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Home My WebLink About0105 HILLSIDE DRIVE - Health 105 Hillside Drive Centerville A= 183-014 SMEAD No.2-153LOR UPC 12534 aouoMwnoounw SHCMTM ar m WUKM wewwsa wnwmm 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 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. A. General Information 1. Inspector: �- Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 he Local Approving Authority 12-1-14 Iriipector'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 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 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: System is in good working order with no sign of failure. 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 m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 page. City/Town 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 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 El ® 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 1/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts _ F Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments qM s 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 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? ❑ ® 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: ® ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 page. CityfTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2014 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:. tSins-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 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 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: Not since new in 2012 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form G Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 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: 2012 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 18" Depth below grade: 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.): Good condition. Septic Tank (locate on site plan): Depth below grade: 12"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: 1500 gal Sludge depth: 6" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 page. City/Town 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 26" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 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 15ins•3113 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 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 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 0 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.): Good condition with water at working level and no sign of back-up from field. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): Leach chambers in good condition and empty at inspection with no visible stain lines. 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 t5ins-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 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r d 1 0 -9-,3( 4� P t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 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: 50' 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: 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: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. 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 o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Hillside Dr Property Address Donald Reeves Owner Owner's Name information is required for every Centerville MA 02632 12-1-14 page. City/Town 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TQ4�i T F�3!/ STABLE . L - -ATI N �J c5.i SEWAGE# C'�� e� e ASSESSOR'S`MAP cti LOT IAISM.I.E1Z'. rNA M&flip B ivOI. SEPTIC TA:� CAPAC / NO.OFBEDROOt+lfS BtJ#Y3�ER OR O�1�*IER DA ca Pr ANC �A Separattan Di5tattce.Betvr.eri fhc Maxirtutn Adjusted Graundvi+ater Table to the'Bottam df Leacttng Facility feet Private stater SuPFIY $li and Leach o FAc tty (if aay�velis exss on site ar:Within20O fwt't lei ft ng facility) beet Edge ofW- a tid and I.eac gl€ti: i ty{if any wetlands exist withist 3130 feet Qf=eacitifa Facilityj' Feet Furnished by` `� LFr dv^-f o � v p CIS I of 9 No. ge) 2-70 '" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppliration for BisposaX,,*ps flan ConstCUCtion permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. COl' % S� /)G.Owner's Name Address,and Tel.No. Assessor's Map/Parcel "'''j 01`( /v �- Ins ler's Name Address,and Tel.No. 507--,q"• O S`3 d Designer's Name,Address,and Tel.No. rO 97, &G 7•/(04 a A&,& , C'v. t0.- s l�o ti A u 4s at Type of Building: ? ,d Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers Cafeteria O YP g ( ) ( ) Other Fixtures Design Flow(min.required) !/U gpd Design flow provided 3; gpd Plan Date 6 02 3 "f Number of sheets Revision Date AIA Title n e Size of Septic Tank r S O Type of S.A.S. S00 , &A.6" Description of Soil `�'/ Nature of Repairs or Alterations(Answer when applicable) C_t, �- Date last inspected: Agreement: The undersigned agrees to ensure the constructio d mai tenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro ntal C e and not to place the system in operation until a Certificate of Compliance has been issued by this Boar t ealt Signed In �� Date Application Approved by Date C Z--- Application Disapproved by Date for the following reasons Permit No. Date Issued No. "'- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ~! 