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Home My WebLink About0027 HOLLY HILL ROAD - Health 2T ttoltyn°RUFRoad r Centerville P A - 187 017 S111 �10—cub� UPC 12534 No.21153LOR HASTINGS,MN f FROM :down cape engineering inc FAX NO. :150e3629880 Apr. 21 2006 Oe:33AM P2 i down cape enq ineerinq, inc CIVIL ENGIW6 & LANP 511MYOF5 959 MAIN 9r/ WUTf 6A YARMOUTWOK, MA 02675 (908) 362-4541 FAX (508) 562-9880 r y April 21, 2006 Town of Barnstable Health.Department Tom McKean, R.S., C.H.U. 200 Main Street Hyannis,.MA 02601 Re: Amylynn Guthinger, 27 Holly Hill Road, Centerville,MA Dear Mr. McKean, This letter is to verify that the cabana house building sewer at the above referenced location is directly connected,to the septic tank. Our firm dug up the septic tank cover and determined by flush test that the effluent from the cabana building is piped into the existing septic tank. Please do not hesitate to contact me should you have any questions and/or comments. Sincerely, d, H OF 4c OJALA CIVIL y e•./1 r1 —'� No.46502 Q Daniel A. Ojala,P.E., P.L.S. (;IsTE�``�t��` Down Cape Engineering, inc. �SS ION AL DAO/hdv Town of Barnstable Health Inspector optHe Toy, Office Hours y�e` do Regulatory Services 8:30-9:30 Thomas F. Geiler,Director 1:00—2:00 • sARNSTABLE, + "�: ,.� Public Health Division AlE p �s Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-63 AMNESTY PROGRAM APPLICANT— SEPTIC QUESTIONNAIRE 1. General Information: Size of Property: �Z Address: Map IS7 Parcel ell Name: /x I Phone #: /7 0 -�J��v7 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? -- If yes, how many? 2c. How many bedrooms total are proposed at this property (including the amnesty unit)? 2d. Please include a copy of the floor plans for the entire property - showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES or NO If the dwelling is,c-onnected toTpublic sewer skip,questlons,##4�'through#9:below, 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or "?,NO 6a. If yes,how many bedrooms were approved according to this permit? Fedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES CDor :NO u�. .8. Is there an engineered septic system plan on file at the Health Division? kL 9. Has the septic system been inspected by a DEP certified inspector within the last two ye03 FOR OFFICE USE ONLY 2The Public Health Division has no objection to / bedrooms at this pSpecial Conditions. Signed: te: Z q O;/hea1th1wpf1es/amnestyapp "'Y I r 02/09/2006 10:26 15087906230 BUILDING PAGE 02 4 r2� L � tITCHEN BATH ' L ete SUE UIT r b - eaa ea (' b p aNt nMfaoce ew q . -10e B m 4.z-.r t f FLOOR PLAN 5CALC: I/A'- V-O' CONT.wooe VENT T 12 '3Y s)zztoy ® 112 w X l o11v! la/ i TO 5TORAGI; ti .V.T 91UNLOAT 1 UE5 r3DTRArrING �vQy\Z` 1 O urre 00 �� O15Ck • 4 Q T o BROOKIla MR51 rLOOR SuDF=R . w,w lbf � N l ' CRAWL 5rACE aO'a 5o'a I" O04CRtm COI.rAP 1 6LD . 5E,CTION SCAL2e 1/4': I'1T y tJ C9 L0 t N M `1 09 1 0) sQQ 7S b® S? OI �b 1 p 1 R N Ul OD m i 9 C t 4 gaQl I p) n "�$I 1 N 1 J m �T� I z,iz 'a I (A I I 4 L�J 70 -D I I I e� j rn -- I -d 1 I1 II 1 4 I L 1 I I H sit 1v 1 DATE 08/1%/03 AIMEE GUTWINGER IDMSQH27 �M HOLLY WILL RD. M,M � Q sw-u p GENTERVILLE, MA. 02632 NF7IETH L MJRPHY 2 11 D QMC� Y �� C t s+/m1 a w► P> GUTHINGER Az. W f 02/09/2006 10:26 15087906230 BUILDING PAGE 04 'ANOMSEW WINDOW_A21 ' Ia 12r El I A B RAR[WARD wr1T1 I r S MM.11mcAL®GAstr r.N49 W.C.9ITINGL=.S.-r,W.3.TMCAL I A G CORNGR OOARM.TYRCAL - ----- (�Qrec� C --_-__ � ASS - - --_- \JJ FRONT ELEVATION 'GALE: 1/d' 6� On reNDOW GAS rIP47LACC vew I I 1 I I 1 1 ——— - ———————— —� RIGHT SIDE ELEVATION SCAM 1/4'— I'-0' 02/09/2006 10: 26 15087906230 BUILDING PAGE 05 y Q d �Z 6 NIJ I Z,I g I x 9 fWczE,TWICAL 1 1 1 TT OCWN9POVf OD R 1 DI't WNDOW Z /RAT�<mR I I O Pao ------------------- LEFT 51DE ELEVATION SCALE: IW— I'.0- 21 AN0MeM WNDOW•A21 N 12� ® N ............... ZJ U1 QL i w ul ------------------ REAR ELEVATION SCALE: 1/4' 1'47 T I L I L 1_ !I -J--i AL-L ---- -------- -A-J. _J_ __ff illv, L-J LJ L J TOWN OF BARNSTARL.E LOCATION SEWAGE # — � �y ASSESSORS MAP & LOT VILLAGE INSTALLER'S NAME&PHONE NO. 57 SEPTIC TANK CAPACITY LEACHING'FACILITY: (type) j NO.OF BEDROOMS--- ' BUILDE OWNS a PERMTTDATE. COMP LIANCE DATE: O� ! Separation Distance Between the: 'I Feet Maximum Adjusted Groundwater Table tothe Bottom of Leaching Facility l Private Water Supply Well and Leaching Facility (If any wells exist. o' Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leachin�lity) IFurnished by O ! lip �00 ,�'h d Sh 1 ,_ TOWN OF BARN/STABLE 000 1113105 �LOL'P.