HomeMy WebLinkAbout0004 HILL CREEK ROAD - Health (2) HILL CREEK `
CEN TERVILLE
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UPC 12534
NO.21„53LOR .�
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When -
filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr, IRS
use the return Name of Inspector
key.
Eco-Tech Environmental
r� Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
-, E June15 2013
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system 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.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 off,Winrrtonm:Subsurface Sewage Disposal System•Page 1 of 17
I
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The
scope of this inspection is limited to health and environmental compliance and the septic system has
been evaluated according to the conditions observed on the day it was inspected. No estimate or
guarantee of system longevity is made or implied by a passing determination.
Removal of garbage grinder is recommended
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑. The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts s
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must 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 ces
spool
sspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
El ® than '/z day flow
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
C. Checklist
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?
El N 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® El Was of break out?P 9
® ❑ 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:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Original house contained 4 bedrooms. A Building permit(#72232)to add a fifth bedroom was issued
on 10/15/2003 with Health Department review. Leaching capacity of existing septic system is 850
gallons per day according to a "Certified Plot Plan" and septic design dated 7/28/83 by Baxter& Nye
Inc. for Moore Homes.
Number of current residents: 5
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 233 gpd
9 ( Y 9 (gpd)):
Detail:
2011, 2012
Sump pump? ❑ Yes ® No
Last date of occupancy: I current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ _ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner's agent
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of 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 contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
30+years. Certificate of compliance was issued 12/28/1983 per as built card at Health Division.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank (locate on site plan):
1
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 9.5 x 5 x 6-1250 gallon
Sludge depth: 4 in
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 30 in
Scum thickness 1 in
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended every 2-4 years. Tank
and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was
observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
o�M 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at outlet inverts
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.):
D-Box appears structurally sound and functioning as intended. No evidence of leakage in or out was
observed. Some solids in sump. A bucket of water was poured into the distribution box and was
observed to pass through in a rapid and unobstructed manner, and could be heard splashing down
into the leach pits.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching pits appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into
the distribution box and was observed to pass through in a rapid and unobstructed manner, and could
be heard splashing down into the leach pits. An inspection hole was dug into the stone of one
leaching pit and no effluent contact staining was observed in the stone or overlying soils. No standing
effluent was observed to a depth of 3 feet below the top of the leaching pit.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of lVlassachusetfs
Y -
To le �facI,,a ➢n� ction For
Subsurface:,Sewage.:Disposal System Form- Not for Voluntary Assessments
M4 4.'HillCreek,;Road-aka 73 Scudder Bay Circle
Property,Add[ess -
Patrcia A. Morris Trs,
Owner
Owrie's Name _
information is
requiPedforevery Cen.terville... MA 02632: June 1,5, 201a -
page. CityfTown State Zip Code Date:,ofansp'ection:
D. System Information (coot.)
;-Sketch Of Sewage Disposal:System Provide a.view of,the sewage disposal'system, including-ties to
at least twa,<pei manent reference Iandn 'Ws.or.benchmarks.,Locate all•wells within 100 feet; Locate
Where public:water-supply entersthe'building.`Check one of the boxes below;
hand-sketch in the area below
0 drawing attached separately
a l�
v Z
�N2
, C
-C '"
K9
� L � �r0 ►
t5iris'•3113; - Tufe 5'Officihl lnskction Forth:S6b-uAace Sewaga bisposa],Syslem.•Pag3 15 of17
s
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is required for every Centerville MA 02632 June 15, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 25+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: not indicated. Compliance date: 12/28/83
Date
❑ Observed 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:
Town of Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Design plan on file with the Board of Health shows bottom of system to be 4 feet above the bottom of
a witnessed test pit in which no water or groundwater mottling was noted. Town of Barnstable GIS
Department records indicate that the property is over 25 feet above groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
4 Hill Creek Road -aka 73 Scudder Bay Circle
Property Address
Patricia A. Morris Trs.
