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HomeMy WebLinkAbout0163 FIVE CORNERS ROAD - Health 163 FIVE CORNERS ROAD CENTERVILLE A = 168 - 071 S M EAD® KEEPING YOU ORGANIZED No. 12534 _ 2-153LOR SUSTAWABIE MW.RECYC9 WE CONTENT 70Y urore rorso�ino POST-CONSUMERS www w ore ro _ sulm MADEW USA GET ORGANIZED AT SMEAD.COM 00 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Diooe;al *pgtem Contructiou 3dermit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 1 6 3 Ft UE dopli(`&* RD Owner's Name,Address,and Tel.No. L'lslL �C-A-1 ACS O-Cac9C=TW Assessor's Map/Parcel �� ®� �'� FW6 bow W tV�V!L��C—' Installer's Name,Address,and Tel.No. 50g -q--7?'fig 7 7 Designer's Name,Address and Tel.No. C,4?5tut ae U0r&/,Pk 5cS V O 4SSoatAr.:-!�_,C; t53C:OwZ t S e u!i R-0 Type of Building: Dwelling No. of Bedrooms 3 Lot Size ,oZ� t49 t_ sq.ft. Garbage Grinder ( ) Other Type of Building 2GStD&VTjAC.. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3n gpd Design flow provided .4q,3:J2 gpd Plan Date (e,s yA©-- 100 Number of sheets Revision Date Title 1(03 t?C G0(kWGAS RO*'b Size of Septic Tank 1,5,0 0 Type of S.A.S. (a) 5 OCR 44-C— C_'J4*4og8d;4S Description of Soil tXC-I G'a kk!2;E -5AA-7,j CO. aq rt /56 p<.A&f Nature of Repairs or Alterations(Answer when applicable) X&)s7*,L_ 6VCCtJ N—t U t Soo GQL SQ9Z�Ie-- K4X [S[)t774 4 raL;T ®r- a —Cza��C^tie Co 4�L�&Aj 1 K)G,- 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 I J,ealth. Signed Date �+ Application Approved by Date Application Disapproved by: Date for the following reasons Permit No Date Issued ------ f90 iNo. c1 �a "{ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computers, VVV PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes _ 2pprication for �Dioogal *pgtem C,onmructiou Permit _ Application for a Permit to\yonstruct( ) Upgrade Repair U Abandon p (�j pg ) ( ) 19 Complete System ❑Individual Components Location Address or Lot No. cotes R� Owner's Name,Address,and Tel.No. ,Y C`t/I G(..G &CA'Z p.l GFs fti(O c�C."f Assessor's Map/Parcel f GR( 0-7 1(O J FW6 6012AJ PID C�V I u—C^ Installer's Name,Address,and Tel.No. ��� —��?`��7 :Designer's Name,Address and Tel.No. 5'09-:R 33—00 W C,4p& vt aE uwrEK.BAi5cS V 4 45Soall(047-X_S j t'3 3,%v u r r R n Type of Building: Dwelling No.of Bedrooms 3 Lot Size (. ;Lqci t sq. ft. Garbage Grinder ( ) Other Type of Building QGSI DENTjA . No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 349,33 gpd Plan Date (o- a0 3 Ol`� Number of sheets a Revision Date Title I(0'S F1 vC Cok.N6AS PZ*j) G� KylLC.E Size of Septic Tank 56 Q Type of S.A.S. �.Z� 500(ioc GN.4'ZC86�L� Description of Soil h'MC D - C{)A-R5;E Co, �t� /5� L C-44JJ , r Nature of Repairs or Alterations(Answer when applicable) IkK--,714t,4,_ �N/CQ) N-(U (SUO (2AL s�rl� rrtiJ�, 0 tQ04 -aO toV 7y-)—(;L) §�6p CTr4Ct.0A) N l Z) C6 1C4WCr 644,04 Date last inspected: Agreement: The undersigned agree'§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. Signed Date f�pp A5•- o ("q Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. U Date Issued - THE COMMONWEALTH OF MASSACHUSETTS F BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance r THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( x) Upgraded ( ) Abandoned( )by CV Ec c IM aj7M O S7� at �` V1✓E CORP6X—f" Ao c_AaJ7ZMV(L ,97 has beenconstructed in accordance. with the provisions of Title 5 and the for Disposal System Construction Permit No. �� P O Ap dated Installer �2AQ&W(DE Designer u 14 A!� :5aQZ'ZS #bedrooms Approved design flowss Q gpd The issuance of this permit .hall not be construed as a guarantee that the system wt I fu ct on as de/s''.g{n dd Date (� 1 Inspector v+ s� � � _-_-_- T_-- � _. --- ----- --,---- ---- - .