. LEACHING _H Elev. 3 M Liner E I 0 o 1 FIELDS, TRENCHES, AND OTHER SOIL ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL y 51.6f ! 43.6 ~ = !, HAVE AT LEAST ONE (1) INSPECTION PORT CONSISTING OF PERFORATED 4" PVC PIPE PLACED LO Existing a o J w V.j 44.8 VERTICALLY To THE BOTTOM OF THE SOIL ABSORPTION SYSTEM WITH A CAP, TIED WITH MAGNETIC �+ �n 43.63 MARKING TAPE, ACCESSIBLE TO WITHIN 3" OF FINAL GRADE. Existing �? ;r 43.0 T 3/4" to LOCUS GAS BAFFLE • 't r W a °° N iv' 1-1/2" STONE 5.) PIPING SHALL CONSIST OF 4" SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A v PROPOSED (Double wasn) MINIMUM CONTINUOUS GRADE OF NOT LESS THAN 2% FROM THE BUILDING To THE SEPTIC TANK, GAS BAFFLE y DB-3 W-20 THREE (3) 500 GALLON H2O PRECAST AND NOT LESS THAN 1% OTHERWISE. D-BOX 41,0 CONCRETE LEACH CHAMBERS WITH 4' OF Elev. SITE LOCUS EXISTING`' NOT TO SCALE 6.) DISTRIBUTION LINES FOR THE SOIL ABSORPTION SYSTEM SHALL BE 4" DIAMETER SCHEDULE 40 I-5'± -� STONE ON ENDS AND 4" ON SIDES 39.6 PVC (OR EQUIVALENT) LAID AT 0.005 FT/FT. UNLESS OTHERWISE NOTED. LINES SHALL BE CAPPED 1,500 GALLON PROPOSED I AT END OR AS NOTED. SEPTIC TANK 1,000 GALLON �- 5± ± LEACH CHAMBERS 5.6' R 7.) LINES FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE FIRST TWO (2) FEET BEFORE (To Remain) SEPTIC TANK FLOW PROFILE (ENO VIEW PITCHING TO THE SOIL ABSORPTION SYSTEM. DISTRIBUTION BOX SHALL BE WATER TESTED TO ASSURE EVEN DISTRIBUTION. NOT TO SCALE { EL=35.4 Bottom Test Hole 8.) GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES IN ORDER TO PROVIDE A WATERTIGHT SEAL. 9.) HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. 10.) IN ACCORDANCE WITH 310 CMR 15.221, ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING TAPE. 1.) Assessor's Map 248 Parcel 004/002 11.) THERE ARE NO KNOWN WELLS WITHIN 150- OF THE PROPOSED SOIL ABSORPTION SYSTEM. 2.) Book 29109 Page 35 12.) FROM THE DATE OF THE INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL RECEIPT OF 3.) PL. Bk, 126 Page 77 THE CERTIFICATE OF COMPLIANCE, THE PERIMETER SHALL BE STAKED AND FLAGGED TO PREVENT 4,) This property is in a Wellhead j USE OF THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. Protection District 13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UNLESS 5.) This property is not in the Flood Zone CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE / Map 248 1 f Parcel 004001 14.) THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF THE BOARD OF HEALTH AND THE DESIGNER, THE DESIGNER SHALL CERTIFY IN WRITING THAT THE I SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS OF THE PERMIT AND THE APPROVED PLANS. 48 HOURS ADVANCE NOTICE IS REQUESTED. s 1 as•1 " Maximum Feasible Compliance 15.) LOCATION OF UTILITIES IS APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FOR ' t {�g.8� 160.DETERMINING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO ` t -- $6 Variances: 310 CMR 15.221 (7) General Construction COMMENCEMENT OF ANY WORK. THIS INCLUDES, BUT IS NOT LIMITED TO, REQUESTS TO DIGSAFE, ` ' r` #15 Requirements for All System Components: ANY PRIVATE UTILITY COMPANIES, AND THE LOCAL WATER DEPARTMENT. ��" Existing o ' P �w l #1g ( System 1.) Variance for the 20 setback between,the edge of the SAS N 16.) CONTRACTOR SHALL VERIFY THAT ALL WASTELINES ARE CONNECTED BY WATER TESTING V j / n, ...