HomeMy WebLinkAbout0166 FIVE CORNERS ROAD - Health 166 FIVE CORNERS RD
CENTERVILLE
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No. 4210 1/3 ORA
ESSELTE
10%
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TOWN OF BA fRNSTABLE
L CATION 1 6 Q(4 6 661kl$ �L c SE WAGE# 20 t 2 —Z 9t�'
VILLAGE ASSESSOR'S MAP&PARCEL
NSTALLER'S NAME&PHONE NO. SO y-S CC ZO/0
SEPTIC TANK CAPACITY 1000
LEACHING FACILITY. (type) YA-e—ya60,✓\ (size)
NO.OF BEDROOMS 2
OWNER V Ok/L �4-A It t-Q
PERMIT DATE: 2 ^( 2 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1A Feet
Private Water Supply Well and Leaching Facility(If any wells exist on h
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of le � Feet
FURNISHED BY
9 `
i
0'Z
`g`"
y
s,
No. Fee /v�•('/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN►OF BARNSTABLE, MASSACHUSETTS
application for Misposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair(,Mk Upgrade( ) Abandon( ) ❑Complete System K Individual Components
Location Address or Lot No. A0 b Fc v2cd",-ems tL.1 Owner's Name,Address,and Tel.No.
Geap/Parcelf r7
Vh n zr�t iL���q,Assessor
InstAiler's Dame,Add ye and Tel.No. Designer's Name,Address,and Tel.No.
y�ASOW tie (d� A-nc•�A,�r� �@��-C �C 7� act 2.ra p�.s
8-OX (Q fa l S'A--dc,L tc-k -d t-5—C 5 ""- Z"6 130.k FS- SAVTd—i 14 &M J00"36z. 2 4 z z
Type of Building:
Dwelling No.of Bedrooms Z Lot Size sq.ft. Garbage Grinder( )
Other Type of Building XT44oftt K./ No.of Persons Showers( Cafeteria( )
Other Fixtures
Design Flow(min.required) 2— gpd Design flow provided ?4-P-60-7 gpd
Plan Date l /`2_ Number of sheets 2 Revision Date /(0'f A-e
Title
Size of Septic Tank �X(JTIivS /Q00 Type of S.A.S. N2& @4CJ f A �b
Description of Soil 4
Nature of Repairs or Alterations(Answer when applicable) A-Ce & !ICGf
Z A A#le,5'5' . 4rh e
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 Bo alth.
Signed ;7Date
Application Approved by Date — (� 7'-
Application Disapproved by Date
for the following reasons
Permit No. 0 1 Date Issued
No. �O '� : � �C1 Fee v'� '•
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWNI! F,.O :BARNSTABLE, MASSACHUSETTS Yes
2pplication for ]Disposal OpsOm Construction 3permit
Application for a Permit to Construct( ) Repair()tf Upgrade( ) Abandon( ) ❑Complete System 91 Individual Components
Location Address or Lot No. /to 6 F, jC CO,Alec S fL J Owner's Name,Address,and Tel.No.
C e ."< l(e 7664 SS h 1.,, 6e cy
Assessor's Map/Parcel /6,/((3 S q._C
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
J/—'/i,4/_Ii y fPl✓ic 7'NC t'K.Q4-er d fo— 5
/3ox (o(occ cz )( 3 ; S Zino /3ok �,i/ Se?✓tc/ 623-0 J(W36Z 252 �
Type of Building:
Dwelling No.of Bedrooms Z Lot Size sq.ft. Garbage Grinder( )
Other Type of Building 114C No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) Z Z O gpd Design flow provided ?4 1-4 7 gpd
Plan Date Number of sheets 2- Revision Date /V o M,Q
Title
Size of Septic Tank PJ�/,f�jM5; /000 Type of S.A.S. •fj fe p4C_i t2 f A-r/C
Description of Soil ,Se 2 /,C�All
Nature of Repairs or Alterations(Answer when applicable) W eg l�w,e A r C-V, -G1
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 Boar alth.jzlt�zl -
Signed Date %--/Z 2—
Application Approved by 0 -5 Date �--
Application Disapproved by Date
for the following reasons
Permit No. o` 0 1 0 Date Issued
i
- - - - - -- -------------- ---- --------------------------------------
A THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY that the On-site/Sewage Dis osal system Constructed( ) Repaired 0/0 Upgraded( )
Abandoned(
at f� /(/e ( D rve --S �p/1-/i'/ ds/qeen constructed in accordance
with the provisions of Title 5 andOiq for Disposal System Construction Permit No. o?o 1.1 -.2 dated ' o
Installer&4-e e 1 C/ y ;jyC_ Designer
#bedrooms Approved design flow 2 2-0 gpd
The issuance of this permit shall not be construed as a guarantee that the syste will func n designed.
