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HomeMy WebLinkAbout0069 HALYARD WAY - Health �9 .1�ia. rd Way Centerville FIR 194 067 a w R 4 r v P m y UPC 12543 n10� 5�, 3LOR Maa*"Joa YN i t COMMONWEALTH OF MESA 'CHTuSETTS EXECUTIVE OFFICE OF E-NZ IRO-!\T, -T_4i.AFFAIRS .DEPARTMENT OF ENlTVIRON-MEIN-MEN T'R.OTECTIO'! TITLE 5 /qx ^ �� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SU13SLRFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 9 /Ll 7G (C4 et-01 wq Gee•, rv,' C ��ol6 Owner's Name: Owner's Address: Gt H rr.�/Jt pa�oZ Date of Inspection: g Name of Inspector- (please print) Company Name: A6; l'1 O—T E HH Mailing Address: a, /01.$� i Telephone Number(5,1-Y CERTIFICATION STATEMENT =`t I certify that I have personally inspected the sewage disposal system at this address and that the;n o ` lion re3$ited -c below is t ue,accurate and complete as of the time of the inspection.The inspection:pas pero_rmed ba ed on m �' training and experience in the proper function and maintenance of on site sewage disposal systecri ms.I a a DLPW - approved system inspector pursuant to Section 15.340 of Title 5(310 C1MR 15.000). i?ie s,sre rnz y Passes Conditionally Passes Needs Further Evaluation by the Local Appro.vin Fails Q Author.'<< /21�Inspector's Signature: p � Date: a8 0 The system inspector shall submit a copy of this inspection report to the Approving Authori:•DEP)within 30 days of co letinQ this ' Board of Health or mP J inspection.If the system is a shared system or has a design floe-of 10.000 gpd or heater,the inspector and the system owner shall submit the report to the appropriate regional o ice o=the DER The original should be sent to the system owner and copies sent to the buver,if applicable; and-�e a,_ro :n� authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at t time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 611512000 • Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM TNSPECTION FORNr PARS-A CERTIFICATION(continued) Property Address: 7 *17e4 0.,C-1 Owner: r Date of Inspection: g p Inspection Summary: Check A.B,C,D or E/ALWAYS complete all of Section D A. Sys asses: I have not found any information which indicates that any of the failure criteria described ir.310 C'v R 15.303 or in 310 C_MR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.� System Conditionally Passes: /y One or more system components as described in the"Conditional Pa:,s"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health. will pass. Answer yes;no or not determined(Y,N;ND)in the—for the following statements. If"not dete=' ed"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is s ructurall unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System tz�ll pass inspectio-n 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 Cer tifcate of Cor-ipliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to?�roken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass_nspect?on if(Cif�h approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled of replaced '_`'D explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). T1 e cvs-, pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed N'D explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSIIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INS-SPECTIO FORM PART A n � CERTIFICATION(continued) Property Address: �j / /7 A„� �✓G 01 Owner: Z�„ Date of Inspection: a g O C. Further Evaluation is Required by the Board of Health: I'" Conditions exist which require fiuther evaluation by the Board of Health in order to deter—r e i f the s,:Ten is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CA—IR 14.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the eni-ironment: Cesspool or priw is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt Lia.sh 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 Rater suppi,7. The system has a septic tank and SAS and the SAS is within 50 feet of a private water sTmplz:w-el?. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more~o-.a private water supply well`*.Method used to determine distance "This system passes if the well water analysis;performed at a DEP certffl laboratory- for col fo m bacteria and volatile organic compounds indicates that the well is free from pollution from that fac h- and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp prow ided that no caber failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNT-ARY ASSESS-TENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM LNTSPECTION FUR1I PART A CERTIFICATION(continued) Property Address: O+l c�rC G✓�v�_ Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: YesN��. o//////''' ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the round or surface waters due to an over loaded- or Clogged SAS or cesspool V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool -_ iquid depth in cesspool is less than 6"below invert or available volume is less than day-flow _ Required pumping more than 4 times in the last year 1\OT due to clogged or obstructed pipe(s). Nu ribe_ �f times pumped ` y portion_of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privv is within 100 feet of a surface water supply or tributary to a surface /7water supply. _ v portion of a cesspool or pries is within a Zone 1 of a public weL. ny 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 tom a-private.eater supply well with no acceptable water quality analysis. [This system passes if the well water analysis. performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] / (Yes/No) The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CNI M 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10.000 gpd to 15.000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Xese