-- No. G l —` �' — Fee z� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS N Bi5po5al *y5tem Construction Permit Permission is hereby granted to Construct ( ) Repair (K) Upgrade ( ) Abandon ( ) iSystem located at �, 1 UE C'�A��dC.6� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this�i r Date �j j Approved by K 7D Town of Barnstable w Regulatory Services Bwxxsras[.a, a Richard V. Scali, Interim Director MALSS. Public Health Dlvlsl® a6gg. y® Thomas McKean, Director 200 lain Street, Hyannis,IV4A 02601 Office: 508-862-4644 Fax: 508-790-6304 In taller& Designer Certification Form Date: E 17 sewage Permit# XD/7—)-6_Assessor's IMap\Parcel 607 Designer: Uf/ InstaIler: f J CS Address: :� 2 d Address: C ?l '' 4� !l Ap On g/ �1�/�jl��� � was issued a permit to install a (date) (installer) septic system at 3 �i 'fo�s ��r based on a design drawn by (address) dated 6 '2-4 (designer) i I certify that the septi system referenced above was installed substantially according to the design, which magi include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected a d theX . were found satisfac o �, r�c � p 1JL ��`r 4if�/C lam' .!� S`fi I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateraltt relocation of the SAS or any vertical relocation of any component of the septic system) in accordance with State & Local Regulations. Plan revision or certified as-built by d .�signer to follow. Strip out (if required) was inspected and the soils were found satisfactorl. I certify that the systelrn referenced above was constructed iri-compliance with the terms of the IAA approval letti rs (if applicable) k s I staller's Signa ire) Pesigg;ne r's Signature) (Affix Designers Stamp Here) PL EASE RETURN 'I'O D STA)�I.E PI1lE$1E,It✓ REALT I-I DIVISION. CERTIFICATE E BUILT COCP3LIAleiCE iFVII.L iIV®T' )�E ISSUED L'N'rIL )f3 TTH 'I'IIIS FORM AND AS- >BUIi�I'C.�ItD AItE RE�EITVEI3�Y I'IIE I�AI��S�'A)�LE PL7DY,IO IIEAI✓'I'I'i DI�ISIOl�. 'I'IiAI�iI� YOU. j Q:\SepticlDesiencr Certification Form Kev S-14-i:.doc i TOWN OF BARN�STABLE LOCATION 14P3 F l VC C.okWEk$ k V SEWAGE# AO C®I — AO VILLAGE C'.ckLTL-k'V[U.0 ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO.e-A 6<-AbG C OCSXYTEW 14-EW11 SEPTIC TANK CAPACITY . 1 500 �J LEACHING FACILITY.(type) M 500 G 01144A oa5(size) 11 ag 31 Y. NO. OF BEDROOMS .3 OWNER 13C4TJL(Cj—,— J d0C.eCr,) PERMIT DATE: (Q"' )LO i COMPLIANCE DATE: 3 o —®t o I�7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Il0 -4 Feet Private Water Supply Welland Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) &144 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 4 Feet FURNISHED BY 1 AJQF- J(t)8 ELY7Ea1-(SiES A- I 3tJA 0 3 3v� A - 39. 1bc t ,g a 0 00 . ' . /s 200 Toe-, x k now"":An l't9rr`j' ,,1�/�¢ ot63 , .. ,bxs� 1 �,.. \ ',M.. .ti� H a\1�i�J.V:. SdC�Y Lf��/I"• iaTma"warlkect yfii 'pe�" 1� ►��S? ' An . o , 044 • .•..._.. ._:,:.:.,.- a�.a,.,, wow. *ew.w ...,x, .. .. -...�.. A ' .a.4• �-�"�'�4F£ . �.i'.:" � }`� ;'$v' a .'f' _k f 4k F- } 3 t Foe- 4 7 k A �i� 6mm de�c� i1.Obmnidn A• f fill/ I�rlwww�l�i, w�a�^�w�MI , • w�•�....+^ �'S°. i 9:Y `per k.'. 7-7 +c^ tw �'� d, E ®k ��-- Ill "' �w s ar � : / vA at lad a= tP '� a ' rrnnl, to* � x . wed „z .,..:. OBMVI 14 some VIKII "'Dan ot t ,.fie `Hi. F` K .. � •1z.! '`•�Q'�SF2 fir. '•� s� "•a '�k•+�,, � �'.t A � •'SLOG eA- phone DWOWMVAU Kill," am"CAm— --wouxim so cow NOw . , , r. o ' 4 y r`a 5 ! 3 i ar 8�: o^ s M � x ...x,. '.,� -#p,>,.:sa •�Y`+F. �' ,7.X �:'. �,'.k�$ :�,5,�`e. "' ��'St,.tWF`°'� .ri. . ..t. v .....,�,,. 1.++, a-..... ... 911 in t11 am ilk 11440 fw ft6paotaftoftalor-ol pa • s uw !b4 laftl7. . s OF THE Tp� Town of Barnstable Barnstable .�ti Regulatory Services Department A&ft&1caCft HARNSfABM I 69. ,�� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 6296 May 31, 2017 MOULTON, DENNIS P &BEATRICE S TRS 163 FIVE CORNERS ROAD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 163 Five Corners Road, Centerville,MA was inspected on 05/09/2017 by Mark Polselli,'certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Cesspool is structurally unsound. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas Mc �ean, R.S., CH0 Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\163 Five Comers Road Centerville.doc ♦ Town of Barnstable + lAltNSTABIE, # Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA-02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLINES TO'REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground Y . ❑Pumping more than 4 times during the last year not due to clogged or obstructed Pipe = ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q Single Cesspool- ❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑Leaching pit or cesspool with high liquid level, <12"below inlet (per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER /14 . vivoUlyi, Repair deadline: WSEPTIMDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Forme Not for Voluntary Assessments zA Fv-e- n e UTI Property Address rS �C I`+a / �A Owner 2Gt�/1 C- / otjl 'o L, information is Cwner's Name / required for every Ce o 4�e -1 G 4 tl /it�-t page. City/Town .„ State ----- �` Zip Code Date of Insfpection CN Inspection results must be submitted on this four. Inspection forms may not be altered in an way. Please see completeness checklist at the end of the form. y Important:when A. General Information filling out forms on the computer, use only the tab key to move your 1 Inspector: cursor-do not use the return M a Y" is ell key. Name of Inspector ��vl 0 l EC he Company Name 1610 4 9? Comy A panddress — as City/Town r /_ n �� State[ Zip Code J °.8 7�t/�pZ Telephone umber License Number B. Certification i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I araj a DEP approved systearn inspector pursuant to Section 415.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes Fails ❑ Needs Further Evaluation by the Local Approving Authority Ct/9 11L&/ Inspect 's Signature Date / The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is CeM-kY-I/I Q �� �� 6 3� required for every J� 9 page. City/Town State Zip Code Date of spe tion B. Certification (coot.) 7 Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 It"N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /6 3 F1 v� 6)✓vZ-err Property Address Owner OW Owner's Name information is t,�Vl / D�6 �� required for every ` � / page. City/Town State Zip Code Date of In ecti B. Certification (cont.) Qfi ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced 0 Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address A0 61 V7 Owner Owner's Name //JJ information is Ce w�VI & 1%4 !1-16 �l required for every ,5 page. City/Town State Zip Code Date of In pec on B. Certification (cost.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary_ to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must Indic es" or"No" to each of the following for all inspections: Yes No C-e TOL2/ 0�7t/t Ll ✓��0 t, Backuewage into facility or y�omponent due to overloaded or ❑ clogged SAS or cesspool ❑ Er�Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 521� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 2111, Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 �/�pp��C � Ft ✓ -L �Ol�1/t fir - Property Address Owner O� /�'� Owner's Name information is /'Q I _ v` /le �� ©a G 3� required for every (� `d-�'ij� ( � � � page. City/Town State Zip Code Date of I spe ion i—: Be Certification Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ � Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis nd chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address C®kllvull-s Owner 41/71V"I Owner's Name information is 63� required for every e� ���� !