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0088 FIVE CORNERS ROAD - Health
88 FIVE CORNERS RD., CENTERVILLE A= 168 037 I //// aECYnf,� mead, UPC 12543 o �� No. HASTINGS,MN .:.:-,.,.�:.�e.,,..' -.;:�e.:��'.3:.._,:.��.ti..:,.:_.�.nm:�s;...,.u�uA.c�.�..n:.�;.�:�..a,:.,���:�.�s.a..�.a.,rw�..�- -y — —ter.. - � •.;3a:.ViNs� '..Jrwe =— "�-a No. o oo-' —3 f 3 Fee ( / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4' 0[ppYication for MigpogoY �&pgtem Congtruction Permit Application for a Permit to Construct( ) Repair P"Upggrarde( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. &a r\wF'CO lU(J ��[ Owner's Name,Address a d Tel.No. CGtrI F�vi//fz 17,gece ycc Assessor's Map/Parcel $8 ,::i k- G14A"';Icu �2z J 3 e�Te� It�c Installer's Name,Address,a4d Tel.No. Designer's Name,Addres and Tel.No. �- �Z,-uce `tac lr S t rt` ,.c rY�es o sma Ea!iN , Cq� �9�a �ei A w,Ce Type of Building: Dwelling No.of Bedrooms Lot Size 3 y9 sq. ft. Garbage Grinder (.Vf Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 22 Design Flow(min.required) a30 gpd Design flow provided J 5 gpd Plan Date J^ J a©�7 Number of sheets Revision Date Title Size of Septic Tank /500 G A - Type of S.A.S. GB . nHon ee5 — c oa) Description of Soil �5 E�Sd OS'S e17 /9 X/ Nature of Repairs or Alterations Onswer when applicable) A/�Ae /�movc CfC(S/irl C'['S1 o6 r �� o i r �n-57// IS 6 G-/Tim - 0 fox d o? -soo em 1 Chan c�S cos x 3` %A�+�� 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 oWHe,4th. Signed GG. •� Date SW75 o io 7 Application Approved by t7. Date g'- P.-Op"7. Application Disapproved by: Date for the following reasons Permit No. oz) _3 b ) Date Issued S" D Jot s � `1/ No. . IJ t Fee .. J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION—TOWN OF BARNSTABLE,..MASSACHUSETTS Yes ZIppricatton for D gpoghl *pgtemc Cougtruction J)ermit Application for a Permit to Construct( ) Repair(�j Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components 0 Location Address or Lot No. ba k`r r co 2.ntorj 20l Owner's Name,A dress,aq Tel.No. Assessor's Map/Parcel 8 f3 ht"F ('14 A"`' o Installer's Name, ddress,ar�d Tel.No. _ Designer's Name,Address.and Tel:No. '�(`VGC \tQ.Cr.i�.Slrr 87 1ZanQ �er...l`C SO&� Cis `o?�aa C� Y- T)rpe of Building: Dwelling No.of Bedrooms Lot Size f "3 L/ sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -30 gpd Design flow provided �'`' i gpd Plan Date. Cad Number of sheets Revision Date Title, Size of Septic Tank /JO'Q I �. Type of S.A.S. 0- 0 GAI rtmn&t _S ( oa) Description of Soil Nature of Repairs or Alterations(Answer when applicable) F/10,e kewlotrr Ot r^,7,h, ,LsT// /5066617--wk- 3oX d 62-SQ0619i. CAAiubne.5 o?SX ISE,441 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 H1ea th. '-a Signed"&(4'1 �/ Date SFD ,�d�a � Application Approved by Date o.a. Application Disapproved by: Date 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 ( Y) Upgraded ( ) Abandoned( )by S F1 O t`ry,t-n e Cp\S l . at 881FWl, Cv c ar" C rv• has been co tructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 71, P-00 — 3g2 dated Installer�crC / ��C l�rs 1« Designer. !,siJ(ICA( A Pyr'/c #bedrooms OZ Approved design, ow 1 gpd 0 The issuance of this permit shal4no,/be b/e c/on'struueed as a guarantee that the system 1 j,'function as designed. /�j Rl �/ Date I/ 69/0 I Inspector .rt V ,t �{ _: 10 I No. d DU r� 3 b J Fee 160 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS ligogat 6pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair (ice) Upgrade ( ) Abandon ( ) System located at 88 �1v Q CCa&A(, ) ce and as described in the above Application for Disposal System Construction Permit.The applicant reco nizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date / — 5" Approved by TOWN-OF BARNSTABLE �► LOJ CP.TION e!a 0 -S 1►. SEWAGE # �z;)00�'3� `•.'LLAGE C�X<T=y�v°�L '' ASSESSOR'S MAP& LOT O INSTALLER'S NAME&PHONE NO.a n a-C-r-1 S(er i'o SEPTIC TANK CAPACITY So 0 G Alo LEACHING FACIL=: (type) 5-00 N IWWLQL (size) 13r.42, NO.OF BEDROOMS - BUILDER OR QWU-R 6r7 PERMIT DATE: ! -S—o COMPLIANCE DATE:4cp T 0 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 Furnished by Pr I l Regulatory Services fad Thomas F. Geilery Director Public Health Division Thomas McKean, Director 20o Main Street.Hyannis,MA 02601 Fax: :08-790-6304 office: 509-862-4644 installer 8t Deter C'ert3flcationFrm Date: SE i% 0Loo Designer: Installer: -i ee�N-c,al cr Address: �� �6 � Address: On (�._�-_©t����..�p� .�;��5 d'� vas issued a permit to install a �--(date) (installer) C based on a.design drawn b� septic system at g a ���-"`'2�Cst `� �-F=`3' (address) dated 0 {designer) 1 certify that the septic system referenced above changestalled such as lateral reldca ion oigthe " to the desigci, which may include nor approved distribution box andlor septic I certify that the septic system referenced� or ray ove was insta icaillr Vocation cif and compofl tni greater•than 10' lateral relocation of of the septic system) but in accordance with State & Local �1�itirsris. Play: revision car certified as-built by designer to fellow. �'1H OF IVn`f. DA R N 'y ; ER { (Inst I s igaature) No. 11�'r _-- c , 1 S1N17AO' \fl (1?esngner's Signature) (A► x Designer's Stamp Her , flFWATE ®lF ' IS�TJE ; � . k JtN TO I S�AII� IIBLDiG PLEASE T[ IL ro iI �I WML 1B [. >F3I�ILT CARD EIVED ZC�Y 'TIME HA 1S'TA�IL.E )PUBLIr HE�LTH I�I�'ISiQ? r THANK YOUT. Q: Meallft;septic/oesiener ceniricutaon Form l,;S. Postal Service,. CERTIFIED MAILTM RECEIPT (Domestic Mail Only;No Insurance Coverage Provided) For delivery information visit our website at www.usps.com® M PS Form 3800,June 2002 See Reverse for Instructions Certified Mail Provides:■ A mailing receipt (esianaa)ZOOZeunf'009£-odSd • A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years , Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Maile or Priority Mail& ■ Certified Mail is not available for any class of international mail. , ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage'to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". • If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and,affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. IN SENDER: • • - M'' COMPLETE THIS SECTION ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X ❑Agent. ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(.Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: if YES,enter delivery address below: ❑No 11 Ms.Marie Joyce 88 Five Corners Road 3. Service Type Q �. ., C erville,NIA 02632 ❑certified Mail ❑EWess Mail ❑Registered- Ij Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2: Article Number 7005 1160 0000 0191 3547 (Transfer from�rvlce IaDeq PS Form 3811,February 2004 Domestic Return Receipt 102W5-02-M•1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS I Permit No.G-10 • Sender: Please print;your name,address; and ZIP+4 in.this box• PUBLIC HEALTH DEPARTMENT TOWN OF BARNSTABLE 200 MAIN STREET HYANNIS, MA 02601 P`OF THE T Town of Barnstable Public Health Division cgesp%r y .6 Man Street 3"� Hyann sl MA 02601 1101111111 •• _ zo ' ® 7005 1160 0000 0191 3547 _ _ 021A $ 05.210 0004606238 JUL18 2007 '• MAILED FROM ZIP CODE 02601 I Ms. M'ai e Joyce 88 Five orners Road Centervill MA 02632 N:Exxr- 029 5 i 0.2 07/3i1/07 RETURN TO SENDER i NO MAIL. RECEPTACLE UNABLE TO FORWARD mc: 02601400:200 *096 rl--t91 0260104002 t j� I I-� i / S 1 y Town of Barnstable Regulatory Services Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 18, 2007 Ms Marie Joyce 88 Five Corners Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5 The septic system located at 88 Five Corners Road, Centerville, MA was last inspected on June 7th, 2007,by Robert J. Bortolotti, a certified inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The leaching pit is in failure You have 1 year from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEAL , DEPARTMENT Thoma A. McKean, R.S., C.H.O. Agent of the Board of Health 1Y�- O,I/IONVFEALTH OF-�/1ASSACHUSETTS� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.' —. CI EIEP ARTiYIE2*I'I'=OF:E3VIR'ON lYIEIV.TAL PR aTE CTIO1 TITLE 5 0FFIC1_-f,1L INSPECTION�FOR34—?RIOT FOR VOLUNTARY ASSESSMENTS SUF�SURFACE. SEWAGE:DISPOSAL SYSTEM FORM. PART A CERTIFICATION Propertr Address: Owner's wine: (-j Owner's Address: c� .. P S6 �; ..Date:df Inspection: Name of Tnspecto - 1p rintj : 0�—�.J d � Company 1`Iame: :ease cr"f Mailing Address:. TdA d �/� r Telephone Plumber: .`. ►� m CERTIFICATION, STATEMENT 1.certify that I-have personally inspected the sewage disposal's.ystem at this address and'tha-t 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 enperience.in the proper function and maintenance of on:site sewage.disposal systems. I am a DEP -approved system inspector pursuant to Section 15:340 ofTitle'5`(3.10 CMR 15.-000). The system: Passes CondifionaIly Passes. Needs Further Evaluation.by fhe:Local Approving Authority as Inspector's Signature: Date: �. The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or. DEP)w=:thin 30 days of completing this.inspection. If the system:is-a shared.system or has a design flow of 10,000 apd or Beater,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 appaicable, and the approving authority. ?Motes and Comments — ***This report only describes.conditions at the time of inspection.and under.the conditions:of use at that time:,This inspection does not address how the system will perform in the futufe'under the same or different conditions of use. Title.5 Inspection Fo.,, 6%1 5%2000 page 1 _ f t �, , - • ' Page 2.of I l OFFICIAL INS.PECTION:FORTvI-NOT FOR VOLUNTARY AS'SESSME TS:'. SUBSURFACE'SEWAGE'DISPOSAL SYSTEM INSPECTION FORM:'.. . PART A CERTIFICATION(continued) Property Address: 8�T Owner:-. Date of Inspection:. Inspection:Summary: .C:heek-'A:,B',C,D or E/ALWAYS complete.all of Ser.tion.D A. System Passes I have not found any information which.indicates that any of the failure criteria described in 3 I0:CvLR 15303 or in 310 CMR- 15:304 exist.Any-failure crite.rie.not evaluated are indicated below. Comments: B. .. System Conditionally Passes: One or more system components:as described in the"Conditional Pass"section,-aced to.be replaced or, repaired.The system, u on com completion of the.replacement lacement or re ai.•.to rasa roved b.. P P P p p the Board of Health;.will ass. P Y ,.. P Answer yes,no or not determined(Y,_N;ND)in the : for the:following statements. if"not determined"please explain. The septic;tankis metal and;,over 20 years old, or,the septic tank(whether metal or rant)is structurally unsound, exhibits substantial:infiltration or.exfiltration or.iank 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'expIain: _. Observation ofsewage..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 B.oard.of Health): broken pipe(s).are,replaced. obstruction is-removed distribution:.box is leveled or replaced ND explain: The system required pumping more than.4 times:a year due to broken or obstructed i e's .The-system will Y PP t ) . pass-inspection if(with.approval:of tM Board of Health): broken pipe(s).are replaced obstruction is:'removed . ND explain: P'aee* of.11 OFFICIAL D'ISPECTIOIN FORPI -. TOT FOR VOLUNTARY ASSESSMENTS �UBSUR_ SCE SE'Sx A E.pISPOSAL SYSTEM•INSPECTIONFORM PA RT:;A CERTIFICATION(continued) `Property Address: Owner: Date of inspection: 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 heal&,. safety or the environment. 1. System will pass unless Board of.1aealth determines in accordance'with 310 CMR 15303(1)(b) that the system is not fuhctioni"ng in a mannei-which will.protect:publ'ic health,safety apd"the environment: - .Cesspool or privy is within 50'feet of a'surface water Cesspool orprivy is within 50 feet of a borderingvegetated wetland'.or'a salt'marsh� Z: System will fail ltnless the Board-of-Health(a;nd'Pub1fC. 'ater Supplier;if ariy).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 SA5is.