Owner Owner's Name
information is Centerville MA 02632 June 15 2013
required for every ,
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
}
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map l 4' Parcel 0v�3 --.- Permit# 2
- r
Health Division 15 Y
U �C �� �--C/IV L f Date Issued /0 ••/,S -,�
Conservation Division Ntdo 64,
'�G ; 'i 'Application Fee
Tax Collector Permit Fee_ r d
Treasurer fJ .-- -cam, tt,� �1'.. �, ,
i< CTil. LED I14 COMPLIANCE
Planning Dept. VATH TITLE 5
Date Definitive Plan Approved by Planning Board
EINVIA ON,'ENTAL CODE AM
TUB"I F"2OULATIONS
Historic-OKH Preservation/Hyannis
n
Project Street Address
Village CC 11,(' "'�M,6 Y'Y\A
Owner 0 to-�2 i A r i Address
Telephone ,� \
Permit Request V i� -C,`lcr CG'� n j J o--,'1 0 � ' kl 6.'\
ELOU(Y� �A 00 2 �a��is bEcA 1 b A-Vk,\ Lo oz�A Azc�
Square feet: 1st floor: existing Z.3'L•�iL 3 proposed 1�3 2nd floor: existing proposed Total new C1 V -
Zoning District t Flood Plain Groundwater Overlay
Project Valuation -2-5 y 000 Construction Type u000A �A.m
Lot Size Grandfathered: 14Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family C Two Family ❑ Multi-Family(#units)
Age of Existing Structure C Historic House: ❑Yes k No On Old King's Highway: ❑Yes ❑No
Basement Type: 4 Full ❑Crawl ❑Walkout ❑Other 4A
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) i c 3 c�
Number of Baths: Full: existing new I Half: existing new
-Number of Bedrooms: existing_ new 1
Total Room Count(not including baths): existing l7 new ► First Floor Room Count 5tyrN t
Heat Type and Fuel: V Gas ❑Oil ❑Electric ❑Other
Central Air: OLYes ❑ No Fireplaces: Existing ZJ New r) t ' Existing wood/coal stove: ❑Yes )6 No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage: existing ❑new size Shed:❑existing ❑new size_Other:
Zoning Board of Appeals Authorization ❑ Appeal# n�Y� Recorded❑
Commercial ❑Yes 11i No If Yes site plan review#
Current Use � - -- -
Proposed Use
BUILDER INFORMATION
Name �'r�C tom`1
Telephone Number
Address y if-' af'1 i �a�l License#
6d, Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO C,).1 r(A C
SIGNATURE DATE �+I ,p D j
LOCATION E)N A G E PERMIT NO.
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INSTALLER'SNAME A ADDRESS
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INSTALLER'S NAME & ADDRESS
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DA T E PERMIT ISSUED
DAT E C,OM.PL1ANCE ISSUED
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DATE: DECEMBER 10,2002
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73 SC[iDDER BAY CIRCLE
CENTBRV 1E,MA.
/ DEMOLITION NOTES O TTICLE
L AL WALLS.DOORS,MWOM talc.%t"DAS M TO BE FEMOYM CHEM
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/. \ OUTI•!'15,EwsnNB RETawNB WALL rJ• cAiM.,M.AND KRING BALK TO tEAMST JWTION BOX SCALE. AS NOTED
— DATE: DECCEIvvB3ER 10,2002
-- DRAWN:MJ
--------------------------- —--- (REVISED 9/09/03
DRAWING NUbfBER
PARTIALDEMOLMONPLAN A- 1
SGALS V4•a I'-0° .
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M� GAS
WATER METER ® '
LOT 24 EXISTING CONTOUR 104IN
4-4 / PERCENTAGE OF LOT COVERAGE
LOT AREA 28640f S.F.EXISTING
- - - - { EXISTING PAVEMENT 2.2%
/ - - TOTAL COVERAGE 14.0%
C} ~ TOTAL PROPOSED 5.9% s
S 8p'24'36�� NEW TOTAL COVERAGE 19.9%
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_ \\ LOT 23 = LOCUS MAP
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RES
S.F. PLAN REF: 27801 A SHEET 1
62 ACRES �'Rs. CERT REF: 120378
- _ - - - �.� \\ oo '�. ASSESSOR'S MAP: 187/023
_ ZONING: RD-1
SETBACKS: 30'-10'-10'
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PROPOSED \ \ \ ��'� ;�12 - _._ DATED: 7/16/14
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- -aos CENTERVILLE, MA
DRIVEWAY.'
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LOT 22 � � D,-,;��
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YANKEE LAND SURVEY LLC
GRAPHIC SCALE 153 LOVELLS LANE SUITE 103
30 o 15 30 60 MARSTONS MILLS, MA
NOTES: TEL: (508)428-0055 FAX: (508)420-5553
SEPTIC SHOWN PER TOWN RECORD. 1 inch = 30 ft ankeesurve omcost.net www. ankeesurve net
ELEVATION DATUM ASSIGNED. y y y
SHEET 1 OF 1 JOB#: 55115 JM