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0155 FIVE CORNERS ROAD - Health
155 FIVE CORNERS RD., CENTERVILLE +JPC 12534 No.2 1,+ 5�R HAeTINAA, YN a Timothy B O'Connell 8/26/2015 Health Inspector Dear Sir, At your request I am answering your registered letter to me regarding the home located at 155 Five Corners Road which you have assumed belongs to me and is a rental property. This property does not belong to me or my wife Joanne even though we did cosign for my son's loan to purchase the home. My son Michael Bodley is the sole owner of this property and lives in the house full time. Michael has been a responsible business man in the town of Barnstable for more than ten years and regrets that his neighbors have complained about cars parking in his front yard. To this end he is taking steps to complete a respectable parking facility in the same location. For this reason no "application for rental registration" will be submitted. Respe lly, 7ger W Bodley 99 Holly Point Rd. Centerville, MA 02632 508-3621354 COMPLETE • ■`Complete`items:1;.2' and 3.Also complete A Si ure . "item 4 if Restricted Delivery`is desired. ❑Agent ■ 'Print your name and address on the reverse°; ::,A< :: ❑Addressee so that we can return the card to you: Rgceiv d by Tinted N e) C.,Date of Delivery ■ Attach this card to the back of the mailplece, or on the front if space permits. D. Is elivery address differe m'ern 1? ❑ s 1. Article Addressed to: If YES,enter delivery dress elow: ❑No f _ Roger Bodl.ey 155 Five-Corners Road 3. SerXe Type Centerville, M,.6,. 190bertified Mail® ❑Priority Mail Express' � ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number ` 7014 1200 0001 0358 1267 -(transfer from:service labeO PS Form 3811,July 2013 Domestic Return Receipt UNITED $TATESbE First-Class Mail Postage&Fees.Paid I USPS -;r »` M-w € Permit No.G-10 • Sender: Please print your n me, address, and ZIP+40 in this box' I I f °'I' 'ff�'f ''> € iiifii•��'`�s'ifPift���'"��' F�l.f:�,, } ,�1�=�( I I t Town of Barnstable CF THE Tp� ti Public Health Division Thomas McKean, Director ` BA"SrABLE' 'MASS. 200 Main Street 9 :d Hyannis, MA 02601 Fax: 508-790-6304 August 10, 2015 Roger Bodley 155 Five Corners Road Centerville, MA 02632 As of'October 1, 2006 anew rental registration ordinance was put into affect requiring all property owners of rental units to register their rental units with the Town of Barnstable Health Division. Once registered all rental properties will receive a yearly inspection to insure no Massachusetts State Sanitary Code or Town of Barnstable Ordinance violations exist. According to our records, you own the rental property at 155 Five Corners Road, Centerville, MA.-Enclosed is an application. If dwelling is occupied, you must provide occupants name(s). Also provide the occupant's contact phone number for inspection scheduling purposes. Please use a separate application for each rental unit you own. Should you need more applications, they are available online at www.town.bamstable.ma.us. Go to. the Health Division page by looking in the Department Menu. There is a link to the Rental Registration information on the Health Division page. You may print out as many as you need, and return them to the Health Division with the appropriate 2010 fees included. This must be completed within (14) fourteen days of your receipt of this letter. Failure to comply with this ordinance will result in the issuance of anon-criminal ticket citation in the amount of$100. Each day of non-compliance is considered a separate offense. Should you have any questions, please feel free to call 508-862-4644. Thank you in advance for your cooperation. l ; Timothy O'Connell, R.S. Health Inspector Health Division Direct#508-862-4646 I Citizen Web Request Page 1 of 3 =- e3le -y. \ MASS, eaT Logged In As: Monday,August 10 2015 TOWN\oconnelt Citizen Request Management Route to Users Search Requests Create Requests Reports Request Information Request ID: 53633 Created: 8/6/2015 9:26:33 AM Status: Assigned To Staff Assigned To: O'Connell,Timothy Health Office Anonymous: Yes Request Category: Chapter II : Housing Substandard edit Routine work: No Estimate: No