system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinkingRater sup ply e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IZ�—PA;cr_one II of a public water supply well =_ If you have answered"yes"to any question in Section E the system is considered a significant treat or "ves"in Section D above the large system has failed.The owner or operator of any large system.cQ,S;dere. Q significant threat under Section E or failed under Section D shall r 15.304. The system owner should contact the appropriate regional office o the De the im m a,cOc d�C e epartnienr. T;+l., c r_.. f Page 5 of I 1 OFFICL4L INSPECTION FORM—NOT FOR VOLUNTARY TARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO` FORM (PART B / CIIECELIST Property Address: / G! crc/ ( / w ✓,' Owner: J T!'ti Z C-y 1 ' Date of Inspection: ate p Check if the following have been done.You must indicate`yes"or"no"as to each of the follo-in_: Y---- 10 /Pumping information was provided by the owner;occupant or Board of Health ",,"—Were any of the system components pumped out in the previou_s.two weeks Has the system received normal flows in the previous two week period? 61 Have large volumes of water been introduced to the system recently or as part of this inspection Were as built plans of the system obtained and examined?(If they were not available note as Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out e, _ Were all system components,excluding the SAS,located on site? v — Were the septic tank manholes uncovered,opened,and the interior of the.tank inspected so_`ne condir_on of the baffles or tees, material of construction,dimensions,depth of liquid depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the-170�Der maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determ_-:ed based on: Yes o Existing information.For example,a plan at the Board of Heal`L Determined in the field(if aay of the failure criteria related to Part Cis at issue a T im -:; . ; r diz- nce is unacceptable)j310 C-MR 15.302 3 pp_axt_a`on o_ " a``' Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLVINT_ARY ASSESSMT TS SUBSURFACE SEWAGE DISPOSAL SYSTEM n- SPECTION FORM PART C SYSTEM INFORMATION Pro pertly Address: (� 9 h g ar G✓ti P .. Owner: �/ Z Z�.. ti Of Date of Inspection: 02$ p n wV CO\DITIONS RESIDEN IAL Number of bedrooms(design): Z Number ofbedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x a of bedrooms): �30 Number of current residents: / Does residence have a garbage grinder(yes or no): /vo Is laundry on a separate sewage system fives or no)-/,� Fif yes separate inspection required' Laundry system inspected(yes or no):11W Seasonal use: (yes or no): /" Water meter readings,if av ilable(last 2 years usage(gpd)): Sump pump(yes or no):_ Last date of occupancy: G k rnh'j4- CONMERCIALANDUSTRIAL Tv pe of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,ete.): Grease tiap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL n-TOR_'VTATION Pumping Records Source of information: w Muo L�— Was system pumped as part of the insl5Fction(yes or no):�G o If yes;volume pumped: gallons--How was quantity pumped determined? Reason for in : P� g TI 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) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance ce= -:�= -e^e obtained from system owner) —Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age f all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):— Taal_ c r Pace 7 of l I OFFICIAL I1\TSPECTION FORM—NOT FOR VOLLTTA RY ASSESS_IEENTS SUBSLWACE SEWAGE DISPOSAL SYSTEM T SPECTIO'\FORM PART C SYSTEM INFORMATION(contirrued) l Property Address: C 9 /�A/9 aV /4; Owner• -1-lGi ZZ&'-VZ, Date of Inspection: BLILDING SEWER(locate on site plan) Depth below grade: /� / _Materials of construction:_cast iron 4/4U PVC_other(exTlain): Distance from private water supply well or suction line: Comments(on condition of joints,venting;evidence of leakage,etc.): SEPTIC TAINK: (locate on site plan) Depth below grade: Material of construction:_vconcrete_=petal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a Copt-0 certificate) v �� Dimensions- Sludge depth: 02 Distance from top f sludge to bottom of outlet tee or baffle: Scum thickness: -eSf / <v Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottoms of outlet tee or baffle: 3 How were dimensions determined: 0'0 le R i c,e yl ee— Comments.(on pumping recommendations,inlet and tlet tee or baffle condition.structural inte Iiouid leve s as lated to outlet invert, evidence ofj ea ,ge.etc.): / [n N't J✓! 0 112p c4 o� V �� �'I/l 1✓'�O� G�+l.. /vJ Con / 'ON. /V0 QG GREASE TRAP:/—P/(Iocate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiber Class polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scam to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition.structa_al as related to outlet invert,evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNT_a.RY`ASSES SAIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM L'VSPECTION FORNT PAnT C SYSTEM INFORMATION(continued) Property Address: �-V "7& o✓C (,✓c, Owner: Date of Inspection: TIGHT or HOLDING TA1V K:/V (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass__polyethylene ozltierfexplain): Dimensions: Capacity: Qallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches,etc.): DISTRIBUTION BOX: Z/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:✓4o, "1 A—�— Comments (note if box is level and distribution to outlets equal any evidence of solids carryover: an; e-vidence of leakage ' or out of Pox. etc.) // dx i I /1/0 so f�C'f lf'b 1-2a 4Si PUMP CHAMBER:A (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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLL-FINTARY