� 2 � /C( / page. City/1 own State Zip Code Date of Inspe tion Co Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ mping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? ❑ u e large volumes of water been introduced to the system recently or as part of this in ection? ❑ re as built plans of the system obtained and examined? (If they were not ailable note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank ins cted for the condition of the baffles or tees, material of construction, mensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? T e and location of the Soil Absorption System (SAS)on the site has een determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): �J DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): �y t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments //�� / l V, �rvtC�s Aj Property Address j vlor�/f�� Owner Owner's Name information is CeN 'ed/vt �f 0 l 6 7� / required for every ,/� d page. City/Town State Zip Code Date of Insp ction D. System Information Description: J l s-P r! C c�ss Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 24.4o Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes tom Laundry system inspected? ❑ Yes ❑/No Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Y s No Last date of occupancy: /v at Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(g)d) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface ewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M Co. col Property Address 163 v-e_ �2✓S Owner Owner's Name / information is ,, 'v required for every �`f l�✓ � page. City/Town State Zip Code Date of I spect' n . D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? --- ------ — _— Reason for pumping: Type of Sys tic tank, Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address y/T1 information is Owner �0 Owner's Name G C �Yqd�- / required for every 2 0 �v page. City/I own State Zip Code Date of In pecti n D. System Information (cont.) Approximate aloe o allncomponents, date installed (if known) and source of information: 2" Were sewage odors detected when arriving at the site? ❑ Yes to Building Sewer(locate on site plan): Depth below gra e: feet Materi 'of construction: cast iron ❑40 PVC ❑ other(explain): + � �s Distance from private water supply well or suction line: s � feet S wad Comments(on condition of joints, venting, evidence of leakage, etc.): 2 a S-� Y« —Ce t,./,2 en- Septic Tank(locate on site plan): Depth below grade: / feet Material construction: concrete ❑ metal ❑fiberglass ❑ polyeth lene other l y ❑ oth„ (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No Dimensions: `S y Sludge depth: J 7 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner information is Owner's NameCet., I_�v/ � �( required for every Y-e /� o� ) page. City/I own State Zip Code Date of I sp ction D. System Information (cont.) Septic Tank(cont.) l/ Distance from top of sludge to bottom of outlet tee or baffle ` Scum thickness c�c yr ✓`7 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Mow were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): g y G� W G /t"70J� -ems ID I�vt r �i p v7 -z,s CP to.e' 121-14 014 -/-/L kv 6,; j Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom,of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 3 Co. vra.-S Owner Owner's Name infgwired for ormation is re every C.�N ✓(/G � � �� � � / page. City/I own State Zip Code Date of In pectin D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: --- -- —____ Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tt vy-- Co k-kl p,�c Xd Property Address Owner Owner's Name information is C�e v` required for every page. City/Town State Zip Code Date o Insp tion D. system Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): (/Z ch,c c---J aP4c:/ /0 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments WCj Property Address /� > Owner Owner's Name information is Cep �r�1 _7� required for every page. City/Town State Zip Code Date of in pec on ®o System Information (cunt.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions.- El overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer X Dimensions of cesspool /O Ci Materials of construction Indication of groundwater inflow ❑ Yes FLj No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M �3 FV� Property Address Owner Owner's Name _ information is Ce"4vv/ �IT �q�6 3� S required for every 6 page. City/Town State Zip Code Date of I spe ion D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Olc� &o-,,_ j e- Ari 5 _154��C� cc r-e-V — — 6 l o C� Lrs' f 0 C.z <s o.v/. o�✓ s ��� ot-1 0 �Lr 11511 -e SS O0 lac 14fo Wrc' Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, Level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Ak / Owner's Name information is �p ��// ©�C:� required for every e� '"✓vl a //�jpage. City/Town StateZipDate of I pectin / D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least o permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate wher ublic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately �G l✓ r- SP �� c f t5ins.doc•rev.6/16 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is �� �` �6 required for every page. City/Town State Zip Code Date of I spe tion De System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / 1 / Estimated depth to high ground water: -- feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ ecked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: � — Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts F Title 5 Official Inspection Fora a Subsur face Sewage Disposal 9 p System Form - Not for Voluntary Assessments �J Owner Property Address Owner's Name CJv7 ` information is Ce ? _ � / 3� required for every "`� t � page. Clty/I own State Zip Code Date of I spe ion E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems) completed LJ Sy m Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE 1Cws7G u lr ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. (AA&� _ SEPTIC TANK CAPACITY /a ac> �r LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within. 300 feet of leaching facility) Feet FURNISHEDBY �A eye �- 3z ` P , CC .33 •� CP A ' 45.35 GENERAL NOTES: .61 1. VERTICAL DATUM: __ASSUMED 2. MUNICIPAL WATER _ IS AVAILABLE. sf°o¢o Benchmark: Car. of Step 3. SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT o� at Elev. 47.7' SYSTEM UNLESS OTHERWISE NOTED. 4. ALL PRECAST UNITS TO CONFORM TO AASH TO: _ H_10 & 20 45.82 5• PIPE PITCH-1/4" PER FOOT UNLESS OTHERWISE NOTED. 1, 6• ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE r' WITH MA ENVIR. CODE (TITLE 5) AND LOCAL -4s REGULATIONS. °aeFe� x4 s6rlc�' 1B= 1Sak x�4605 7• CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES 2 \ PRIOR TO CONSTRUCTION. u� 1 1 t 01 oak . 03 40� 46.78 ` �1 1 ok �� 8 Garden LEGEND: 8" Oo 2S,x-46:25--- x 46.37 - .;:., , `5�� �- s9�- PROPOSED CONTOUR 64, .77 TH-1 P ¢� ss PROPOSED SPOT GRADE 6 ❑ 45.68 '12" Oak TH-2 0 0 �J3 47:09: ;:.:;..'`:.:::' , - 40 EXISTING CONTOUR �.� X 30.23 EXISTING SPOT GRADE o� .14� 47.15 \ .°° TEST PIT 14" Oak \ Al/ 46.9 �t 47.24.; `. `..::.N \ uu '�^x 46.75 ® EXISTING WATER SERVICE _ ,�C5 O 4 98 0 �4� % x'4 4 O 47.29 OM`'maces. ::. ...;. n� o X- WORK LIMIT LINE .22 ( ?/ 47 43 ry . 1 47.1 ..: ,._e/. :.�,..:::::: '.:' OF of + 47.09 .,`' Full Base. � 4�;�e, 46.86 J4' ly Existing Ire 99 9 x VON HONE 7 46. 46.83 Dwelling 47:53. i o H °o 47. Top Fndn. 16' S641 51 El. 48.0 \ 47.68 46.94 �FGISTERE�. Garage / 9> A (slab) Lot 13 46.89 16,249 f S.F. ASSESSOR'S MAP: 168 >>g 72 / a NOTE: This plan is to be used for septic PARCEL: 71 47.77 OO system purposes only and is not to be REFERENCE: PL. BK. 235 PG. 55 Patto o mo ' 0 used for any other purpose. sta FLOOD ZONE: X Town of Barnstable g° Area 4774 tee 25001 C0563J(07 16/14) � 163 FIVE CORNERS ROAD Locus 47.00 V ft CEN TER VI LLE, MA 3 Route 28 �° �0 3 o u s, 47.s4 Q �. O� ,00�a associates FOR: Beatrice a73o .. / L � ° � SEPTIC SYSTEM DESIGNS Beatrice Moulton Westminis r Rd Di0 320 Cotuit Road Septic System NOTE: Pump and backfill existing 2 /tea Son) 50 3 0041 Site Plan 163 Five Corners Road 47.26 � (0) 508.833.0041 septic tank and cesspool(s). / . X (C) 508.274.0074 Centerville, MA 02632 d Replace any Orangeburg pipe �� s R°° e'S back to existing cast iron pipe su la S v e exitingfoundation with .Sch. 40 1 / ArneH. Surveying 4" PVC pipe. Arne Mapl1�L.S. DATE REVISED SCALE SHEET NO. West Barnstable. MA 02668 „ , LOCUS MAP N.T.S. 46.s5 sae-362-0834 06/20/2017 1 = 20 1 of 2 a f Provide Riser over D-box NOTE: All components to be marked with NOTE: To prevent breakout, final T.O.F. (Full) to within 6" of final grade ! magnetic tape or similar prior to final cover. grade of EL. 43.5 to be carried EL. 48.0 -\ (Cover to be watertight) out a minimum 15' beyond edge F.G. EL: 46.8-47.7 F.G. EL: 46.5 F.G. EL: 46.0 Maintain Min. 2% slope over leach facility to of leach facility.