--''ON -7 �•>e��fs�� /iy SEWAGE # _ 0-7 ~' VILLAGE 0;4Y-ervj11e ASSESSOR'S MAP & LOT Ar"49!P/ INSTALLER'S, 4' &PHONE N0. ly6e.-d4, d®ld _AT SEPTIC TAN'I{�CAPACTTY -6 LEACHING FACILITY: (type) NO. OF BEDROOMS J' BUELDEkT OWNE rERMTTDATE: 1� COMPLIANCE DATE: 0-3 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 (1f any wetlands exist within 300 feet of leachin ility) Feet Furnished by o-°✓ i 3 "[ V - QQO L No. 0 —c�0 Fee THE COMMONWEALTH OF MASSACHUSETT'S 3 Entered in computer: IZ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZppYication for Mig �-*p�tern Construction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No.,L7 y //d /fVikd Owner Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. A d'A-Y CQ�V.V Type of Building: Dwelling No.of Bedrooms—`� Lot Size / sq.ft. Garbage Grinder Other Type of Building No.of Persons 5 Showers( ) Cafeteria( ) Other Fixtures Design Flow 5-50 gallons per day. Calculated daily flow S5—Z gallons. Plan Date :Z/ Z&A3 Number of sheets Revision Date X/ Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d bythis Board o�� Signed Date Application Approved by tw, Date Application Disapproved for the following reasons Permit No. a 0 09 Date Issued l Fee — THE COMMONWEALTH OF MASSACHUSET _7__r Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zlp rication for �Digoo - *pgtem Construction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ' Location Address or Lot NoA 7 lloltl l7.�� oet Owner(�Name;Address and Tel.No. Assessor's Map/Parcel Celt 7",er-v 1*7 8 7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. co/jv- 17t - z//Z& Type of Building: Dwelling No.of Bedrooms_`J Lot Size 3 sq.ft. Garbage Grinder(1� Other Type of Building No.of Persons .S Showers( ) Cafeteria( ) Other Fixtures Design Flow S5V gallons per day. Calculated daily flow Ss+Z- gallons. Plan Date Y 2 Zca3 Number of sheets �/ Revision Date di. Title Size of Septic Tank ( �� Type of S'A.S. S w G�t1„. r �. etj r� Description of Soil a �' Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: `**'The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system, in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi' cate of Compliance has been issued by this Board o ealth. Signed Date S 7 Application Approved by 1/,J. S Date r / Application Disapproved for the following reasons Permit No. - *;t Q 0�- Q UX. Date Issued 7 - ------------------------- — l 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 e 04je-r at `Z r7 o k y 1�_W ; de w�" has been constructed in accordance with the provisions of Title 5 and the for Disposal System,Construction Permit N .QUO 3-ol V 9 dated 's Installer ��e�'Qi� ��— `' i Designer M� _ s c'{d./t~2� 7 The issuance of th's pe#init shall not be construedlas a guarantee that the system wrl' n e'igned.S, Date �o S D 3 k Inspector_ ------ ------------------ ---- -- No. 200 auk � t e Fee So THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 0iou ar 6potem Construction Permit Permission is hereby granted to Construct( )Repair( -5 Upgrade( )Abandon a'1 System located at 11Y and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this ermi . Date:_�0; Approved by YIN y iL�. TOWN OF BARNSTABLE 1,C)CA-11.ON 0 NO y � Rc� SEWAGE # `4VtLLAGE &An Ciyi)&, ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 9L " Ste/ e S 6esuotl.s LEACHING FACILITY: (type) ces J CD S (size) NO. OF BEDROOMS 3 