ASSESS-jIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOWNT PART C AlSYSTEM INNFORMATION(continued) Property Address: 9 A A LL GeN ram, Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: G✓ 3, S �,, s�. leaching galleries,number: l leaching trenches,number, length: �� P7 2'^cS leaching fields,number, dimensions: overflow cesspool, number: innovative/altemative system Type/name of technology: Comments(note condition of soil,s moans of hydraulic failure,,level of ponding,damp soil, condition of vegerat cn, etc.): /i - be� _ �`-eoH c-,., JAy 0 d CESSPOOLS: /lam {cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc ): PRIVY: AL/(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 ve_e-a-on, Paae 10 of I, • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE-v;[EISPECIIQ_N TCtRNf PART C SYSTEM TV-FORMATIO?v(continued; Proper-L Address: Owner: Date of Inspection: • p� SKETCH OF SEvv,AGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least t-o permanent reference land_�arks or benchmarks. Locate all u-elIs within 100 feet.Locate v.-here public water supply enters the building.. —94 -96 J . .yL m 10 �. LOT #3 ENCLOSED s DECK. z , PORCH . ! �}/ - 13 z x�� {S� f ' Aa— /6 t gy7STsN t s l z HOUSE 04 + �a as < + t Jj t \+ EXIST- 1000 + I ;j Septic Tank J gal. t i \ 215' f + i i \ Qp�T �T J 1 ` " �C \ Q, 1'ta D#3NE1yAY a�� t !'v TEST HOLE #;© s 1e. ELEV. 99.00 DcBox ;t ' 115 4" °+IC ; T� \� 45.00' n� � `�. VENT t �fr Page H of i l OFFICIAL ITNSPECTION FORM—NOT FOR VOLL'1 I AR 'ASSESSNIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM LNSPE.CTION FORM PART C n SYSTEM ENTORtiDiTION(continued) Property Address: 7 q cY (,✓��_ C L e" 1 R Oner• J hr-,ze.,/ Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells � �V 9-F Estimated depth to ground crater `T� feet � Please indicate(check)all methods used to determine the high ground Rater elevation Obtained from system design plans on record-if checked,date of design plan re�=e vved: O s ,ed site(abutting property./observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must desc e h you established the hhii�h grow d i-�t ater aellevation:/ 2 , r Gam, flOH �S! �✓ Gi G,� r S ' M ' Thomas F. Geiler,Director MASS. $ Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 09/03/04 V Designer: _Shay nvironmental Services, Inc. Installer: Robert Septic Services. Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street MA 02536 Yarmouth. MA On 9/01/04 Robert Septic Service was issued a permit to install a (date) (installer) septic system at #69 Halyard , Centerville, MA based on a design drawn by (address) Shay Enviro=* ental Services, Inc. dated 8/31/04 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation 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 any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-b b designer to follow. HOf9,4 CARMEN tiGN E. taller's Signatu e SHAY No. 1181 Sq '/TAR��� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Heat Se tic/Desi er Certification Q p gn n Form COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL P OED OD�A , FAILED INSPECTION 7AUG :004 TOWN OFSTABLEHEAPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 69 Halyard Way P Centerville fOA '^ Owner's Name: David Chace PARCEL. ' Owner's Address: 464. , LOT Date of Inspection: Name of Inspector.(please print) Wi 11 i am E_ •Robinson Sr. CompanyName: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville, MA Telephone Number:��5081 775-8776775-8776 CERTIFICATION STATEMENT i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Co ditionally Passes eeds Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: ,—Ii-'o`� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRhvr DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments 'tom ****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. �r Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIrFIGATIION:(continued) jig Property Address: 69 Halyard Way Centerville Owner. David CLace Date of Inspection: �- Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys, m Passes: 1 h ve not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments B. System nditionally Passes: One or ore system components as described in the"Conditional Pass"section need to be replaced or repaired.The s stem,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain. The s1pe(s) c tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exis substantial infiltration or exfiltration or tank failure is imminent_System will pass inspection if the existingtankreplaced with a p complying septic tank as approved by the Board of Health. •A metal setank will pass inspection if it is structural) sound not leaking and if a Certificate Y g to of Compliance indicating thhe tank is less than 20 years old is available. p ND explain: Obsetion of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed p or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of oard of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expl e system required pumping more than 4 times a year due-to broken or obstructed pipe(s).The system will pass in ection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed N xplain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: - 69 Halyard Way Centerville Owner; David Chace Date of Inspection: — ,B C. urther Evaluation is Required by the Board of Health: onditions 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. Sy em will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(b)that the cyst in is not functioning in a manner which will protect public health,safety.and the environment: esspool or privy is within 50 feet of a surface water esspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Systett will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fi