Date /* Inspector
- --------- ----------- --------- ----------- ---- ----------------- ------------------- - ----- ---------- -----------
No. i�C I Lf Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal 6pstettt Construction 3permit ,
Permission is hereby granted to Construct( ) Repair U grade( ) Abandon( )
System located at G (o /��(i W �O/AV e_ C4
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 _ n
Date _ �� - I� Approved by �(�
Town of Barnstable
RegulltoryServices
Thomas F. Geiler, Director
( 1 �rvsrnst,E,
'i6 9. Public Health Division
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-362-1644, Fax: 508-790-6304
Installer & Designer Certification Form
Gy
Date: I �� Sewage Permit# 20(-,? ��.�,ssessor's Map\Parcel t b l
Designer. Installer: �� / U `l
Address: c) &YY (Is Address:
On U ��i� was issued a permit to install a
(date) 61 - ram, (installer)
septic system at I�P C t/V`-� Q/UQ�(S based on a design drawn by
(address)
d '� '" ► ¢-� dated
(designer) �,
�f 1 certify that the septic system referenced above ,was installed substantially according to
the design, which may include minor approved charges such as lateral reiocation Of the
distribution box and�'or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or an, 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.
• ������ OF ,ygsf9cy
o A 'FN�M
c" l
( nsta ler's Signature) � o,o.1.t4 • 4y
` o '�EGlS1E �
1` SAN I TAR\P�
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNVABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COiNIPL1ANCE WILL NOT BE ISSUED UNTIL BOTH THIS F0104 AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q: Health/Septic/Designer Certification Form 3-16-04:1doc
I
Town of Ba Instable P#-- -
of
Department of Regulatory Services
. • Bate /
eBce, : Pubffe Health I)1V1S1on
tb`¢ tee$ 200 Main Street Hyannis MA 02601
3
'
Date Scheduled � Time . Fee Pd
__�
i
oil Suitability Assess�ne�c 'for Se e Disposal
Performed r Witnessed By:
LOCATION & GENERAL IIVFORIVIATION
Location Address i Owner's Name J O*-dJ �^t► r1 h/ .�
Address
Assessor's Map/P4rcel: S Engineer's Name / ' •^'� '
NEW CONS1RUtt']ON REPAIR Telephone#
Land Use ' i� �l Slopes(91b) J .�iI Surface Stones /`ra
---2)00
Distances from: Open Water Body ft Possible Wee Areal LCJC�ft Drinking Water Well ft
i
htainage Way >1 00 ft Property Line �/L�—ft Other ft
SKETCH:(Street name,dimensiods'of lot exact lry-- PO�nles&perc tests,locate wetlands in proxitnity to holes)
5 _0
\ 165• N
A
�OZ / /
4ys °b i
/0S /003 /Oqp2
Parent material(geologic) �i w�S Depth to Bedrock '
Weeping from Pit Face '4
Depth to Groundwakcr. Standing Water in Hole:' i
Estimated Seasonal;Vigh Groundwater , I
Dt'ERMINATION FOR SEASONAL HIGH WATER T"EE
Method Used: I In.
