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HomeMy WebLinkAbout0015 HOLLY LANE - Health 15 Holly Lane Centerville F/R A = 228 027 No. 4210 1/3 ORA Pendaflex' 100 0 r" o� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 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. A. General Information 1 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 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 by the Local Approving Authority 6-20-10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. V v t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage D osal System-Pa, R c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 it page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: 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. 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 s.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 Lk t5insp official document•03/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 y Commonwealth of Massachusetts . Title 5 Official Inspection Form Su bsu rface.Sewage Disposal System Form -Not for Voluntary Assessments 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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)jb)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. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 1- . - - --------------- Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6°below invert or available volume is less than '/ 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. t5insp official document•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I I� J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface,Sewage Disposal System Form -Not for Voluntary Assessments a 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No. I I I s $ ❑ ® 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.) El ® 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 L Commonwealth of Massachusetts N W Title 5 Official n Insp ecti0 Form r m _ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 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 CM 15.302(5)] I t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 6-18-10 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �nM 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner--pumped last year Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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): Approximate age of all components, date installed (if known) and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"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: 12" Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness. 0 Distance from top,of scum:to top of outlet tee or baffle 6"- Distance from bottom of scum to bottom of outlet tee or baffle- 6 How were dimensions determined? Tape t5lnsp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 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.): 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 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): t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 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. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM ' 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. 1�5 E) G _ r p_0 t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 16 d Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Holly Hill Rd Property Address Kristine Callahan Owner Owner's Name information is required for every Centerville MA 02632 6-18-10 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: 10, 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: pate ® 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 10'. t5insp official document•03/08 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 I TOWN OF BARNSTABLE 4 LOCATION ,�d LL y L AA/e SEWAGE# 0 d 411f . 'YLLAGE C e..lfe hill P ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO.- 4A A C D A4{4 e If * S vA SEPTIC TANK CAPACITY / S G O LEACHING FACILITY: (type) L e A Cf/ Z 12 (size) 3,2 ox U''' 4 NO.OF BEDROOMS BUILDER OR OWNER 4a 2 PERMIT DATE: 5Z Z)� COMPLIANCE DATE: 1 03 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist .within 300 feet of leaching facility) Feet Furnished by 1 ' 1 I � / city z I've J Re $50. 