HomeMy WebLinkAbout0168 HIGHLAND DRIVE - Health 168 Highland Arerme
Centerville 'P �
A = 190 132
��EcvCiroc
'mead.
UPC 12543
No.53LOR Pon,�aNs�`r
HASTINGS. MN
I
TOWN OF BARNSTABLE 233
LOCATION \6 X O t q)r U and SEWAGE# a QV0
VILLAGE r'(LNk1xJL« ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. -t
SEPTIC TANK CAPACITY ! , l_.C"C�0 G OGk I �-e.,r�yt k .20
LEACHING FACILITY:(type) 4 L c G ek(.,M�ry4&;S(size)
NO.OF BEDROOMS � 0 r2 f C,V\f 5 cfe.0_,p r;
t.
OWNER c,
PERMIT DATE:/ f (a COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY { P( �
31
�r
1 T
No. 01D t —131 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplication for Misposal *pstrm Construction 3permit
Application for a Permit to Construct( ) Repair(`t/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.` Owner's Name,Address,and Tel-No.
Assessor's Map/Parcel r
Installer's Name,Address,and Tel.No. J Designer's Name,Address,and Tel.No. 5_0X 3 6 d 131
S t� �� ��"n�- °�cc�N.nv►fin
15 f-CA S .s-C Gnct 1,
Type ofgilding:
Dwelling No.of Bedrooms Lot Size (' O sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) '3 d gpd Design flow provided gpd
Plan Date c�7 l Number of sheets Revision Date
Title
Size of Septic Tank k 5_y V (Yc;,L �-\t O Type of S.A.S. 4n a O OQQ,,C LA `C ,(,, C�XG �c�S
Description of Soil iN4 J (R c rC& s c,-,J to �� .� -7 1 a
Nature of Repairs or Alterations(Answer when applicable)__ QV D kc Q_X ZN _D ss
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o Health.
Signed Date
Application Approved by 7)N�nh S Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued f A4
Fee
^� yYc ryY,
No. a�0
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
-PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for 13t'spbeal *psUm Construction Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.`Oc \Ac(,��.\(�✓� Owner's Name,Address,and Tel.No. ;
Assessor's Map/Parcel
�'�_ 3a �. 5 � M clr PC,
Installer's Name,Address,and Tel.No. J Designer's Name,Address,and Tel.No. ro 2( 3(o a 13 Z
sCi st ca 6 �� S c �r-e \ ,c�S �? 6 Sao c b
Type of B ilding: S ,
-Dwelling No.of Bedrooms Lot Size L'i `c�2�� ' sq.`ftf"' Garbage Grinder(
Other Type of Building No.of Persons �'`j Showers( ) Cafeteria( )
Other Fixtures.
Design Flow(min.required) 226 gpd Design flow provided s gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank (y cal.. �A I O Type of S.A.S. h a y (3 OX lf, C c�x n 6�IS
Description of Soil ^(.0 rs e S J W I 'S A-0,.1 t l n %2"OQ(T
f
r
Nature of Repairs or Alterations(Answer when applicable)_��Ssr—
r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o ealth.
Signed Date l sf io
Application Approved by YL� / 1.�.-'2 c. S Date Lo
Application Disapproved by Date
for the following reasons
Permit No:, (((i 1 Date Issued '7`q l Ae
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by
at (, �-�c G �,.\ c ���r c 2 \-has been constructed]in accordance
with the provisions of Title'5 and the for Disposal System Construction Permit No. dri p` )dated
Installer �c K r c�� Designer k_\-- G.fn S
#bedrooms Approved design flbav and
The issuance of this erm`t shall not be construed as a guarantee that the system will '"ctioas designed. (
Date (p Inspector �/ „i I
I' ----------- ------------------------------------------------------------------------------------------------------------------
-_m No. c�0 (� ? Fee 10d, --
THE COMMONWEALTH OF MASSACHUSETTS T
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal .pstem Construction Vermit
Permission is hereby granted to Construct( ) Repair(V Upgrade( ) Abandon( )
System located at
4 .
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
i
Provided:Construction must be completed within three years of the date of this permit. '
Date Approved by
i
Town of Barnstable
Regulatory Services
r
Richard V. Scali,Interim Director
sKAM� Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
9 Installer& Designer Certification Form
Date: 1 G Sewage Permit# Assessor's Map\Parcel
Designer: 'CMP 1$F_1,3 k h A W Installer: _i-A,-
Address: � � Address: t�� � � ®v"T
0n _(o k was issued a permit to install a
(date) (install`err))
septic system at � � �( (��c,l••(w�6 �lJr C—V "�,*A�Iebased on a design drawn by
(address)
Eke &,dated 7 \ to
(designer)
`IZi 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. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State rat Local Regulations, flan revision or
Y certified as-built by designer to follow. Strip out(if required)was inspected and the soils
r<, were found satisfactory.