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 l:'of apublic waier supply. The system has'a septic tank and SAS and the SAS i's;within''50.fe'et ofa priv.ate-•water supply well. The system.has aseptic 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 lal.oratory, 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: � t Page 4 of.11 OFFICIAL INSPECTIOiy FO.R .3VOT F r`J.OR O dT R .ASSE 1lIEi`iTS SUBSUR:FACE•SEWAGEl�i<I'DISPOSAL.SYSTEM•INSPECTION FORry PART A CERTIF,ICATIO (continued) Property.Address: 'icy �T Owner: Date of Inspection:. `7,j4yj' D. System Failure,Criteria applicable to all`systems: You must indicate"yes" or"no"to each.of the•fo:llowing for all:inspections: Yes No T Backup of.sewage into:facility...or system component due to.overloaded or.ciogged SAS or;cesspool Discharge:or Pondin,�'of effluent to the.surface of'the ground.or surface waters due to an overloaded or clogged:SAS,or cesspool _ Static liquidl'eveI in the.distribution-box above..outlet.invertdue to an.overloaded.or.clogged SAS.or cesspool: ` L.iquid.depth in cesspool is less.than 6.."below invert or available volume is.less than %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. i Any:portiorr,of cesspool-or privy.is.within 100!feet of a.surface water supply or tributary to.a.surface water.supply:j: . :Any portion of a cesspool.or,privy.is withi.ma Zone l of a:public well. _ Any portion of a cesspool.or privy is.within.50-feet of'a""'.private water supply well: Any: ortion of a cesspool or-privy. 1.00 feet.but.greaterahan.50<feet,fro:m a private water supply well with no acceptablemwater quality analysis..[This system passes if the.well water analysis, performed a.t:.a-DEP certified laboratory,for'coliform.ba.eteria and:volat'ile organic-compounds indicates that the.well is free from pollution from-that.fa6lity,and the.presence of ammonia nitrogen ands:-nitrate nitrogen.is equal:to or less than.S ppm,.provided that no:other failure criteria are triggered.,A..copy!of the analysis:must•be attached to this form.] (Yes/No)The system'fails.I have determined that one or more of the above failure criteria exist as. described`in 110 CMR 15:D03,therefore-the system fails.The.system"owner should:contact the Board of Health to determine what.will`be rfecessaryto 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.1.5,000 gpd: You must indicate either"yes" or"no"to each of the following: (The following criteria.apply to Iarge systems.in addition.to the criteria above) yes no - the system is within 400 feet of a.surface drinking water supply — _ the system is wittin200'.feet.of a tributary to a surface drinking water sup .piy the system-is located in.a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a in Zone 1I of a public,water supply Well.. If.you have.answered"yes:"to any question in.SectionE the.system is considered a significant,threat, or answered "yes"in Section D'above the large system has failed.The owzier 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. I Page S of 1.1 OFFICI[ I. Ii`dSPF:CTI07 FfJRi�✓I NOT FOR SjOI UIIARY ASSESSMENTS SU SURFACE'SE ✓ .E ISPOSATI SYS ' IM INSPECTION F0 2iY -PART`R CHE IMTST Property-Address: — C' Owner: Date of Inspection: f Check if the following have been done..You.must indicate"yes"of"no.."as.to each of the-foIlowine: Yes. XO ` Pumpina.information was.provided by the owner,•occupant;or Bbard'ofHealth jWere ally of the system components pumped out in the previous two-weeks ? as 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"ote 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 r V _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the fries or tees, material of construction, dimensions, depth•of liquid,.depth of sludgeiand depth ofscuii ? - 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).onthe site has been'determine-dbased on: Yes no i/ Existing information. For example, a plan at the Board of Health. Z/— Deterinined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)I 5 I Page 6 of 11. . OFFICIAL INSPECTION FO.RY1 3.00T FOR VO1;UN BAR :ASSESSMENTS. SUBSURFACE.SEWAGE;DISP.OSAL SYSTEM INSPECTION FORM. PARTS:C SYSTEIVt.INF. RtATIOi`t QQ Property Address O.wn e r: Date,of Inspection: -7 / FLOW CONDITIONS RESIDENTIAL Number of-bedrooms(design): Number.of`bedrooms(actual),: DESIGN flow.based on`310C Z 15.203 (for example- 11.0 pdx rru o f bedrooms):�o?� Number.of current residents. Does residence have a 'arbage grinder(yes or no):. Is laundry on.a:separate;sewage system(y s or no}: .[if yes separate inspection required] Laundry system inspected(y Z. or no); Seasonal use:.(yes or no): Water meter readings,,if av ilable(last 2 years usage:(gpd)): a. Sump.pump (yes or no): } Last date of occupancy:, - V,�� b • C OM MER CIALAND USTRIAI Type of.establishment:. } Design flow(based on 3110 CM—R'I5.203): Qpd ' Basis of-design flow(seats/persons/sgft,etc.):. Grease trap present(yes:ormo); Industrial waste holding tank present(yes or no):— Non-sanitary-waste discharged to the.Title 51system(yes or no): Water meter readings, if available: Last date of occupancyluse: OTHER(describe): 4partofthe,in GENERAL IN .ORMATIONPumping Records Source-of infoianation:Was system pumped'as pection(yes or no): If yes, volume pumped: gallons--How was.quantity pumped ped 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) Inno.vative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained`frorri system'owner) _Tight tank, _ .rtach.a copyof the DEP approw.al ,er(describe pproxi ate age of all components, date installed(if known) and source of information: Were sewage adorn:detected when.arriving at the.site(.yes or no Page 7 of I l OFFICIAL INSPECTION FORMA-NOT FOR"VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM-INSPECTION-FORM: PART;.0 S��S'I'EM.I.�IFORM..ATION(continued) Property Address: Owner Date bf Inspection: T `7 BUILDING SEWER (locate on site plan.'`/U Depth below.grade: Materials of construction:_cast iron _40 PVC other(explain): Distance'from private water supvly well or suction line. Comments(on'condition'ofjoints; venthig, evidence of leakage, etc,): SEPTIC TANK0,A/ ate on site plan) Depth below grade: Material of construction:. concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal lisp age:_ Is aze:corif=.ed bva Certificate of Compliance(yes or no):_(attach..a copy of -Certificate) Dimensions: Sludge depth:. Distance from top of sludge to bottom of outlet tee or.baffle:. 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: How were dimensions.deterrnined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid-levels as related to outlet invert, evidence of leakage; etc)`. GREASE TRAP: locate on site.plan) . Depth below grade: Material of construction: concrete. metal_fiberglass_polyethylene_other • (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom,of scum to bottom'of outlet tee of baffle: Date oflast,pumping: Comments (ori.pumping recommendations, inlet and outlet tee orbaffle condition, structural integrity, liquid levels as related to outlet invert, evidencz of leakage, etc.): Page 8 of 11 -OFFICIAL..INSPECTION.FOR - NOT FOB:. 