Depth ob�terved standing;in obs.hole: in. Depth td Sall Mottles;
Depth toiweeping from side of obs.hole: 777:-7 in. Oroundwnter Adjustment
Index Well# _� Reading Date: Index Well level i AcU•Actor _ Adj.f)roundwnterLeVel.,,s
PERCOLATION TEST . Date-
Observation I Time at 91,
Hole#
Time at b" .-.-•------
Depth of Perc
Start Pre-soak Time.@ � Time(9"-0) —
Ak
End Pre-soak
Rate MinJInch `
Site Suitability Assessment: Site Passed Site Failed:_— Additional Testing Needed(YIN) '
Original:.Public llc;lth Division Observation Hole Data To Be Completed on Back—
***If percolagon test is to be conducted within 100' of wetland,you must first notify the
week prior to beginning.
Barnstable Conservation Division at least one (1)
DEEP OBSERVATION HOLE LOG Hole#�_
Depth from Soil Horizon Soil Texture Soil Color Soil Other
.Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent %Gravel
oil— �at A vn/3p
it
21orl 1�2t' 2.5'
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
cc Consistent %Gravel)
a� g t1 s-kw 10 . l n�
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (MUnSeII) Mottling (Structure,Stones,Boulders.
! Consistent %Gravel
DEEP OBSERVATION HOLE LOG Hole#_N
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders.
Consistency, ra I
F
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes
Within 500 year boundary Nov Yes r
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? YLOIX
If not,what is the depth of naturally occurring per ious material?
Certification rr
I certify that on l d (date)I have passed the soil evaluator examination approved by the
Department of Enviro mental Protection and that the above analysis was performed by me consistent with
the require training,expertise and experience described in 3,10 CMR 15.017.
Signature Date
Q:\.SEPTICIPERCFORM.DOC
6 4
DATE: 6/14/99
PROPERTY ADDRESS:
-----------------------
166 Five Corners Road
Centerville, Ma.
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank
2. 1 -1000 gallon leaching pit
3. 1 -Distribution box
Based on my inspection, I certify the following conditions:
4. This is a title Five Septic system ( 78 Code)
5. -The septic system is inproper working order
at the present time .
6 . The waste water is 44" below the invertpipe
of the leaching pit .
SIGNATURE:1 _, .
Name:_,L omber JTr�______
Company: Jose2h_P. Macomber_& Son , Inc .
Address:— Box—66
--- ---------------
Centerville , Ma . 02632-0066
--------------------
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
A
,o
LOS. P. MACOMBER & SON, INC.
anks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections JUL3 1999 ,
66 Centerville, MA 02632-0066 �WNOFBq� ,
775-3338 775-6412 S y
•
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500
TRUUY COX
Secret.•
ARGEO PAUL CELLUCCI DAVID B. STRU)'
Governor Co rrL.—niss;oc,
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
CERTIFICATION
Property Address:1 66 Five Corners Road Nam. of Owno.Parj ogr ej 5ema'n
Centerville Addrasa of Owrser•
Dsu of Inspection: /, d �qq
Name of Irupoctce:(J�6a{a`f'firfU'JoseAh P. Macomber Jr.
1 am a DEP approved system Inspector pursuant to Section 15.340 of Title 6 (310 CMR I5.000)
company Nam.: Joseph P. Macomber & Son, Inc.
L&IngAddraaa: Box 66, Centerville., Ma _ 02632-0066
T el eo)ona Number:5 0 8-77 5-3 33 8
CERTIFICATION STATEMENT
I csrtity that I have personally Inspected the sewage disposal system at this address and that the Information reported below is true, accurate
and compiste 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:
2POS303
Conditionally Passes
Needs
_
Fu ving Authority
Fails
Inspector's Signature: nhoA
Date:
The System Inspecto all su mit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)whhin 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•Environmemai Protection. The original should be sent to mR
system owner.and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
1 r
revised 9/2/98 Pgeelof11
`� Printed on R.cy0kd P+µr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address 166 Five Corners Road, Centervile
Own": ar_j brie-Freem•an ;•,�+;
Data of Inspecdon: 6/1 4 j9 9
INSPECTION SUMMARY: Check A, A C, o/ D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 1fi.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, o,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 pumpirtg•mom than-four-ftes a yeardue to broken or obstructed pipe(s). The system wiil-jmss—
inspection if(with approval of the Board of Heeith): - - -
broken pipes) are'replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPORT A YSTEM INSPECTION FORM
CERTIFICATION (corronuod)
POPOty'A,. 166 Five Corners Road, Centervill
e
Miarj or e' F'reIemap,jW? w)
tkt.of ' 6/1,4—
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which reQulra further evaluation by-the Board of Health In order to determine If the system i+ lolling to prot►ct the
public haalth,+j}etY and the environment.