(Existing grade Existin f- revent Ronding F.G. EL: 46.0-46.5 meets breakout.) Install risers w/covers over inlet and Min. 2" of 1/8" - 3/4" Washed Stone or Ins ection Port within 6" to grade outlet to within 6" of final grade Geotextile Fabric L=40' (Access Covers min. 20" diam. per Code) ., " Exist. invert 4" SCH 40 P L=25 , _ 3/4 - 1 1/2 Double Washed Stone Cast Iron 4". to' .• 4 SCH 40 PVC 4" SCH040 PVC CAS=2.0% 2 Top of Peastone or Geotextile Fabric EL. 43.5 EL. 45.08 ta- ®S=2% 19.MI 6 @S=4.15% 0.5�AIN a®a�aB.3 24" Eff. Depth 12 ®B®aaBB EL. 44.0 --EL. 43.33 a®®a®aa Bottom 40.5 EL. 44.25 Install Gas Baffle EL. 43.5 EL. 42.5 Use 2 - 500 Gallon Precast Chambers PROPOSED DB-3 H-20 DISTRIBUTION BOX' (H-10) with Double Washed Stone IN 7.1 Watertest for levelness 4' Ends, 4' Sides (Install PVC Inlet & Outlet Tees) if more than one SEPTIC SYSTEM PROFILE (25' x 12.83' x 2') PROPOSED 1500 GALLON EL. 33.4 H-10 SEPTIC TANK outlet ' N.T.S. Bottom of TH-1 SOIL LOG ADDITIONAL NOTES DESIGN CRITERIA Number of Bedrooms:Existing 3 Bedrooms SOIL EVALUATOR: MARK POLSELLI S.E. #2912 1 Contractor to confirm soil suitability prior to installation. Contact BOH and INSPECTOR: JU NALD D2017 10:0AIS, R.S., BOH Design Sanitarian in the event of varying soils from original soil test. Soil Type: Class I DATE: JUNE 13, 2017 10:00 AM g y gPercolation Rate: PERMIT: #15377 <2 min/Inch PERCOLATION RATE:<2 MIN/INCH IN C1 2. Locate, Pump, and bockfill Failed Cesspool(s). Any contaminated materials within 5' of proposed Leach Facility to be removed. Replace with clean fill Daily Flow: 110 G.P.D./Bedrm x 3 =330 G.P.D. TH - 1 TH - 2 per Title 5 specifications. Confirm original cesspool filled. Design Flow: 330 G.P.D. (Min. Required) EL. 46.4 EL. 46.5 3. Water line to be sleeved at any sewerline crossings and within 10' of any Garbage Grinder: Not Allowed A A septic components, as needed, per Water Department requirements. Leaching Area Loamy Sand Loamy Sand Contractor to verify location of water line prior to construction. (330)/0.74 = 445.94 S.F. 4 10YR3/2 10YR3/2 Required: 4" 46.07 4" 46.17 4. Septic Tank and Distribution Box to be placed on 6" crushed stone or 330 G.P.D. x. 200% = 660 G.P.D B B (Proposed) compacted, level base. Septic Tank Required: Minimum 1500 Gallon Pro Loamy Sand Loamy Sand 1 ( P ) 29" 10YR4/5 43.98 29" 10YR4/5 44.08 SEPTIC TIES Use 2 - 500 Gallon Precast Chambers H-10 with C1 C1 Double Washed Stone: 25' x 12.83' x 2' Medium Coarse Perc Medium Coarse Sand 57" Bottom Sand 2S• y\ 2 25' + 12.83' 2= 151.32 S.F. 10YR5 4 10YR5 4 Bottom 11 Area: ( 25' x 12.83'= 320.75 S.F. / / O 35 Bottom Area: O Total Area: 472.07 S.F. N 4' Desi n Flow Provided: 0.74(472.07 S.F.)= 349.33 G.P.D. 2' 163 FIVE CORNERS ROAD CENTERVILLE, MA tm9' associates PREPARED 156" 133.4 156" 33.5 SEPnc SYSTEM DESIGNS FOR: Beatrice Moulton OWe1Nn9dn No Groundwater Observed No Groundwater Observed. Sop F" 320 Cotuft Road Septic System 4 4$�' Sandwich, MA 02563 163 Five Corners Road (0) 508.833.0041 Site Plan 24 Gallons in 8: 11 min. PERC RATE: <2 MIN/INCH C1 Horizon (C) 508.274.0074 Centerville, MA 02632 O O Gora9e I, Mark Polselli, S.E., hereby certify that I am currently approved by the CStob) Surveying DEP pursuant to 310 CMR 15.017 to conduct soil evaluations and that I AHOjala Surveying the above analysis has been performed by me consistent with the ArneH. Oak P.L.S. requirements of 310 CMR 15.017. I further certify that I have I 211 Maple street DATE REVISED SCALE SHEET N0. west successfully passed the Soil Evaluator's Exam on December 14, 2004. Barnstable. 02668 362-09334 06/20/2017 1" = 20' 2 of 2 l .