0,LU—TARY ASSESSMENTS. SUBSURFACE SE-WAGE DISPO$AL SYSTEM INSPECTION FORM PART C. SYSTEM-INFORMATION(continued), PropertyAddress ,{,Q�C Owner: W;0 ( ra6w.'Pra Date of Inspection: 7 TIGHT or HOLDING TANK: (tank inust.be pumped at time ofinspection)(locate on,.site plan). Depth;below grade: Material of construction: concrete metal fiberglass_�olyetiiyl'ene ocher(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: Comm, ents�(condition of alarm and float.switches, etc.): DISTRIBUTION BOX:, (iz present must.be'opened)(Locaie on site.plan) Depth of liquid level above outlet invert: Comments (note:if box is:Ievel 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 ot*no): ` Alarms in working.order(yes or no):. Comments(note.condition of.pump chamber, condition of pumps and appurtenances, ecc.): Page 9 of 1 1 OFFICIAL LINSPECT'ION FOR—Al—NOT.FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SE WAGE DISPOSAL SYSTEM INSPFCTION:FOR I P.ART'C Q , SYSTEM INFORi'YMTION(continued) Property Address:A Ave Owners Date of'Inspection SOIL ABSORPTION SYSTEM (SAS):r(loete on site plan,excavation not required) If SAS'not located explain why: Type leaching.pits,number:, Ieaching chambers,number: :leachin'.galleries,'number: leaching trenches,nuinber,'lenath: 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 soils condition of vegetation; ) � Q, CESSPOOLS: (cesspool must be pumped as part of inspection)( ocate on fit p an) Number and configuration: j Depth'—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspoo Materials of construction:,7 Indication of_Qroundwater in—how..(yes or no Co ments (note c- Lion. signs ofhydrauhc faiIu e:leyei o".ponding, condition of vegetation•, etc:): �. /1 PRIVY: (locate or_site plan CL�'�C C% _ A/Iaterials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)- 9 1 1 • Page 1:0 of 1.1. OFFICIAL INSPECTION-FORM-=..NOT FORRVOLUNT•ARY ASSESSMENTS . SUBSURFACE SEWAGEDISPOSAL SYS`I'E-(INSPECTION FORM. ART.,C SXSTEM XNFORMATI0'`(:(continued). Property ddress:.j0Q Me Owner: Date of nspectlon:. SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the;sewage disposal system including ties to at Ieast two permanent reference landmarks or , benchmarks, Locate all:wells within l00 feet:Locate.where public water supply enters the bu'ldin-. I rn aeespoof Pane I 1 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE WAGE DISPOSAL SYSTEM.INSPECTI0N, FORM, .PART-C SYSTEM-INFORMATION(continued) G� Property Address: Own er- Date of Inspection. . -7 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated-:depth to-groulid water feetz Please Indicate (check)all methods used to determine the high ground water elevation: Obtained frorn•systzm desitrn plans on record -If checked,date of design plan ieviewed: Observed site(abutting propertylobservation hole within 150 feet of SAS) Checked with Focal Board of Health-explain: Checked with.local excavators,installers- (attach documentation) Accessed USES database-explain: You must describe how you established the high ground water elevation: • � J�i��d?d / �®mil ✓� v �°4' d i 11 Permit Number: Date: Completed by: /mod" HIGH GROUND-WATER LEVEL COMPUTATION 'Site Location: ] /�'f!� /�� r �dl ' Lot No.. Owner: V©Yc,e. Address: y Contractor.: Address: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. .............................................................................. .Date C!/ lry month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well.................... ............................... 7 OWater-level range zone ..................................................... . STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to ��y_ water level for index well........................... : month/year STEP 4 Using Table.of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well(STEP 3), and water-level zone (STEP 213) Z` determine water-level adjustment .......................................................................................... STEP .5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from.measured depth to water levelat site (STEP 1) ................................................................................. .............................. Figure 13.--Reproducible computation form. �5 '. �` "�— ������� _� d �� � �' � . . . Fir T WN OF BARNSS'TABLE LJCATION S� �°� ✓�•� i � SEWAGE # NLLAGE ASSESSOR'S MAP & LOT f INSTALLER'S NAME&PHONE NO. A ' SEPTIC TANK CAPACITY LEACHING FACILITY: (type)/4 /` (size) zr�, t� NO. OF BEDROOMS BUILDER OR OWNER. T� �' PERMTTDATE: 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 L.5aching Facility(If any well ds exist within 300AltZofac ility) Z Feet Furnishe L F vt, ol 11261 cp r t 1 �pFTHE Tp� • �' ,��ti• Town of Barnstable 0 • Regulatory Services zA�vsrAsr.>?, r MASS. Thomas F. Ceifer, Director Urfa),-a Building Division Tom Perry, CBO, Building Commissioner MO Main Street, Hyannis, MA 02601 www.town.barn stable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 Building Permit Procedure for Residential Addition Or Remodel Or Dock Determine map and parcel number and enter it on application. ❑ Historic District Commission, 20.0 Main Street, approval required prior to construction/demolition for any properties located in a Historic District: • Old Kings Highway Historic District(north of the Mid Cape Highway) • Hyannis Main Street Waterfront Historic District(See map for boundaries) Historic Preservation (if applicable). ❑ IfZBA relief(Special Permit or Variance is required for Project); ❑Copy ofZBA decision ❑Documentation proving that decision was recorded at the Registry of Deeds Win one year of ZBA decision date ❑ Approvals from the following departments are required and can be obtained at 206 Main St,: ❑Health Department (8:00—9:30 AM& 3:30-4:30 PM (as of March 2"d, 2005) Conservation Department (8:00— 9:30 AM& 3:30—4:30.PM) Tax Collector (can be obtained from Building Department) ❑Treasurer (can be obtained from Building Department) Permit must contain complete owner information, full description of project, correct square footage of project, valuation of project, building detail for Assessor's Office, complete builders information, including signature