The URL can be used to link to this page

Home My WebLink About0020 FERNBROOK LANE - Health 2A Fernbrook Lane Centerville P A = 208 085009 IN �J�Q�cvc�b�m riu UPC 12543 No.53LOR_ HASTINGS.MN J No. y 10 �Q Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for �Digpooal 6p6tem Cottgtruction Permit Application for a Permit to Construct( ) Repair( j Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. CQ0 Owner's Name,Address;and Tel.No. � (,v� Assessor's Map/Parcel C Installer's e,Ad ss and Tel.No. C 11L/4M P/l / Designer's Name,Address and Tel.NnI-�k)�`�V l � Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �t7 �✓� gpd Design flow provided j�, �'jr gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �/b b 6 Type of S.A.S. S Description of Soil Nature of Repairs or Alterations(Answer when applicable) _-- M5'/,(] 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 Board of Health. e Date Application Approved Date C5�`O�Q Application Disapproved by: Date for the following reasons Permit No. 0401 1a-- Date Issued �� No. V — — V' � Fee Il & ti�.w�,�oe u I Entered n omputer: ,��TkI�COMMONWEALTH OF MASSACHUSETTS i cYes — ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS i Rppr%catton for Mtzponl impotent Conotructiou permit Application for a Permit to Construct Repair Upgrade Abandon Complete System Individual Components } Location Address or Lot No. O ;C,5,VjV/58 d 0K'Q Owner's Name,Address,and Tel.No UK p(,v�(_."D i i Q i Assessor's Map/Parcel r _ b /f, �6 Installer's N �%A d��ss,and Tel.7 o. / 01c", Designer's Name,Address and Tel.Nn�A�E/v In Ry 9 6 // 5 ,`yr�a 5 / �o v�wlc-�,¢ 4,74 Type of Building: _ r Dwelling No.of Bedrooms Lot Size ,5 � 7 sq.ft. Garbage Grinder ( ) F ' Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 'Design Flow(min.required) ?:3O gpd Design flow provided �'j C r" 1 gpd Plan Date Number of sheets Revision Date y ,. Title Size o�Septic Tank �/d 6 y Type of S.A.S. S Description of Soil i �'- Nature of Repairs or Alterations(Answer when applicable) P, 4_ i , 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 Board of Health. -� / C� Gli Date " / Application Approved Date e Application Disapproved by: Date for the following reasons Permit No. Date Issued -------------------------------- THE COMMONWEALTHCOMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance � THIS IS TO CERTIFY,that the On-site Sewage Disposa System Constructed ( ) Repaired (jam''"Upgraded ( ) Abandoned( )by V-)j k.-/- /j V 6 K, at nl D EE 0u8R00 f C f_AN I I has been constructed in accordance with the provisions of Titl 5 and the for Dis sal Sy st Construction Permit No. dated Installer p / � [ Designer #bedrooms Approved design flow ^(}, gpd The issuance of this permit s all no be construed as a guarantee that the system i I f nct*1 i ash esi ne � Date Inspector t I 1 j No. �� _' Fee l HE COMMONWEALTH OF MASSACHUSETTS 4 PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=i!5po.5ar 6p.5tent Construction Permit Permission is hereby granted to Construct ( ) Repair (4- ) Upgrade ( ) Abandon ( ) System located at ��Q ��F1�JyR po O r I—AiV P a_ 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: Construction�m st be completed within three years of the C ate o hi�permi . G Date CJ� Approv d by y TOWN OF BARNSTABLE LOCATION 60 R20 08f SEWAGE# �VILLAGE Clt�aTrZ W. `ASSESSOR'S MAP&PARCELe��""a °J©� INSTALLERS NAME&PHONE NO.(V f4—A P JAZSlrZ✓ SEPTIC TANK CAPACITY r Off? LEACHING FACILITY:(type) O (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: ,Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Aa - Ge 9 3 /4-q - 31 A-5-- ,Y � TOWN '' OF BARNSTABLE LOCATION ern 6'd K Lh SEWAGE # VILLAGE �a-'�P�Ud f C ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �G r I LEACHING FACILITY: (type) L�' c °� (size) NO.OF-BEDROOMS BUILDER OR OWNER 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 f leaching facility) x`r Feet Furnished-by..__S� N'� /VI-�/Ty l� �k Sfa?cl , __- 13' r b -�- 34' -.%i�- IVY` P o - Dfl � E . I x7 -a Message Page 1 of 1 Wadlington, Ellen From: Miorandi, Donna Sent: Thursday, March 06, 2008 8:54 AM To: 'Dmeyer369@comcast.net' Cc: Heath DeptMailbox Subject: RE: 20 Fernbrook Hi Darren, We NEED revised plans for the property. I walked through the house with Billy Dinger and it definitely has always been a four(4) bedroom house and.thankfully it is not in the Zone of Contribution. Thanks! Donna P.S. I think we or at least you should be doing a walk-through at perc time or at some time previous to permitting. Suggestion also that floor plans be put on plans. This situations are becoming more and more problematic. -----Original Message----- From: Dmeyer369@comcast.net [mailto:Dmeyer369@comcast.net] Sent: Wednesday, March 05, 2008 8:12 AM To: Miorandi, Donna Subject: 20 Fernbrook Hi Donna. w How do you want me to proceed with 20 Fernbrook. Apparently its a 4 BR house, which they installed for, but Assessors have it as a 3 BR. What do you need me to do, to get the compliance. Thanks. Darren 1 4/16/2008 i � T'own of B A rnstab le P# me �• � Department of Regulatory Services �Bw i Publiciealth•Division Date_ 1bsq ems$ 200 Main StreeL-Hyannis MA 02601 yy rfO hAA1 J/194ral Date Scheduled v' : Time_ 1� Fee Pd. i Foil Suitabili Assess.meet for Sewage Disposdi Performed By: " � • �� ' Witnessed By-, rri 1�Vlyl`�'1 LOCATION & GENERAL INFORMATION Location Address' rwOOy, 1 �, Owner's Name L i6E►'1-r`EAV I Lt.(__� MA Address ram: q Assessor's Map/Ntcel: °Z0q l®�j S/QO I Engineer's Name r C v ion �— t 0 NEW CONS1RU01ION REPAIR X Telephone# i 12t?sl�la� (46) Surface es Land Use Slopes Stones Distances from: ripen Water Body. 2a� ft Possible Wee Area 26O ft Drinking Water Well l�� ft ))rainage Way ft Property Line !d—ft. Other ft SKETCH:($treet name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) p • i i s • i i Al Parent material(geologic) qG�Q �u'w � I Depth t0 Bedtoek ' Depth to GroundwaWr. Standing Water in Hole: I Weeping from Plt FAce N Estimated Seasonal tVgh Groundwater N lYt TERMINATION FOR SEASONAL HIGH WATER TADLE Method Used: Depth Gibperved standing in obs.hole: _in. Depth td 5all M0ttlf s:—Y Depth toiweeping from side of obs.hole: i in, Groundwater Adjustment Index Well#_ Reading Date: Index Well level. ,,,.e, AtJ.factor,,,._.�. AdJ.