` and the Founde.tion. An 10A' setback is provided. ✓ WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. o ciI , O A liner is also provided. 17.) CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANYO SEPTIC SYSTEM COMPONENTS. _ ___ z t _ .' Lot 2 -\� D / An 10.0' Variance is requested. 310 CMR 15,405(1)(a) ' r HOLES I 17,240± SQ % -`- � SAS epth bengreater18.) TET OMPLETEEAEENVIROMETLCOD, TITE5SILSCANB Ft .2 than 36" AND TEST DATA IS-NOGUARANTEE SOIL IN IF --{4s/ HO Units are proposed with a vent. (310 CMR 15.221(7)) SOILS DIFFER FROM THOSE SHOWN IN THE SOILS LOGS, DESIGN ENGINEER IS TO INSPECT THE Map 248 o (47 �� T�#1 (47v 54' Held 18' Variance Requested (Not to Exceed 72") SOILS PRIOR TO PROCEEDING WITH INSTALLATION OF ANY SEPTIC COMPONENTS. Parcel 003002 a t •�L 19.) EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED;WITH CLEAN SAND AND 1 17E A o `- .------ °�' �.-� ABANDONED IN PLACE OR REMOVED AS REQUIRED. AREA TO BE COMPACTED TO MINIMIZE SETTLING. _ / 2 Bedroom ,, o •N O Top stepTOF EL 49.3 .L TP #2 % �? / Cj MM EL ` 50.0 / SYSTEM DESIGN CALCULATIONS vent ;* !f SAS (48. o� Line , o (aa.:) #17A W s ~rrtj -- O -Q SEWAGE DESIGN FLOW: TWO 2 - BEDROOM DWELLINGS 0 110 GPD/BEDROOM = 440 GPD _J (MINIMUM DESIGN REQUIRED 440 GPD) TEST HOLE LOGS " ' ° `- TOFE Bedroom= 48.4 `- w Q SEWAGE DESIGN FLOW PROVIDED: THREE (3 500 GALLON CHAMBERS z r (47.9) , ) r LQ WITH 4 STONE ON THE ENDS AND 4' STONE ON THE SIDES Test Hole 1 {EL=47.4±) 4$ -- B q ST� 47.9 l Poved Vt = [(33.5 x 12.83) + 2(33.5 + 12.83) (2) x .74 = 455 GPD PROVIDED Depth Elev. Layer Soil Class Soil Color y' ' See Note (,7.a} 455 GPD PROVIDED > 440 GPD REQUIRED F'6ved Drive 149.85' 0"-loll 46.6 A Loamy Sand 10YR 4/1 2s t475, --N $1i3 0;w-- _� / SEPTIC TANK CAPACITY REQUIRED: 440 GPD X 200 = 880 (MINIMUM) " (47.8) -- TWO COMPARTMENT OR SECOND TANK REQUIRED 10 -27 45.1 B Loamy Sand 10YR 6/$ b� '� '` -3 Poved Drive SEPTIC TANK CAPACITY PROVIDED: 1,500 GALLON SEPTIC TANK EXISTING 27"-144" 35.4 C Medium Sand 2.5YR 7/3 l _ (47.2) '- PROPOSED 1,000 GALLON SEPTIC TANK (INSTALL AFTER EXISTING 1,500 SEPTIC TANK) #19B Map 24$ #19A l (/ Parcel 004003 NO GROUNDWATER ENCOUNTERED Test Hole 2 (EL=47.4±) _J Depth Elev. Layer Soil Class Soil Color , 0"-loll 46.6 A Loamy Sand 10YR 4/1 10"-27" 45.1 B Loamy Sand 10YR 6/8 Note: ofi This plan is only valid for current regulations and may 27"-144" 35.4 C Medium Sand 2.5YR 7/3 Scott A. not be suitable for future regulation changes that may occur. j rn o McGann U #1224 W P. Proposed Sewa e Disposal System NO GROUNDWATER ENCOUNTERED �0do. �ti`a' (� g p y DATE OF TESTING: 7/16/10 P 13003 SOIL EVALUATOR DAVID MASON 1 7A & 1 7B)Elliott Road Centerville, MA WITNESS: DAVID STANTON, BARNSTABLE BOH ` V'� Prepared by: PERCOLATION RATE: LESS THAN 2 MIN/INCH Prepared for: All Ca p PERC IN C LAYER Cape Se tic LLC GRAPHIC SCALE NO