inctioning in a manner that protects the public health,safety and environment: _ T1 e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surfac water supply or tributary to a surface water supply. e system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. he system has aseptic 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 front a pr ate water supply well•• Method used to determine distance •' his system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bac eria and volatile organic compounds indicates that the well is free from pollution from that facility and the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fail a criteria are triggered.A copy of the analysis must be attached to this form. 3. Ot r: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 69 Halyard Way Centerville Owner: David Chace Date of Inspection: r B D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool -Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or / cesspool S Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow �t>Required pumping more than 4 times in the last year.NOT due to clogged or obstructed pipe(s).Number of times pumped And Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00,feet of a surface water supply or tributary to a surface water supply. 1 . _ Any portion of.a cesspool or,privy is within a Zone I of a public well. _ 4,,,-_,0 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 coliform bacteria and volatile organic compounds indicates that the k•cll is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] ti 5 (Yes/No)The system fails.I have determined that one or more of.the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Larg Systems: To be con 'dered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gPd• You must. icate either"yes"or"no"to each of the following: (The follow g criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ — th system is within 200 feet of a tributary to a surface drinking water supply t e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped ne 11 of a public water supply well If you have swered"yes"to any question in Seclinn E the system is considered a significant threat,or answered "yes"in Secti n D above the large system has failed.The immer of operator of any large system considered a significant thr at under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The sy tern owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 69 Halyard Way Centerville Owner: David Chace Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health .//Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? _ , Have large volumes of water been introduced to the system recently or as part of this inspection Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _V/_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the affles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _17 Was 1 _ he facility owner(and occupants if different from owner)provided with information on the.proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes ..no 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 ClAR 15.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 69 Halyard Way Centerville Owner: David . Chace Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 " DESIGN flow based on 310 CMR 15.203 example:le: 1.10 gpd x#of bedrooms): .�G 6 ( P Number of current residents.:- Does residence have a garbs grinder(yes or no);2 0 Is laundry on a separate sewage system(yes or no*o [if yes separate inspection required] Laundry system inspected(yes or no):/LO Seasonal use:(yes or no): 9, d Water meter readings,if available(last 2 years usage(gpd)): 2003 — 93, 000 Sump pump(yes or no):,,,I, 2UU2 — 7 , 0 0 Last date of occupancy: COMM/tae L/I USTRIAL Type oshme Design ase on 310 CMR 15.203): gpd Basis o w(seats/persons/sgft,etc.): Grease ent(yes or no):_ Industria holding tank present(yes or no):Non-saaste discharged to the Title 5 system(yes or no):Water adings,if available: Last dacupancy/use: OTHEribe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of a inspection(yes or n _ If yes,volume pumped:_gallons-=How was quantity pumped determined? Reason for pumping: TYPE SYSTEM - • _ eptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: / 20,d old Were sewage odors detected when arriving at the site(yes or no): -i-C� 6 Page 7 of OFFI CIAL INSPECTIO N FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 Halyard Way Centerville Owner: David Chace Date of inspection: f —� BUILDIN/SEWE ocate on site plan) Depth beloMaterials on:_cast iron _40 PVC_other(explain):Distance frater supply well or suction line: Commentsn of joints,venting,evidence of leakage,etc.): SEPTIC TANK: V(locate on site plan) Depth below grade: 9 Material of construction: ✓concrete metal fiberglass_polyethylene _other(explain) If tank is metal list age:— Is age confirmed-by a Certificate of Compliance(yes or no):_(attach a copy of certificate) , , / Dimensions: ao 4 a S 1(i Sludge depth yam' Distance Gom top of sludge to bottom of outlet tee or baffle: _ Scum thickness:_ Distance from top of scum to top of outlet tee or baffle:,_ Distance from bottom of scum to bottom of outlet tee or baffle:,e How were dimensions determined: rg l w ��'—K Comments(on pumping recommendations,inlet and outlet tce or baffle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): y alas GR[TRA (Iocatc TRA :_(locate on site plan) Delow ade:_Maof a nstruction:_concrete metal fiberglass_polyethylene_other (ex :DiScc ess:Diom top of scum.to top of outlet tee or baffle: Difrom bottom of scum to bottom.of outlet tee or baffle: Dast pumping:Cots(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as to outlet invert,evidence of