I certify that the system referenced above was constructed h cc with the terms
of the RA approval letters (if applicable) .
fi
(Installer's Signature)
4i.
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE ULURN TO B&MSTARLE PUBLIC H. EALTH DIVISION. CERTIFICATE
OF COMPLIANCE VVIILL NOT RE_ISSUED I(IINTIL BOTH THIS F0' M AND AS-
CARD.ARE RECEIVED BY THE BARI'S'TARLE PUBLICHEALTII DIVISION.
THANK V®L'.
Q:`Septic\Designer Certification Form Rev 8.14-13.doc
r
Town of Barnstable P# /50�Z-3
Department of Regulatory Services
H natwar�►er�o k Public Health Division Date
MABA
ta3a. 200 Main Street,Hyannis MA 02601
Date Scheduled
Time U.G M Fee Pd.-
Soil Suitability Assessment or Sew e �� 333so
_ tJ' .f Drsposa
Performed•B : 5 j J �� �'`� L /Jr
y Witnessed By: ✓� w_ �L
LOCATION&.GENERAL INFORMATION
Location Address `�D 1, C ,) (1 Owner's Name (� ry
C Address ( ko r tit(.l L, (/ !J
Assessor's Map/Parcel: V 3 2 Engineer's Name
NBW CONSTRUCTION REPAIR Telephone#
���Dom" �� Slo es 96 •�LJC7
' Land Use• p ( ) L,� Surface Stones
Distances from: Open Water Body 11 Possible Wet•Area — ft Drinking Water Well ft
Drainage Way ) ft Property Line le) _f ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pero tests,locate wetlands-In proximity to holes)
/X
441
Parent material(geologic), g ) -�� Depth to Bedrock �
Depth to Groundwater. Standing Water in Hole: �-' Weeping from Pit Fnea
Estimated Seasonal High Groundwater
DE T RMINATION FOR SEASONALMIGD WATER TABLE
Method Used: �
- � Depth Observed standing in obs,hole: In, Depth to Boll mottles;
Dellth to weeping from side of obs.hole: In. Groundwater Adjustment (k.
index Well- Reading Data: Index cIi Iovol .,, Ac�,titetor, , ,A ,C3t�7unv;ate."•.l ev:.t, _
PERCOLATION TEST Data TIMa ILI,C1-
Observation
Hole# Time at V1
rl
Depth of Pero 7 L Time at V
Start Pre-soak Time 0 "OL Time(91 )
End Pro-soak S
LZ
Rate Min./Inch
Site Sul tability Assessment: Sito Passed Sitp Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back---------- - , '��
***If percolation testis to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:ISBPTICIPERCFORM.DOC
DEEP-OBSERVATION HOLE LOG Hole#
Depth from Sail Horizon Soil Texture Sdil Color Soil• Other
Surface(In.) (USDA) (Munsell) Mottling (Stnuctum,Stoner;Boulders.
consistency,%Orayell
�' r LS Lv`3L �l3
z S S
DEEP OBSERVATION HOLE LOG Hole# Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
A L 5
LS
�Lei C� �t-es 10YA 6
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulder..
,
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soli Color Soil Other
Surface(In.) (USDA) (Munsell) Mottling (Structure,Slopes;Boulders.
Consistency, 9myell
i
Flood Insurance Rate Map:
Above 500 year Mood boundary No— Yes
Within 500 year boundary No "+ Yes,;
Within 100 year flood boundary No. Yes .
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed thrpughout the
area proposed for the soil absorption system? 5 _—
If not,what is the depth of naturally occurring pervious material?
Certification
I cerdfy that on 11•! A (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by ma consistent with .
the required train ertise and experience described in 10 CMR 15.017.
Signature Date 4 Z� Zex 62
Q:WEFrrlC\PBRCPORM.DOC
I G /1 I TOWN OF BARNSTABLE
LOCATION I6 b 1&44,o/ Gi' SEWAGE #
VLLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE N0,
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
�:B MDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet-of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
p�i�
��, � . ,
� �b
' �
51
TOWN OF BARNSTABLE
LOCATION ��b '4 A 141� b r. SEWAGE #
VILLAGE QQA-r-f%J b- ASSESSOR'S MAP & LOT O 2,
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY CWP OI
LEACHING FACILITY: (type) # (size)
NO.OF BEDROOMS 3
1 s
'BUILDER OR OWNER Go"
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If.any wetlands exist
within 300 feet of leac'ng facili Feet
Furnished by �S Ct�; ��/
a
P
BAc,
Jy�'
y
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
MAY 1 9 2004
TOWN OF BAwNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 168 Highland Drive MAR
Centerville, MA 02632 PARCE4
Owner's Name: Geri Kelly LOT
Owner's Address:
Date of Inspection: May 11, 2004
Name of Inspector: (Please Print)James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
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
Conditionally Passes
Nee urther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: May 17, 2004
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system 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