1) SYSTE3d VALL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 AND�(1)�80NU�� SYS
IS NOT FUNCTIONING W A WARNER WVtCRyaLL.PRQ=C•I THE PUBUC�lLT3iAND SAFETY
Cesspool or privy I+ within 60 fait of surface water
Cesspool or privy Is within 60 last of a bordering vegetated wetland or a salt marsh.
0 WATER UPKIER, IF
NES
2) SYSTDd Va-L FAIL UNLESS THE
E{AB7 PROT OF HEALTH"D PUBUECTS THE PUBUC HEAL LH AND SAFETY AND THEYf?IVIA�O FNT:�T THE SYSTD
FUNCTIONING W A tvlA11NER
The system has a septic tank and soil absorption system(SAS) and the SAS Is within 100 toot of • suriaco water supply
tributary to a surface water supply. w•u.
The system has a septic tank and soil absorption system and the SAS Is within a tons I a public water supply wou.
The system has a septic tank and soil absorption system andand the SAS Is within 60 foot off a privet• wsur suDDIY
Of more from &
The system has a sopdc t unread*oil ab3o(ptlon system water analysis for coU o,m bac SAS ltarls and von s lots than OOotoigt NC comD�nds inckstos uu
wellprivate water supplyonla
well Is tree from pollution from that facility and the pre& a °�P axlmationonot val di.gen and nluat• rJuog•n Is aural tow •+;
than 6 pOm• Method used to determine distance
3) OTHER
tie N4
es
. Page 3 0(11
revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddras.s: 1 i6, Five Corners Road, Centerville
owns.: MA 3 Or'i Freeman r'-7_. �'� Vy!�• "�.���
Data of Inspection: 6/1 4/9 9 -
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
__4'0 1 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
L/ Backup o+sewege irttoiaci6ry-or•-system component,due%to an overloaded orcbgged-SAS-orscesspool.
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 he distrl ution box above outlet Invert due to an overloaded or clogged SAS or cesspool.
yo—
Liquid depth in�less than 6" below Invert or available volume is less than 1/2 day flow.
V 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 60 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' 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}set of a surface drinking water supply
the system•irwitWn 200 (eetof-e-taibutary-4o a surfaoadrinkieg•watw-supply —
l� 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 Infor,)ttation.
revised 9/2/98 Page 4of11
1
1 '
! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropenyAddr"4:166 Five Corners Road, Centerville
owner: Marj ori.e. Freeman
Date of Inspection: 6/1 4/9 9
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 systemcompoaenu.kwuabean puaVad+for✓at.Jeast Two-wesks and'the'system hasb"a mcaiuiwg we.a.l flow
rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
Inspection.
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 condition of baffle:
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe 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)
115.302(3)(b))
_ The facility owner.(and.occupauts,lf diflaren2lroar.oacner),tvaraprauided.wi2h)nfnrmalioaon thy=�ainta��� �f
Subsurface Disposal Systems.