BUILDER OR OWNER E �e. M4r�Or/f, CUm,�+)ASS 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 CF►Furnished by SDeUn FOiC L l3Ath in (SgS�e�T . . . a*3 A3- . Ay- IP1 �3y- (00 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL. PR �NED MAR 0 5 2002 TOWN OF BARNSTABLE HEALTH DE PT TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 27 Holly Hill Road SYSTEM#2 Centerville, MA 02632 Owner's Name: The Estate ofAfariorie Cummings Owner's Address: Same Date of Inspection: February 19, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 187 Osterville,MA 02655-0049 Parcel: 017 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 N ds�Further Evaluation by the Local Approving Authority F ils 1 Inspector's Signature: _ Date: February 21, 2002 The system inspector shall subm 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 I f Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate oTMariorie Cummings Date of Inspection: February 19, 2002 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 l 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 I Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate of Marjorie Cummings Date of Inspection: February 19, 2002 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: 27 Holly Hill Road Centerville, MA Owner: Estate ofMarforie Cummings Date of Inspection: February 19, 2002 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 '/2 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 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 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.] 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 must serve a facility with a design flow of 10,000 gpd to 15,060 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate ofMariorie Cummings Date of Inspection: February 19, 2002 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 ? n/a 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 f Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate of Marjorie Cummings Date of Inspection: February 19, 2002 FLOW CONDITIONS RESIDENTIAL Number ofbedrooms(design): n/a Number of bedrooms(actual): 3 Note:Slop sink, laundry, and DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 bathroom in basement flow to Number of current residents: 0 this system. Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 1999-44,000 gals.; 2000-32,000 gals. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gnd 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: None on file-per treatment plant 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 ✓ 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 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Holly Hill Road Centerville, M4 Owner: Estate of Marjorie Cummings Date of Inspection: February 19, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Under slab 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: 2'6" 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 5'T x 12'bottom to grade Sludge depth: Ft Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 0" 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: Measuring 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. No scum was present A slop sink laundry and a bathroom in the basement flow to this system. An outlet tee was present. 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate of Marjorie Cummings Date of Inspection: February 19, 2002 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 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Holly Hill Road Centerville, AM Owner: Estate of Marjorie Cummings Date of Inspection: February 19, 2002 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 12'bottom to grade and was dry. No scum line was present. Clean sand was on the bottom. There were no signs of failure. The cover was Y below grade. 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate of Marjorie Cummings Date of Inspection: February 19, 2002 Map: 187 Parcel. 