leakage,etc.): 7 Page 8ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 Halyard Way Centerville owner:--- pavid Chace Date of Inspection: TIGHT or HOLDING ANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constructio : concrete metal fiberglass__polyethylene other(explain): Dimensions: Capacity. allons Design Flow: gallons/day Alarm present(ye or no): Alarm level: Alarm in working order(yes or no): Date of last pu ing: Comments(co ition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: U� Comments(note if box is level and distributionto outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUI11P CHAMBER: ocate on site plan) Pumps in working order yes or no): Alarms in working or r(yes or no): Comments(note co ition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 Halyard Way Centerville Owner: David Chace Date of Inspection: --© SOIL ABSORPTION SYSTEM(SAS): 1/(locate on site plan,ezcavation•not required) If SAS not located explain why: Type eaching pits,number: leaching chambers,number: leaching galleries,number. leaching trenches,number,length: - leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soi,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cc spool must be pumped as part of inspection)(locate on site plan) Number and configuratio Depth—top of liquid to in t invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater in ow(yes or no): Comments note conditio n ion o soil,signs of hydraulic failure, level of :ponding,condition of vegetation,etc. g g ) PRIVY: (locate on sit plan) Materials of construction: Dimensions: Depth of solids: Comments(note conditio of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i f f 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) P Property Address: 69 Halyard Way `. Centerville Owner: David Chace Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate al wells within 100 feet.Locate where public water supply enters the building. r e L 10 Page 11 of I 1 e� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 Halyard Way Centerville Owner. David Chace Date.of Inspection: SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water JCS feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: ljecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must desc ' e how you established the hi ground water elevation: / ,, 9,5 Il TOWN OF BARNSTABLE 1*3CATION 69 4EN MW LA.-i14 SEWAGE # � VL.LAGE ��d�-( � ASSESSOR'S MAP & LOT i -- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY !F-- PGI S i-A k �S LEACHING FACILITY: (type) size) _-� -5�t%1-X �NO.OF BEDROOMS yUILDER OR OWNER C PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet" Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �v�`� y A 7 O J /� t �`�y� � �e,�Si � � _ �� � � ,. _� ���G� � � rt lG' � � � ��' �� l � a � �� No. Fee 0 THE COMMONWEALTH OF MASSACHUSETTS � Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ® ZippYication for �Digogaf *p5tem Conotruction Permit Application for a Permit to Construct( )Repair X)Upgrade( )Abandon( ) ❑Complete System Individual Components Location Address or Lot No. (,Oq tAQr Z Wc� Owner's Name,Address and Tel.No. C��% I cwR Assessor's Map/Parcel i 9 y 6 Installer's Name,Address,and Tel.No. C SVC• Designer's Name,Address and Tel.No. u �� � Sv�S ��Ig-a9b Type of Building: Dwelling No.of Bedrooms 43 Lot Size a3 sq.ft. Garbage Grin er(A04,- Other Type of Building !nn�2 No.of Persons Showers( ) Cafeteria( Other Fixtures t Cam-1L�—\--- ki" &Q4\. 16 Design Flow gallons per day. Calculated daily flow_�?)1.C5 gallons. Plan Date /1)!J� Number of sheets Revision Date Title ti� t Size of Septic Tank Qt)Qs i�5-� Type of S.A.S. vt � � el �'S Description of Soil V p Nature of Repairs or Alterations(Answer when applicable) _ PAC,. 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 Certifi- cate of Compliance een issued by foa�_�rdofh. Signe Date G/ Application Approved by Date Application Disapproved or the following reas Permit No. r Date Issued 01 .:.`-a^- .....may,,.,;. _�;�.y� ^.. _ �. w _^ .. : .- y-..:✓:. r+..;.;.,;,.�+;d:.��M.�V-•' t-. h.....�a.-r_ :+.4.-<.'....::..r. ,h r.w+'".y,d••. - -��yl�r-•.+,+`._ .[1.91C."r .rx No. r m o b Fee P THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE., MASSACHUSETTS' Yes 01 � Yic-atio.n for dig ogar * gtem ctCongtruction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System> Individual Components Location Address or Lot No. tAQ` ©f Wo- Owner's Name,Address and Tel.No. Assessor's Map/Parcel ,nM Installers Name,Address,and Tel.No._t t7�V , � C SJt• Desi ner's Name, ddress and Tel. o. S I ic,� ll��l nJl�nrr l SvCS yg-4)--qt ycCl`no13'�N�Mf1 (�yg_5310 �X �• �"c 09s31- . . Type of Building:,'2• „�., ' q Dwelling `+ ..No.of Bedrooms � Lot Size o�3 � I sq.ft. Garbage Grinder Other Type of Building . /Q— No. of Persons Showers( � Cafeteria �- OtherFixtureg� cGoaA<DvA k-+ (_� sit�k Design Flow 3?�o gallons per day. Calcu�ateddaily flow ` �JJI S gallons, Plan Date �. I1)Y _.Numb`er�off sheets Revision Date "'- Title aeG� S C 5nS'Yf10 l,)��_ f Size of Septic Tank ` 1 i 00D ;C,\ 5XtS+- Type of S.A.S. C he M�QrS Description of Soil Nature of Repairs or Altefations(Answer when applicable) ` Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance-w-ith the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has-b-6en tssueft thisfBoar`dof-He �thM Signe ' Date t�f' ll Application Approved by 62B Date x" Application Disapproved for the following reasp JI Permit No. Date Issued i r ` _ t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Comptiance THIS IS TO CERTLF—Y, that the On s�q Sewage Disposal System Constructed ( ) Repaired ( )Upgraded(X ) Abandoned )byCsC'�tS C at \Np h b-6 constructed in accordance with the provis�ons of Title 5 and the for Disposal System Construction Permit No ' dated Installer � �' S t 'F�c Designer v� tti-o�, o The issuance of this-n e t al t be construed as a guarantee that e sys e i�uno as designed. Date //t��� inspector _ F No. i{4----- --.