and date of application. ❑ 5 sets of reduced house plans measuring 11" x 17", scaled 1/4"=1' & fully dimensionalized are required. Plans must include a foundation, cross section, framing schedule, insulation detail & floor plan showing location of smoke detectors (located with a Red `S'.) ****** IF USING ENGINEERED LUMBER AND/OR STRUCTURAL STEEL, ENGINEERING DATA MUST BE PROVIDED****** Plot plan or mortgage survey required for any addition. Workers Compensation Insurance Affidavit form must be submitted for any workers hired. In the event the homeowner takes out the permit, subcontractors hired must supply this. Copy of Insurance Compliance Certificate must be on file. ass Compliance Checklist Construction Supervisors License & Home Improvement Contractor's License OR Homeowner License Exemption Form must be submitted if homeowner is acting as general contractor or builder for the project. Property owner must sign Property Owner Letter of Permission. A NON-REFUNDABLE Application Fee must be paid upon receipt of application number. All checks should be made out to the Town of Barnstable CHIMNEYS: Need Home Improvement License, no plot plan required EJ PIERS AND DOCKS:Need Construction Super License AND Home Improvement License. OWNER CANNOT PULL OWN PERMIT. Projects requiring the use of a crane must complete the forms issued by the Aeronautics Commission Q:forms/bldgpermit/R_addalf 070610 '•_ Town of B' nstable p# ,Ilt: Department of Regulatory Services Public Health Division Date MAU 200 Main Streeq Hyannis MA 02601 lED MA't (9 Fee Pd. Date Scheduled � me `oil Su,ta ility Assessment for Sewage Disposal I Performed By: Ul �/✓P !V' ;c�l ! Witnessed By: y Y iy LOCATION & GL.INFORMATION 1.".-LtionAdd.-essgs �V� V S ��. Owner's Name 7yGr, 6 14�v � + Address �U BGx .�Q _ � ``. Assessor's Map/P�tcel: �(p I Engineer's Name�j�. NEW CONS. U(�TION REPAIIt Telephone# �09 3(,)-J��a i Land Use `--�-- Slopes(�o) �� Surface Stones +� Distances from: Open Water Body> ft Possible Wee Area ft Drinking Water Well 2 C00ft i Drainage Way (� ft Property Line ft Other A SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) PP-opaS&-c s t . -.w *TM :s'` •,.�'"� �'°'v��pis '�'� _ • i i i i ' G 1 Parent material(geologic Depth to Bedrock ' Depth to Groundwater. Standing Water in Hole: I'f �,` Weeping from Pit.FAee -- r Estimated Seasonal Vigh Groundwater N LL_ DtTERMIN TION FOR SEASO�AL HIGH WATER TADLE Method Used: Depth dbperved standing in obs.hole: in. Depth 10 Sall mottius: Depth toiweeping from side of obs.hole in. ©toundwater Adjustment 1 j Index Well# Reading Date Index WeU level 7r7��,.e_,..... Adj.factor, _ Adj.d►OundWntet Level— Index e PERCOLATIdN TEST �$tp T>n� Observation I " Hole# Tune at 9 f Depth of Pere Time at ti" � Start Pre-soak Time.@ V - - "�'•. Time(9"•6') End Pre-soak t Rate MinJlnch Site Suitability Assesmeat: Site Passed X, _ Site Failed: Additional Testing Needed(Y/N) Original:.Public Hen`Ith Division Observation Hole Data To Be Completed on Back-- ***If percolajibn test is to be conducted within�100' of wetland,,-You must first notify the Barnstable C¢]*servation Division at least one(1)week prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consis enc %Gravel) li_ rc it 14t° 2tt E5 � fEN 1040 MASStU10- DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell). Mottling (Structure,Stones,Boulders. Consistency,%Gravel) 0t, Gstt t tC : 2tt- 132t' C, MSD, 0.J L =SY "he e DEEP OBSERVATION HOLE LOG Hole# ALIA— Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, n Gravel e DEEP OBSERVATION HOLE LOG Hole# Al Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. I I _ Flood Insurance Rate Maw I �^ Above 500 year flood boundary No`/ Yes ^__ Within 500 year boundary No^ Yes •y Within]00 year flood boundary No 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? tf If not,what is the depth of naturally occurring per ous material? C- - Certification el I certify that on 1 0 ` (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 with the requireCtr ' inexpertise and ex erience described in 3,10 CMR 15.017. Signature Date Q:\.SEPTICVERCFORM.DOC � ► --�-� ►� rL �- r s rc% A c� o V7, �S-15 . Pouf h -q6l I <L- 6� \ ovi v1 � �� � ✓� Co r�e.rs � c� ���2 i�vi 111L No 0� Pc-r J COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRON1ti1ENTAL AFFAIRS 1 I ENVIRONMENTAL P �,,OTTE—CTION. DEPARTMENT OF .; �C) a ONE WINTER STREET. BOSTON, MA 02108 617/7)9*?-5500 4 NILLIAMF NELD GoNcmor 4 ARGEO PAUL CELLUCCI ,98 „�D _ i �T Lt.GoNcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPI30N FORM Cc T PART A CERTIFICATION E tUte, Of ,aoresa Ke ATtN1�-Rbrb rt Crook Property Address: 88 Five Comers Road Cent, Address of Owner: r Date of Inspection: 4/10/98 (If different) box 1 01 2 Name of Inspector: jnGepb P Macomber Jr. Litehfield,Conn. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) 06759 Company Name: J.P.Macomber & Son Inc . Mailing Address: Box 66 Centerville,Mass . 02632 Telephone Number: 508_775_�J 18 CERTIFICATION STATEMENT I cenify that I have personally inspected the sewage disposal system at this address and that the information reposed b2lo„ is :r e J:(U' and complete as of the time of inspection. The inspection was performed based on my training and experience in the proaer i rc,Dn a maintenance of on-site sewage disposal systems. The system: Z1Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: d'.fiL , Date: The System Inspector all submit a copy of this inspection report to the Approving Authority within tnirry (30; days of com ie~ z !- -inspection If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector anc the system �r-.I s_or the report to the appropriate regional office of the Department of Environmental Protection. The original should oe sent !o :rk s,�-:eT o, and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI S�Jh SSES: ---E�— ave not found any information which indicates that the system violates any of the failure criteria as defined it 3'0 Any failure criteria not evaluated are indicated below. COMMENTS: __— B) SYSTEM CONDITIONALLY PASSES: C� One or more system components as described in the "Conditional Pass" section need to be replaced or repairec. completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances, If "not determinec', The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a C-- • <a: c Compliance (anached) indicating that the tank was installed within twenty (20) years prior to the date o re o the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or ezf:l:r;: cr ,r failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conform„nx as approved by the Board of Health. (r•vi••d 0�/25/97) Y&y• 1 of 10 DEP on the WOnd Wide Web nnD rrwww magnet state ma us/oep Pnnteo on Recycied Paper // i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.ti, PART A CERTIFICATION (conlin5ed) Properly Address: 88 Five Coianers Road Centerville,Mass . 