revised 9/2/98 Page 5of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 166 Five Corners Road, Centerville
Owner: Marjorie -F-reeman
Date of Inspection: 6 1`4%§9'
FLOW CONDITIONS
RESIDENTIAL:
Design flow: a g.p.ddbedro
Number of bedrooms( sig Number of bedrooms(actual):_,
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):_
Laundry(separate system) ( es or If yes, sepawelmpaction•requirad
Laundry system Inspected Wor no) 19 9 7- 6q om o I�S6. ��
Seasonal use(yes or no):
Water meter readings,If available (last two year's usage(gpd): P.D.— IV`I• I
Sump Pump(yes or no):AA Lj
Last date of occupancy• =+
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow: d ( Based on 15.203),f
Basis of design flow
Grease trap present: (yes or no)29
Industrial Waste Holding Tank present:(yes or no)A/
Non-sanitary waste discharged to the Title 5 system: ( es or noldY
Water motor readings,if avails le:
Last data of occupancy:
OTHER:(Describe) /f I A
Last date of occupancy:_ _
GENERAL INFORMATION
PUMPING RECORDS and source of informatio
System pumped as part of i pection:(yes or no)
If yes, volume pumped: gallons
Reason for pumping:
TYPE 0 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
Othgr
OXl TE%of al components, date instaIted f k w nd source of f oration: -
Sewage odors detected when arriving at the site:(yes or no)_
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Progeny Addrasa: 166 Five Corners Road, Centerville
Ownw: tIargj gri'e?<Freeman
Darts of kuPecti°n: 6/1 4�9 9
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of ons uction:l� as If o 40 other(explain)
)�� ti I
Distance from Private water aupply well or suc on ins 1.0 1
Diameter
Comments: (condition of Joints,venting, svldence of fsakage,-etc.) -
S C K:
(locate on site plan)
Depth below grade:
Material of construction:jk nc' to metal,!AFiberglass,toPolyethylenodVother(explain)
If tank Is[note],list age Js.age.confumed by Certificate of Compliance A49(Yes/No)
Dimensions: r Jr yu/r 6 /"
Sludge depth:_ If _.
Distance from top ofJ1ludge to bottom of outlet toe or fraffle:
Scum thickness: _ e
Distance from top of scum to top of outlet tee or baffle: ��
Distance from bottom of scum to bo o of outlet t a or baffle:!1L_
How dimensions were determined:
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or•bafflea, depth of liquid level In relation to outlet invert, structura;4ntegrity.
evidence of leakage,etc.) Pump tank Pxryy 9— g r-6, Inlet & eat-het—tees
str-tie-terally "ttnd cmd shows no evidence of ea age into
o x .
(locate on sits plan)
Depth below grade
Material of cons truction:44—*concreta lmetall•Flberglass&--4 Polyethylens.Vo other(axplain)
Dimensions:
Scum Wckness:
Distance from top of scum to top of outlet too or baffle: -4114
Distance from bottom of a um to bottom of outlet too 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 (coertinued)
Property Addre": 1,66 Five Corners Road, Centerville
owner: Matj btie,<Fre-eman .
Date of Inspection:6/1 4/9 9
TIGHT OR HOLDING TANK:4)614Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construcdon.I)A concretedl4metal4&Fiberglass44Polyethylane.04other(explain)
AXA
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present '/
Alarm level: Alarm In working order:Yes/,4 No/vi4
Date of previous pumping:
Comments:
(condition of Inlet tee, condition of alarm and float&witches, etc.)
fight Or holding tank-, arp nni- pl g�g�b
DISTRIBUTION BOX:,
(locate on site plan)
Depth of liquid level above outlet Invert:_
Comments:
(note-If level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.)
Distribution box has ona latpral Nn nir; dapaQ of sel}4s
carrg nvpr Nn ov; �v^^vc v= +-i—e 0, Out of the box
PUMP CHAMBER:,&C
(locate on site plan) ,1
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.)
Pump chamhpr i -, nnf- present
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropeMAd& s: 166 Five Corners Road, Centerville
Owner: hlar.j ori!e,F,rir a an
Date of Irtspecuon:6/1 4/9 9
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 gallerlas,number:,
leaching tranches,number,length:
leaching fields,number, dime dons:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to medium fin . sand . No signs of hydraulic failure
nr i nniji ng qQi l i c dr. 3l080tati,QP :I-i3 A,0r--mig.
CESSPOOLS:
(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)
o
Cesspools are not nrpspnY _
Comments:
(note condition of soil, signs of hydraulic failure,-level of ponding,condition of.vagetation, etc.)
Cesspools are not present
PRIVY:6."I+e
(locate on site plan)
Materjals of construction: /U� Dimensions:
Qepth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,Pevel of ponding, condition of vegetation;etc.)