----,---- --------Feet/ ✓r i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogal *pgtem Congtruction Per M- tt Permission is hereby granted to Cons uct( )RgPair( )Upgrade. )Ab=n_don( ) System located at (D9 Ho, .1CCCGN @� ?1`� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Con%ru clI�ion nws/be c mpleted within three years of the date of this '/rmi . Date: ! 11/'�T- A rovedb � 1 - � PP Y 1 1. E tNE Town of Barnstable T (� °'rtio Regulatory Services ( _o Thomas F. Geiler, Director * snaxsznsLE, S, Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644' Fax: 508-790-6304 Installer& Designer Certification Form Date: 09/03/04 V v - Designer: Shav Environmental Services, Inc. Installer: Robert Septic Services. Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street MA 02536 Yarmouth, MA On 9/01/04 Robert Septic Service was issued a permit to install a (date) (installer) septic system at #69 Halyard , Centerville, MA based on a design drawn by (address) Shay Environmental Services, Inc. dated 8/31/04 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation 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 any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-b b designer to follow. OF Q0 CARMEN o E ( staller's Signatu e No.SHAY 1181 �FG/ST` 1�Q / SgN17AR��a (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form .r `,�r0 s Fps.. ...... THE COMMONWEALTH� O C ,OFMA�S^CHU u TS ALTH ..................... . ......... OF..... Appliration for Disposal Works Tonstrurtinn thrutit Application is hereby made for a Permit to Construct ( or ,Repair ( ) an Individual Sewage Disposal at Syst 4� .. - -------------------------------- . ... . --- ._ ... . L..... dress o t o Ow dr •....._..._ ... ....................... .......... dA . ... ►Wa — Installer Address � QQ Type of Building Size Lot e?Z-- a ---. ...... _Sq. feet Dwelling—No. of Bedrooms............ ..........................Expansion Attic Garbage Grinder W aOther—Type of Building ............................ No. of persons......._.................... Showers ( ) — Cafeteria ( ) P4 Other fixtures .......................................... W Design Flow............ .....10................_._gallons per person per day. Total daily flow_-'. .......................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width--------.----------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing t�j k '-' Percolation Test Results Performed by..__� � ...._.... 1st �<<��. . --------)�� Date aTest Pit No. I................minutes per inch Depth of Test Pit.................... pth to ground water---__-_----______--_-_. Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix ---- •• ............................. ....... .........-- . ..................................................................... Description of Soil----. ----- °� • ---- -- ---------------------•----------------------------------------- W ------------------------------------------------------------------------------------ •-----------------------------------------------------------•---------------------------------------•--•-.------ VNature of Repairs or Alterations—Answer when applicable-------......................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITi U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Co liance has bee 'sued by the board of h . of Signed -- -- -------- -�...................� Application Approved B . --.��. ....... •-•---•- -- ----- ------- •------( =�} PP PP Y---•---•-------- Date Application Disapproved for the f 11 wing reasons-----------------------------•-•-----------------------------------------------------------......----------•-••- .................................................................----•--••-----------............-•---'---------------------••--•---------•-•-••----•-.........................._.Date------•---•-.. PermitNo......................................................... Issued....................................................... Date ~ d No............:'._..:✓ i THE COMMONWEALTH OF MASSACHUSETTS r. BOARD OF HEALTH /5/ ..........OF.... .//r ./ .���rfirtt�io�c fur :����u�tt1 larks C�on��rnr�ion �eruti� Application is hereby made for a Permit to Construct (41 or Repair ( ) an Individual Sewage Disposal System at Ci <�,�,:�.-c .c ........... ----....-.....,1.. - - --- -------------------- ------ ---•-- ----------------.....----------•- /(/ Locatio - .ddress c/'{,� /y ,;,!��,� /J ..... !/37z.d�cJ /F f /!fr!-r_? . -- %�+L1 f•--i f�'!.:: .............................. -.-. .---.._"......,..............p. ___.._..___.._ "- ... ' Owner _.._..--••-•--...................... . ' � .� s n, .................................. Installer Address � /J Type of Building Size Love-_`1!?2�:_Z....Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic 4A Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers (" ) — Cafeteria ( ) P4Other fixtures --------------•--------------------•------------------'----------------------------------------•- W Design Flow............1 �_)..•.................gallons per person per day. Total daily flow----013., WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter-----........... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing ~' Percolation Test Results Performed by--- „�*��� ���`~ 4`� Date ` ... Test Pit No. 1................minutes per inch Depth of Test Pit----------- --------- Depth to ground water........................ 4� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Descriptionof Soil_. ...................................................................... f �- ,re,— W UNature of Repairs or Alterations—Answer when applicable..............................................•.._.........................._..._.............. . ---••---•.....--•--.....--•-•----...•-•------•-•-•----••-----•----•••-------•-•-•---•--•-••--•-------------•---..._....---•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Co pliance has been issued by the board of health. Signed ` 1✓v�t d_ ` `pM= 1'f -- _ . k. Y... Date Application Approved BY - ------------- --------- } Date Application Disapproved for the of wing reasons---------------------•------•----------------------------------•---------------------------------------....-- ----------•-••------------------•---------'--...........................•---------...------------•-•---......--------• ......--...--- Datr PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f _ ...........O F..e,.?X<' fi' __ t. r.t . , ............................ 01rdifirat e of Totnpfiatta TH S TO.CERTIFY, That the Individual Sewage Disposal System constructed ( Or Repaired ( ) by. l . .-> =. .--..:..... Installer ------ ------•••••- has been installed in accordance the provisions of�TiITLE 5 of The State Sanitary Code as described in the -application for Disposal Works Construction Permit No......................................... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNrtTION SATISFACTORY. DATE........................ t� gs.....----•-•------•------------ Inspector.......... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.. ✓.�. .�a ........................................OF.... s;C. ".!- ? ............. FEE........................ �i��rg��� ork� �on�#rion rrtni# Permissionis,hereby granted......I.........-.............................................................................................................................. to Construct,,( _gpRgpair ( an.Individual Sewage Disposal Sy4em at No... ......... /?�f�/_.t f JStreet t as shown on the application for Disposal` 7orks Construction Permit No.......`...'....a Dated..... 1$ o�d of Health DATE------..••--- .L_q..._•.2 'S FORM 1295 A. M. SU IN, IN:_ BOSTON 74 Z3 �00.00 \ ; ,PA ;��QW _ //.D'X,3 3.30 G.PO. �p Z ifo s. 'X.za _ ,3� G.00, cd M rt. aj; .fo 's.� ;fir /a . : = so, G:•no. ToT.4L.' .4/L}!FL4!:"W= .33QG.Po 3/ Fouoar cs� RICHARO ate\,; PETER lot i K A: SULLIVAN !. ��,.'t N ►�i t � o BAXTER; v, No.24048O ��S �ty0� Ado •p`��ls �a�� ` ,F pq vE �. t 1 �/ ._.. \ 4v.00hu VA AL�A <03 jz (Lo IJ fr f-�•FcQ�•°Bq�tL�TL�F Nt�Er,-�a'�, _ C1 '1/ 6. /06. �.. �• ate' Box /.v . GAL. To Al C[ M y, N/As y /it/✓. . /Nr/. E v �i�tltt •; .Si��vE lol},Z. /c¢,: G'E.2T/F/EO PLOT ,oL4N �•� c �•�.6LLoG.�Tioy CC-`�J7Z7-vi L- c` Go , O.4TE M, /qy ZZ, i9gS PAN 14' (2.qt' Z07" 30 GE2r/may 7//.QT THE r7o LI vb4 7iOV Sl-lewAl /C4�lJ /3vo 3 j'' l��GC 70 �/E�Ea v GOMPGY�S Imo//T.�►�.T E,S/l���NE i B,4X7Z:_01 A/yE 1,Ve. A�Sv�.fFT'�/�G•� .2EQlJ%�E�I�NTS.o� Th'� ,e,E6isrE.2c=.D.G4rvo.Sli.2�Eya,2s ToW.y of. $i4N "� t�w� is iVOr" - L oC.arE.v lt//T.S�/y_ .UE_ L aooPL4�iti. k� 47—,I MG ' 6 :Tyls�!,el/ /.s iVoT a-4fEO Gov,4N/iY_ST,2— �/!r'1E�YT.Sv,2l/EYsl�t/O 43; S�oew-,4 ot/aT ICE USEp 23, �J2� Sr L,o 3l ���t►�.� ���Lam_.�.C_ _r� . ��... ,-r-�t� v Ad y � N 5 T�MC `a SULUVAN �f.. No. 29733 �r.c7F'c c ✓ ,F 1. ''? ✓mi C�..\.:y ,. . /y Town of Barnstable OptHE Tp�, Regulatory Services �Thomas F. Geiler,Director O M • anruvsrnai.e. * l J 9� MASS. Public Health Division �FD1A°'�p Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 09/03/04 v - Designer: _Shay Environmental Services, Inc. Installer: Robert Septic Services. Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street MA 02536 Yarmouth, MA On 9/01/04 Robert Septic Service was issued a permit to install a (date) (installer) septic system at #69 Halyard , Centerville, MA based on a design drawn by (address) Shay Environmental Services, Inc. dated 8/31/04 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation 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 any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-bufll b designer to follow. �H of M,4s sac a� CARMEN y�N o� E. ( staller's Signa e SHAY C No. 1181 I S T c N'�O SgNITAO' (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form LOL- 0 7- 3U HALYAllp �4yE AGE PERMIT NO. VILLAGE ` CA-` /ZVIG i- I I N S T A TIERS NAME i ADDRESS S U I L D E R 0 OWNER DATE PERMIT ISSUED :. DAT E COMPLIANCE ISSUED � ����� � u � � �y�, 0 ��` � Y VENT PIPE (O Least 24 inches tall) SECTION A -A 10' min. from ;NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. Schedule 40 PVC w/Chorcool Odor Filter ALL OUTLET PIPES FROM THE Existing Foundation house to septic tank PROFILE VIEW OF LEACHING SYSTEM DISTRIBUsETroR��TiEA�sTBz F7 12• CONCRETE COVER i TOP OF FOUNDATION = ELEV. 100.00 (Assumed) c Septic tl in 6 i� osiet�ed rode ode over SAS - ELEV- 99.00-usl be ' -,r - 1- o�. 1 9 Grade over Septk Tank - 99.00 Grade over D-Box - 99.00 /�-(� 1 3 - 5'OUTLET `•••f_'. N r/f-_ r/7- .Wrl Pwdne / \- KNOCKOUTS 3 J +•- r e 5.5' .,..,,_,..,._..,- i OUTLET Tlox- S 0.02 11 3 HOLE H-20 ` DIST. BOX 3' Maximum Cover Top of SAS -Elev.=95.75 14' EXISTING S-0.01 or Greater S• 0.010' Per foot ♦ •� -�• Y 4�a w 1 ��!Ma1rMiVft y ►fv PIPE -` 1,000 GAL + o C3 to 0 0 C3 0 "+ yt +/ x FROM Exist FOUNDATION w X 'SEPTIC TANK 8 �� a o Eneatw. to d o d o 0 0 0 4" - SCH. 40 T 1as'. 4 +; '�. , a � y s' ;': h 20 DeP Q O O f A k r• p W owe N _ PLAN SECTION CROSS--SECTION .� f � .