0-net: Estate Of Dorcas Kerr Date of Inspection: 4/1 0/98 BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the dish bulion bo= s cue oro'�e c' = Pipets) or due to a broken, sealed or uneven distribution box. The system will pass nspeclio�" I lWIM a 3 = Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced /Sc116 The system required pumping more than four times a year due to broken or obstricned o :.e s T,ne s's,e'- , inspeciton if (with approval of the Board of Health): broken pipes) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 1—,'P Conditions exist which require further evaluation by the Board of Health in order to determine ( !ne ',,stem is :a: public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNC1iONINC ;� > WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or prry is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a sall marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) 0E7i:�' '•i ^.> THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFE--1 A.ND T-i: ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 fee'. c a s.r-3ce tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a �-ohc li9 The system has a septic tank and soil absorption system and the SAS is �uhm 50 fee, of 3 :r w3:er s_.,= The system has a septic tank and soil absorption system and the SAS is less man 100 feel ��L: 5: ce: :)r '' - _ - private water supply well, unless a well water analysis for coliform bacteria and solal,le org.-,- the well is free from pollution from that facility and the presence of ammonia nitrogen ane r. :ra,e less than 5 ppm. method used to determine distance � (approximation not val,c. 3) OTHER J I --- tr.v:..d 0./75/f71 D•90 3 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 88 Five Co6ners Road Centerville,Mass . Owner: Estate Of Dorcas Kerr Date of Inspection:4/1 0/98 D) SYSTEM FAILS: You must indicate ei: er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 C»R 13,303 Tne bas:s for this determination is identified below. The Board of Health should be contacted to determine what will be necessan• to corie . the failure Yes NO Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. 160/G1E.. Static liquid level in the distribution box.above outlet invert due to an overloaded or clogged 5A5 or cesspoo' Liquid depth in cesspool is less than 6" below invert or available volume is less than 1,'2 day flo". Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped C -fl Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. -L-1 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supp.. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well "r.h no acceptable water quality analysis. If the well has been analyzed to be acceptable, artach copy of well water analysis :ur coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: fit,/D The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant tnreat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply / the system is within 200 feet of a tributary to a surface drinking water supply _ Ie 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 88 Five Coiners ROad Centerville,Mass . Owner: Estate Of Dorcas Kerr Date of Inspection:4/1 0/9 8 Check if the following have be-n done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping iniormation was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving norm& flow rates during that period. Large volumes of water have not been introduced into the system recenii� or as part of th,: inspection. As built plan, have been obtained and examined. Note if they are not available with N/A 4 _ The facility or dwelling was inspected for signs of sewage back-up. The system noes not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system c:n,ponents, 14uding the Soil Absorption System, have been located on the site. �Lr�jlJk'- The septic t::nk manholes were uncovered, opened, and the interior of the septic tank was inspected for condition o: baffles or let , material of construction, dimensions, depth of liquid, depth of sludge, depth of scum / — The size and loca:,Dn of the Soil Absorption System on the site has been determined based on The facility ).�,ner (and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surace Disposal System. 'Y Existing l:,fo: nation. Ex. Plan at B.O.H. _ Determined jn the field (if any of the failure criteria related to Part C is at issue, approximation of d stance is unaecept.,ol,: j 15.302(3)(b)) (revised 04/25/97) Pegs 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 88 Five CoAners Road Centerville,Mass . Owner: Estate Of Dorcas Kerr Date of Inspection: 4/1 0/98 FLOW CONDITIONS RESIDENTIAL: Design flow: %* 8.p,d./bedroom for S.A.S. Number of bedrooms:_26 Number of current residents: V Garbage grinder (yes or no) &,' 2 Laundry connected to system (yes or no):,t"S Seasonal use (yes or no):W r g Water meter readings, if available (last two (2) year usage (gpd): 4 + Sump Pump (yes or no): lob /�/ 'f — oo Last date of occupancy. aky COMMERCIAUINDUSTRIAL: Type of establishment: yl? Design flow: X,,13 gallons/day Grease trap present: (yes or no)AZ6 Industrial Waste Holding Tank present: (yes or no)40 Non-sanitary waste discharged to the Title 5 system: (yes or no)X0 %Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: d GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)-X,C, If yes, volume pumped: ^U g Ilo s J Reason for pumping TYPE OF SYSTEM ,e,W Septic tank/distribution box/soil absorption system Single cesspool Overflow 4�- LoaL)e_?(,o4;W_ T Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) I/A Technology etc. Copy of up to date contract( Other y� APP OXIMATE AGE of all components, date instaNed (if known) and source of information: eia4all Sewage odors detected when arriving at the site: (yes or no) (r. is.d 04/25/97) D.9. 