edit Date scheduled: edit Estimated 8/20/2015 Change Estimated Jul August 2015 Sep Completion Completion Date: Date: Sun Mon Tue Wed Thu Fri Sat 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 25 26 27 28 29 30 31 1 2 3 4 L5 Created By: Sousa, Vanessa Priority: Medium edit Health Office Citation Numbers: edit Requestor Information Requestor Request DETAILS: LOCATION: 155 FIVE CORNERS ROAD Centerville, Ma 02632 Request Parcel Number Map: 168 !Block: 072 l Lot: 000 Owner of property is living in garage. He is renting his main home and basement. There is a driveway in Parcel Lookup back of home, but people are parking in front lawn. Email: Edit Requestor Information http://issgl2/internalwrs/WRequest.aspx?ID=53633 8/10/2015 "8/10/2015 /ryLi Health Master Detail Logged In As: TOWN`IleaItll Health Master Detail Monday, August 10 2015 Application Center Parcel Lookup Selection Iteais � Parcel Septic Perc Well Fuel Tank Parcel: 168-072 Location: 155 FIVE CORNERS ROAD, CENTERVILLE Owner: BODLEY, ROGER W&JOANNE T & MICHAEL W I Business name: Business phone:; Rental property: D Deed restricted: 0. Number of bedrooms : 0 Contaminant released: 0 Fuel storage tank permit: E Sage Parcel Changes� rRRetum to Lookup Parcel Info Parcel ID: 168-072 Developer lot:LOT 14 Location:155 FIVE CORNERS ROAD Primary frontage:86 Secondary road:LUMBERT MILL ROAD Secondary frontage:181 village:CENTERVILLE Fire district:C-O-MM Town sewer exists at this address: No Road index:0545 Asbuilt Septic Scan: 168072_1 Interactive map0ZN1(: . Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT Owner Info owner: BODLEY, ROGER W &JOANNE T& MICHAEL W Co-owner: streets: 155 FIVE CORNERS ROAD Street2: City:CENTERVILLE State:MA zip: 02632 Country: Deed date:1/16/2014 Deed reference:27939/99 Land Info Acres: 0.35 use: Single Fam MDL-01 zoning:RC Neighborhood: 0106 Topography:Level Road:Paved utilities:Septic,Gas,Public Water Location: Construction Info[Building No ear Built Gross Area Livinn Area Bedrooms Ba-d rooms 1 11970 13396 11764 13 Bedrooms2 Full 0 Half Buildings.value:$121,700.00 Extra features: $30,500.00 Land value: $131,700.00 http:/fiissq l2fii ntranet/healthM aster/H ealthM asterDetai i.aspx.?ID=168072 1/1 TOWN OF BARNSTABLE LOCATION/ 55' Five 6ey^3e1% PC) SEWAGE# Q d a ct VILLAGE 69Nf2i'Vt be ASSESSOR'S MAP&PARCEL 1 INSTALLER'S NAME&PHONE NO. -a?%J a e A 13rex_,,:_a 3 N c SEPTIC TANK CAPACITY .2 - l Mo G'.GI Ir�A9 X/S ti I LEACHING FACILITY: (type)11C„v %A-Ap N (size) 5,(61;y 3 yC NO.OF BEDROOMS OWNER�L(t ,��2,, PERMIT DATE: 7 —/:3 COMPLIANCE DATE: 1 Separation Distance Between the: NoNP PacGvad a",-d Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility a f D e!C Feet Private Water Supply Well and Leaching Facility(If any wells exist on fsite or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY DOW IS 1 wpj A -3- 8 i3 3 )3 c i 38 lei 30,5 -7 3cl,c 7— ST t t H 10 E5, r 7 c i �� �� � ' yr r y \ V v No. ' + Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftpfication for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair v<1U00`pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. jjJ Owner's Name,Addr,�ss,and Tel.No. c+e�a,rrv,lf c a✓ra s et, Assessor's Map/Parcel 2 Installer's Name Address,and Tel.No. Designer's Name,Address,and Tel.No. //n C/ A) Type of Building: Dwelling No.of Bedrooms `7j Lot Size /5 15Ql sq.ft. Garbage Grinder( ) Other Type of Building tXC2L2y,$,- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3:1!© gpd Design flow provided �1 06 gpd Plan Date Number of sheets r Revision Date Title Size of Septic Tank Z /floo C;4/le"V Type of S.A.S. 00 Description of Soil Nature of Repairs or Alterations(Answer when applicable) `%,�, <e.`� „/Uz'bc, S. 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 of Health. Si �"—"'"`� Date 7 Application Approved by Date gam( Application Disapproved by Date for the following reasons Permit No. Date Issued C 3 JA lu 6 1 ( Tl� No. 6 ._ 1 A Fee l/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for 30(sposal 6pStrin Construction 3pPClnit Application for a Permit to Construct( ) Repair(I✓"Upgrade( ) Abandon('') ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel .� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.Noa dV � Type of Building: i Dwelling No.of Bedrooms Lot Size / S h'/! sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Design flow provided -:2 `gpd Plan Date Number of sheets Revision Date t. Title Size of Septic°Tank 2 Y reZ4>J Type of S.A.S. C-00 i✓ /�.e,--n /s 'Description of Soil i + Nature of Repairs or Alterations(Answer when applicable)J j�, ���� ���J �i Q @y 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. 1 Signed � — Date y Application Approved by ( Date X_2 _ a Application Disapproved by Date for the following reasons Permit No. C Date Issued ------------------------------------------------------ --------------------------------------------- - - TH E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( �� Upgraded( ) Abandoned( at P- has been constructed in accordance �y with the provisions of Title 5 and the for Disposal System Construction Permit No.a.o13--215'`dated o Installer'Z.�,�rt�A '27�ors, T-P c Designer C .S . A) 1. �Jc I.y Y N #bedrooms Approved design' flow `, 1i� gpd The issuance of this permit s all/not be construed as a guarantee that the syste w'1 function as desi `ed. c� Date �'"� Inspector ,r ✓ _ L� ---------------------------q----------------------------------------------------------------------------------------------------------- No. ( � Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS misposal *pste5-construction 3permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at / S d . ,g ,.r s 12eJ C-^4-- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. _ Provided:Construction must be completed within three years of the date of this permit. Date — Approved by v Town of Barnstable Regulatory Services Richard V.Scali,Interim Director Public Health Division 039. ► " Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: eZ J Sewage Permit# a©i 3-2 Assessor's Map\Parcel Designer:. Zt ta1�(� Installer: 5 ��, Address: /,0 Za Address: p, D1c IBIS 026311 ��v�fr�'vr)I-r fU o On , - 1J"A F-wo-,m ze-ir was issued a permit to install a (date' (installer) septic system at sS F;or < er,,r[g 're� based on a design drawn by (address) dated 7-6-/-3 ( esigaer) I certi that the septic stem referenced above was installed substantial) according fY P Y y o dmg to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed ' liance with the terms of the IAA approval letters (if applicable) tp of . UNDA J. i PINTO +� Installer's Signature) No IV W ; esigne s ature) (Affix DOPNOMORISip Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WH.L NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU. 0A• %entirUlPaio er f:erfifientinn Fnnn Rev R-1A-1 I rinr. Town ®f Barnstable Departinent of Regulatory Services snrwarAD Public Health Division Date MASS 200 Main Street,Hyannis MA 02601 PFG MA'I A / . Date Scheduled \a �'�' Fee Pd. �D S®►al Suitability Assessment fir Sewage Disposal Performed By: Witnessed By: - Y}y LOCATION& GENERAL INFORMATION s r 5 Location Addr Owner's Name DJ�►�tl� uD I fi4 N d,4 1 (l� Address Ce✓t rVI 1 _aii nc/p GeA�, II-t Aql� O�3Z Assessor's Map/Parcel: —�2 Engineer's Name Ltn/lifA ff--Y to _k NF.W CONSTRUCTION REPAIR � Te.Ie: (,jp�) Land Use es i cfx'` l d� t S!opcs(%) Z '— S76 — Surface Stones ' 4jQ Distances from:'Open Water Body°>700 _ft Possible WeLArea_Al/� _ft Drinking Water Well 1,4 ft � f Drainage Way Al A_ ft Property Line /_ ft Other__ N/A ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) C b � PT — — Tei A ttt�vi.2 �l Five G®���►'ZS � �1 Parent material eologic) �n ge_� Tt� Depth to Bedrock Depth to Groundwater. Standing Water in Hole:_ 4A Weeping from Pit Nce Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: Id, Depth to Sgll mottles. Depth to weeping from side of obs,hole: ln, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level, Adj.factor— Adj.Groundwater Level PERCOLATION TEST bate �� Thne Observation Hole# TP Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ o Time(9"-6") End Pre-soak At!! ��p gzwr �urJQre6C)CtV Rate Min./Inch 4a M Site Suitability Assessment: Site Passed I/ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Cuiiipleted on Back----------- ***If