HomeMy WebLinkAbout0061 HARRISON ROAD - Health 61 Harrison Road
Centerville F/R
A = 229 080
No. 42101/3 ®RA
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION a
a dRECEIVED
t
FAILED INSPECTION APR 15 2003
BARNSTABLE
TITLE 5 TO,NHE�ALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 61 HARRISON RD CENTERVILLE 02632
Owner's Name: CLAIRE DPWILD
Owner's Address: 32 CRbCKER ST CENTERVILLE MA.02632 " "I
Date of Inspection: 3/19/03
Name of Inspector: (please print) JOHN GRACI,INC. �� Q
Company Name: SEPTIC INSPECTIONS
P Y
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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
_ Conditiona Passes
_ Needs Fu r Evaluation by the Local Approving Authority
X Fails
Inspector's Signature: Date: 3/19/03
The system inspector shall submit fcopy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If the system is a shared system or has a design now 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
THE SYSTEM FAILS TITLE V INSPECTION.THE SYSTEM CONSISTS OF SINGLE CESSPOOL AND SINGLE
CESSPOOLS DO NOT MEET TOWN OF BARNSTABLE'S TITLE V REQUIREMENTS
****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.
L11 cYlnnn 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 61 HARRISON RD CENTERVILLE 02632
Owner: CLAIRE DEWILD
Date of Inspection: 3/19/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
THE SYSTEM FAILS TITLE V INSPECTION.THE SYSTEM CONSISTS OF SINGLE CESSPOOL AND SINGLE
CESSPOOLS DO NOT MEET TOWN OF BARNSTABLE'S TITLE V REQUIREMENTS
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.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
I
Page 3 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 61 HARRISON RD CENTERVILLE 02632
Owner: CLAIRE DEWILD
Date of Inspection: 3/19/03
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well".Method used to determine distance n/a
"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.
3. Other:
n/a
Page 4 of 11
.j
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 61 HARRISON RD CENTERVILLE 02632
Owner: CLAIRE DEWILD
Date of Inspection: 3/19/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped 4 YRS AGO INFO FROM OWNER.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 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 (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. 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)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 61 HARRISON RD CENTERVILLE 02632
Owner: CLAIRE DEWILD
Date of Inspection: 3/19/03
Check if the following have been done.You must indicate"yes"or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components, excluding the SAS, located on site
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information.For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(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: 61 HARRISON RD CENTERVILLE 02632
Owner: CLAIRE DEWILD
Date of Inspection: 3/19/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 0 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):220
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no):NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): hh
Sump pump(yes or no): NO V 0��0 13
Last date of occupancy: n/a V ` - �� l —
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a _
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: 4 YRS AGO INFO FROM OWNER
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
_Septic tank,distribution box, soil absorption system
X 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): n/a
Approximate age of all components, date installed(if known)and source of information:
1957 INFO FROM OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
F
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 HARRISON RD CENTERVILLE 02632
Owner: CLAIRE DEWILD
Date of Inspection: 3/19/03
BUILDING SEWER(locate on site plan)
Depth below grade: 48"
Materials of construction:_cast iron =40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: (locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: n/a
Sludge depth: n/a
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage, etc.):
n/a
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle:n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
Page 8 of 11
,4.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 HARRISON RD CENTERVILLE 02632
Owner: CLAIRE DEWILD
Date of Inspection: 3/19/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
NONE
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 HARRISON RD CENTERVILLE 02632
Owner: CLAIRE DEWILD
Date of Inspection: 3/19/03
SOIL ABSORPTION SYSTEM(SAS): _ (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
n/a
CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 1
Depth—top of liquid to inlet invert:24"
Depth of solids layer: 2"
Depth of scum layer: 3"
Dimensions of cesspool: 6' X6"'
Materials of construction: BLOCK
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
CESSPOOL DOES NOT MEET TOWN REQUIREMENTS.SYSTEM NEEDS TO BE UPGRADED.