(lrpUttdWAt@PLeVtll,,,e i PERCOLATION TEST . Date- T4ne Observation I Tithe at 9" Hole# N i Depth of Perc Time at 6" Start Pre-soak Time.@ __ Time(9"•6") ..—.-- / i End Pre-soak Rate Minilnch Site Suitability Assessment: Site Passed '� Site Failed; Additional Testing Needed(Y/N) v�J H lth Division Observation Hole Data To Be Completed on Back-- - / OrigtnaL.Public e;i ***If percola#6n test is to be conducted within 100' of wetland,you must first notify the I�X Barnstable C4 serva ion Division at least one(1)Weck prior to beginning J DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other .Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nsis enc %Gravel) u Ln4 . jD R3 �`, 4 S �O�RS`g D�IZ G _ �.sy.7lY 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)- 0 It-5It u Co lbY�3l� "-18" �o an /oY� s� • A192�-G 2. ply DEEP OBSERVATION HOLE LOG Hole# A Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.' Cons i to c %O vel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nitn Flood Insurance Rate May: Above 500 year flood boundary No_ Yes , Within 500 year boundary No_X Yes Within 100 year flood boundary No k Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pe vious material? Certification I certify that on b cic� (date)I have passed the soil evaluator examination approved by the Department nvi on. entaI Protection and that the above analysis was performed by me consistent with the required trai tin ;expertise hnd exp fence described in 3,10 CMR 15.01 . Signature Date Q:\.SEPTIC\PERCFORM.DOC SENDER: COMPLETE THIS SECTION . . ■ Complete items 1,2,and 3.Also complete 7A. 7nat ,item 4 if Restricted Delivery is desired. %-� Agent ■ Print your name and address on the reverse Addressee I so that we can returnthe card to you. . inted Name) C. Date of De ry i ■ Attach this lard to the back of the mailpiece, ! I` or on the front if space permits. D. Is delivery address different from item 1? es 1. Article Addressed to: If YES,enter delivery address below: ❑No ! \ S C'k 3. Service Type �� J� J e- 9 Certified Mail ❑Express Mail ❑Registered ■Return Receipt for Merchandise L Z�o�p ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7006 215 0 0 0 2 1038 6 711 I (Transfer from service labeQ { PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 I UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 I • Sender: Please print your name, address, and ZIP+4 in this box • I I Town of Barnstable r' Health Division 200 Main Street o \ Hyannis, MA 02601 __ —� S �oF ti Town of Barnstable Barnstable THE T . H 4 t . .�t Regulatory Services Department VEV EzI ASS. /q t' RARNSTABL ,16� Public Health Division �ED MAC a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO February 4, 2008 f + Financial Asset Services Attn: Jessica Parra j - C-)B `D` f ate 1300 Quail Street Newport Beach, CA 92660 ,y; Do g pal ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 20 Fernbrook Lane, Hyannis MA was inspected on January 30, 2008, by Shawn McElroy, certified Title V Septic Inspector for the State of Massachusetts. The inspecti of the septic system showed that the system FAILED under-the guidelines of 95 TITLE V (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. • Liquid depth in cesspool is less than 6" below invert or available volume is less then '/2 day flow. You are ordered to repair or replace the septic system within Sixty (60) days from the date of this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDE E BOA OF HEALTH T oinaS " c ean, R.S., CHO Agent of the Board of Health Ce,rV, ,i lam\w. ` �E '1�U� 2l S V Ooo a� %031& 6-M Q:\SEPTIC\Letters Septic Inspection Failures\20 Fernbrook Lane.doc I V Commonwealth of Massachusetts Title 5 kcal Inspection Form Subsurface.Sewage Disposat System Form-Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services a 0`L 0%5.p09 Owner Owner's Name information is required for Centerville MA 02632 1-30-08 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information 1. Inspector. Shawn Mcelroy Name of Inspector Shawn Mcelroy Enterprises Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Cityrrown state Zip Code 1-568-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personalty inspected the sewage disposal system at this address and tl-ai the c information reported below is true,accurate and complete as of the time of the insp�ction.The ins.,pection was performed based on my training and experience in the proper function and maintenan f o"ite sewage disposal systems.I am a DEP approved system inspector pursuant tw-Section B.34C& Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fags, ❑ Needs Further Evaluation by the Local Approving Authority a t C-n 1-30-08 inspector's Sigfiature Date The system inspector shalt submit a copy of this inspection report to the Approving Authority(Board of Health or DER)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 show 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 systems will perform in the future under the same or different conditions of use. t5insp•08106 Tba 5 OffkNaf Inspec§on Form:Sutsuurface Sewage Deposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's Name information is required for Centerville MA 02832 1-30-08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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: 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. Answer yes, no or not determined (Y,N.ND)in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old'`or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or date 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 t5insp•08/06 Title 5 Official Inspection Force.Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts ,Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's Name information is required for Centerville MA 02632 -1-30-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cunt.): ❑ 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): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 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. t5insp-08/06 Tiffe 5Offidaf tnspectinnforrr[Subsurface Sewage Drsposal System-Page 3 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's Name information is required for Centerville MA 02632 1-30-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health(cont.): ❑ 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 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 lever 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 '/Z 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 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. t5insp-Oa(06 TAfe 5 Official trapection Form:Subsurface Smage Disposal system-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's Name information is required for Centerville MA 02632 1-30-08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) D) System Failure Criteria Applicable to All Systems (cunt): Yes No ❑ ® 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.fair.