017 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. l�as� V- ' sY � 5� .la �/- Yo a3 81 Ll / 63- A a- 50 . T Go y 10 v Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate of Marjorie Cummings Date of Inspection: February 19, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25'+1- feet (Adjusted High Ground Water Level was 18.7) 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: You must describe how you established the high ground water elevation: The bottom of the cesspools to grade was approximately 12'. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 25'+/-to ground water at this site. Using the Cape Cod Commission Technical Bulletin, the high ground water adjustment for this site (Ml W 29, Zone D, 10/01)was 6.3. 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 BA.RNSTABLE Lr..rCAJ1ON �� 01I l'41 I I SEWAGE # -_"VILLAGE Cer►T�ciV� ASSESSOR'S MAP & LOT /97 o ? INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY US Spa I LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 BUILDER OR OWNER IMAM D n e. CVY►�►M 1/ici.S 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 facility) ) Feet Furnished by htACC IU✓1 b�C '� t 3A�k AJ %JB p yl i �a" S° f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 27 Holly Hill Road Centerville, MA 02632 Owner's Name: The Estate of Marjorie Cummings Owner's/Address: Same ; / Date of Inspection: December 11, 2001 ' � p 1' Name of Inspector: (Please Print) James M. Ford M -- Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 187 Osterville,MA 02655-0049 Parcel: 017 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 Con nally Passes Nees er Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: December 12, 2001 The system inspector sh\suba 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 I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate of Marjorie Cummings Date of Inspection: December 11, 2001 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: 27 Holly Hill Road Centerville, MA Owner: Estate of Mariorie Cummings Date of Inspection: December 11, 2001 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 CNM 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: s 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 r Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate of Mariorie Cummings Date of Inspection: December 11, 2001 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 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 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.] No (YesfNo)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 must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate of Marjorie Cummings Date of Inspection: December 11, 2001 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 ? n/a 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: 27 Holly Hill Road Centerville, MA Owner: Estate of Marjorie Cummings Date of Inspection: December 11, 2001 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: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 1999-44.000 gals.; 2000-32,000 gals. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: None on file-per treatment plant 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 ✓ 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 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: 27 Holly Hill Road Centerville, MA Owner: Estate ofMariorie Cummings Date of Inspection: December 11, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC ✓ other(explain): Orangeburg pipe 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: 16" 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: S'W x S'T x 9'bottom to grade Sludge depth: 1'6" Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 0" 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: Measuring 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 1'6"ofsludge on the bottom. The outlet pipe was broken off. Recommend repairing or installing new PVC line. The cover was 16"below grade. 