2pplication for 33isposaLftstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 10C- /'i�S, - , / Owner's Name Address,and Tel.No. j 40- 3 4,d - 500 7 Assessor's Map/Parcel 1`(3 Installer's Name,Address,and Tel.No. 5d s-qV- 0 S'3 a Designer's Name,Address,and Tel.No. SO r S6 2./617/ airy wu� Type of Building: J Dwelling No.of Bedrooms i, Lot Size �`7 ° sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) r Other Fixtures Design Flow(min.required) //U gpd Design flow provided 3 a'y gpd Plan Date gl a S t ( a, Number of sheets ( Revision Date 4114. Title Size of Septic Tank / rj UU Type of S.A.S. 4" Description of Soil .Q �,� • S Nature of Repairs or Alterations(Answer when applicable) pt�a[.g�n c � C F,e.t�p uaC —y fi /.c-.e.fQ 0VA. �'`"�� S U �l.e�[.•C—4, C G�ee,4,,✓ w ' f Date last inspected: ,,,Agreement: - { The undersigned agrees to ensure the constructiio�a�tid maaii tenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Cdde and not to place the system in operation until a Certificate of Compliance has been issued by this Board 6&. ealt _ Signed //. I� • Date Application Approved by - Date �---- Application Disapproved by Date for the following reasons Permit No. Date Issued J, THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,th t the On-site Sewage Dispo al system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )byat /D # /' /� s, '.1°, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '201�^27y dated Installer (� N�Ll�r Designer #bedrooms Approved design flow Yy gpd The issuance of this permit sh 11 not a construed as a guarantee that the system will function He n Date —j f Ca- Inspector ------------------------------------------------------------------------------------------------------------------- ------------------- 3 No. got — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem)Construction 'ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date Approved by Town df Barnstable Regulatory Services r • Thomas F. Geiler,Director BAMSrABM "�; Public Health Division FD 1A�A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: �0 Zo iL Sewage Permit# ?d Assessor's Ma \Parcel I 3 o 14 P _ Designer: S)Z;RfYd*J A , H-� , AE Installer: Address: 123 97� (fA Address: � On ,� 24 2 P %�a t i was issued a permit to install a (date) (installer) septic system at /o S H-rc c S i D4 .D/Z/v� based on a design drawn by. (address) 57Z:9 ALc�,O A , 1 M�4SLpE dated 1 Z 3 20/2- (designer) �I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lat relocation of the SAS or any vertical relocation of any component of the septic sys ) but in cordance with State & Local Regulations. Plan revision or certified as-b t y deli to follow. T'D1-1 t ft�q yY ,.� Ian 'f3.rt{ ;''YF _ ifFtt an tip. (Installer's Signature) (Designer's Signature) (Affix De igl/ner's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH.THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Revised.doc TOWN OF BARNSTABLE LOCATION MS b l l Sl.(�-Q p C- SEWAGE# 2,0 1-.) - ;kn Q VILL-AGE C-f-0"S `(LV l0-2 ASSESSOR'S MAP & LOT t 3 1 D Ll go INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1500 LEACHING FACILITY: (type) (size) X—SC"(2 G-A L NO. OF BEDROOMS BUILDER OR OWNER O 1-'�Gt l. tf V S PERMITDATE: 1f /Arf a COMPLIANCE DATE: 21101/a Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility rJ Feet Private Water Supply Well and Leaching Facility (If any wells exist j on site or within 200 feet of leaching facility) N.` Feet Edge of Wetland and Leaching Facility(If any wetlands exist ) within 300 fe t of leac g f ty) N l Feet Furnished by � � C4Arpc� A � p to l 3 Town of Barnstable P 4 �� ✓/ _ Department of Health,Safety,and Environmental Services J ,►,E Public Health Division Date t� / 367 Main Street;Hyannis MA 0260.1 BARNMBI$MAM 019. fetes+" Date Scheduled Time I Fee N. ' e Soil Suitability Assessment for Se e Disposal ' Performed By: 6" Z:j7,t� HNAv" P6 Witnessed By: _ l LOCATION &;GENERAL INFORMATION Location Address Owner's Name �,,� e� �� _ Address V d L r t> Assessor's Map/Parcel: 1.q 3/p/4 . Engineer's Name $77&�0-4 6--' NEW.CONSTRUCTION REPAIR ✓ Telephone# Land Use Slopes(%) /O Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft 3 Drainage Way ft Property Line lC-) + ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) �,1 d h t tl :^ �U""Ztr�?Y Parent material(geologic) Depth to Bedrock 2 ' Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Esilinated Seasonal High Groundwater ri;ETIJ INATIO FOR SEASONAU RIG VVA1: R TABLE Method Used:. Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date Ttmc l >axe Observation I Hole# Time at 9" �t Depth of Perc e Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak L I Rate Min./Inch LZ- Site Suitability Assessment: .Site Passed Site Failed: Additional Testing Needed(Y/N) ' Original: Public Health Division Observation Hole Data To Be Completed on Back—� Copy: Applicant DEEP OBSERVATION HOLE LOG `Hole#_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.