Privy is not present .
revised 9/2/98 . P;iee9of11
SUBSURFACE SEWAGE DISPOSAL SYSTY-M LNSPErMON FORM
PXRT G
SYSTY-M tNFOR;4AT10N (contlnuoC)
ProportyAddrwu: 166 Five Corners Road, Centerville
ow:..•: t4arjorie Freeman
6/14/§9
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atlasst two permanent reference landmarks or benchmarks
locale all wells within 100' (locate white public water supply comas Into house)
Centerville Osterville Marstons Mills
Water -Company
428-6691
i/
all-
\C /
I �
revised 9/2/98 P.t� toorLl
SEWAGE DISPOSAL SYSTEM IN SUBSURFACESPECTION FORM.
PART C
SYSTEM INFORMATION(continued)
PropertyAd&"s: 166 Five Corners Road, Centerville
Owner: Matrj�orie Freeman
Data of kupection: 6/1 4/9 9
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 4 Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed.Sits(Abutting property observation hole,basement sump etc.)
Determined from local conditions
_Checked with local Board of health
Checked FEMA Maps
l� Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used Water Contours Map
Gahrety & Miller Model
121142
„41
revised 9/2/98 Page 11or11
,s•Iwtn r.lv-nTT-.'T\TrJnI'n11A nfTrtalAJY\fR'fA\+fT/T+r'nT ARwlY til�I'I'�11rn .Y'T'"--r-a��..�..r-...
TOWN OFBARNSTABLE BOARD OF HEALTH
1( SUDSURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION I
`. F-•7n-�".•t:\-T.IIA-.+rrV7lrra•nnn TTnl9f n.�rrrr.r.t'1.1v.wr.wwwr•rwr�Om•+vAr�rR1�r+ mnn�..rr+.rasr.rR+.r..+•.--..-r.-• -•„ -..A
'-TYPE OR PRINT CI.EARLI'-
PITOPERTY INSPECTED
STREET ADDRESS 166 Five Corners Road, Centerville
ASSESSORS MAP , BLOCK AND PARCEL
OWNER' s NAME Mari.or e` F.reeman
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber- Jr. .
COMPANY NAME Joseph P. Macomber & Son, Inc.
COMPANY ADDRESS Box 66, Centerville, Ma. 02632-0066
Street Town or City Stat• tIP
COMPANY TELEPHONE (508 )775 -3338 FAX ( 508 )790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that tile information reported is true ) accurate , and
complete as of the time of The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
L/
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or Lhe. enviroment as defined in 310 CMR 16 - 303 . Any failue
criteria not evaluate n r
d are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have con3licted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the DOARD OF 11BAL1'll:
If the inspection FAILED, th'e owner or•"oporator shall u� pgrado ' the eyotem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CMR 16 . 306 .
partd . doc
TOWN OF'BARN'STABLE
LOCATION yy�--� f // SEWAGE # ra s L f►`�h
VILLAGE /l'' / t ASSESSOR'S MAP & LOT
INSTALLER'S NAME& PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Sep
aration aration Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exis
within 300 feet o leachin f cilit Feet
Furnished by �
y
d0l,�' ��
WAGE PERMIT NO.
L0 CA . 10�_ �
VILlAG
IN.STA LLER'S NAME & ADDRESS
B UKDE R OR OWNER
DATE PERMIT ISSUED ley Zc'. 72
D A T E COMPLIANCE. . ISSUED ��
r
r.