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.):
n/a
4
Page 10 of 11
.c
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 HARRISON RD CENTERVILLE 02632
Owner: CLAIRE DEWILD
Date of Inspection: 3/19/03
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 all wells within 100 feet. Locate where public water supply enters the building.
in
Page I I of 1 I
e�
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 HARRISON RD CENTERVILLE 02632
Owner: CLAIRE DEWILD
Date of Inspection: 3/19/03
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from systetfi design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER WAS DETERMINED BY VISUAL AND USGS MAPS AND CHARTS- 12+FT
TO OF BARNSTABLE
LOCATION (Q1 �SIT�� SEWAGE# I�3
VILLAGE �`�°t` �1`e ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY .
LEACHING FACILITY: (type) 5�S `aG'L' (size)
3 D�t
NO.OF BEDROOMS
BUILDER OR OWNER Li Lr-
PERMITDATE: _-j1�- COMPLIANCE DATE: ��I
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished.by
f
I-Y t
Not ,T ti _l FEE
Board of Health, C�S�('Q�� MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair( Upgrade
Abandon( ) -,XComplete System ❑Individual Components
Location 7s ors Owner's Name v IC/()%r
Uw
Map/Parcel# a Q Address
Lot# 4B Telephone#
Installer's Name ' C Designer's Name .
Address Address rl,�
Telephone# Telephone#
Type of Building `d O) Lot Size 1'2 y 640 sq.ft.
Dwelling-No.of Bedrooms -� 3 dui (7 Garbage grinder
� (�
Other-Type of Building ,aC%Q_ No.of persons Showers (✓/) Cafeteria
Other Fixtures A- MG
Design Flow(min.required) `���_gq Calculated design flow r*J.�0_ De ' n flow provided 3 � gpd
Plan: Date D*.) Number of sheets 1 Revision Date
Title SAAS)f U1
Description of Soil(s)
Soil Evaluator Form No. �' Name of Soil Evaluator OLTYIQ Date of Evaluation 1 T
DESCRIPTION OF REPAIRS OR ALTERATIONS
The dersigned agrees to install the above described Individual Sewage DT,7�i.ce
alSystem in accordance with ther�rovis [i and
further ee of to plac a tem m ration until a Certificate o ONIZI;Iffig . ITIN6
Signed Date STALLATION AND CERTIFY ITING
40 THE SYSTEM WAS INSTALLED IN STRICT
j
Inspections ACCORDA"CE TO PLAN.
.! . �. ..�. ... _. ... -y`.-` •� `4'•. �1..Y�.',ti" �^(�^^'.•Y Y��`'.vYt^rvrlrv'�`"'rrv,'."Yg.�4'.«c�-`.N'`"+�+"'.•..^.+�.,-,r,..l..f•.,r.^rr... ." - �.. , ,'F . ....�. -
ft
No. 'z• U 8 � ?la. ''i. ` FEE
Board of Health,
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
1
'��-�•`Application for a Permit too Construct( ) Repair( ) Upgrade Abandon( ) Complete System ❑Individual Components
Owner's �
}
C
Location � , O ' Name �^\SCN� � • 1 >J�\`P `;1� �._ ' r2 Map/Parcel# d �?Q Address au-r<
Lot# 11P ` Telephone#
Installer's Name 1 Designer's Name�� � \ �-C, J(.S
Address T� �9�• •\ ria Address'--B,,, L.? � (��C�l)� r•b,
Telephone# �y `� Telephone# }}
Type of Building `a\�\�C1�U` / Lot Size 1.2, 640 sq.ft.