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 I Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate of Marjorie Cummings Date of Inspection: December 11, 2001 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 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate ofMariorie Cummings Date of Inspection: December 11, 2001 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: 1 Innovative/altemative 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 S'W x 4'T x T bottom to grade. The cesspool was dry. The scum line was 2'6"up from the bottom. There were no signs of failure. The cover was to grade. 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.): i 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 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate ofMarlorie Cummings Date of Inspection: December 11, 2001 Map: 187 Parcel: 017 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. 3AGk '� f3i - yl S° (o- SFS a 10 Page 1 I of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Holly Hill Road Centerville, MA Owner: Estate of Marjorie Cummings Date of Inspection: December 11, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25'+1- feet (Adjusted High Ground Water Level was 18.7) 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: You must describe how you established the high ground water elevation: The bottom of the cesspool to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 25'+/-to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high ground water adjustment for this site (Ml W 29, Zone A 10/01)was 6.3'. 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 andlor this report. 11 GrA de. Ors 1 °�•a 14,C)k Grovn leve i � /oJol o2S: 0 �Plo. GrovA(�WATer I eve I D L W J Z Z U) W J= N n ay ppz EJA LY µ�LL ROAD / 5.1 I,j NOL _ti opD \ / Ye tj :a: � ` 114.E 21.101 is 11" V G� LOT AREA / / // ` // 1/ IHE OF EXISTING 37,344t 50. FT. / ((� 1 Wr CIA= m g PROPOSED ' aNil I EXISTING GARAGE 1 / a U cA m�Oo w. P DITION �` l }jn I In 4(p, PO1,x /L Ix3 pm or_r TING / / PRO OSED/ SITE PLAN LU SCALE=V-20' J V ` TNS Pew K4IST OEP3 TED V /� PREPARED FOR AIMEE GUT14 NGER �� Fes• DATED AUGUST 15 2005 L LU R LU Z i QNV I I . 1 Z � N rc� I CONT CONC.PTG Twl _•——�— [i �1\ ®rQTCMEN=V B O FTO 4'-0'MIN.m IBe Ow wN.GKAGeI a i I CRAWL SPACE I Xcu I24' 6'4 POCKeT I ' (- � m ------ --- ————— r—� I I I I ( I B0.0P WALL SUITE h g I i � J I I FORBRC07 UST ¢ 4 I ICONC.P3OOPNGS x 12' L—J I I BULKN611p ITmICAL a-12'Du .p a 5'fEel LALLY COWMNS L�kppp5eI LOCH=t i. I I II 1 �r�.�r.r�•rr��...GC�IBNN9(d... N 2446 I \ d446 � I A j: ' I W.� •'�\ MMG068 '- I I WOOD DEC a I I I OB 5 Pf. I I 10'SONOTU5G 7$ 5'-4 SW' 7$ 4 x 4 P05T J e$ a$ c y FLOOR PLAN g$ perp(( A H Fi SCALE: 1/4"= 1'-0' FOUNDATION PLAN SCALE: 1/8°= 1'-0' CONT.RIDGE VENT 2x 12 RIDGE BD ,as G' 12 N cl�-,b 2 z 8's•16.O.C. p � A M STORAGE H 2x I 5@ 16° TOP O (2)2-2 x E's BA - .. I/¢•CDX PLY.BM, .W/SYJ MCOAT coo IX35TRAPFING o I x 4 BEAD�5 BEARD W GUES i ON 2 x 6.IClsts LSUITE N D�rt��••'•`yK Ib•O.C. 2x 10 KOOK KArMFt5 �Vy' 4 u n N W,CL2 T WRAPPED ®16.0•C. a �y +Lr � i,; m m. Lei K 5 BFLOOR D D FIRST FLOOR I x 4 mmodAW bEOKINd 5UBPLOOK O.C:. _. P. x s slM AB44 AlUlUtIllf1lAIdQ�tJR W/6/B�P .B. � LVl BEAM � � —— —— /`// � CRAWL SPACE 4 b,,Q° E 10�0 SONG TUBE5 W Lmu .. - y w lu 301x 30'x 12" CONCRETE COL.PAD Lu m$ °QNV E3LDG. 5ECTION FRAMING FLOOR PLAN SCALE: 1/4'= I-O° SCALE: I/4°= I'-0" �Y r 1 s'-o" 10 J� 2 Bet 4 2-32 5�� 2'-32 /V \ BENCH SEAT o FIR0POSED- / FLO STATION K I\TECH EN GAT EDRAL i 305 S FT. ci a PATIO G B' 4' KITCHEN DESIGN 00 I BLUESTONE I U o ISL IND BY OTHER AND ! I � ��N I Ly� OWNER o I w o z co 4'-4" I cn WIN CABINET Q w UN. ER v � 8" DIA.COLUMN (o 20'-41 I 2 ON HALF WALL STEP. OWN 6" Z � � �� 4n_ - . — - - - — 3'-0" rY42Q � L �l �goz Z o EXISTIN E NEW i / Q M . BED DINING I / U m ui _XISTING BASEMENT F AREA I / W `� ACCESS — o 1� I / j v o \ I / � W J FF-- CL N H ALL SED � ,AR _ _ — — — — — c�osE GE E SLAB FT. OW70 P/4 ki 14 (/f N EXISTING - a LIVING ROOM EXISTING BEDR e DEN BEDRO 1SE EXIS INGj 4001 RHEAD GARAGE DOOR FRONT D OR `N CUSTOM TRANSOM ABOVE 11 I RE M VE BAY WIN[OW WpH2852 WDH B52 WDff 852 - - N E W DECK 8" COLUMN MAHOGANY i TOP FNDN. AT EL. 31 ,7' SYSTEM PROFILE TEST HOLE LOGS "- ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) ACCESS COVER WATERTIGHT To ARNE H. OJALA PE (WATERTIGHT) ENGINEER. 