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 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 has fair.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. t5insp-08108 Tine 5 Off=af tnspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's Name information is Centerville MA 02632 1-30-08 required for every 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 one ® ❑ Existing information. For example,a plan at the Board of Health. ® El approximation 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)] t5insp-08M Title 5 Official Ruction C-wm:Subsurface Swage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner owner's Name information is Centerville MA 02632 1-30-08 required for every page. City(rown state Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system?fsf yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes JZ No Water meter readings, if available(last 2 years usage(gam): Sump pump? ❑ Yes ® No Last date of occupancy: 12-07Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CUR 15.203): Gallons per day(9pd) Basis of design flow(seatstpersonstsq.ft., etc.): Grease trap prese11? ❑ Y eJ ❑ 1,4u Industrial waste holding tang present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if auaUabte: Last date of occupancyluse: Date Other(describe): t5insp-08/06 T€#e 5 Official hispeabon%m:Subswface-Sewage Drsposal System•Page 7 of 15 Commonwealth of Massachusetts , Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner owner's Name information is required for Centerville AAA GM2 1-30-08 every page. City1rown State Zip Code Date of Inspection D. System Information (cant_) General Information Pumping Records: Source of information: NIA 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 11 - Overflow cesspool ❑ Privy D Shared system (yes or no)(if yes,attach previous inspection records if any) ❑ InnovativelAttemative technology.Attach a copy of the current operation and maintenance contract o be obtained from system owner an (� y ) ❑ Tight tank.Attach a co of the DEP approval. g PY pPr'o Q Other(describe): Approximate age of all components, date installed(if known)and source of information: 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•08M6 F"we 5 Off=W kspecftn Form SLtsurtace Swage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-loot for Voluntary Assessments 4 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's fume information is Centerville I61IA 02632 1-30-08 required for every page. C'ttylfown state Zip Code Date of Inspection D. System Information (cont) Building Sewer(locate on site plan): tp4t Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): 12" Depth below grade: feet Material of construction: ® concrete ❑metal ❑fiberglass ❑polyethylene ❑ other (explain) If tank is metal, list age. years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gal Sludge depth: I Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet t 14" ee or battle How were dimensions determined? Tape 15insp-DaW Tee SEA A: a Fome subf�semaqeDsposw System-Pane 9 of 15 Commonwealth of Massachusetts Fills 5 Official Inspection Farm Subsurface Sewage Disposaf System Form -Not for Voluntary Assessments �w 20 Fernbrook Ln Property Address Financial Asset Services Owner Owner's Name information isCenterville MA 02632 1-304)8 required for every page. CRy/Town State Zip Code Date of Inspection D. System Information (cat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.) Good condition with all baffles in place. Grease Trap({ovate 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: we 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): t5insp-08= rids 5 OfficW taspeceon Form:Subsislace Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal:System Form Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's Name information is required for Centerville MA 02632 1-30-M every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cunt.) 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 Distribution Box(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(locate on site plan): Pumps in working order. ❑.Yes ❑ No Alarms in working order. ❑ Yes ❑ No t5insp•08M Tr de 50fti Inspecbm Earn_Svbsurtace Sewmge Disposal System•Page 11 of 15 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's Name information is required for Centerville MA 02632 1-30-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had clear evidence of being filled beyond its capacity. t5insp•08/06 Ydte 5 Offio t fnspedion Form Subsurface Sewage D'sposal System-Page 12 of 15 Commonwealth of Massachusetts F .Title 5 Official Inspection Form Subsurface Sewage Disposall System Form -Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's Name information is required for Centerville MA 02632 1-30-08 every page. City(rown State Zip Code Date of Inspection D. System Information (cunt.) 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 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.): t5insp•08/06 Tide 5.Dffkaaffespectonrf*m-Subsurface Smaage Disposal System•Page 13 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's Name information is required for Centerville MA 02632 1-30-08 every page. City(rown State Zip Code Date of Inspection D. System Information (coat.) 