. Dwelling-No.of Bedrooms �p l Z 1 �')C 1 SA l 1C,O� Garbage grinder"(
!/ �� Showers (�
Other-Type of Building a('1Q- No.of persons ) Cafeteria LV
- -Other Fixtures LC- C), � C�2n \C11C
Design Flow (min.required) gp Calculated design flow De 'gn flow provided J l gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator \ C [\ Date of Evaluation 71 7�
DESCRIPTION OF REPAIRS OR ALTERATIONS -Ka\sex E" CZ4,m C"� n
� F
The r deriigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fur ees, of to plac a system m Aeration until a Certificate ofCom Hance has been issued by the Board of Health: f
Signed 'I Date -
Inspections
II
No. DOU3- 30s ¶' FEE S�
Board of Health, L./1G1A.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑Individual Component(s) Q/
aa``Complete System
f The and si ned er cer ' that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded (Abandoned ( )
by:
at -* (01KW Ur1 )
has been ifstalledin accordance with the pro psions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicatio o. vU 3 3PA , dat J) . Approved Design Flow (gpd)
IV Algh�Installer �_ / 07
Designer: Inspector: Date: L �/
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. U 0 3 " ✓�(� FEE
Board of Health, ' Y tq l� , ALA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission P
hereby granted ; Con truct� ) epair� Upgrade" ) Abandon( ) an indi-,ddual sewage disposal system
at 1 1 1�• V [ as described in the application for
Disposal System Construction Permit No. ;tU 0 3-34f , dated /( U
,l
Provided: Construction shall be completed within three years of the date of this per,,it. All l cal conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health
TO OF BARNSTABLE
LOCATION (at SEWAGE # 3
. VILLAGE ��° �1�e ASSESSOR'S MAP&LOT Eel— Q`?Q
j INSTALLER'S NAME&PHONE NO,
SEPTIC TANK CAPACITY /502 1/20 t t�
LEACHING FACILITY: (type) '�.5 °�' (size) �� �-t .(o r
NO.OF BEDROOMS
i BUILDER OR OWNER
� 7
PERMTTDATE: COMPLIANCE DATE: '
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
I
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
I
f/
�311
r
All �`
CARMEN E. SHAY (508)-548-0796
ENVIRONMENTAL SERVICES, INC. P.O. Box 627,East Falmouth,MA 02536
August 13, 2003
RE: Certification of Title V Septic System Installation:
Residential Property 61 Harrison Road, Centerville, MA
Dear Sir or Madam:
On August 8, 2003, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at 61
Harrison Road, Osterville, MA, based on a design drawn by Shay Environmental Services on August 6,
2003.
XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan
I Certify That the Referenced Above Septic System Was Installed With Changes but in
Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow.
The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is
Required.
If you have any questions, please do not hesitate to call the undersigned at (508)-548-0796.
Sincerely,
CARMEN E. SHAY
ENVIRONMENTAL SERVICES,INC.
OF ktq
o� CARMEN yam
E.
0 SHAY N
No!1181
C n E. Shay, R.S., C. o
President �a13TIfE
SgNITAIV
-Sep - 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 N • v�
:NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION
FORM
6'p_*-Ar,*1 A4,gY hereby certify that the engineered pian signet by me
Claret to 221, concerning the property located at
all of the
i;I'ow;ng c:.n(ena.
• This failed system is connected to a residential dwelling only. There are no
_orrvnercia.1 or business uses associated with the dwelling.
• Tie soil is ciass!,.ed as CLASS I and the percolation rase is less than or equai to
-ri:nxes per.:nch. The applicant may use historical data to conclude th,s fsc: or may
.or:duc( )re!tm.jnary tests ac the site without a health agent present
• 'here :s no incre:,;e in flow and/or change. In use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than fourteen
a9ove the maximum adjusted groundwater table elevation. (Adiusc :he
.'%ri(!,Yater cable using the Frimptor method when applicable)
Please complete the following:
Ground SUrlace Elevation (using GIS information) _ 4 4. Oo
5' G.W E!cvat:on :d;uscment for ',nigh G.W.._-_... -
�'FT=F REM7 8 ETWEEN and B 20 .to
S:ci'dE D —_ D ATE: �—�-a
NOTICE
3asec ,-on, t^e allo4e information, a repair perrrut wil! be issued for ')edr^ems
TLV I r.urn `:r )ddiw: nal bedrooms are authorized to t`te future withoue ,naincerec
ep,, _�aem plans
)cam!r,:0u �ucc.tmp
0
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: La C'>[r'�Sd1 �I Con Aav1\W— Lot No.