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 88 Five CO$ners Road Centerville,Mass . Owner: Estate Of Dorcas Kerr Date of Inspection: 4/10 98 BUILDING SEWER: (Locate on site plan) n J Depth below grade:Ot'0 Material of construction: ,1, cast iron 1 40 PVC _ other (explain) Distance fromr)private water sup y well or suction line _ Diameter Comments: (condition of joints, venting, evidence of leakage, eta) J \ _ sc t SEPTIC TANK:Agwe (locate on site plan) Depth below grade Material of constructionxLh concrete,t,)_2metalA FFiberglass,L, PolyethyleneAj other(explain) AA If tank is metal, list age dA Is age confirmed by Certificate of ComplianceR',l (Yes/No) Dimensions: )"; Sludge depth: ti'A' Distance from top of sludge to bosom of outlet tee or baffle:!_ Scum thickness: /Vh Distance from top of scum to top of outlet tee or baffle:_ 4_ Distance from bosom of scum to bottom of outlet tee or baffle:.�i? How dimensions were determined: k, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 721, G GREASE TRAP: L-,,,J:, (locate on site plan) Depth below grade: 'Vlq Material of construction:Pi/7concrete/meta l4 FiberglassA,'l_Polyethylene,�other(explain) Ah� Dimensions: a i . Scum thickness: 40 Distance from top of scum to top of outlet tee or baffle: AL Distance from bottom of scum to bottom of outlet tee or baffle.A• Date of last pumping: d1A Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (r•vi••d 04/ZS/97) P•g• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR." PART C SYSTEM INFORmATION (continued) r Properly Address: 88 Corners Road Centerville,Mass . 0-ner. Estate Of Dorcas Kerr C)ate ei In)pecl;on: 4/10/98 TICH1 OR HOLDING TANK: S Tank must be pumped priU: to, or at (ime of nspeC11on) IIOC,3:e e.-) s,:e plan) De;:.r 210,.• grade 1014 M.a:ei�a� o• consuv�ron:.(l�, concrete.�J�metaLL/{F�berglass�i,�Polselhyieneti�-otherlexpla�n) D�mens�or) ��t� Cacao-, gallons Des,gn Io•, gallons/day Alarm. .r•el /)A Alarm in work,ng order , Yes:. L Nv Date w pre iCv) pumping. _ COmmerl) Iconc,tic.n of inlet tee, condition of alarm and float switches, etc I DISTRIB ;TION BOX: -1/y6_ l,c<j:e _ s :e plan) De-:- _, d level above Outlet inyen C0m,e-:s tno:e i le,el and distribution is equal, evidence of solids carryovef, eyicence of leakage into or out cl x+. PU."P CHA.%ABER:/x tlo(:a:e c� site plan) P.mpi .r . or'cing order. (Yes or NO) Alarm$ ..Orking order (Yes Or NO)Ali7✓" Comm,er.:s mole :Orc,:ion of pump chamber, condition of Pumps and appurtenances. etc.) lr.•:r•c :�/75/S7) Y.g. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.vt PART C SYSTEM INFORMATION (continued) Properly Address: 88 Five Co*ners Road Centerville,Mass . Owner: Estate Of Dorcas Kerr Date of Inspection: 4/1 O/98 SOIL ABSORPTION SYSTEM (SAS): ,locate on site plan, if possible: excavation not required, but may be approximated by non intrusive methods; If not determined to be present, explain: Type leaching pits, number: leaching chambers, number: leaching galleries, number:_ leaching trenches, number,length:-- — leaching fields, number, dimensions: l'/ overflow cesspool, number Alternative system: Name of Technology: fT 2 - Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) h/1,441VIA) T6 MCA . JA.-t S,�.li�_ �'c 5;��+:s t�� 14�1dr4._/ it F;� Ja-we� 0;- -- ✓� e ram,r„,'ti ':s .e �ti,/tea —— CESSPOOL# l� oocate on site plan) number and configuration: f Depth-top of liquid to inlet�invert: �� r Depth of solids layer: 'V4(I Depth of scum layer: q Dimensions of cesspool: ` Materials of construction: indication of groundwater: inflow (cesspool must be pumped as pan of inspection) ol(w!.C_- /7 �/f� ii >iL'�.Y��IL✓G' Comments. (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) P R I VY: 4_)C%ti Y_ (locale on site plan) ,materials of construction: Dimensions X'-'rz Depth of solids Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc ) n _ _ (r.v1s.d D.9. 8 of 10 SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORs,. PART C SYSTEM INFORMADON (continued) Proper.} ACCIM:88 Five Conners Road Centerville,Mass o»ner Estate Of Dorcas Kerr Dale o' In""'on: 4/1 O/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: cl.,oe ties to at least two permanent references landmarks or benchmarks Ioca:e all wells within 100' (Locate where public water supply comes into house) Co"'yl�yV^\S. �CC� I `3-3 :1/iS/971 P.g. 9 of 10 SUBSURFACE SEWAGE DISP. t SYSTEM INSPECTION FORM I SYSTEM INFOI !ON (continued) Property Aidress: 88 Five Cogners Road Centerville,Mass . Owner: Estate Of Dorcas Kerr Date of Inspection: 4/10/98 r Depth to Croundwater Feet Please indicate all the methods used to determine High Groundwalc( EI(:.a.ion: Oo:ained from Design Plans on record -------------- ser:at on of S to (Abuning property,pbservation hole, baser.,err limp etc.) -z' De!ermine it from local conditions Chec, with local Board of health Cnect FE,ti'�A Maps j�/ C:nec': ;)..,-ping records l•nec', local excavators, installers i.se '_,SCS Data Descr,De r }ovr own words how you established the High Groun, .vxcr:levation. Must be completed) Used Water Contours Map Gahrety & Miller Model 12/16/94 lr•v:�•C -�!75/971 P.C. llbv: 10 i TOWN OF Barnstable LYJARU OF HEALTH SWISHFACF SFHA(;F I)I SPOSAL SYSTF,M I NSI'ECTION FORM - PAR'r U CEI('f l FI C/',T I(_i ...�� � ... .—�f I1.�� •'T..T.�1•r.1T1 1'1 T TITf TT.T1'.r—'.1 ••ItRT7 1TR1CT'-T�.T".'o1.�RiT�Ti1T7TT1 ITnf R'TTTrT'1 iO_TTT-r�� —r r— r ... —TYPL OR PRINT CI.EARLY— PROPERTY INSPECTED STREET ADDRESS 88 Five Co nners Road Centerville,Mass . ASSESSORS MAP , DLOCK AND PARCEL # Ah d OWNER ' s NAME Estate Of -Dorcas Kerr PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. . COMPANY NAME J.PMacomber & ScaT 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or Clty Stet. L!P COMPANY TELEPHONE ( 508 1 775 - 3338 FAX (508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa- system a this address and that the information reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and am recommendations regarding upgrade , maintenance , and repair are consistert with my training and experience in the proper function and maintenance site sewage disposal systems . Check one : 4Z System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or the environment as defined in 310 CMR 15 . 