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_ A -C- -'N -A YA- 4/9 v 0 t5insp•08= TWe S MW hspec6cm Farce Subsudam arage Disposal!Se System•Page 14 of 15 Commonwealth of Massachusetts ,Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Fembrook Ln Property Address Financial Asset Services Owner Owner's Name information is required for Centerville MA 02632 1-30-08 every 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 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 propertylobservation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show groundwater at 20'. t5insp-08/06 Title 5 Offidall hmpechm Form Subsurface 1 Sewage D'sposa System•Page 15 of 15 • Town of Barnstable OF'THE 1p� Regulatory Services sARNSTABM ; Thomas F. Geiler, Director 9 MASS. g $ 1639. Public Health .Division ATED��A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. t Date: / 16 / d( TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 06 D BUSINESS LOCATION: C20 V'ri-b mo INVENTORY MAILING ADDRESS: o TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: AI,1,5 CVA a. EMERGENCY CONTACT LEPHONE NUMBER: 5D8 " 77/ LD gc/'? MSDS ON SI E? TYPE OF BUSINESS: i h INFORMATION/RECO MEND IONS; Q /t�� Fire D•strict: fl.A.l S S o — � 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 materials 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) Misc. Corrosive NEW USED 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 Misc. 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 Misc. 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 (inc. carbon tetrachloride) �2NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers �/�' /��P.V�•a S ��.� f�,� ��. (including bleach) �; j Spot removers &cleaning fluids b7lt (dry cleaners) QsiDih " Other cleaning solvents _ Bug and tar removers L`v J ,��E� w Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS +oa YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 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.) Business Certificates are available at the Town Clerk's Office, 1s' FL., 367 Main -Street, Hyannis, MA 02601 (Town Hall) &Aid .' DATE:If 4 �LA.. M, gi Fill in.please:APPLICANT'S YOUR NAME: 10 # BUSINESS YOUR HOME ADDRESS: TELEPHONE # Home Telephone Numbed' NAME OF NEW BUSINESS I. na TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES -NO. Have you been given appr al from the building di :is"on? YES NO ADDRESS OF BUSINESS iCS7� AP/PARCEL NUMBER V V ZS too F�ga..v O��®tC B.N Ce.N�fefV,`LL /wA ®:t6',�a 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 St.=(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 CO ISSI ER'S OF C a This individ al has e:i4n. f any permit requirements that pertain to this type of business. \ Aut orize nat re** OMMENTS. d d 5 , S i 2. BOARD OF HEALTH r 'Z This individual h be n inf me of tl}e perrvA r uirements th pertain to this type of bWinesq. A orized Signature" � L COMMENTS: 0 3. CONSUMER AFFAIRS *eformed SING AUT RIT This individual ha of the rein r quirements that pertain to this type of business. Aut orized Signat re'' COMMENTS: i YOU WISH TO OPEN A BUSINESS. ow For Your Information: Business certificates(cost $30.00 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.) Business Certificates are available at the Town Clerk's Office, 1s` FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) :.. DATE: I ( ib (05 ,Ma ; R1M Fill in please: r + r J , � - APPLICANT'S YOUR NAME: WC��/✓ rRei 0 s (3c,Vt91V AGE+ CIAO' BUSINESS YOUR HOME ADDRESS: Of-d 6MC Rd fly � � x cely7oR a a TELEPHONE # Home Telephone Number Y7 0 021 NAME OF NEW BUSINESS TYPE OF BUSINESS CIS L cC6WV19e�0 4A 500- IS THIS A HOME OCCUPATION?-- -- YES , NO. Have you been given approval from ---Nt9'� y C/o ADDRES BUSINESS MAP/P.ARCEL NUMBER 7 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 St.-(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 C ISS NER'S OFFICE This indiv ual h s era-inf a any permit requirements that pertain to this type of business, Authorized nature"* COMMENTS: — v Ud�'�--- 2. BOARD OF HEALTH This individual ha a informed f rmit re uiretTT that pertain to this type of business. AA QAuthorized Si_abii *` COMMENTS: -f'� 3. CONSUMER AFFAIRS(LICENSING AUTHORITY This individual h n inform f,the lice o r re ents that pertain to this type of business. Authorized Signature" COMMENTS: t _ R - ' Date: �> TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: �J yV Q IAtDll BUSINESS LOCATION: `jjq GL(� 6-tA op_ 10 (rp,617jcgU i'LLp, /1I,4 Da63, MAILING ADDRESS: �8 Q� a6� �}yAd_ S /YIp a Mail To: TELEPHONE NUMBER:C`7 Al2 r a f 6�6A Board of Health Town of Barnstable CONTACT PERSON: S P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: rIDAY 5 1 6q 6g a8�q65Hyannis, MA 02601 TYPEOFBUSINESS: G0NLoR�L CnWR A�b� Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO C>L This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: Q��PerAe na TELEPHONE: 9q a 6 LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity i Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) X1 Hydraulic fluid (including brake fluid) t�yl Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel _ Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal 7;K Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) _ Swimming pool chlorine Rustproofers _ Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar IT Fertilizers Paints, varnishes, stains, dyes � PCB-s Lacquer thinners Ar Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers Metal polishes hydrochloric acid, other acids) Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): _ Spot removers & cleaning fluids 1A (dry cleaners) _ Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS + COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION_ a David B.Mason,R.S,Certified Title V Inspector,508-833-2177 (BAR 2 3 2004 IT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION LAN G Property Address: 20 Fernbrook Rlesdy Centerville,MA Owner's Name: Mike Duffly ;4AR ®� Owner's Address: 20 Fernbrook,Centerville,MA- PARCEL p.1 -Z Date of Inspection: March 6,2004 Name of Inspector: (please print)David B.Mason Company Name:—N.A. Mailing Address: 4 Glacier Path East Sandwich,MA 02537 Telephone Number: 508-833-2177 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authori Fails 0 Inspector's Signatur • f Date: The system inspector shall submit a copy of this inspection report to the Approving A thori (Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to.the system owner and copies sent to the buyer,if applicable,and the approving authority. : Notes and Comments: System as inspected appears to have operated based on occupancy level. Septic tank should be pumped as a matter of maintenance. The information as identified represents only the