Owner: t Address:
Contractor: atau %,c7Dc,) ddress: 1�2-7r .
Notes:
STEP 1 Measure depth to water table
tonearest 1/10 ft. .............................................................................. .Date S ,
month day year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well....................................................
OWater-level range zone ..................................................... -�
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ........................... 3 �Q•�
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment ........................................................................................... Z'
STEP 5 Estimate depth to high water
by subtracting the water,
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) ...............................................
...;....................,...................,.
f;
Figure 13.—Reproducible computation form.
15
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AL titan PM FM 7 W , .• I-OOTE: ALL PIPES ARE TO BE 4,. HEDULE 40 P.V.G.P Y.C. _` 0 NW ,gvm ",1 _ 2,[-iD min. PROPIL VIEW OF�LBACHING SYSTRr SET LVAL MR AT LAST2FT. .. r 0040"CMI 4 0ho,so to tic tonk 1*' %Exist Foundaton s1 I
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greft , KNOCUM �SAS- ELE%.21,50
Gro b o Sp Tort 90110 ow 0-9=4ftm _ 1 1, 91�11r _,#/**WON&W J �
' . ,, - .I ft &S V)
1 a o b
GUILET 4 15 1 # - e _
'0 �02 i3 H H-10S-Ml n . -.
_ ;:OW.Box ,`�. "� r Ud*mm Cover L.�" , ' 0
-, 1 .1 11OR GRtA 1V
21 NEW I t-om r � ff� -I 4IGO Toof SAS 00v.-95 - .� 4 . 40 T 7. .SEI W PPE p - - SC IS., � 1.500 CAL CnMaUNDATMJ0 , � � P4
.SEPTIC TANkk an .0
4 PCAN SECTION CROSS-SECTI -
- ON
H20 aftdift T, D806 e 0 '2� i efim ' I� ,ISI . I�� r
IR ff k;T - A � Sid*WUU ISIXAM , li, I 1,of 21 ' NG �3 LMS 1 7 = al ' '. 4 �D0 V3 :HOLE:H _20 DISTRIBUTION BOX I in . V 001 .. it - 2 I -
6wo3/4* 11 > . I/rSYSEM PROFILE TTO SCALE,
, 0cc " .6 1 � Lo cusMAP4 '' , � ;0 INot o S(Me ", 1, a 1 '1 - , - 1 n, 11,.:
I' If*cv* ywth �,
, = ' % , ., . 1
0 Etrftrttive Lertpth
S
-- - :
6 hL of 3/4i 1/2 ,. �01L ABSORPTION SYSTEM (SAS) '.J
-i"ded I , 0. I
M1, GENERAL NOTESINFILTRATOR MODEL 3050 (W�2b LOADING)/ SUMMER1
-I Ta�R* R EQ VALE 11
� 11QJ1= 2i (O UNT) 1. Contractor, s i"ponsible for:Oigsafe rib i #Caton
I •� .I No and protection underground utlities and OVERAL HEIGHT OF INFLYRATOR IS 30'-/EFFECTIVE HEIGHT IS 24
. 2. e Sept.c„toftka4*distrA 'on box shal ,be set . • .
IA k" . ,7� /2 tan®.
VAR REQUESTED & Backfill should be clean sand or grovelwith no
" istones over 3 n .size.;, ;
3-2V OWL MANIMLES i o in from 10 Feet to 7 feet. ' .
I 4.-Tis system is subject.to Inspection during installation
. 10__r ASPHALT 1. ,by-Carm6n E.,Shay,-xErivfronmental Services, Inc.
; -� DRVEWAY 1 ,Tho sha install this system in, accordance
.r � with Title-V of ,the Massachusetts ,state code, the approved plan
1 ? and.Local Regulations. .