****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.
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
CERTIFICATION (continued)
Property Address: 168 Highland Drive
Centerville, MA
Owner: Geri Kelly
Date of Inspection: May 11, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
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:
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 168 Hikhland Drive
Centerville, MA
Owner: Geri Kelly
Date of Inspection: May 11, 2004
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
"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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 168 Highland Drive
Centerville, MA
Owner: Geri Kelly
Date of Inspection: May 11, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation,
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ ✓ Any portion of a cesspool or privy is within a Zone I of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for 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 forma
No (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 System:
To be considered a large system the system roust 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
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 95 Chipping Green Circle
South Yarmouth, MA
Owner: Joseph Dilk
Date of Inspection: May 3, 2004
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?
✓ 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?
✓ 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
✓ _ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(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: 168 Highland Drive
Centerville, MA
Owner: Geri Kelly
Date of Inspection: May 11, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n/a [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)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): end
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 2 years ago-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool k
✓ 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:
Unknown-original system
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 168 Highland Drive
Centerville, MA
Owner: Geri Kelly
Date of Inspection: May 11, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank)
Depth below grade: 12"
Material of construction: concrete _metal _fiberglass _polyethylene
✓ other(explain) Cesspool block
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 5'W x 6'T x 8'bottom to grade
Sludge depth: 10"
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: --
Distance from bottom of scum to bottom of outlet tee or baffle: --
How were dimensions determined: Measurinz stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
The cesspool had 6'of water on the bottom Liquid was up to the outlet tee
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 168 Highland Drive
Centerville, MA
Owner: Geri Kelly
Date of Inspection: May 11, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(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: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
i
Page 9 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 168 Hikhland Drive
Centerville, MA
Owner: Geri Kelly
Date of Inspection: May 11, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
✓ overflow cesspool,number: I
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
The overflow cesspool was 5'W x 6'T x 8.5'bottom to grade and had 2 5'of liquid on the bottom The scum line was at the
same level. There did not appear to be any suns offailure The cover was 15"below Qrade
CESSPOOLS: None (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: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of i l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 168 Highland Drive
Centerville, MA
Owner: Geri Kelly
Date of Inspection: May 11, 2004
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.
8Ac, �.
A 81 .a
l �
a s
10
Page 11 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 168 Highland Drive
Centerville, MA
Owner: Geri Kelly
Date of Inspection: May 11, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
r
You must describe how you established the high ground water elevation:
Using a Barnstable topographic map and a water contours map the maps were showing approximately 25'+/-ground water at
this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
TOWN OF BARNSTABLE
LOCATION x 7J SEWAGE #
VILLAGE Ge,' ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. T01, A,
SEPTIC TANK CAPACITY
LEACHING FACILITY: (typej A e S (size) 3'✓ X°�X`�
NO.OF BEDROOMS a2
BUILDER OR OWNER /7Gu C�#Iles
PERMITDATE: '/`f 5 COMPLIANCE DATE: &', ~- i�-
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
.,t
IA
f,15"'
77 .
23
ao
' ` aoal y
t
ACCESS COVERS MUST BE Wl THIN 9" MINIMUM. INVERT C L E VA T I ONS : DESIGN CR I TER I A : GENERAL NO TES :
6" OF FINISH GRADE 3' MAXIMUM COVER
105.7 FIRST 2' TO INVERT AT BUILDING: 103.0 DESIGN FLOW:
104-0 BE LEVEL MIN 2" OF PEASTONE INVERT /N SEPTIC TANK: /02.O 3 BEDROOMS AT 110 G.P.D. PER I. THIS PLAN /S FOR THE DESIGN AND CONSTRUCTION
103.2 103.4 OR F I L TER FABRIC INVERT OUT SEPTIC TANK- 101.75' BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY.
4- DIAM P1PE 101.s INVERT IN DIST. BOX: .
3/4" - I l/2" D 1 A. 10127 NO GARBAGE GRINDER 2. VER T I CAL DATUM IS ASSUMED, FOR BENCH MARKS
l03.0 10I.75 /0/. l � I2' %o'12 DOUBLE WASHED STONE INVERT OUT DIST. BOX: !O1• l
GAS / / 101.27 !X v /0/.01411 100.0 INVERT IN LEACH CHAMBER: /0/•0 SET. SEE SITE PLAN.