25.0' MINIMUM .75' OF COVER OVER PRECAST WITHIN 6 OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 24,0 DAVID STANTON 4 � WITNESS. 2" DOUBLE WASHED PEASTONE RUN PIPE LEVEL DATE: 4/22/03 a o oA 2$.3 FOR FIRST 2' 3' MAX. < 2 MIN INCH IRS ' PROPOSED 1500 PERC. RATE - 0v� 021 GALLON SEPTIC t 21.33' �`� R 1 22.0 21 .75 ("� CLASS _ _ SOILS P# 10472 Locus TANK (H- 10 ) GAS21% .Q O 0 [� [� (� [� -`-- BAFFLE 21 .17A<� G' 205 Cp M CJ r-1 Cl F-1 ED 0 0 4' AROUND 23.5'f * CQC70M 0 EJ0MM 6" CRUSHED STONE OR MECHANICAL 2' .. a Q 0 171 d 177 � � 171 [�] ELEV. COMPACTION. (15.221 [2]) `b' o-- 18.5 „ V QOE� DEPTH OF FLOW = 4' 6 2-I- � 2 3.5 S�v ( % SLOPE) ( SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED ST'JNE . 0 TEE SIZES: INLET DEPTH = 10" 1 " OUTLET DEPTH = 14" A • �LS LOCATION MAP NTS FOUNDATION- 68 SEPTIC TANK 10' D' BOX 21 LEACHING 4" 1OYR 4/3 56' FACIL! Y 51 ASSESSORS MAP 187 PA CEL 17 E ZONING DISTRICT: RD--1 , FS YARD SETBACKS: ! *THE INSTALLER SHALL VERIFY THE 1011 7.5YR 5/1 FRONT = 30' f LOCATIONS OF ALL UTILITIES AND ALLBUILD ` f PRIORING TO SEWER OUTLETS LANY PORTIONELEVATIONS ILL ROAD _ _ _ �� 27'2 B SIDE 10, j", SEPTIC SYSTEM DOLLY K r -k zs1 LS 10 r, 31 _ 13.5' 24" 10YR 5/6 PLAN REF. - 21. 26,3 Cl FLOOD ZONE: C 114.66 27.0 S 26, PERC LS + 79,4 .3 25)9 , VV 58 II„ . .. 1 QYR 5/$ ! - u L-63.24 C2 I 21.10 R-_47 5.00 AP ROX. GAS W G 28.4 M5 22. LI E AN 7 2.5Y 6/4 ATE LIN , 120" 13.5' \ 5 N 0 NO WATER ENCOUNTERED NOTES: i n / SEPT!r NOT AI_I.OWFD ti / + 2 Q-- 1 I Hr4'ftVX. NGVU DESIGN FLOW: BEDROOMS ( 110 GPD) = 550 GPD 3o.a ?. MUNICIPAL WATER !S EXISTING .,r, cr�nr,� �r r•t;1 LOT ,AREA ! USE 550 n D� 3 ,:544 t 5 r'I'. 1 3. MINIMUM PIPE PITCH TO BE '1/8" PER FOOT. 31.01; SEPTIC TANK: 550 GPD ( 2 ) 1100 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 + 3 .a 32,E USE A 500 GALLON SEPTIC TANK 5. PIPE JOINTS TO BE MADE WATERTIGHT, EXIST, DWELL. 31.5 LEACHING; 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. TF - 31.7' 2(47.5 + 10.83) 2 (.74) = 172 ENVIRONMENTAL CODE TITLE V. SIDES: 7. THIS PLAN IS FOR PROPOSED SEPTIC SY,'TEM ONLY )AND IS NOT + q g INV. OUT 23.5't 47.5 x 10.83 (.74) - 380 TO BE USED FOR ANY OTHER PURPOSE. (UNDER SLAB) INV. OUT 28.3' 3 8 , BOTTOM: 8 PIP FOR SEPTIC Y "+ a�i / cs� 747 552 E 0 SEP C SYSTEM TO SCH. 40-4 PVC, cv7 L ! .4 c3! TOTAL: S,F. GPb 9, COMPONENTS NOT TO BE BACKFILLED OR CONCEALD WITHOUT N X , USE (5) 500 GAL. LEACHING CHAMBERS (ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION', OBTAINED o t.3 A OD 5' STONE AT ENDS AND 3' AT SIDES FROM BOARD OF HEALTH. + 2 .6 O 1 I PROVIDE 32.6 1 1 EQUAL) WITH 2. 10. PUMP & REMOVE OR FILL W CLEAN � SAND EXISTIN� SEPTIC SYSTEM CLEANOUTS AS � ( / ) E C O 1 I NECESSARY X I N i w BENCH MARK - NAIL SET IN I FENCE POST EL. = 33.2 rn + 24. H LL X 1 + 30.3 + 32.3 ?3.5 -LEG E N TITLE 5 .�TE PLAN + 1$5 + 29 g X . LL__JJ I-�. 0) 4 OAK 100.0 PROPOSED SPOT ELEVATION + 22,3 OF 7 H HILL R OAV' : I , i C 24„ 0 K }c H 100x0 EXISTING SPOT ELEVATION IN THE TOWN OF. 7,9 10Q PROPOSED CONTOUR C ENTERVI LLE) BARNS AB LF _ HOLLY 268 100 EXISTING CONTOUR PREPARED FOR: HICKEY CONSTRUCTION GUTHINGLR 7 14" OAK ' 20 0 20 41 40 6 x 1 x BOARD Or HEALTH „ - 4 PRUCE + 2 + 30.7 X�_X�-�-X MA SCALE: 1 " ,20' DATE: APRIL_ 24� 20Q3 30 31 APPROVED DATE 29 19.9 2g 12" PINE /. fax 508 asz-988o 27 down cape engineering, inc, OF M CIVIL ENGINEERS �y>� �r �. � pF M Ass9� � AR H. �G q� N ems : 4 LAND SURVEYORS a . LA '^ H = c IL t 03- 06 939 main st, ydrm uth; ho, 02675 _. . �s �F f 1E4 q si G� s S. roNq O ATE