_+* 6. If, during installation the'tontroctor encounters, any
PUT - 6 C"i LOT J 15A soil conditons or; site conditions that are different
"IT . . � - . from those' "wn on the soil to or our design Ig .
THE ACCESS COVERS FOR THE SEPTIC TANK, - , installation must hdft,& Immediate notification be I
DSTRBUTION BOX AND LEACHING COMPONENT e mode to Carmen E. Sh Envionmental Services, Inc.
iIF7i::"z , - i. .. Z JSHAM BE RAISED TO WITHIN 6 OF "
FINISHED GRAM 40 MIL Rubber Liner 7. No vehicle or he, machine shall drive over the
STEEL RENFOACEDPRECAST CONCRETE INSTALL nW-*flX GAS BAFFLES OR EQUALS FROM ELEV. 195.00 To Elev.93.00 & 1 0 Feet septic.system unless noted a H-20 septic 'components.
ON AL OUTLET TEE ENDS Be'Ond Each End of SAS or Dwellin B. Install Tuf-rRe s baffes or eqalsIn 'all outlet ends.PLAN VIEW ------__ ga u
9. All Distribution 'Lines shall be,4" diameter Schedule .40 NSF PVC pipes.3-24*REMNAKE
I \ I , 10. All sold piping, e" & ratings shall ,be 4 diameter
` � 0-% I " � . _1
11 -�- ., e k I II/ "PAY" �% Schedule 40 PVC pipes with watertight joints.
0*L I < I f
. F * rMI I * r rr r I // \ 11, Municipal Water Is Connected to` Residence and Abutting
OUTET t %\ II ' " ' \1 Properties Within 100 Feet.
W1 - N 86d 274 00 r0 .
.
; E 4'-4'wA X I 1 .A
U*4d 4*11 O 0 / % - Failed I _THE PROPERTY LINES & HOUSE LOCATION ARE APPROXIMATE AND
- LLD-Bo -_� .. I Cesspool COMPILED FROM THE SURVEY PLOT PLAWGENERATED BY 'KAaSE&KELLOGG
., �_ '- 1500 ' I. . _98 OF HYANNIS, MA ENTITLED "RESUBDVSION OF LOTS IN CENTERVILLE, MA"
;r -:C- _2_2 _ -_,-.. .q-..I 0 / * Tank _ �I_ ..n.-1� .7,: C!I(-e W-r ....--.1 - DATED MARCH23,"1955. PLAN BOOK -121. 'PAGE 87.
\ 0 V1. :14 l2 a , AND IS NOT JNTENDED TO BE SURVEY PLOT PLAN
CROSS SCTION END-SECTION I t. I .F -I , I T SHOULD 3E USED FOR NO PURPOSE OTHER THAN
. I In I I 11 I . _ I THE, SEPTIC SYSTEM.INSTAUATION.
. , , I .
IMI PIC-AL-1-500-GALt-ON-SEPTIC-TANK I I �0 I TESV f0 f N -- - _ ____1__ - I .
EV 4
NOT TO SCALE , tr . � �_1 4 -, II
H-20 LOADING IL C 0 � I -
" , SfoA " SPACE N . " . . L E G E
4 --FOUNDATION ____ �PERCOLATION TEST " ., ----- 1 I I
;" .,I-
, . I S"&M
, - I /. DENOTES PROPOSEDDate of Percolation'Test: JULY.7.L2003 c 2 BBDROOM / 90 i0431
Test PerformB . ' ARMSHAY, IQ I I'll . 1I - � SPOT GRADEyC .0 1 Hours
Results Witnessed By. .WAIVER( per BARNSTABLE B.O.H.) t 1
EXCAVATOR: `SHAY ENVIRONMENTAL SERVICES INC. . I 1 ' 11 � A I I,, �� Vti DENOTES EXISTING
r . I / II I I -0 - XL104.46 SPOT;GRADEPercolatIon Rate: Less Than 2 MPI 0 44" B; / I I.\ . • "\ 0 00, / / I \\ �
Test Hole / 1 \ L PROPER
No. 1 /// / / \ TY LNE .