GROUNDWATER ENCOUNTERED G Brian T. Dacey 618 Route 28 30 0 15 30 60 150 PO Box 95 West Yarmouth, MA 02673 Centerville, MA (508) 771-4200 allcopeseptic@gmoil.com ( IN FEET } 1 inch = 30 ft. Date: 10/02/19 Sheet 1 of 1 By. MA Check: SM Project No. AC-198 I i j 4 ASSESSORS MAP: TEST NO L E LOGS NOTES: PARCEL: _ - FLOOD ZONE: �� 4`�=�'G��L--� SOIL EVALUATOR �%��It2�� ._ ._. WITNESS 1't_ �' 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: -- � / a''� 'L�` '`�'Q DATE: L 1 ?..C71 Health Regulations. PERCOLATION RATE .G_7,WkUJ I�,.. 2) The installer shall verify the location of utilities, sewer inverts and septic components prior to installation and setting base elevations. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.The first TN- I TH-2 two feet out of the d-box to the leaching shall be level. L 5 Y' tt7 4) This plan is not to be utilized for property line determination nor any other A4 Purpose other than the proposed system installation. I'D ln� 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H10 septic components. LOCATION MAP �� `T �' 4 � j 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total r � design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed 25 2i ��J approval of the design flow by the owner. PINE CPt/f31/C WAY) T � � 9) The existing leaching or cesspools shall be pumped and filled with material ' per Title V abandonment procedures. Those within the proposed SAS shall lc�aaj• 9Q2. r // 6 S?0, M be removed along with contaminated soil and replaced with clean sand per A■3 Jr •• � Arc. 102.1 g 7-4 0 .,. �Cj N (aJl,�t W�c�?1�2. e �Z �+C ?, I E p __ __.... .. _ Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with en r ends grouted if SEPT I C' SYSTEM DES I G N applicable. The proposed SAS is being installed below the water service --�" 40. line. The line is to be sleeved as aforementioned and maintained in place. _a --` 11) If a garbage grinder exists it is to be removed and is the responsibility of the o 1 vJ FLOW ESTIMATE owner to ensure such. 12)The installer is to take caution in excavation around the gas line if such BEDI OOMS AT JID GAL/DAY/BEDROOM -220GAL/DAY exists. I 4 to — 5 ' i__ _ 13)The installer shall verify the location, quantity and elevation of the sewer SEPTIC TANK lines exiting the dwelling prior to the installation. i -_ -�, ---� lw 2A� - _---- --- . ./DAY x 2 DAYS GAL i USE /SrVGALLON SEPTIC TANK p3 107,00 —;.o�� SOB',4 �1t O Ct AH A RPTION SYSTEM Mid rODD Q ~ r ....11 " l '� 0 �� /'� SIDE AREA: `� •; '(_y' /loin X D `74" ou ' BOTTOM AREA:� 30 CV) Q' w SFPTwIC SYSTEM SECTION -�. N 4.a�. I z N v� o p 'I �IG4-k b1C. Co 0 w � b Dr ' -ve lu Ole 0( 1 fD 2 l7G 3 p5 Pit �b a2 t \,Tfs F4ft 1 Al,L IN +p 00 /�' � 7 6�u1 l�� Uj —>�=BOA" ✓� b ' ` t6 GAL S M 4 o SEPTIC TANK 'Ib 1 F a r�+� d� �� Hr� v �, 144:64 __.. __- --_ ------- ------ .�. /vs0o 57-' d- *W ,• , a o a Q SITE AND SEWAGE PLAN Y LOCAT I ON : -*/S - � PIE i-:-.,.cfAv Alberf i PREPARED FOR : � OEJF 6L, SCALE: CL DAV I D B . MASON RS DATE: Zv b Z DBC ENVIRONMENTAL DESIGNS J W 3 DATE HEALTH AGENT EAST SANDWICH . MA z - 2177( 508 ) 833