303 . Any failu :-e criteria not evaluated are as stated in the FAILURE CRITERIA secs ; 0:, of this form . System FAILED* The inspection which I have con ileted has found that the system :r•• _ : s .o Protect the }public health and the environment in accordance 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURZ CRITERIA of this inspection form . Inspector 8ignature__L4_,' t�y" Date One copy of this,,_. rt.ification must be provided to the OWNER , the 3UY f? ( where applicable ) and the BOARD OF HEAL7'll . • IC the inspection FAILED , the owner or "operator shall upgrade the ey5i-t within one year of the date of the inspection , unless allowed or require' otherwise as provided in 310 CMR 16 , 305 . 1 w _ sbyY �71 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TIT 5 SYSTEM YSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by P The Department of Environmental Protection. June 8, 1995 Acting Director of the ion of Water Pollution Control t r LEGEND F �' �--�-1 PROPOSED CONTOUR 2? 00 ® PROPOSED SPOT GRADE 9 - 28 .. -- 98 -- EXISTING CONTOUR (0 N aCO + EXISTING SPOT GRADE N N ry ry 113.38 ft 96 52 G E \ — ----� — — — — — — — — — -------------� O� t-------------- W— EXISTING WATER SERVICE Q' I I \ \ I I TEST PIT I \ \ \ I r FAIR 0 UMpS TH- ,TH-2 i LOCUS MAP N T.S. 0 0 w I I \ \ GENERAL NOTES: 25' 1J'— -I—N 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL I \ \ Existing Cesspools BOARD OF HEALTH AND THE DESIGN ENGINEER. (Note 10) 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE I II \\ \\ LOCAL RULES AND REGULATIONS. j 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 1 \\ \\ I TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ,I ► \� Ln \, ENGINEER BEFORE CONSTRUCTION CONTINUES. I \ I 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. o `N� I � ^ 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF o I I o I �Q �J THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. C'V7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. EXISTING i �� �j 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. I I DWELLING I O = 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE I j � `O THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. y TOP OF FNDN I m O� �v =� 10. EXISTING CESSPOOLS TO BE PUMPED, CRUSHED AND REMOVED. 0 EL = 25.44 U �� REPLACE WITH CLEAN MEDIUM SAND PER TITLE V. / V J ^ I 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION ------------- 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY I I \ I Q I AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. > i 14. NO WETLANDS WITHIN 150' OF PROPOSED LEACHING. �� I \\ \ -�—— ——I_ �� OF s, 15. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPECIFIED) M I 1ry �0 q s9 i I \ �I IV > i � 'ER✓ y MAP.- 168 j I \ Q I ` No. 1140 LOT. 037 \ a I ; - - - - - - - - - - - - - - -j- - - -� - - - --�- - - ' 0 31.75 ft 0 I Cv 73.19 ft — — — — 'NITAR PROPOSED SEPTIC SYSTEM UPGRADE PLAN {,EDGE OF PAVEMENT I0-6 88 FIVE CORNERS ROAD, CENTERVILLE, MA 1. Prepared for: Marie Joyce SURVEY REFERENCE: Engineering by: Surveying by: SCALE DRAWN Jq PLAN OF LAND BY ED KELLOGG, CIVIL ENGINEER F VE CORNERS R O A D DARRENM.MEYER,R.S. ��_Tech 1�nviroameata! 1"=20' DMM PO BOX (508) 364-0894 DATED: MARCH 1, 1962 E4STSANDWICH AM 02537 DATE CHECKED S a 508-3622922 09/03/07 DMM of 2 1 r- ELEV. TOP j FOUNDATION I (Existing) i 25.44 / F.G.EL: 22.0 FINISH GRADE= 19.0- F.G.EL: 21.0 F.G. EL: 19.0 f/ MAINTAIN 2% MIN SLOPE OVER LEACHING AREA MAX. COVER OVER LEACHING = 3.0 FT. COVERS TO WITHIN 6 OF G RAD 7.: r 2" H 3/T DOUBLE 3/4" - 1-1/2" DOUBLE WASHED STONE „ WASHED STONE s" . 4" SC. . 40 PVC4 SCH 40 PVC ' @S=2% 10"I ' ®®®� PEE3E ® S= 1% MIN. 6 MIN. (MIN.) THIS ARE TO BE 14" ( ) S= 1% ) ®E 0r '7 y 4" scH 40 PVC INV.1.7.39 2 EFFL . DEPTH ®®®®®® ""'�`" t NV.17.89 INV.17.19 131123 3 EXIST. OUTLET GAS PROPOSED DB-3 4" 2 X 4' BAFFLE EL. 18.44 •. N H-10 DISTRIBUTION BOX L --------- EFFECTIVE LENGTH = 25' AIR INV. 18.14 PROPOSED 1,500 GALLON SEPTIC TANK INV. ELEV.= 15.5 GAS BAFFLE TO BE INSTALLED ON BREAKOUT OUTLET TEE AS MANUFACTURED BY TOP CONC. ELEV.= 16.20 ELEV.= 16.0 TUF-TITE, ZABEL, OR EQUAL INV. ELEV.= 15.5 ® ®® ®®® . NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING ®®®®®®® PIPE INVERTS PRIOR TO CONSTRUCTION BOTTOM EL.= 13.5 ®®®®®®E 2) D-BOX SHALL BE SET LEVEL AND TRUE TO 4' 5. FT. 4' GRADE ON A MECHANICALL COMPACTED SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2) SEPARATION 5.5 FT. EFFECTIVE WIDTH = 13' 3) INSTALL INLET & OUTLET TEES AS REQUIRED 1 SEPTIC SYSTEM PROFILE BOTTOM OF TESTHOLE EL: 8.0 = SOIL ABSORPTION SYSTEM (SECTION) SOIL LOGS P#: 11921 (500 GALLON LEACH CHAMBER (H-10) LOADING) N.T.S. DESIGN CRITERIA DATE: AUGUST 31, 2007 NUMBER OF BEDROOMS: 2 BEDROOM EXIST. (No proposed increase in flow) / 3 BR DESIGN SOIL EVALUATOR: DARREN MEYER, R.S., CSE SOIL TEXTURAL CLASS: CLASS I WITNESS: DONNA MIORANDI DESIGN PERCOLATION RATE: <2 MIN/IN HEALTH AGENT DAILY FLOW: 110 G.P.D. DESIGN FLOW: 330 G.P.D. Elev. TH-1 Depth0. TH-2 DepthSEPTIC TANK (VOL. REQUIRED): 330 gpd x 2 = 660 gpd (USE NEW 1,50OG SEPTIC TANK) 19.0 0. 19.19.0 a. GARBAGE GRINDER: NO (not designed for garbage grinder) FILL FILL GARBAGE AREA REQUIRED: 330 gpd/0.74 = 445.94 S.F. 18.17 10" 17.75 15" A A LOAMY SAND USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS (H-10 LOADING) F LOAAYMRY SAND 17 17 B 1OYR 4/1 22„ WITH 4 FT. ON ALL SIDES: 25'L x 13'W x 2'D 17.5 18" LOAMY SAND BOTTOM AREA: 25 X 13 = 325 SF B LOAMY SAND 15.5 C1 10YR 6 6 42" SIDE AREA: (25 + 13) X 2 X 2 = 152 SF 10YR 6/6 42" TOTAL SQUARE FEET PROVIDED = 477 vs. 445.94 REQ'D 15.5 C1 DESIGN FLOW PROVIDED: 0.74(477 S.F.) = 352.98 G.P.D. vs. req'd 330 GPD SAND MEDIUM PERC®14.0 MEDIUM Q� OF MASS 2 5Y 6 6 SAND o��bA'RE� 9�y� / PROPOSED SEPTIC SYSTEM UPGRADE PLAN / 2.5Y6/6 �Ui y ' 88 FIVE CORNERS ROAD, OSTERVILLE, MA C j No. 1140 Prepared for: Marie Joyce 8.0 132" 8.0 132" \ G� -_ Engineering by: Surveying by: SCALE DRAWN JOB. NO. PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) a 11-1 DARRENM.MEYER,R.S. Zoo-Tecb 172rjmamenta! N.T.S. DMM NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED NITAR�A PO BOX981 (508) 364-0894 1 u J EASTSANDMCH,MA02537 DATE CHECKED SHEET NO. v ' 22922 09/03/07 DMM 2 of 2 t i