/ / I \.DPTH SOIS �ELEV. /// // / I V 11 . . go PROPOSED CONTOUR
o 9850 I// / I / OI \\ _ __88 ___, ' ' -
wy • 3 97 EXISTING CONTOUR
_ / I ;/ / /Loon ____ \ koLOT #18 , '_
10W 3/2 98 --_ - / / // / JI *
0"-s" . 497�75 / I, I iz smriet +/- 15 DEEP JESTIHOLE &
= / / / 1 6 ' PERCOLATION TEST LOCATION
L I / // 1 , I �0
.to fR 5/6 I I I I I P
fr- 'a. a, 94.50 I I I I L - 6 FOOT STOCKADE FENCE
Modkwn �/, I I I A� -
/= 1 I I 1 : .\\ 3� .
"Y 7/4 I I I I .\\\ 6 04-
.
a. 12q 1 I I I \ 1. 4 REV.: 8/4/03 -- per Cl,ent
1I I II I \ \N O' � d
i I I �
Perc #1 I LOT PL AN%
Depth to Perc- 50" to 66" * I i?P0$ %\ P 4i0
Perc Rate= Less Tho 2 MPI % I F PROPOSED SEPTIC - SYSTEM UPGRADEGroundwater Not Observed % - ? - % e
, No Observed ESHWT " -G 98, % % .
M \ \ .,ADJUSTED'H20 Eiev. = None \ 0 P
6 . Ms. SUSIE , CHASE
_ 1 , . I I ATPkOJEMI BENCH MARK
TOP OF FOUNDATION 6 HAR IS N OAD
EL = 00.00 . . . R
I IEV. 1 (Asumed) ."
.CENT RVILL A
Design Calculati ' E, M
ons
, I Number of Be s: i �droom 2 Equvalento0LGal/ aY (30Gal./Day Min..pr Titl V) P EPARED By.
-, I
Gabe Grinder.'No .
rag N
aching Cacity Prpoed: 30Gal./bay Minimum'(Min.:Per Title V) ARM, W E SAAyLe " � I
Septic 'Tank : 2 x 330 Gol./ a 660 USE 1 500 GAL Sptic Tank. ` � , 0Dy e SH ONAMNTAL SERVICES, INC.
_SOIL ABSORPTION AREA. Using percolation rate of,<2 min./nch .. NO WETLANDS ARE PRESENT wrrHIN 200 OF PROPOSED SAS. ,' .
0 20 I 404 " '" Bottom Areo: 0.74 al/sq. ft. x 290sq. ft. 214.80gaons 4,50 0 P ,g . . . Ox, I
�I C4 , I " x*Sidewall Area: 0.74 gal./sq. ft x 156 sq. ft. 115, 4 gallons EXISTING�CtS�POOL To BE PUMPED & 19TV_ EAST FALMOUTH - M -A 02536
ProvIInT. 330. 4 gallons OR REMOVED IF,FOUND 4 BE NECESSARY To 'NSTUN 4 \. A EW W VITAR
� TEL/FAX 508-548-0796
Use- 3 HIGH CAPACITY INFILTRATOR CHAMMHAVING-A 2' EFFECTIVE DEPTH NOTE:'� ANY STRIPPED OUT'SOC IN BO I " LONTAING LEACHATE
1 SCALE: 1"=20 DRAWN,BY: CES DA :(4-,W x 7 1) TO USED 2' OF WASHED STONE ON THE SIDES AND SCALE, 1 =20 FROM THE EXISTING LEACH Pfrs/cEsspou sTo BE-DISPOSED TE DULY 10, ,2003
4, OF ENDS. ; OF AS PER BOARD OF HEALTH SPECIFICATIONS. . _1 PROJECT#SD447 FILENAME SD447PP.DWG SHEET 1 OF 1
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