percolation test is to be conducted within 100' of wetland,you roust first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP-OBSERVATION DOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other n Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones,,Boulders. onsistency,%Gravel) YK r • > DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. consistency,% rav lovh q Cj la � � DEEP OBSERVATION DOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) r• DEEP OBSERVATION DOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, Flood Insurance Rate Mau: Above 500 year flood boundary No— Yes' Within 500 year boundary No= Yes =� Within 100 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? "� If not,what is the depth of naturally occurring pervious material? Ceatification I certify that on a003 (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 required training,expertise and experience described in�10 CMR 15.017. Signature Rs �� Date�z� � S�-� ate(, I • . , Q:\S.EPnC\PERCFORM.DOC t j COMMONWEALTH OF MASSACHUSETTS Aad� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIO as ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 j jj O t✓ to 1`IDY C X S 4* ARGEO PAUL CELLUCCI Governor ommissimer SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION System#1-with bathrooms Property Address: 155 Five Corners Road, Centerville, MA Name of Owner: Marie Hamel Address of Owner: Same Date of Inspection: July 1, 1999 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Telephone Number: (508)862-9400 Map: 168 Parcel. 072 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system ✓ Passes Conditionally Passes Needs Further Evaluajy the Local Approving Authority 'ls Inspector's Signature: Date: July 8, 1999 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page IofII Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. ® Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced ® The system required pumping more than four 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 revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that.the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 D. SYSTEM FAILS: You must indicate either "Yes" or "No"as to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this detemunation is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than'/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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9I2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 Check if the following have been done: You must indicate either"Yes" or "No" as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n/a As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ — The site was inspected for signs of breakout. ✓ _ All system components, excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge, depth of scum The size and location of the Soil Absorption System on the site has been determined based on: ® ✓ Existing information. For example, Plan at B.O.H. ✓ e Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)]. ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 2 Total DESIGN flow n/a Number of current residents: I Garbage grinder(yes or no): No Laundry(separate system)(yes or no): Yes ; If yes, separate inspection required Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last two yearga usage(gpd): 1998-68,000 gals.; 1997-49,000 gals. Sump Pump(yes or no): No Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd(Based on 15.203) Basis of design flow Grease trap present: (yes or no) _ Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no) _ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: None on file-per treatment plant System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Unknown Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 5" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8'6" x 4'10" x 5' (1000 gal.) Sludge depth: I° Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How dimensions were determined: Measuring stick Comments: (reconitnendation 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.) The baffles were present. The liquid level was even with the outlet invert There were no signs of leakage The system receives flow from only 2 bathrooms. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees.or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Five Corners Road, CenterviUe, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: None (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER None (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order: (Yes or No) Comm-ents: (note condition of pump chamber,condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: 1-5' Wx 7' T Alternative system Name of Technology: Counts: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.) The cesspool was dry. There were no signs of failure The bottom of the cesspool to grade was 9'6" CESSPOOLS: None (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 Map: 168 Parcel: 072 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two pennanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Door '13 Al i3- �a- 3a- n A3 - 3S� a 3 - P9 3 6 �ivc CO(ncr•S 9-c4 , revised 9/2/98 Page 10of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater _Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators, installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Using Cape Cod Commission water table contours and USGS Barnstable Topographic maps, the maps are showing 35'+- at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page 11 of 11 TOWN OF BARNSTABLE, LOCATION �SS Pwt COMA.-. (Z8 SEWAGE # VILLAGE CzAkkLIA ASSESSOR'S MAP &LOT I(A 0-74-k INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACTFY I U�o l �raS LEACHING FACILITY: (type) C C 5s (s e) NO.OF BEDROOMS BUILDER OR OWNER MAC)t- Mf, PERMPTDATE: 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 Ao0 r A 3 13 A- • •, a n� �1Vt COMMONWEALTH OF MASSACHUSETTS �, =•-1— .f ,, EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR ^ DEPARTMENT OF ENVIRONMENTAL PROTECT ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 'I/r'Q JUL 2 7 19 99 MOF�;,,,__TRUDY COI E 1H �°�lE �Secretary ARGEO PAUL CELLUCCI DA .I�"1 ��TRUHS Governor E �C'oIItmustoner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION System#2- with kitchen&laundry Property Address: 155 Five Corners Road,.Centerville, MA Name of Owner: Marie Hamel Address of Owner: Same Date of Inspection: July 1, 1999 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 026SS 0049 Telephone Number: (S08)862-9400 Map; 168 Parcel: 072 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Evaluati n By the Local Approving Authority ails Inspector's Signature: Date: July 8, 1999 The System Inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced ® The system required pumping more than four 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 revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to deternune if the system is failing to protect the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply,or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to detemune distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 D. SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than'/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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 155 Five Corners Road, Cenlerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant,or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n/a As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ s The site was inspected for signs of breakout. ✓ — All system components,excluding the Soil Absorption System, have been located on the site. ✓ e The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles. or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ Existing information. For example, Plan at B.O.H. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)J. ✓ s The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 2 Total DESIGN flow n/a Number of current residents: I Garbage grinder(yes or no): No Laundry(separate system) (yes or no): Yes; If yes, separate inspection required Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last two yeargs usage(gpd): 1998-68,000 gals.; 1997-49,000 gals. Sump Pump(yes or no): No Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: Qpd(Based on 15.203) Basis of design flow Grease trap present: (yes or no) _ Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) _ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: None on file-per treatment plant System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Unknown Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK ✓ (locate on site plan) Depth below grade: 5" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8'6" x 4'10" x 5' (1000 gal.) Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How dimensions were determined: Measuring stick 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.) The baffles were present. The liquid level was even with the outlet invert. There were no signs of leakage. The system receives flow from the kitchen sink and laundry only. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees.or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7ofII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel ' Date of Inspection: July 1, 1999 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present: Alarm level: Alarm in working order: Yes_ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: None (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER: None (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.) revised 9/2/98 Page 8ofII k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Five Corners Road, Ceraerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number: leaching chambers, number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: 1-5' W x 6'6"T Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.) The cesspool was dry. There were no signs of failure. The bottom of the cesspool to grade was 9'6". CESSPOOLS: None (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Cotntnents: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 Map: 168 Parcel: 072 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) r O f/ A a- I O (n L 3 �3• ao revised 9/2/98 Page 10of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Five Corners Road, Centerville, MA Owner: Marie Hamel Date of Inspection: July 1, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater _Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions ✓ Checked with local Board of Health ® Checked FEMA Maps Checked pumping records Check local excavators, installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Using Cape Cod Commission water table contours and USGS Barnstable Topographic maps, the maps are showing 35'+- at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page 11 of 11 TOWN OF BARNSTABLE j 'LOCATION I S5 P%Vf, CarAkrS SEWAGE # VILLAGE Ce-n&rv1Ilk ASSESSOR'S MAP &LOT�(oFr�o�al INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Ce.TSPQts )Size) NO.OF BEDROOMS BUILDER OR OWNER MAr'i iL Amp,I PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any.wetlands exist within 300 feet of leaching facility) Feet Furnished by . . .............................. GA/A A Q Aa 3 /a3 a0 � d 1` ----------- --- --- --------- ------- 24'dzameter concrete covers CENTERV I LLF:, TOP Of FOUNDATION 24'dwmeter concrete covers TOP Of FOUNDATION 24'domeh r concrete covers raised to"Itht,6.of finish grade EL=4.5.5 raised to wthm 6-of fint--5h grade fl-=4&5 raised to wthin,5-of bnf5h grade (or as noted) MA (or as noted) (or as noted) 18"min Cover for IN5TALLER.TO VERIFY THE LOCATION Of ALL F5tng EL=474t IM-20 Loading UNDERGROUND AND OVERHEAD UTILITIES fL=4714.t 47. t fL=46.3-46.&(mvx) PKIOR.TO THE START Of ANY EXCAVATIONRoute 2$ °%\`�✓�\/ •.,;a..:.; °\�/��� °\��/��� ~°��`/��\% /��\� ACTIVITIES AND RELOCATE A5 NECE55AKY (5EE NOTE#15) Route 28 We5tmm 46.4+ Ext5ttnq &15t1rg 45.0 t :I, GF07D(TILEFADRICLOCUS (1A(PL4CE OF 11WL 45.3+ 43.67J\43,50 42.60 112'PEA5TOAIE) CX15ttr .45,2- 45.6- Existing d Existing b 44.2.± 0 �1 ov .* Existing E,(6twg 314'- 1-112'.5TO)VE Gas Baffle Gas Baffe 40- &0 5 M fZ=35 7±Bottom of Test Hole C\j Loll River Road ye5t RunFOUR(4)S eR�)RFCA5 r 500 1z L 5'Fxl_5ting EX15tIng GALLONLE4C�CHAMBERS W17-1-1 2'OP CD tog-Box AROUND EXISTING 10006AU01V Ek'15TINC 000 GALLON (11-20 Rated (END V1f w SITE LOCUS SEPTIC TANK #1 SEPTIC TANKA2 D-BOX I fACH CHAMBERS 5Y5TEM DE51GN CALCULATION5. NOT TO SCALE SEWAGE RE516N FLOW REQUIRED.3&9R"j_?WftL1N6(0 /10 GPO/BEDROOM FLOW PRO f I LE 330 6)"D REQUIRED CON 5TRUCTION NOTE5 5fWA6EDF516A1FL0WFROV1L?fD FOUR(4)500 GALLON LEACtiCHAMBERS 1 .) A55C550r`5 Map I G8 Parcel 72 NOT TO 5CALE (1)-20 RATED)WTH 2'OF 5 rOA(f ALL AROUND 2.) Deed Book 12435 Page 4G 1.)ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE,TITLE 5 (3 10 CMR 15.000): 3.) Plan Book 235 Page 55 Lot 14 STANDARD REQUIREMENTS FOP,THE SITING,CONSTRUCTION, INSPECTION, UPGRADE,AND EXPANSION Vt=[(3,5.0 x.503)+2(3,5,0+6.63)x 2J 74 4.) Thi5 property 15 not in a Zone 11 of a Public Of ON-51TE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOP,THE TRANSPORT AND DISPOSAL FLOOR PLAN 366 9 6TDP90V10f0 Of 5EPTAGE, AND THE LOCAL BOARD Of HEALTH REGULATIONS. Water Supply NOT TO SCALE 3,56 6POPROVIDED>330 6,PD REQUIRED 5.) flood Zone: C 2.) ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE 15 POTENTIAL FOR, VEHICI F5 OR HEAVY EQUIPMENT TO PA55 OVER IT SHALL BE DESIGNED TO WITHSTAND AN H-20 Bedroom SEPTIC TANK CAPACITYREQUIkED. 330 6PO X 200951 = 660 CPO REQUIRED LOADING. If UNDER AN IMPERVIOUS SURFACE,SYSTEM SHALL BE VENTED TO THE ATMOSPHERE. Bedroom #2 SEPTIC TANK CAPACITYPROV1059. 7 WO(2)FY15 TIA tG /00 0 GALLON TANKSLEGEND 3.)TO MINIMIZE UNEVEN SETTLING, SEPTIC TANKS SHALL BE INSTALLED ON A STABLE #1 Bath =2000 CALLON5 MECHANICALLY-COMPACTED BASE ON 51X INCHES OF CRUSHED STONE. Bath 1,93 EXISTING SPOT GRADE Kitchen 24x5 PROP05ED SPOT GRADE 4.)COVERS OVER THE INLET AND OUTLET TEES Of THE SEPTIC TANK,THE DISTRIBUTION BOX, AND THE Bath Bedroom cARrqAcf ooponw 15 lvorpnwmm WITH r/-//,g 9,E51aN FLOW. SOIL ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN G"Of FINAL GRADE. LEACHING FIELDS, #3 --?4-- EXISTING CONTOUR TRENCHES,AND OTHER 501L A1350RP1`10N SYSTEMS WITHOUT ACCESS MANHOLES SHALL HAVE AT Dining _24- PR.OPO5ED CONTOUR, LEAST ONE(1) INSPECTION PORT CONSISTING Of PERFORATED 4"PVC PIPE PLACED VERTICALLY TO THE BOTTOM Of THE SOIL ABSORPTION SYSTEM WITH A CAP,TIED WITH MAGNETIC MARKING TAPE, -W- WATER.5EKVICE LINE ACCESSIBLE TO WITHIN 3"Of FINAL GRADE. -0- OVERHEAD UTILITY LINES _U- UNDERGROUND UTILITY LINES 5.)PIPING SHALL CON515T Of 4"SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON,A -G- GAS SERVICE LINE MINIMUM CONTINUOUS GRADE OF NOT LESS THAN 2%FROM THE BUILDING TO THE SEPTIC TANK, AND <1 LOT 14 WO 0 EDGE Of CLEARING NOT LE55 THAN I%OTHERWISE. g3 Area= 1 5,5 1 1 5.f.t 9 c6 7P FENCE o G.)DISTRIBUTION LINES FOR THE 501L ABSORPTION SYSTEM SHALL 13E 4"DIAMETER SCHEDULE 40 PVC o TEST HOLE LOCATION (OR EQUIVALENT)LAID AT 0.005 FT/FT. UNLESS OTHERWISE NOTED. LINES SHALL BE CAPPED AT END V1 N--41- ST SEPTIC TANK OR AS NOTED. SS D13 D15TPJBUTION BOX -7.) UNE5 FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE fIR'5T TWO(2)FEET BEFORE PITCHING TO 45.5' 5A5 501L ABSORPTION SYSTEM 13 I 1 21 THE 501L ABSORPTION SYSTEM. DISTRIBUTION BOX SHALL 13E WATER TE5TED TU"A55LIKE EVEN 47..,5 38' DISTRIBUTION. r 8.)GROUT TO'BE U5ED AT AtL roih-r�WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES IN PLAN VIEW I CERTIFY THAT I AM!' CURRENTLY APPROVED BY THE ORDER TO PROVIDE A WATERTIGHT SEAL. 45.6 5hed SCALE: I" = 10' DEPARTMENT OF ENVIRONMENTAL PROTECTION PURSUANT TO 3 10 CMR 15,017 TO CONDUCT 501L EVALUATIONS AND THAT 9.)HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS Of THE SEWAGE DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION Of THE SYSTEM. THE 501L ANALYSIS NA5 BEEN PERFORMED BY ME CON515TENT 4 WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE 4 10.) IN ACCORDANCE WITH 310 CMR 15.22 1, ALL SYSTEM COMPONENTS SHALL BE MARKED WITH DESCRIBED IN 310 CMR. 15.017. 1 FURTHER CERTIFY THAT THE RESULTS Of MY 501L EVALUATION AS INDICATED ON THE MAGNETIC MARKING TAPE. 4 ATTACHED 501L EVALUATION FORM, ARE ACCURATE AND IN 4 &,5twy 5epta rink to be 4 ACCORDANCE WITH 310 CMR. 15.100 THROUGH 1 5.107 1 1.)THERE ARE NO KNOWN WELLS WITHIN 100'Of THE PROPOSED 5011-ABSORPTION SYSTEM. 