00 No. �r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pphration for Migpogaf 6potem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System O Individual Components Location Address or Lot No. 2 2 8—2 7 Owner's Name,Address and Tel.No. 15 Ho.L.Ly Lane Cen;te zv.i ue, Nazz. Ke z zy Sm.i.th Assessor's Map/Parcel 27 15 Ko.L.Ly Lane Cen.te zv.i.L.Le, Oazz. Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—2 7 3-0 3 7 7 a. P. Nacomge2 & Son Inc. aC Eng.inee2.ing 2854 CzanPtie22y High ay ox 66 Centeltv.i.L.Le, t7a.6.6. 02632 Caz.t Naiteham, t?az,3. 02538 Type of Building: Dwelling XXANo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 331. 52 gallons per day. Calculated daily flow 3 X 1 10=3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 7 i i i .to zandy .Loam .to fine medium coat.6e .6and. { Nature of Repairs or Alterations(Answer when applicable) I n z.t a.L L-i n g 1— 1 5 0 0 ga L.L o n .6 e/z._-i c ,tank. 1—Di.4b2-iPat.-ion fox. 14'X32'X6" w.i.z<h 40 Ni.L .L.inez, 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 of Health. Signed — Date 8127103 Application Approved by Date '97-O-7 Application Disapproved for the following reasons Permit No. 200 3 It Date Issued THE COMMONWEALTH OF MASSACH'USETTS Entered in computer: Yes s PUBLIC HEALTH DIVISION -TOWN OF BAR TABLES MASSACHUSETTS ' rtcatiotY for ig oga[, p tent Con!Orurttou Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) A[2�Complete System ❑Individual Components Location Address or Lot No. 2 2 8—2 7 Owner's Name,Address and Tel.No. 15 fto eiu Lane Centeay.itle, Na.5d. Ke22y Smith ,AOF,ssor'sMa,p/Parcel ' 27' 15 HoLey Lane Centeavi fie, lea sb. / Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—27 3—0 3 7 7 �. P. Nacomgea 9 Son Inc. IC Eng.ineea.ing 2854 Caangeaay High oay Box 66 Centeay.iiie, Naa.a. 02632 East ldaaeham, Naaz. 02538 Type of Building: ," A. 11 Dwelling XXXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures t - Design Flow 3 31. 5 2 gallons per day. Calculated daily flow 3 X 1 10:3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S.-------`'_ Description of Soil 7i ei to •sandy .foam to Tine medium coaa.se .sand. t. (Answer Insta iin 1-1500 a-Uonnrse t.ic �. Nature of Repairs or Alterations(Answer when applicable) 9 9 R tank. 1-Dis.ta.igut.ion aox. 14'X32'X6" with 40 Nii einea. Date last inspected: Z ell 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 of Health. Signed ,/ ae► _ Date 8127103 ' Application Approved by ' Date Application Disapproved for the following reasons Permit No. 2 0o 3- L( Date Issued - 2 - 3 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed.tQ/. Repaired( )Upgraded( ) Abandoned( )by 1. l. Nacomgea 9 Son Inc. at 15 Nott y Lane Cent eav i fie, l'1a i s. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '-a-�3_ q(Q dated 2 S-6 3 Installer J. 1. Macom9e/t 9 Son Inc. Designer 1C En .ineea.ing The issuance this ermit shall not be construed as a guarantee that the syste c 's s fined. Date - d 3 Inspector 1J L q ; No.2Q0�� Li( / Fee$50' 00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Di5pozaf &pgtem Con5tructton Permit Permission is hereby granted to Construct(XA)Repair( )Upgrade( )Abandon( ) ,System located at 15 Ho-Utj Lane Cent vw iUe,Naa.s. 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: Conn/struction must be completed within three years of the date of this perm' . Date:_ a - 2 �"03 Approved by TOWN OF BARNSTABLE LOCATION �� ,�d LC y I- ANe SEWAGE# x C 6 3 411f VILLAGE C e,4171e0c V,,Il P ASSESSOR'S MAP & LOT 2,9-02-7 INSTALLER'S NAME&PHONE NO. T .4A A C O,K 8 f It * S vA,' SEPTIC TANK CAPACITY 1 So O LEACHING FACILITY: (type) L e A C11 f e 12- (size) 3,2")r/4 a G r k. NO.OF BEDROOMS .