� �, - / o 0 2UnitsQ85' - 1T CONCRETE ttIL1 FOl1NUATITTDDDNNN--_J!! n H-10 II N rn �� .:W.. y o o+ 3.5+- 5--- -3.5' 4 ✓" &r °ba,: t Ott, *�:i SYSTEM PROFILE B h-of 3/4--1 1/r z5' 3 HOLE H-20 DISTRIBUTION BOX a \ IL > compacted stone m y 12 Effective Le th .... ;:.., c - Effective Vidth Not to Scale c > NOT TO SCALE > > > o 2dW Rand MNgaYy l Carnparty®Ml14 SOIL ABSORPTION SYSTEM (SAS) 6 In.of 3 4'-1 1 2' 0 500 - C H-.10 ;LEACHING UNIT / WI N compacted .:«,a ! m ' s GGI s PRECAST GENERAL NOTES NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE Bottom of Test Hole 1 Elev.- 87.00 Not to Scale 1. Contractor is responsible for Digsafe notification and protection of all underground utilities and pipes. v Obs. Groundwater Test Hole 1 Elev.= NONE OBSERVED P r9 P P 2. The septic tank and distribution box shall be set level on 6" of 3/4"-1 1/2" stone. 3. Backfill should be clean sand or gravel with no stones over 3 in size. Design Calculations 4. This system is subject to inspection during installation r by Carmen E. Shay ;- Environmental Services, Inc. Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) i 5. The contractor shall install this system in accordance T Garbage Grinder. No 66 i with Title V of the Massachusetts state code, the approved plan , PERCOLATION ES Leaching Capacity Proposed: 330 Gal./Day Minimum (Min.' Per Title V) t and Local Regulations. Septic Tank - 2 x 330 Gal./Day = 660 USE EXIST. 1,000 GAL. Septic Tank. / Date of Percolation Test: AUGUST 30, 2004 6. If, during installation the contractor encounters any SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch / soil conditions or site conditions that are different Test Performed By. CARMEN E. SHAY, R.S., C.S.E. Bottom Area 0.74 al s ft. x 300s ft. = 222.00 gallons � 66 Results Witnessed By WAIVER (per Barnstable B.O.H.) 9 / 4 q• 9 O� f1J� from those shown on the soil log or in our design Sidewall. Area: 0.74 gal./sq. ft. x 148 sq. ft. = 109.5L1 gallons 00• installation must halt & immediate notification be SHAY ENVIRONMENTAL SERVICES, INC. Providing: = 331.50 gallons ZC i made to Carmen E. Shay,- Environmental Services, Inc. Percolation Rote: Less Than 2 MPI 0 40" Assumed - / EC�R Use: (2) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE DEPTH, cOMM C��. 68 7. No vehicle or heavy machinery shall drive over the �' septic system unless noted as H-20 septic components. TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES AND / 70 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. 4' OF WASHED STONE ON THE ENDS. / 9. All Distribution Lines shall be 4` diameter Schedule 40 NSF PVC pipes. Test Hole ��/ '� / 10. All solid piping, tees`& fittings shall be 4" diameter No. 1 J ' / �� Schedule 40 NSF PVC pipes with water tight joints. DEPTH SOILS ELEV. r �� / 72 11. Municipal Water is Connected to ALL OF The Residence and Abutting 0 99.00 l �\ /�/� �// /�i' ,y74 Sandy ) / ��-76 Properties Within 150 Feet. Loam, THE PROPERTY LINES ARE APPROXIMATE AND 10 Y 3/2 �' / ��� � � �--78 COMPILED FROM THE SURVEY PLAN GENERATED BY 0"-8" A 98.25 �� ,/ r ' BAXTER & NYE OF OSTERVILLE, MA 7. Sandy LOT #30 /' �' ENTITLED "CERTIFIED PLOT PLAN OF LOT # 30 HALYARD WAY Loam �.' /�. � ��� �/ �p BARNSTAVLE, ,MA", DATED AUGUST' 16, 1989, 10 YR 5/8 23,929 Square Feet +/- J,���/ "��' /��' & THE DEED DESCRIPTION ( BOOK 11859 PAGE '113) Be sss7 '// �'� ,.82 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN e ,r/ /, �,/ , i/' THE SEPTIC SYSTEM INSTALLATION. Sand �.�' .'�i� � �� ' 2.5 Y a/e /�. / _ ---84 EXISTING LEACH PIT'TO BE PUMPED OUT AND 42"--144 C, 87.0o REMOVED TO FACILITATENEW E SEPTIC SYSTEM INSTALLATION i NOTE: ANY STRIPPED OUT N E SOIL CONTAINING LEACHATE 8 FROM THE EXISTING LEACH PIT TO BE DISPOSED / --go OF AS PER BOARD OF HEALTH SPECIFICATIONS 0 ETLA DS RE RESENT WITHIN,.200 OF THE PROPERTY >- -, I II 7 ASSESSORS MAP 194 PARCEL 067 i I / 9 7z'' i LEG EN D i � y Perc #1 PROJECT BENCH MARK ' Depth to Perc: 40" to 58" TOP OF FOUNDATION 74 �/ . , / //' DENOTES PROPOSED i, Perc Rate- Less Than 2 MPS ELEV. 100.00 (Assumed) ,/i 104X1 Groundwater Not Observed 8 SPOT GRADE No Observed H2OSElev. None 40 78 / ��/HWT DENOTES EXISTING x 104.46 a 0 20 50 ,, r 100 SPOT GRADE 80 82 / r' LOT #31 PL PROPERTY LINE // / / SCALE: 1 '+=20' 4-� 96r PROPOSED CONTOUR 8 ��' / / i' ENCLOSED 86 / /� ,� �'� 'PORCH DECK ^_��- rr EXISTING CONTOUR 2-18' DIAM. ACCESS MANHOLES / I / i i 1 1 •" DEEP TEST HOLE & B LOT #�29 EXISTING I PERCOLATION TEST LOCATION �� _;-= -_ �'�• ' • i 1 3 BEDROOM 4 - M 6 FOOT STOCKADE FENCE I HOUSE CE4 \\ #69 f INLET OU ET 1 1 1 1, CO) P LOT P LAN THE ACCESS COVERS FOR THE SEPTIC TANK. 1 1 . - DISTRIBUTION BOX AND LEACHING COMPONENT 1 1 I 1 1 \ EXIST. 1000 gal. \ • „ ,n -. SET DEEPER THAN 6 INCHES BELOW FINISHED I 1 1 \ l "• �`• GRADE SHALL BE RAISED TO WITHIN 8' OF 0 F PROPOSED SEPTIC SYSTEM UPGRADE FINISHED GRADE. � z 1 � \ Septic Tank STEEL REINFORCED PRECAST CONCRETE I 1 1 l J INSTALL TUF-TITE GAS BAFFLES OR EQUALS J 1 1 1 \ PLAN VIEW I , 1 11 \ O ,\ PREPARED FOR 3-24'REMOVABLE COVERS 1 v fI I / 1`\ A'`P 11 IbALT \\ � Leach o, M R . D AV I D CHASE. 4• li �\ DRIVEWAY n°�� I T�~ �� _ 3,min. clearance / y\ f \ \\ I t #69 AT INLET 1 2'mF. Inlet to outlet 72rf"rTn.,- �j DYmin. 6' . Ir 5!+• (\ \ �\ x I ouTLET : �, \ � °' � I p � , HALYARD WA - Ir j" •� - \ 1. I s� O # C ENTERVI LLE, MA 5 -r - 5`-r r gg.1 I I EST HOLE 1 E Liquid '-0 min. I L \ x\ ��\ L: . I ELEV. 99.00 r 9 - � � � depth �t - `� D�-Box X PREPARED BY: �• .-- .- f2' 4 10' CAR1I� EX E. SHA Y a-o- - I � \ � � 4` PVC A M k CROSS SECTION END-SECTION 45.00' ���� s' VENT H rNvrlrONMENTAL SERVICES, INC. A L YARD T�JiTA y P.O. BOX 627 TYPICAL 1000 GALLON SEPTIC TANK 9 �F �° EAST FALMOUTH MA 02536 C/STEM + NOT TO SCALE (40 FOOT RIGHT OF WAY) 6' 4NITAF\P' TEL/FAX 508=548-0796 SCALE: 1 "=20' DRAWN BY: CES DATE:- AUGUST 31 , `2004 f PROJECT#SD623 FILENAME: SD623PP.DWG SHEET 1 OF 1 DATA Large Format Box # Doc # � Image