4 Utilized(see Mote.42 0 12.) FROM THE DATE Of THE INSTALLATION Of THE 501L AB50PFTION SYSTEM UNTIL RECEIPT Of THE :0 4\ CERTIFICATE Of COMPLIANCE,THE PERIMETER SMALL BE STAKED AND FLAGGED TO PREVENT USE OF IP-1 48 pn E Fw5t1ng.5epbc Cbnzpvnents to 5cott McGann, valuat THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. Garage47A be Abandoned(See Note 64ifle-_d 5oil E 13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOP,THE SYSTEM AS DESIGNED UNLESS CONSTRUCTED 44. 7P-42 Slab Foundation Deck -1 F f4.4 NO, AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE DESIGNER. 4 LINDA I RI 0 -4 14.)THE BOARD Of HEALTH REQUIRES INSPECTION Of ALL CONSTRUCTION BY AN AGENT Of THE 4G.G IV L BOARD Of HEALTH AND THE DESIGNER. THE DESIGNER SHALL CERTIFY IN WRITING THAT THE SEWAGE 0, � ,.V ExistingExistingBedroom 0 DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS Of THE PERMIT AND THE 00A Dwelling 5T#2 , \6 APPROVED PLANS. 48 HOURS ADVANCE NOTICE 15 REQUESTED. Top of foundation GJST yx /I 1 EL=48.5 15.) LOCATION Of UTILITIES IS APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FOR 1D / 0NAL t DETERMINING THE LOCATION Of ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO ,r 47.O COMMENCEMENT OF ANY WORK. THIS INCLUDES, BUT IS NOT LIMITED TO, REQUESTS TO DI65AFE,ANY 0 4G Surm7 Mark by. &15ting_13epbc T#I c.) PRIVATE UTILITY COMPANIES,AND THE LOCAL WATER DEPARTMENT. Components to be 47.4 A & M Land Services I G.)CONTRACTOR.SHALL VERIFY THAT ALL WA5TELINF-5 ARE CONNECTED BY WATER TESTING WITHIN Removed Otiq�rA23) 45*wye- 47.3 47.uai� 0) 0 818 Route 28, Skdte 3 THE DWELLING PRIOR TO INSTALLATION Of ANY SEPTIC COMPONENTS. INSPECTION NOTE: Existing 5epttc Tank to be Irest Ymmouth, A(A 02873 1AIltzed(see Note A2 0 Pb (508) 73717M AkUdff &nn21&nd#00M0&9tnet 17.)CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION Of ANY SEPTIC PRIOR TO FINAL INSPECTION BY THE SYSTEM COMPONENTS. ENGINEER, SYSTEM NEEDS TO BE COMPLETE INCLUDING BUILDUP FOR COVERS. Cv5 Line In thl.,5 Area LJJ-,,- Sleeve wa.5telfne Prepared for: Note#24) 18.)INSTRUMENT SURVEY CONDUCTED FOR PROPOSED WORK ONLY. 51TE PLAN SHALL NOT BE USED 47.4 o FOR STAKING, OR ANY OTHER PURPOSES. In5talledbelow 6.15 bne 47�2 0 Diane J. Kovanda 19.)TH15 PLAN DOES NOT CERTIFY, GUARANTEE OR WARRANTY COMPLIANCE WITH DEEDED OR ZONING 155 five Corners Rd., Centerville, MA BYLAWS, SPECIFICALLY, BUT NOT LIMITED TO,SIDELINE SETBACKS AND BUILDING HEIGHT TEST HOLE LOG5 C) 3.3 11 2) RESTRICTIONS. OWNER 15 RESPONSIBLE FOR OBTAINING SUCH A DETERMINATION FROM THE 3.3 Proposed Sewage D15F05al 5y5tCM APPROPRIATE AUTHORITY. Test Hole#I (EL-47.0:L-) BENCHMARK 0. 155 five Corners Rd., Centerville, MA 20.) IF SOILS DIFFER FROM THOSE SHOWN IN THE SOILS LOGS, DE51GN ENGINEER 15 TO INSPECT THE Top of Concrete 4G.I SOILS PRIOR TO PROCEEDING WITH INSTALLATION. Depth Layer Soil Class Soil Color Comments EL=45.5(Assumed Datum) Prepared by: 011 2 1.) EXISTING 1000 GALLON SEPTIC TANKS TO BE UTILIZED. PVC TEES TO BE INSTALLED ON INLET AND 10-10.1 fill"-14" A Loam I OYR 4/1 OUTLET PIPES IF NECESSARY, AND A GAS BAFFLE INSTALLED IN THE OUTLET TEE. 1 48"-132" C I Medium Sand 2. 4'�-45" 13 Medium Loamy Sand I OYR 5/5 Test Hole#2(EL=4G.7±) SITE PLAN. CSN ,w 22.)EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN SAND AND 5Y G14 SCALE: 1 20' AN-am ABANDONED IN PLACE. AREA TO BE COMPACTED TO MINIMIZE SETTLING. Depth Layer Soil Class Soil Color Comments $%%e47 W En 23.)EXISTING SEPTIC COMPONENTS TO BE REMOVED. ANY CONTAMINATED 501L SHALL BE REMOVED DATE Of TESTING: OG/27113 U'-12" fill trio! gineenng FOR A DISTANCE Of FIVE(5) FEET LATERALLY FROM THE 501L ABSORPTION SYSTEM AND REPLACED 501L EVALUATOR: SCOTT MCGANN, 5E 12"-1 G A Loam I OYR 4/1 0 20 40 CO `' - P.O.Box 201 Phone:(508)299-3250 WITH CLEAN SAND. AREA TO BE COMPACTED TO MINIMIZE SETTLING. BOARD Of HEALTH AGENT: DON DESMARAIS, BARNSTABLE HEALTH DEPT 10-40 15 Medium Loamy Sand I OYR 5/5 Brewster,MA 02631 Fax.(508)896-1783 PERCOLATION RATE: LE55 THAN 2 MIN/INCH IN"C"LAYER, 4G'"-132" C I Medium Sand 2.5Y G/4 Perc @ G& SCALE I"=20 24.)WATER/SEWER CROSSING: 4"PVC WA5TELINE SHALL BE SLEEVED IN A 20'SECTION Of G"PVC PIPE "ENTERED OVER THE WATER LINE TO MAXIMIZE DISTANCE TO JOINTS. NO GROUNDWATER ENCOUNTERED f I I I I Date:07/08/13 C:\C5N\AM-five Corner5\AM-five Corners-5D5 Plan.dwc3 - Scale:A5 5hown BY:LJP Check:MTAT Project No.C5NO3G5