� BUILDER OR OWNER PERMTTDATE: � COMPLIANCE DATE: ` — Separation Distance Between the: Maximum Adjusted Groundwater Table.to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist ' on site or within 200 feet of leaching facility) _ Feet Edge of,Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i V I •� I ` r , r i l7 ; + i TOWN OF BARNSTABLE LOCATION - l s� l4/J 01'x'1 !Q/�- SEWAGE # '11LLAGE Ck� ' t Crv,l� 2 ASSESSOR'S MAP & LOT 19-28 - O;L INSTALLER'S NAME&PHONE NO. CM28A n,- SEPTIC TANK CAPACITY ClVa A LEACHING FACILITY: (type) 3 P10W (size) NO.OF BEDROOMS BUILDER OR OWNER SM �, PERMPTDATE: 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 facili ) Feet Furnished by��Sn c�on J• �0 Q O a 03 y A d 3(p �S a3(baa 3 301 a7 y 33 a� (03 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FAILED INSPECTION RECEIVED MAY 3 0 2003 TITLE 5 T�WHE�ALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSME SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 15 Holly Lane Centerville, MA 02632 MAP Owner's Name: Kerry Smith ©.�� Owner's Address: 6097 Franklin Gibson Road PARCEL Tracy's Landing. MD 20779 [_CT Date of Inspection: May 14, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 OsteryUk,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ✓ F ils Inspector's Signature: Date: May 18, 2003 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 i y Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Holly Lane _ Centerville, MA Owner: Kerry Smith Date of Inspection: May 14, 2003 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: 15 Holly Lane Centerville, MA Owner: Kerry Smith Date of Inspection: May 14, 2003 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(l)(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: 15 Holly Lane Centerville, M4 Owner: Kerry Smith Date of Inspection: May 14, 2003 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.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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: 15 Holly Lane Centerville, MA Owner: Kerry Smith Date of Inspection: May 14, 2003 Check if the following have been done: You must indicate`yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components, excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 15 Holly Lane Centerville, MA Owner: Kerry Smith Date of Inspection: May 14, 2003 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2001 -210,000 gals.;2002- 180,000 gals. Sump Pump(yes or no): No Last date of occupancy: Approx. 1 week ago COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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: Unknown Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: Qallons--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: Dec. 5185-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r Page 7 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 15 Holly Lane Centerville, MA Owner: Kerry Smith Date of Inspection: May 14, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 8" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of sum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" 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.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage 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 r OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 15 Holly Lane Centerville, MA Owner: Kerry Smith Date of Inspectiion: May 14, 2003 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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Above 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.): The liquid level was above the outlet invert and the scum line was up above the pipe The D-box was broken down structurally. Dirt was caving in. 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: 15 Holly Lane Centerville, MA Owner: Kerry Smith Date of Inspection: May 14, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 flow diffusors-per as built card 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.): I dug down in the stone beside the flow diffusors The liquid level was up to the top and the stone was black The flow diffusors were in failure. The bottom to grade was 32". 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: 15 Holly Lane Centerville, MA Owner: Kerry Smith Date of Inspection: May 14, 2003 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. A 1 a 03 y A 4 / 3 a3(6aa 3 39 a7 y 33 a9 10 f .. 