f r
`r
;� r
R'✓ �
ice._ ���t�
�wc Q�l
I�
y C s CEN TERVILL'E'
Ir-
,r O � • j' LEGEND •
k PROPOSED CONTOUR'
9® PROPOSED SPOT GRADE
EXISTING CONTOUR
+ 96.52 EXISTING SPOT GRADE r ROUTE 28
�vnN W— EXISTING WATER SERVICE
TEST PIT
�G LOCUS
�l TBM = EL. 101 .3
BULKHEAD FOUNDATION
LOCUS MAP
O S�
' LOCUS INFORMATION
PARCEL ID: M: 168 P: 113
TITLE REF: 03
�(o G.qs 101 .3 / 101 1V PROPERTY IS IN ESTUARIES PROTECTION ZONE
OIL ,06 �O � SEPTIC SYSTEM
NNNN 10 .8
a,, �•�, 22s2� �o REPAIR PLAN
NN e� oo, LOCATED AT:
ay 166 FIVE CORNERS ROAD
o
CEN TER VI LEE, MA
NN. ,� PREPARED FOR
GENERAL NOTES: ,,�' 100.2 J O H N 8c S U S A N S H A N L E Y
�.
1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL -
BOARD OF HEALTH AND THE DESIGN ENGINEER. / — insp ports
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS i� �- AUGUST 14, 2012
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE i
i
LOCAL RULES AND REGULATIONS.
3. OEI INSPECTIAGE O
N AND AND APPROVAL SYSL BY THE BOARD OF NOT BE HEALTH PRIOR AND THE `� TH-1 �� OF Mq
DESIGN ENGINEER. �� & 1 00.3 ��Q� PIP
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 1 1/ —2 DR N s
ENGINEER BEFORE CONSTRUCTION CONTINUES. �i j 1 EXISTING LEACH PIT f l_ R
5. ALL ELEVATIONS BASED ON ASSUMED DATUM. ti
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF (5ee note 1 0) O. 1140
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 1 OO 5 \ '�C/STEM
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. ✓�
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. SI� SANITAR�a� ��
8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY EXIST. 1 ,000G
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING F r
CONSTRUCTION. SEPTIC TANK D
10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE V. MEYER OC SONS, INC.
11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION
12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY
AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY P.O. B O X 981
13. NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED LEACHING
14. ALL PIPING TO BE 4" SCH 40 0 1/8"/FT (UNLESS SPEC. OTHERWISE) EAST SANDWICH, M A. 02537
15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW
FOR THE USE OF A GARBAGE GRINDER (5 0 8)3 6 2—2 9 2 2
16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING
SCALE: 1"=20'
SHEET 1 OF 2 J 1461
NOTE:'TO PREVENT BREAKOUT, THE PROPOSED
NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:97.86
` t FOR A DISTANCE OF 15' AROUND THE
_ PERIMETER OF THE S.A.S. '
SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S.
T.O.F. EL.=102.30 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER �F M9s`�9
OUTLET AND SET TO 6' OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G.
F.G. EL.=101.5f o� DARK M^ s
• �F.G. EL.=101.1 f F.G. EL: 101.1 t F.G. EL: 100.80(MAX.) , �F3 �^
C o. 1140
9" MIN COVER/
L = 15't 36" MAX COVER L = 25' L = 5'(MAX) INSTALL INSPECTION PORTS IN EACH ROW S/51 /
0 S=1% (MIN.) EL. = 99.2 ® S=i% (MIN.)' 0 S=1% (MIN.) '�41UITAR��`�
4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC J(
i
10" 14• 6" 10.75" TO
INV.=98.17 48"uOUro INVERT
�E�t INV.= 97.92
PROPOSED INV.=97.50