%Gravel) 22 A l_5 DEEP OBSERVATION HOLE LUG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. J —Consistency.%Gravel Z� t Ilk Ls o1 -�/ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.% ravel X. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.% ravel Flood lnaurance Rate Map: Above 500 year flood 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 throughout the area proposed for the soil absorption system? � If not,what is the depth of naturally occurring pervious material? Certification I certify that on �� (date)I have passed the soil evaluator examination approved by the Department of Environ tal Protection and that the above analysis was performed by me consistent with the required train p ise and experience described in 310 CMR 15.017. . D Signature ate ACCESS COVERS MUST BE WITHIN 9- MINIMUM. INVERT ELEVATIONS : DES I GN CR I TER I A .- GENERAL NO TES : 6" OF FINISH GRADE 3' MAXIMUM COVER 113.8 FIRST 2" TO INVERT AT BUILDING: 110.8 DESIGN FLOW: BE LEVEL MIN 2. OF PEASTONE INVERT IN SEPTIC TANK: 109.0 3 BEDROOMS AT 110 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION 110.2 OR F I L TER FABRIC INVERT OUT SEPTIC TANK: 108.75 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4' DIAM PIPE TEEjjl INVERT 1N DIST. BOX: . 314" - 1 /12" DIA. 10547 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS 110.8 108.75 105.3 2' �° DOUBLE WASHED STONE INVERT OUT DIST. BOX: 105.3 /09 0 v GAS o o a°p 103,2 INVERT IN LEACH CHAMBER: 10✓.2 SET. SEE SITE PLAN. BAFFLE 105.47 0 21 105.2 SEPTIC TANK REQUIRED: "witwitm3 OUTLET 2-500 GAL LEACHING CHAMBERS BOTTOM OF LEACH CHAMBER: 103.2 330 G.P.D. X 20OX - 660 GAL. °A °P W/4' STONE AROUND, 12.$'w x 25'l x 2'd ADJUSTED GROUND WATER: N/A J. ALL CONS TRUCT/ON METHODS AND MA TER/AL S AND D-BOX SEPTIC TANK PROVIDED: 1500 GAL. MIN. MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1500 GAL OBSERVED GROUND WATER: N/A CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6" CRUSHED STONE OR BOTTOM OF TEST HOLE !: 99.0 SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DESIGN PERC RATE C 5 Ml N/l NCH PROFILE : NOT TO SCALE SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT L OAD l NG RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFF i C OR GREA TER 330 GPD / 0.74 GPD15F - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- 1 S TAND i NG H-20 WHEEL LOADS. �, v PROVIDED: 2-500 GAL LEACHING CHAMBERS W14' STONE AROUND. A-471 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 471 S.F. x 0.74 - 348 G.P.D. APPROVED EQUAL. 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED SOIL TEST PIT DA TAN PRECAST CONCRETE OR APPROVED POLYETHYLENE, INDICATES INOICATES BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER PERCOLATION = OBSERVED TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE TEST _ GROUNDWATER OUTLET. TP #1 Ps13712 TP *2 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE". HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. S 83 49 '_go"E 0" 109.0 0' 109.0 FOR L OCA T l ON OF UNDERGROUND UTILITIES. 146.09• A LOAMY l OYR A LOAMY I OYR 5 69°23'00'E SAND 314 SAND 314 8, SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE 26.00' 22"-- - - - - - - - - - - - - - - - - - - - - - 107.2 24" - - - - - " - - - - - - - - - - - - - ' 107.0 DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE CONSTRUCTION INSPECTIONS. C/ MEDIUM J OYR �/ MEDIUM I OYR SAND 714 SAND 714 9. EXIST/NG CESSPOOL TO BE PUMPED DRY. REMOVED GARAGE AND BACKF I L LED WITH SAND. OVERFLOW TO BE r LOT 7D LOCATED AND BACKFILLED. 0 o EXISTING TH,eEE l 5. 120 f S.F. 48" O p , BEDROOM.DWELLING BAh-CORN_ER STEP COVERED WALK '►�ra h(bb � 120" NO WATER 99.0 120" NO WATER 1 99.0 1500 GALLON / /r r �` tK r IV SEPTIC TANK--- SLAB/ EL r r r r �`t. DATE: AUGUST 3. 2012 fr g� :•';.jl -l06.3 109.5 � /r r r I STONEWALL 3 �' r / rr r/ rr /r r /' / TEST BY: STEPHEN HAAS O \ 109.8 �`� IRR/GTIoN BOX @ 110.4 S• w rr /r r / /r / r r/ / r WITNESSED BY: DONALD DESMARAIS /8 TRH rr / rr /r / /r /r PERC RATE: t 2 MIN/INCH - -- .� D BOX! `l . :.ro o� r/rr r rr f / r •Iwr _- _--- -CESSPOOL r-f). YL .----------..-.1 a - -2=500 GALLON r / / // r r r r/ /r 7 t r o - LE4CHIN]C.EHA0ERS N '49 ---- _ '2 fOT.7 k14 STONE ARUND ------------ ' s 12 TREE '- - / r n 1O5.8+ _ _ - -----------.- _.._: - _- 4.6✓ �l / f / --------104---- / / r / r FE SEPTIC SYST" E` M D7SlCN uPx6-o- _ CB/OH FND / i96f l 05 H l LL S l DE OR l Ve . MAP 103 . PARCEL 0 1 4 BARNSTABLLam` . ( cENTERVlLLE ) MA . RourE 6 SER OAo LEGE ND PREPARED F' OR ■ CB CONCRETE BOUND D O N A L D R E7 E vE� S -W WA TER L I NE 5�° O HYDRANT SCALE I 20 AUG'US T 23 , 2012 L OCUS ---G---- GAS L I NE OHW- OVER HEAD WIRES S T E P H E N A . H A A S WEOvaOUET # LIGHT POST ENGINEERING , I N C LAKE -E'--- UNDERGROUND ELECTR 1 C LINE -T- UNDERGROUND TELEPHONE LINE �� %` 9 23 R o u t e 6 A -CTV- UNDERGROUND CABLEV I S I ON LINE / i�� 1 �l �~ Y c► r mo u t h p c� r t MA 02675 ` \� -4-40.4 SPOT ELEVATION ( 5O8�-�- ��,�� ) 362-8 1 32 ........40------- LXISTING CONTOUR ( 508 ) 432-5333 401 PROPOSED CONTOUR LOCUS MAP 0 lQ 20 40 JOB NO: 12- 124