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: 15 Holly Lane Centerville, MA Owner: Kerry Smith Date of Inspection: May 14, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 10 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours man the maps were showing anproximatel y 10'+/-to ground water at this site. This report has been prepared and the system inspected and failed 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 l - i No. :. �1. Fps... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............OF.......P`.> -rAB. .... Appliration for Disposal Works Tonstru.rtion ramit Application is hereby made for a Permit to Construct (V-�or Repair ( ) an Individual Sewage Disposal System at ....16....ilicisviiey. ..... .....kJ all; � -...-----!':!� ��......- L ti Address or Lot No. o .... ....._ �= .t .. r ... ._..... ------ ..cep........fq- erAd Installer Address 7---------- Type of Building Size Lot..... i. .-Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixture . ------.......-----••------------------------•-•----•---•---.......--••-•-----••-•------....----•----- W Design Flow.....................�......Ip..........gallons per person per day. Total daily flow.....................3. 0........_gallons. WSeptic Tank—Liquid cap ity.l000.gallons Length................ Width................ Diameter................ Depth....._.......... x Disposal Trench—No. ............ Width....../2 ...... Total Length..... S'Z—.- Total leaching area.... 74.sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( V) Dosin tank ( ) `" Percolation Test Results Performed by... 1 .. 1_. . _.._._... . Test Pit No. 1.....79i;n....minutes per inch Depth of Test Pit______1 '__.. Depth to ground water....... ----------- 44 Test Pit No. 2......:Z—...niinutes per inch Depth of Test Pit....... ...... Depth to ground water........................ P4 .-••••-•--•------------••••....••---••••...................................................................•------•--••-----------........._......----•....-- 0 Description of Soil...... ....... ........... ..._ ------------------------------- --• ------- U .-•------------------------------------•-- .. .....e...../�I .:...�AA1>-------�---- Z VJZ ..,•............................................ W VNature of Repairs or Alterations—Answer when applicable._............................•__._.....___..........____________.___._.._............._........ ---------------------------------•--•--•---•----------------------------•--•--------•--•---------------•----...----------------------------...---------------...........------.....----------•-......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenAissue !he rd of h h. Signed ..... �✓ �Q ..[�... _ at Application Approved BY . �� •1b_... ate Application Disapproved for the f ollowi easons---------------------•---•-----------•-------•----------•------•----------------•------..._.........•............ ........-•----•------------------------------•-------=---•--•----•---•-•------•-•---------•-•-----••----•---•-----.......-----•-••••----•----•----•----•----•............••---......................... Date PermitNo......................................................... Issued-....................................................... Date No. :. Fizz...,!;.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ---------...... ......OF....... r�.. Is^`,c , pplirtation for Disposal ,arks' Tonstrnrtion Prrmit Application is hereby.made for a Permit to Construct (V1 or Repair ( ) an Individual Sewage Disposal System at . r - I:ocation Address or Lot No.. W Owner Address Installer Address d Type of Building. Size Lot......-.____:..:._n_.___..Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) ..., Q Other fixtures ...... ---•-•--------------•----•---•------••------------•-----------------•--•-••-------------------------•-•••••��;-�.------------•------------- •. W Design Flow........................ ..... ..........gallons per person per day. Total daily flow...................... a.?.. .........gallons. WSeptic Tank—Liquid capa city PAQ.-gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ............. Width...... _..... Total Length..... Total leaching area---- ft. Seepage Pit No--_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ( ) I —I e- 0­4 Percolation Test Result Performed by..%+''` "' �� 'i:;._ ..._ .__ j. :.: :� ?�°�Date_._.._. .--------- Test ti+.._._...,� Pit No. 1..._...:�^-°.....mmutes per mch Depth of Test Pit.................... Depth to ground water..:._.s_.___,......_. fs, Test Pit No. 2...... -___minutes per inch Depth of Test Pit..._._C. n...... Depth to ground water____-_-f . ._ ................................................................................................. Description of Soa1 -----------------••--------- = -------------------••-------- ------------- (�j -----•-••---•--•........... .. .:: � �"'"� L ...... �' 1 •°E t i? ry' W UNature of Repairs or Alterations—Answer when applicable. •-----------------------------------•----------------------------------------...--------......-•------------•----------------------------=--•-----------------------•--------------...............------ Agreement: The undersigned agrees to install- the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'!L- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sined...................................................................................... ................................ + ate Application Approved BY 112. ate Application Disapproved for the follow reasons:-•-•------•-----------------------------•-------•--•--•-•--•-----•-------•------•-............................. ---------•----•-----••--•-----------•----•------•---.-•-•----••------•-•--------------•--•--•-••-----...--•-••--•-•--•-•--•-------••---•-•----•.....-••-•••---•--••--•-----•......-••---•--•---------•--- Date PermitNo......................................................... Issued,.-'-.................................................... Date THE COMMONWEALTH OF MASSACHUSETTS -� ---- BOARD- qF HEALTH t Qrrtif iratr of Tomph anrr Tjz IS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�e or Repaired ( ) bY-----=............................W5 -• AL C0 UU5'T Rc I Q6v_.......... - -----------....................... Ins Iler # V........ ----------------------------•---------------•-•----------------------------••--•-----. has been installed in accordance with the provisions of TIT-LE 5 of The State Sanitary Code as d scribed in the application for Disposal Works Construction Permit No........ __f ZYT......... dated---------¢. . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �" CC -L DATE------------- ............................... Inspector ...•... -=---------•-.----- i ,..• THE COMMONWEALTH OF MASSACHUSETTS ENGlN��R EMS �, .. BOARD OF HEALTH -1- 1-�JRli f . l.r3................OF...... }r-' iQ 't r='�C No -�)��� �.<..... ... .............•••••-••......... FEEC7G Disposal Works Tnnstrnrtion Prrmit Permission is hereby granted...........-••-•-t NC .. O�1S ..c''r...a---------------------•--•- .. ry to Construct ()e) or Repair ( ) a Individual Sewage Disposal System Street as shown on the application lication for Disposal Works Construction Permit No PP �'�--_----- Dated---- -- --���• •------------- :. q ....................................... - oard of Health DATE --------- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS froSPoS - AV� i L FL c)L O =3 I(o _ '31�3o i cav z : G !: %iviw L4_--lI,�.I-I Ft L:;� 5 t Low `D i t=t'u, SGa i, cl `7ort�L `�J�Sr 61�1 -Cad�Pt� i- • ; - �• Phu A T��TAIt_ 01= �lSR�SAt_ `$Etj. : I�;,.�;:�� �,�•b . : All" L 1 Vv �O� •� 1 Q. ... .. •� J-tt• .'' � r� f rc.rE'r1 t��c.,�/���' L �d JtS�.�,�,„zr• l cZ: T1 F U/aT 2 �� r 'TN �>=�,� 1[=.l b 74-O'T' �NoWQ WCV5rciu coml;LY5 -rt4G -rc)WW OF� k- Le �U• (.J�Qv �jUt� `f��. r". _C t I' PL&u- vua erg s rc� b L, w , �r vI UZ - f . 1 _ o: — � ? F�-4 f�, a;�l•� ^, lvoo IUV. iWJ �'t`tT. �� --'-- `' �----� :�.•;,�,:. .� Lv:1 n, �S.U,� i _-`',ac.' .`=:j �., UAV S 64L. 7,I 6� ect :`✓�/'.:...,... :>.,•., to-� c t uv_. �-- 4-s. - aS! , a: T&WV_ 4 Lu• ATE W GLL1� � �._......... .. .. — �;•.,:,.. W 1 Tt i A'or- To l'�r.� \vM114 c D -TOUT-- ALL 440ov-tp. ?