GAS BAFFLE D-BOX 2 TRENCHES OF 6 UNITS AT 5.00'/UNIT = 30.00'/ROW
INV.=97.67 DB-3 INV.= 97.46 SOIL ABSORPTION SYSTEM (,PROFILE)
EXISTING 1.000 GALLON SEPTIC TANK W=
RESTORE VEGETATIVE COVER
EXISTING SEWER OUTLET TO TO LL WITH -CLEAN PERC SAND
TO TOP OF CHAMBERS
60"
r
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING '`` EXISTING SUITABLE
PIPE INVERTS PRIOR TO CONSTRUCTION BREAKOUT=TOP ELEV.=97.86 MATERIAL
2) D-BOX SHALL BE SET LEVEL AND TRUE TO INV. ELEV.= 97.40
GRADE ON A MECHANICALL COMPACTED SIX BOTTOM ELEV.= 96.53
INCH CRUSHED STONE BASE, AS SPECIFIED IN 6.00
310 CMR 15.221(2) 5' MIN. ABOVE BOTTOM OF
3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK T.P. EXCAVATION OR G.W. USE 2 TRENCHES OF 6 - 16"-ARC3616 HIGH
WITH 1500 GALLON SEPTIC TANK IF FAILED, (5.87' PROVIDED) CAPACITY ADS UNITS-NO STONE
DAMAGED, NOT H2O LOADING, OR UNDERSIZED. BOTTOM OF TEST HOLE EL.=89.7 -_
4) INSTALL INLET '& OUTLET TEES W/
GAS BAFFLE AS REQUIRED
SEPTIC SYSTEM PROFILE
TYPICAL SECTION
16"
N.T.S. N.rs
DESIGN CRITERIA SOIL LOG P#:13499
NUMBER OF BEDROOMS: 2 BEDROOM DWELLING/3 EXISTING DESIGN
SOIL TEXTURAL CLASS: CLASS I DATE: DECEMBER 28, 2011 SECTION iNVERr
SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE #1614 INVENT END CAP
DESIGN PERCOLATION RATE: <2 MIN/IN WITNESS: DONALD DESMARAIS, BARNSTABLE BOH
DAILY FLOW: 330 G.P.D. Elev. TP-1 Depth Elev. TP-2 Depth
ADS - ARC 36HC CHAMBER (H20 LOAD1
DESIGN FLOW: 330 G.P.D. 100.7 0" 100.8 0" MODEL ARC 36HC
GARBAGE GRINDER: (NOT DESIGNED FOR GARBAGE GRINDER) A LOAMY SAND A LOAMY SAND
PROPOSED SEPTIC TANK: USE EXIST. 1,000 GALLON CAPACITY 1oYR 4/1 10YR 4/1 LENGTH 63" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT
100.2 B 6" 100.13 B 8" EFFECTIVE LENGTH 60 TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY
LEACHING AREA REQUIRED: (330) = 445.95 S.F.
74 LOAMY SAND LOAMY SAND DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
SIDE WALL HEIGHT 10.75"
10YR bly - 1DYR 6/4 OVERALL HEIGHT 16"
DISTRIBUTION BOX: DB-3 (H20) (3 OUTLETS (MINIMUM))I 98.52 2s" 98.47 28" 4640 TRUEMAN BLVD
OVERALL WIDTH 34.5'PRIMARY S.A.S. C C 10.7 CF HILLIARD, OH/0 4JO26
USE 2 TRENCHES OF 6 - ADS ARC36HC (H2O) UNITS WITH NO STONE MEDIUM MEDIUM CAPACITY (80.0 GAL) ADVANCED DRAINAGE SYSTEMS, INC.
SAND SAND
TRENCHES: (GENERAL USE APPROVAL FOR 7.79 SF/LF OF CHAMBER PERC O 2.5Y 6/4 ry 2.5Y 6/4 PROPOSED SEPTIC SYSTEM SITE PLAN
(CHAMBER UNITS) 12 UNITS x 5.00 LF x 7.79 SF/LF = 467.40 SF gf.•2 8970 'IN" 8980 132' 166 FIVE CORNERS ROAD, CENTERVILLE, MA
TOTAL AREA = 467.40 SF Prepared for: Shanley
PERC RATE <2 MIN/IN. (-Cl- HORIZON)
DESIGN FLOW PROVIDED: 0.74GPD/SF(467.40SF) = 345.87 GPD > 330 GPD req'd NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN DATE:
DARRENM.MEYER,R.S. 1reller & Assoc. NTS D.M.M. 08/14/12
• I, Darren M. Meyer, R.S., CSE, hereby certify that 1*am currently approved by MADEP pursuant to 310 CMR 15.017 pO BOX 981 (508) 775-0735
to conduct soil evaluations and that the above analysis has been performed by me consistent with the CHECKED SHEET N0.
requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Evol. Exam in October, 1999. EASTSANOW/CH,AfA01537
506-3612922 D.M.M. 2 of 2