condition of the system on March 6,2004 at 3:00 PM. ****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. ` Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 Fernbrook,Centerville,MA Owner: Mike Dullly Date of Inspection: March 6,2004 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: 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 a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 (THIS IS REQUIRED TO BE COMPLETED) 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): broken pipe(s)are replaced obstruction is removed ND explain: OFFICIAL INSPECTION FORM- NOT FOR.VOLUNTARY ASSESSMENTS Page 3 of 11 PART A CERTIFICATION(continued) Property Address: 20 Fernbrook,Centerville,MA Owner: Mike Duflly Date of Inspection:March 6,2004 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 4 of 11 CERTIFICATION(continued) Property Address: 20 Fernbrook Lane,Centerville,MA Owner: Mike Duffly Date of Inspection: March 6,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool NA_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO_(Yes/No)The system fails.I have determined that one or 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. 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 lI 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 Fernbrook Lane,MA Owner: Mike Duftly Date of Inspection: March 6,2004 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?(INCLUDING THE SAS) _X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no f 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 CUR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 Frnbrook Lane,Centerville,MA Owner: Mike Duftly Date of Inspection:March 6,2004 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:_4 Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): 2003; 50,000 2002;81,000 Sump pump(yes or no):No Last date of occupancy: (current) COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Property owner 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:No pumping records on file. Per owner system has not been pumped for the last 4 years. TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe):With pump chamber Approximate age of all components,date installed(if known)and source of information: 11 years Were sewage odors detected when arriving at the site(yes or no):NO OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS Page 7 of I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:20 Fernbrook Lane,Centerville,MA Owner: Mike Duffly Date of Inspection:March 6,2004 BUILDING SEWER(locate on site plan) Depth below grade:Approx.24 Inches Materials of construction:_cast iron _X_40 PVC other(explain): Distance from private water supply well or suction line:_NA Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident leakage. Possible pipe is bowed based on positioning of inlet tee. SEPTIC TANK: N.A.(locate on site plan) Depth below grade: 8" Material of construction:X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Typical 1000 gst 8'6"L,4'6"H,518"W Sludge depth:4 inches Distance from top of sludge to bottom of outlet tee or baffle:27" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle: 16" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: actual measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)No evidence of leakage. Septic Tank required maintenance pumping. Outlet tee is precast in good condition. Tank is H101oaded. GREASE TRAP: N.A. 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). 'OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS • Page 8 of I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:20 Fernbrook Lane,Centerville,MA Owner: Mike Duffly Date of Inspection:March 6,2004 TIGHT or HOLDING TANK: N.A._(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: YES (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even with outlet pipe Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Box is level. There is evidence of solid carry over. Box is not leaking. Dbox is 18"below grade. 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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS L Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:20 Fernbrook Lane,Centerville,MA Owner: Mike Duffly Date of Inspection:March 6,2004 SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 6'X6' _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.)- Effluent was 24 inches below the pipe invert. No indication of staining,no ponding or damp soil. Pit is 43" below grade. Riser is 26"below grade. CESSPOOLS: NA (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:20 Fernbrook Lane,Centervill,Ma Owner:Mike Duffly Date of Inspection: March 6,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Loc\a Ae/all wells within 100 feet.Locate where public water supply enters the building. V� q2 OF Pbu-6)& �I S° 2� � � o Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:20 Fernbrook Lane,Centerville,MA Owner: Mike Dullly Date of Inspection: March 6,2004 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water 15 feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain:Recent Test Holes, Existing engineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography does not indicate ground water to be within 4 feet of bottom of leaching facility. Test holes in the area on file do not indicate ground water not within 20 feet of grade. TOWN OF BARNSTABLE LOCIATION /Z /�'��JL� �� SEWAGE # `�19 VILLAGE Ce/UTei�I�/1-+6 ASSESSOR'S MAP Cz LOT 20�, S^G69 INSTALLER'S NAME & PHONE NO. J) JDOScALL 771`1040 SEPTIC TANK CAPACITY /D 00 LEACHING FACILITY:(type) ZeAek l%el (size) /600 ,) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ��5/�{� ii��h� La, -77I` 645 9V DATE PERMIT ISSUED: —12 - 93 DATE COLIPLIANCE ISSUED: //n - -s 9 _- VARIANCE GRANTED: Yes No z l *i f ' i � � � � r 13 i �� c� 3�l` r .Z r.. �:. 3 �� l No.... ..1.=11.1 FEs........r.6.v........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Uiiqpusal Works Tonstrurtion thrmit Application is hereby made for a Permit to Construct (t/) or Repair ( ) an Individual Sewage Disposal t'y Sys em t: ................_...........�..._...............-•---------•-•-•-••---•-----...-•------------ .......................................................... ...... -....._._......__ • �Loegtio AddreV 11 /�'�C�� W Ov(ner /� Address a - .. .............