_' \VA51-4L:D C>aAiTbt1G. os.1 T�>��> G,T-� i of PZO?osr_-L7 v of Af�" _... ,may.: --- PETER cN XI'TIa RtCHARD oULLI1lA -' A. � U ti '�,, Woosa n SAXTE �, 0.a913 01ST ASS! ��NM G. �,/ CL TAWL � flzoP �L m 73 72 ¢7, 9 7S -48./ 44`t I 7'f-( WMPA 1 .191 5 - carcN o,o S�Bn�SiW 50.�, _�cw►� ��./ate.. `fD T72�/1�� BAXTER & NYE, INC. Registered Land Surveyors and Civil Engineers 7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131 WILLIAM C.NYE,A.L.S.-President RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering December 5 , 1985 Town of Barnstable Board of Health 367 Main Street Hyannis, MA 02601 RE: Map 228 , Parcel 27 Centerville Revised Site Plan dated September 11, 1984 Dear Board: In accordance with your request I have inspected the installed septic system at the corner of Pine Street and Holly Lane. Based upon visual inspection, the system has been installed in accordance with the Site Plan . Please note that I directed the installer to inter- change the primary area to the designated expansion . The purpose was to save two large maple trees . I trust that this meets your present needs . Very truly yours , Peter Sullivan, P . E . Baxter & Nye, Inc. PS/fmj A SHOF1# . �s PEUR SULLIVAN -ar j4 NO. 29733 �7 ADO ��c:STERF'C �.� �SStONAL MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS I__ ►'_ O CATION S E W A G E PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS d U I L D E R OR OWNER &5z � DATE' PERMIT ISSUED DAT E COMPLIANCE ISSUED i I � _j F�a yo ti 3? Li I �' Nv al �A 0 t t y,4. 5" DIA. OUTLET(S) 4" =SCHEDULE 40 PVC MIN. SLOPE 1% FINISH GRADE OVER LEACHING FIELD 101 .001-102.001 (PIPE TO BE RE-PLUMBED) � TOP OF FOUNDATION = 101 .44 GENERAL NOTES REMOVABLE COVER SLOPE . FINISH GRADE OVER TANK EL.- 3/4"TO 1 1/2" DOUBLE WASHED STONE TO CROWN OF PIPE °�2% MIN OVER SYSTEM 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE OVER D-BOX=1 0 1 .50' 2"OF 1/8"TO 1/2" DOUBLE WASHED STONE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE PROPOSED PIPE FINISHED GRADE 102.25 @ FOUNDATION = 100.90' ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES. 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD 20" MIN. ACCESS COVEER PROVIDE RISER ISER 6 R OUTLET 47'. r 4" PVC PERFORATED PIPE OF HEALTH AND THE DESIGN ENGINEER. " 36 MAX. SLOPE AT .5% TOP OF S.A.S. = 99.84'-100.00' 9"MIN. 3. 4 SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL 36" MAX. BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED. 99.34' 4. TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE LESS THAN END CAPSMIN.SLOPE @ 1% 6" 3" 2" DROP MIN. 39PROVIDE WATERTIGHT ELEVATION = 100.00' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS 3" DROP MAX. JOINTS (TYP.) I: A 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF 1007.30' 0 4" PVC IN FROM THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. 14" 99.85' SEPTIC TANK 4"PVC OUT TO o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ; \ 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. LEACHING FACILITY I 100. 6 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. -- _. 12" - I I "EFFECTIVE 7. LOCAL BOARD OF HEALTH TO BE NOTIFIED PRIOR TO BACK FILLING WHEN 48" OUTLET TEE 99.75' MIN. 99,58' 99.50' - � _- � _ DEPTH SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS NOT TO BOTTOM OF TRENCH TO BE LEVEL EL. = 98,84' BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH. 6"CRUSHED STONE EXISTING PIPE 16.0' 22"ZABEL FILTER OVER MECHANICALLY 8. ELEVATIONS BASED ON ASSUMED DATUM OF 100.00' MSL OBTAINED PIPE RUN MODEL#A1801 HIP COMPACTED BASE 32.0' 4' 6' 4' FROM A NAIL IN A TREE AS SHOWN ON PLAN. (GAS BAFFLE ON 14.0' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION 6" CRUSHED STONE BOTTOM) 5 OUTLET DISTRIBUTION BOX GROUND WATER ELEV.