102.0 BAFFLE) SEPTIC TANK REQUIRED:
3 OUTLET 4 LC-6 LEACHING CHAMBERS BOTTOM OF LEACH CHAMBER. 100.0 330 G.P.D. X 200% - 660 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND
°P g D-BOX W/3.S' STONE AROUND. t 0'w x 38'! x !2"d ADJUSTED GROUND WATER: N/A
SEPTIC TANK PROVIDED: 1500 GAL. MIN, MAINTENANCE OF THE SEPTIC SYSTEM SHALL
S1500 GAL H-20 OBSERVED GROUND WATER: N/A
EPTIC TANK 6" CRUSHED STONE OR CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL
BOTTOM OF TEST HOLE tel: 93.2 SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS.
COMPACTED BASE
DES!GN PERC RA TE C 5 M I N/!NCH
N PROFILE : NOT TO SCALE SOIL TEXTURAL CLASS - l 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREA TER
330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH-
STANDING H-20 WHEEL LOADS.
PROVIDED: 4 LC-6 LEACHING CHAMBERS
W/3.5' STONE AROUND, A-476 S.F, 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR
476 S.F. x 0.74 - 352 G.P.D. APPROVED EQUAL.
SOIL TEST PIT DA TA& 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
PRECAST CONCRETE OR APPROVED POLYETHYLENE.
/ UP 646-2 INDICATES INDICATES BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER
PERCOLATION _ OBSERVED
\ TEST - GROUNDWATER TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE
\a� TP #1 Pw15043 Tp ♦2 OUTLET.
- ` < 0- HORIZON TEXTURE COLOR 103.7 0- HORIZON TEXTURE COLOR 103.7
LOAMY IOYR LOAMY IOYR 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE`.
A SAND 3/3 `Q $AND 3/3 1-888-DIG-SAFE AND THE LOCAL WATER DEPT.
B• - - - - - - - - - - - - - - - 103.0 B" - - - - - - - - - - - - - - - 103.0 FOR LOCATION OF UNDERGROUND UTILITIES.
\ B LOAMY JOYR B LOAMY IOYR
Qa��3 \ `ram 24 SAND- - - - - - - - - - - - - -4/6 - iol.7 24- SAND- - - - - - - - - - - - - -4/6 - /0/.7 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE
C M-C SAND IOYR C/ M-C SAND IOYR DESIGN ENGINEER TWO DAYS PR!OR TO CONSTRUCTION
AND GRAVEL 5/4 AND GRAVEL 5/4
✓ `� `� �o sto. 52 - - - - - - - - - - - - - - - 99.4 52' - - - - - - - - - - - - - - - ".4 OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE
F C2 MED-COARSE IOYR C2 MED-COARSE IOYR CONSTRUCTION INSPECTIONS.
y� SAND 6/6 SAND 6/6
72
\L`Q T 38 \\� E /
,gyp � /�� 9" EX I S T l NG CESSPOOLS TO BE PUMPED DRY AND
otih 0� / 15, 00, S.F. BACKFILLED_
1 �\ \ 126' NO WATER 93.2 120- NO WATER 93.7
104,0
DATE: MAY 18. 2016
TEsr BY: STEPHEN
A WITNESSED BY: DAVID STANTON
i0 \� �0 /2c \� �00� \\\ C8 FND / PERC RATE: ! 2 MIN/INCH
T'S'
-
' OFF
\\ +104.5 �< \ /
D BOX• •••• .:.,� c / /
CO 104.9
103.2 P9 1500 GAL\,ON
SHED `�
SEPTIC TANK\ CESSPOOL
+l03.7yo, ___�/ x
103,3
4 LC6 PRECAST CHAMBERS
W/3.5 STONE AROUND 103. 7\\ °
0
CESSPOO
1
Gi��
i
F9 a O
u'F OO Tp*I
TPs2 SEPTIC SYSTEM DESIGN
'
1 BM NAIL /N l2"TREE 68 H l GHL ,A "O OR / VE . M,AP 190 , P.ARCEL 102
`f'�•
oc�g0 QZ
EL-105.0
BARNS TABLE , ( CENTERV / LLE ) MA .
PREP,AREO FOR :
LEGEND MARK C A R O L S A N,A C L E T O
LOCUS
CB CONCRETE BOUND
-W WATER LINE SCALE : 20 DUNE 27 . 2016
Q HYDRANT
op
-G GAS LINE STEPHEN A _ HAA. S
ROUTE 28 OHW- "AVER HEAD WIRES
4A- 'LIGHT. POST _ ENG I NEER I NG , INC
---E-- +UNDERGROUND ELECTRIC L 1 NE / � R . 0 Box 1 6
-T- UNDERGROUND TELEPHONE L l NE S o u t h D a n n i isM A 02660
-CTV- 4UNDERGROUND CABLEVISION LINE �``.� /i '� �t ( 508 ) 362-8 1 32
+40.4 !SPOT ELEVATION �
40--•---- EXISTING CONTOUR
L 0CUS MA P 0 /0 20 40 40 'PROPOSED CONTOUR JOB NO: 16-030