•--------------------•-------- ------�:.`_... -•........"......------------------------- Installer Address ..Sq. feet Type of Building 3 Size Lot___��-s�_-_.-... Dwelling—No. of Bedrooms............................................Expansion Attic (/di)) Garbage Grinder (,'O) aOther—Type of BuildingZ&llI No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures -------------------------------- -------------- W Design Flow...............11�....................gallons per p per day. Total daily flow---------_.._.�a..........._.................gallons. 9 Septic Tank—Liquid capacity-_-.�W allons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.-______-_--___-____ Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing t nk ( ) ~' Percolation Test Results Performed by----. �a- Date---- -3—l oe ,� --------------- 0-4 Test Pit No. 1................minutes per inch Depth of Test 4-0 i Depth to ground water........................ 0-4 (N Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ O Description of Soil.......fit _ U --•---•---------•------------------------------ ---- ••----------------------------- •-------------------------------------------------------------------------------------W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ......................................-.....................-----------------------•--•-•-•---•.....---------------------------------------------------•----------------•--------------•-•-•-•......••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia has bee ' 4bl, he board of health. Signed 9_M ....... Dace ApplicationApproved By ----------- V --------------------------------------------------------------------------- ---- Dace Application Disapproved for the following reasons- ---------- - ---------------- -------------------------- -- ---------------- ---------- -- ------------------------------- ---------------- - --------------- Dace Permit No. -----7.a_----la—. .�......... .................. Issued ....../ '`./.��`--`�-�� Dace s— _ Ire X r Fmc ......... -r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Biq v iial-Workg Tonotrurtion 1hrutit �,4 Application is hereby made for a Permit to Construct ( V or Repair ( ) an Individual Sewage Disposal System at: - a �----------•_.. .......� � -----------------�..-...---------...-•----------------------...._........----- Lo¢ation-Addres or t�No: Owner ----Address �✓ Installer Address j v Type of Building 677 Size Lot____�.....................Sq. feet �-t Dwelling—No. of Bedrooms............................................Expansion Attic (M5) Garbage Grinder (Nu) Other �.�___�__—T e a yp of Buildin1�111�__g No. of persons____________________________ Showers ( ) — Cafeteria ( ) Other fixtures ......................... •••--•--- W Design Flow_______________f��____________._______gallons per pe>son•per day. Total daily flow..._._.........�-�_._._�_________________.__.__gallons. WSeptic Tank—Liquid capacity_. QWgallons Length................ Width................ Diameter-----------_.... Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by....... __------__Y-� f<�_ _______________________________ Date_____�r'_J 3 `9 OL as ..._••••-••-•-••-•-_... ,.� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil_______ �d� U •---••-•----•-••----•••----•••-•------••-•-••-•-•--•-----•-•••---•------••-••---•••-----------•••-•------•-----•---••------•-•-•-------•-•--•-•---•••--•---•----•••--•••------------------•--•---•-•-•- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... .........................-.............................................................................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliajad# has been issued b he board of health. Signed .. ---------------------------------------- ......------------.--- Date Application Approved By -----------b-en-. ice^�.�. ti ......./';�6---e ? 2 Application Disapproved for the following reasons: ---_- ------------------------------------------------------------------------------------------- -- ------------------------- ................................................ ... ----------------------------------------....------------------------------------------------------------------....---------------------------- ........................................ ....... . qDate Permit No. ..... -------------------------- Issued ------/�!f"--� "`... '.`► ..------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cex#iftrate of Contylian e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( �) or Repaired ( ) by....�j......- ........................... Installer at ....LUT /a FFRNl3(Z OU/� 4,ACE NTH A- V/ LC- .. ......... - .........................................................----------..................................... has been installed in accordance with the provisions of TITLE 5 o The State Environmental Code as described in the application for Disposal Works Construction Permit No. ........7........41,..l..el............. dated ................--.....-----.---------....----.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. i .. Inspector ..............------ ......................--------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / TOWN OF BARNSTABLE Disposal, ork.5 Tonoir iott autit Permission is hereby granted �� = .......................... to Construct (✓) or Repair ( ) an Individual Sewage Disposal Syst at No...4:T._.l a...._t r_'eN6/e—(VlG L/1tiE Ca`,r/T�/L�/1 1 t..L..F_ Street g ,•�1 .-- �� as shown on the application for Disposal Works Construction Permit No./p�_-��,�1__ Dated.... --------------- � ........... _ -----••-----------•---------•---•--••--- - -----•••--•--_.__----..`-��--••••- DATE. / "' Board of Health ----•--•--------••-------------•----�--��--------...-•--•-- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS /� r �7 G� ^ 11066 4:�A`•"" , N. f o►J '3hGk N EeW PIT 51DEw/4 L AWA lg8 5F� �{ 9f , ' w I �2. �'Eetl'$ (_/�► B0170M AQ64. _ -t 6 SF �4 . ' •TOTAL VA 1L F'1.a1V = 330 6PD' DK-`• T�E¢4a[.ATtoN A7E _ l°�u .2Mi>�I./ 5S � r i OF F Haan PETER + BAXTER s (�oc.t-:1i2 3,q2 FG= 3l, TF= 44- F'4= 37 Low ' F it1d. vKT INV. GAL 35.0 "• i 4DOd' t �!� Bo➢c S�j{(�ric bAL +M fL 141 -r J! Z - 3 t-1 t z.3 _ � y r� WWWEv Pry,TIJA JI sEr t , �' Alo% 1 1 1 �R.\/It.,LE 444L�'o, I�� p DATE; �2, ,�� ►�Z... PLAN TrY T4 AT.T4•CE,_.,�P6� -A't`64,. E fzF1•ICr=_ ow:N N oN co/A L)6 wrrr� =-tug :5 +�III�Ir�' Lam' qMjY TFlrAla `_ L C G: 1 LI °i`7'2 � S14 17ZOFt-575 44L: LAW b Suev yorzS IS Nor- T04EJ a l AN.': t�J =4rtEI�Yt zw i L_ ' E+1Gi N 4JE .5 SuCr. cy A�J� THE �FFF eTs-440 Y u yr 13E ,. . o STk\./I L LE titA,4 , VS To G6TA W,5 Rza� y f, l.i uES APPLICANT, "3Agslt>E SolLt))w6 �, OF �Z MAT' 2oS F-L vS Ad'L 40 ; / i v It f17 t' 4+ r. 1 � o' 'f/ ••`.ji �ZAIN3� a, yb R'x l � ° f s•-J tea, �'� � I �: 1 47.(, � AZ 431 a 44 ONOF 3 k ' L lr y JMRAF0 U t 'BAXTER r� { v 3JULLIVAil ` c� r ►►.=aoc9 f No. 2 33 �'�•. i d `_ Town of Barnstable Regulatory Services Thomas F. Geiler, Director nnaysrnst.s. h"� Public Health Division Thomas McKean, Director 200 Main.Street,Hyannis,MA 02601 Office: 508-862-46-P Fax: 508-790-6304 Installer & Designer Certification Form Date: Sewage Permit#, 667 Q 4ssessor's Map\Parcel 08 6b Designer: UP^ Installer: Address: ?0 r 0X Address: "6 P4/U7-26C S7-- On %yeas issued a permit to install a Y(date) (installer) septic system at )-U �' ��FX7'� �.�r-�� based on a design drawn by (address) dated (designer) 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation Wthe distribution box an&'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 anv vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by desianer to follow. OF 1(11nq�taller's Signature) 1 1140 SiE � SOI TAR�1`� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COiNIPL1ANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Heaith/Septic/Designer Certification Form 3-264doc I i 46 LEGEND m PROPOSED CONTOUR ` 0 9® PROPOSED SPOT GRADE a ��% `\ \�'�• -- 98 -- EXISTING CONTOUR ®o. a N i \ G 44=' s / --_\\\ \\ \\\\ + 96.52 EXISTING SPOT GRADE HENRY t BENCH MARK t yjA i%" ' \\ \\\ ��'� W— EXISTING WATER SERVICE pGEIV�["EF�i� E�cP�� PAINT SPOT IN DRIVEWAY i! �� TH-1 TEST PIT FERN ELEVATION = 41 . 63 i%��' \\ \\ \ �, a' v ent�r�j�� GE BARNSTABLE- GIS DATUM 4 ^�!�- '\ \\ �\ `.� gtA AY AM IStOCIC s fie, I 12. Muu a CHUIRC ti TERS►DE +~ LOCUS MAP N.T.S. O \ 42 \ \ GENERAL NOTES: i i � � � ° \ \ \�\ 'stin Leach Pit \ \\ \ \ 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL ' I (No e 10 ° \ \ BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. 0 \ 1 \ 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR OT I I ` \• TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE I \\ \ 1\ `� - \ DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING \ A R E A = 18567 s f `\ B \\ \ FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN \ \ ------- _ `\ ENGINEER BEFORE CONSTRUCTION CONTINUES. 20 rt ------ \ i" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF Existing 1,000 gal \ ,s �� 4 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF _ _ •� ��Q \ Sep tic Tank �!46 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED �joe TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. °�•, i'�Otef 1 \i /i �� i" 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE \ i' off• 1 Z i" THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING Opp, CONSTRUCTION. 10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND FILLED Q 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 14. NO WETLANDS WITHIN 150' OF PROPOSED LEACHING. -42 - ��-------�___-__- _ - _ - - I � � /" 15. ALL PIPING TO BE 4 SCH 40 / / (UNLESS SPECIFIED) ® 1 8FT (" U p) - -- 1 1 -1- i� i, 40 38 27,62 ft..i - -- -/--'----/ 38 40 42 44 f C SYSTEM TIES O A-1: 23' B-1: 12.5' OF M A-2: 27' B-2:. 19' ��?�� gs�9`y� PROPOSED SEPTIC SYSTEM AS-BUILT -PLAN A-3: 40' B-3: 37.5' °r 20 FERNBROOK LANE, CENTERVILLE MA A-4: 34' 3-4: 31' l No. 1140 Prepared for: Mike Dedecko A-5: 46' 8-5: 43' MAP.- P08 Engineering by: Surveying by: SCALE DRAWN JOB. NO. SURVEY REFERENCE: A-6: 57' 3-6: 44' T LOT.•0851009 DARRENM.MEYER,R.S. .900-Tech Endioamental 1"=20' DMM PLAN OF LAND BY BAXTER & NYE, INC. A-7: 65' B-7: 54' NITAR\p� LCP#.•182613 PO BOX981 (508) 364-0894 EAST SANDWICH,MA02537 DATE CHECKED SHEET NO. DATED: AUGUST 1982 ' 2,L�-0 p 508-362z922 02/28/08 DMM 1 Of 2 i ELEV. TOP FOUNDATION (Existing) 41.74 F.G.EL: 41.0 i FINISH GRADE=41.2 � f F.G.EL: 41.2 F.G. EL: 41.2 , MAINTAIN 2% MIN SLOPE OVER LEACHING AREA MAX. COVER OVER LEACHING = 3.0 FT. -' COVERS TO WITHIN 6 OF GRADE s" INSPECTION PORT W/IN 6" OF FINISH GRADE - ------------] f. , 6" . 4" SCH 40 PVC I 4" SCH 40 PVC o 0 0 0 0 0 0 0 0 0 0 0 ®S=2% 10"1 ® S= 1% MIN. (MIN.) TEE'S ARE TO BE 14 ( ) e © S= 1% (MIN.) 4" scH ao PVc INV.38.33 , ° ° ° ° ° ° ° ° ° ° ° ° INV.38.53 INV.38.13 GAS PROPOSED DB-3 ° ° ° ° EXIST. OUTLET BAFFLE H-10 DISTRIBUTION BOX 1 INV. 38.78 EXISTING 1,000 GALLON SEPTIC TANK INV. ELEV.= 38.08 roe r 9„ MIN. GAS BAFFLE TO BE INSTALLED ON NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING OR?'of J/b•ooU46XE ASHm STONE OUTLET TEE AS MANUFACTURED BY PIPE INVERTS PRIOR TO CONSTRUCTION PER TI TLE 5 TUF-TITE, ZABEL, OR EQUAL 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT EL. = 97.98 GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.=38.08 INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2) Jos"- I- 24" 30 5" 3) REPLACE EXISTING 1,000 GALLON SEPTIC °0 w�s�m I; AZ i TANK WITH 1500 GALLON SEPTIC TANK BOTTOM EL.= 36.08 � IF FAILED, DAMAGED, OR UNDERSIZED. 8" 5O" 8» 4) INSTALL INLET & OUTLET TEES AS REQUIRED SEPARATION 5.13 FT. I� �46'p - I SOIL LOGS SEPTIC SYSTEM PROFILE BOTTOM OF TH-1 EL: 30.95 SOIL ABSORPTION SYSTEM (SECTION DATE: FEBRUARY 27, 2008 N.T.S. DESIGN CRITERIA SOIL EVALUATOR: DARREN MEYER, R.S., CSE NUMBER OF BEDROOMS: 4 BEDROOOM DESIGN WITNESS: DONNA MIORANDI SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) HEALTH AGENT DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 110 G.P.D. Elev. TH-1 Depth Elev. TH-2 Depth DESIGN FLOW: 440 G.P.D. 41.64 A LOAMY SAND 0" 41.20 A LOAMY SAND 0" GARBAGE GRINDER: NO (not designed for garbage grinder) 10YR 3/2 10YR 4/2 SEPTIC TANK: 440 gpd x 2 = 660 gpd USE EXISTING 1,000 GALLON SEPTIC TANK 41.23 B 5" 40.79 5" e ;y LOAMY SAND B LEACHING AREA REQUIRED: (440) = 594.59 S.F. 10YR 5/8 LOAMY SAND ; .74 10YR 5/8 USE FOUR (4) INFILTRATOR 3050 UNITS WITH 4 Fr. STONE 39.97 Ci 20" 39.70 18 ON THE SIDES & 2.1 FT. STONE ON ENDS: 34' L x 12.16' W x 2'D C1 BOTTOM AREA: 34 x 12.16 = 413.44 SF SIDE AREA: (34 + 12.16) X 2 X 2 = 184.64 SF PERC 038.20 I TOTAL SQUARE FEET PROVIDED = 598.08 vs. 594.59 REQ'D ME SAND ARSE MED - COARSE I� DESIGN FLOW PROVIDED: 0.74(598.08 S.F.) = 442.58 G.P.D. vs. 440 G.P.D. req'd SAND OF 2.5Y 7/4 2.5Y 7/4 ?�� Mgss9�yG PROPOSED SEPTIC SYSTEM UPGRADE PLAN r DARREN M. MEYER 20 FERNBROOK LANE, CENTERVILLE, MA 31.39 123" 30.95 123" No. 1140 " Prepared for: Mike Dedecko PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) 'PE6�5fEp Engineering by: Surveying by: SCALE DRAWN DATE NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED I DARRENM.MEYER,R.S. rco-Tech Isnvlroumentel N.T.S. DMM 02/28/08 �4A#ITAR�aa PO Box981 (508) 364-0894 EAST SANDWICH,MA02537 REV. DATE CHECKED SHEET NO. 508-3622922 03/06/08 DMM 2 of 2 46\"�• LEGEND 00, "' r PROPOSED CONTOUR �' 400 N PROPOSED SPOT GRADE Q �; �� • t -- 98 -- EXISTING CONTOUR a 44 � ,s / �\ \\\\ + 96.52 EXISTING SPOT GRADE HENRY BENCH MARK \\ �\ yy— EXISTING WATER SERVICE , PAINT SPOT IN DRIVEWAY %" �� \ � � �;' CENTER V E ELEVATION = 41 .63 %' TH-1 �� ` TEST PIT FERNS '9> m �= \ \ enterville� E a BARNSTABLE GIS DATUM 42,� \, \ c AY 927D IStOrIC WATERSIDE '" o �� \\ �\ `•� LOCUS MAP N.T.S. 42 o GENERAL NOTES: stin Leach Pit \ \\ \ \, 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL (No e 10 0 \ 1 BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS �• OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. 0 \ O \ 1 \ 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR i \\ < ,3 \ 1\ �� `'� TO IGN NSPE TION VEER.D APPROVAL BY THE BOARD OF HEALTH AND THE 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING AREA = 18567 S f FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN \ \ ——————— __ �\ > ENGINEER BEFORE CONSTRUCTION CONTINUES. \• \�� Z 20 ft 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. Existing 1,000 g0/ \\ /� �� 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF �S / !) THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF Sep tic Tank ) ff/ %/46 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. �`•, i'�Otgf 5 1 \j // ,/ i 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE i (07� 1 Z C) / i ;i" THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING `• i Opp / ,� i!� CONSTRUCTION. i •�' // �i i j 10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND FILLED 0-1 \ I • • // ,i i �� 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION GAS SERVICE — ' ' / // /i / 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY I ) AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY \r ' / / / i" 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 14. NO WETLANDS WITHIN 150' OF PROPOSED LEACHING. 7 — - - - i i / i 15. `,A \ 42 - - - -�T______�_ I � / i. ALL PIPING TO BE 4" SCH 40 ® 1/8-/FT (UNLESS SPECIFIED) — — — — — — { 127.62 f t 38 40 4 2'�-------�---- J 44 0 SYSTEM TIES OA-1: 23' B-1: 12.5' �\� OF MAss A-2: 27' g-2: 19' ��`�� 9 PROPOSED SEPTIC SYSTEM AS—BUILT PLAN DAR M A-3: 40' B-3: 37.5' 20 FERNBROOK LANE, CENTERVILLE, MA A-4: 34' g-4: 31' " No. 1140 "' Prepared for: Mike Dedecko A-5: 46' g-5: 43' SURVEY REFERENCE: A-6: 57' Rf6)STERc� MAP.• 208 Engineering by: Surveying by: SCALE DRAWN JOB. NO. B-6: 44' 1009 DARRENM.MEYER,R.S. E 00—Teob 1'•nvironmenW 1"=20' DMM PLAN OF LAND BY BAXTER & NYE, INC. A-7: 65' B-7: 54' e SAWA%\pa LCP#.LOT.•08 126182613 Poeox961 E4STSANDWICH,MA02537 (508) 364-0894 DATE CHECKED SHEET NO. DATED: AUGUST 1982 Z Z�l'�p 508-362-2922 02/28/08 DMM 1 Of 2 ELEV. TOP FOUNDATION (Existing) 41.74 F.G.EL: 41.0 F.G.EL: 41.2 F.G. EL: 41.2 FINISH GRADE=41.2 A MAINTAIN 2% MIN SLOPE OVER LEACHING AREA MAX. COVER OVER LEACHING = 3.0 FT. A' COVERS TO WITHIN 6 OF GRADE 6" INSPECTION PORT 4: W/IN 6" OF FINISH GRADE �. 6" • w„• 4" SCH 40 PVC 4" SCH 40 PVC;e a o 0 0 0 0 0 0 0 0 0 0 0 0S=2% 10"t S= 1% MIN. 6 (MIN.) TEES ARE TO BE 14 (MIN.) S= 1 (MIN.) 4" SCH 40 PVC INV.38.53 INV.38.33 INV.38.13 ° ° ° ° ° ° ° ° ° ° ° EXIST. OUTLET GAS PROPOSED DB-3 HO HO ° ° ° ° BAFFLE ••. '.. '• ' H-10 DISTRIBUTION BOX INV. 38.78 EXISTING 1 ,000 GALLON SEPTIC TANK INV. ELEV.= 38.08 MW?F 9„ MIN. GAS BAFFLE TO BE INSTALLED ON NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING OR2•aF ooustE asrrmsnNE PIPE INVERTS. PRIOR TO CONSTRUCTION PER TITLE 5 OUTLET TEE AS MANUFACTURED BY TUF-TITE, ZABEL, OR EQUAL 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT EL. = 97.98 GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.=38.08 INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2) oauet�wasNm s>a� 24" 30 5" 3) REPLACE EXISTING 1,000 GALLON SEPTIC IN TANK WITH 1500 GALLON SEPTIC TANK BOTTOM EL.= 36.08 IF FAILED, DAMAGED, OR UNDERSIZED. I 8„ 50„ 8„ 4) INSTALL INLET & OUTLET TEES,AS REQUIRED `�--� SEPARATION 5.13 FT. I 146" - SOIL LOGS SEPTIC SYSTEM PROFILE BOTTOM OF TH-1 EL: 30.95 4 SOIL ABSORPTION SYSTEM (,SECTION) DATE: FEBRUARY 27, 2008 N.T.S. DESIGN CRITERIA SOIL EVALUATOR: DARREN MEYER, R.S., CSE NUMBER OF BEDROOMS: 4 SEDROOOM DESIGN WITNESS: DONNA MIORANDI SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) HEALTH AGENT DESIGN PERCOLATION RATE: <2 MIN/IN EleDAILY FLOW: 110 G.P.D. 1.6 TH-1 Depth Elev. TH-2 Depth DESIGN FLOW: 440 G.P.D. 41.64 A 0" 41.20 p" GARBAGE GRINDER: NO not designed for garbage grinder) LOAMY SAND A LOAMY SAND ( 9 g g 9 ) 10YR 3/2 10YR 4/2 SEPTIC TANK: 440 gpd x 2 = 660 gpd USE EXISTING 1,000 GALLON SEPTIC TANK 41.23 B 5" 40.79 5" LOAMY SAND B LEACHING AREA REQUIRED: (440) = 594.59 S.F. 10YR 5/8 LOAMY SAND .74 10YR 5/8 USE FOUR (4) INFILTRATOR 3050 UNITS WITH 4 FT. STONE 39.97 Cl 20" ` ON THE SIDES & 2.1 FT. STONE ON ENDS: 34' L x 12.16' W x 2'D 39.70 Cl 18 BOTTOM AREA: 34 x 12.16 = 413.44 SF SIDE AREA: (34 + 12.16) X 2 X 2 = 184.64 SF PERC ®38.20 TOTAL SQUARE FEET PROVIDED = 598.08 vs. 594.59 REQ'D MED - COARSE MED - COARSE DESIGN FLOW PROVIDED: 0.74(598.08 S.F.) = 442.58 G.P.D. vs. 440 G.P.D. req'd SAND SAND �� OF 2.5Y7/4 2.5Y7/4 PROPOSED SEPTIC SYSTEM UPGRADE PLAN DARREN M MEYER 20 FERNBROOK LANE, CENTERVILLE, MA 31.39 123" 30.95 123" No. 1140 Prepared for: Mike Dedecko PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) Engineering by: Surveying by: SCALE DRAWN DATE NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED C�Sj(\ DARRENM.MEYER,R.S. lsco-Tecb EDVironmentel N.T.S. DMM 02/28/08 NI TAR PO BOX98f (508) 364-0894 EASTSANDWICH,MA 02537 REV. DATE CHECKED SHEET NO. 508-3e2-2922 03/06/08 DMM 2 of 2