- 93.77' THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE OVER MECHANICALLY TO BE INSTALLED ON A LEVEL STABLE - AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY COMPACTED BASE C BASE. FIRST TWO FEET OF OUTLET 5' MIN. DISCREPANCIES TO THE DESIGN ENGINEER. PROPOSED 1500 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE �� �� �� TYPICAL FIELD PROFILE FIELD END VIEW STRUCTURES SHALL BE MADE WATERTIGHT. LENGTH 10' 6' WIDTH 5 8 DEPTH 5 7_ CROSS SECTION VIEW FIELD DETAILS 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH NOT TO SCALE NOT TO SCALE NOT TO SCALE DETERMINATION FROM APPROPRIATE AUTHORITY. • 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS TEST PIT DATA'� t '+•• ! • • LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE • , • f 525 THEY SHALL WITHSTAND H-20 LOADING. . r• r j/l� t 7• " +• �•. ,�;�•,r°, + �- . �f f 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND •' +• • AGENT: Samuel White, R.S. FINES. <Woe r . • • ' + �'� SOIL EVALUATOR: Samuel Philos Jensen • •• • +• •�•• {( . 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND !}t.► "+:•, +• 160 • • . • If DATE: July 17,2003 UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF N + • + •+ • • h TEST PIT#: 1 LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN • ``�--�, ,jy COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN • �0• • f �y ELEV TOP: 98.69' ACCORDANCE WITH 310 CMR 15.255(3). * ELEV WATER: 93.77' 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN MAP 228 REMOVE AND REPLACE UNSUITABLE •, . r �� � ' SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. .�� + ♦ y_� PERC RATE: < 2 Min./In. PARCEL 28 MATERIAL 5'AROUND AND BENEATH .� r It •� 16. PROPOSED PROJECT IS LOCATED WITHIN: LEACHING FACILITY TO EL. 94.44' 6 ` - " " � B.M.g MU t� �� DEPTH OF PERC- 55 -73 ASSESSORS MAP 228 PARCEL 27 WITH CLEAN, COARSE SAND Nail in Tree a Elev. = 100.00' E@ChW ! i � 4 - -� + TEXTURAL CLASS: 1 17. OWNER OF RECORD: SMITH, JOHN A. & LORRAINE S. Assumed �' •... . ,•. ADDRESS: 15 HOLLY LANE " CB/DH + * • • h h '�r�• R, 0 Fill 98.69 CENTERVILLE, MA 02632 �87 37 20 E FN 1� r Fill `f, • "�l y r'' �'• • �� + • • FEMA FLOOD ZONE ZONE C C" S87"3T20"E + '+ /; // ,'•~•� . 38" 95.52' AS SHOWN ON COMMUNITY PANEL# 250001 0005 C N 1 .00, 161.31' • +, ; I //r • •. Sandy Loam 10YR 5/6 i • fi • // • w.. •. B •; ,i ' ++ ' �' 18. PLAN REFERENCE: LO 30" ' • . 1. PLAN RECORDED AT THE BARNSTABLE COUNTY REGISTRY OF DEEDS IN PLAN BOOK 58 � ==-- MAPLE �`' • PAGE 23. LL `' ��• • • 51" 94.44' 2. PLAN RECORDED AT THE BARNSTABLE COUNTY REGISTRY OF DEEDS IN PLAN BOOK 194 40 Ml!- GFOMFMBRANE LINER 5 m e r d+♦ th .e4�► •: F-M-C Sand 2.5Y 6/4 p � ::•- `?2° ":�9.L PAGE 105. C z _ �`= • •�� '1 +� ,. Loose; Single Grain 3. PLAN RECORDED AT THE BARNSTABLE COUNTY REGISTRY OF DEEDS IN PLAN BOOK 539 p �"' 55 PROPOSED 14'x 32' LEACHING FIELD J Q :. +'`�f r t �'!t` �^ -. 10-20%Gravel PAGE 29. 11 --: - 23.5' L�O f-"' 'er 4. LAND COURT PLAN 17678 F. MAP 228 t :_: :::=:.:_:: ' $ . ' ' 1 APLE ; II 1 � � • 7 DEED REFERENCE MAP 228 - -: / f- iq '- " 1. BOOK 5252 PAGE 247 y PARCEL 27 ! o moo. I �� . 41 �� �� �,. , 59 93.7T 0 Calculated S.H.G.W. + ��� • •r 20. ALL DISTUFfBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. PARCEL 170 30,820 S.F. Y - Z 28.9' p 21. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY 1, o 00 0 mi `� FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY 01 OO / 11.1' PROPOSED 1500 87" 91.44' FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. m �� Q. ! / #15 � - _ I GALLON SEPTIC TANK LOCUS PLAN Standing Water Observed ,� EXISTING L CHERRY I EXISTING 1000 GALLON TANK TO BE rn 3-BDRM SCALE: 1"= 1000' I PUNCTURED AND ABANDONNED IN 120 88.69, DWELLING ACCORDANCE WITH TITLE V J TOP OF DESIGN DATA PERCOLATION TEST RESULTS LEGEND FOUND. N o 1 1 EXISTING LEACHING PIT-O BE PUMPED I EL. = 101.44' / co Uu AND FILLED WITH CLEAN SAND NUMBER OF BEDROOMS: 3 DEPTH OF PERC.: 55"-73" o z DESIGN FLOW: 110 GPD/BDRM START PRE-SOAK: 11:10 EXISTING CONTOUR TOTAL DESIGN FLOW: 330 GPD END PRE-SOAK: 11:19(24 Gal.) I J DESIGN FLOW X 200 % = 660 GPD F-5-0-1 PROPOSED SPOT GRADES TIME AT 12": N.A. =� USE PROPOSED 1500 GALLON SEPTIC TANK TIME AT 9": N.A. r-5� PROPOSED CONTOUR _ PAVED p TIME AT 6": N.A. 100-- DRIVE NUMBER OF BEDROOMS: 3 TIME FROM 9"TO 6": N.A. EXISTING OVERHEAD UTILITIES m - RATE: <2 Min./in. _J DESIGN FLOW: 110 GAL/DAY/BEDROOM Q TOTAL DESIGN FLOW: 330 GAL/DAY W EXISTING WATERLINE -x-x-x-x I \ >< SEPTIC TANK: GAS -- EXISTING GASLINE 1 j w 330 GAL X 200% =660 GALS. DESIGN CAPACITY i s; _ �D 1w USE PROPOSED 1500 GALLON SEPTIC TANK No TEST PIT LOCATION o� 2 a GROUNDWATER ADJUSTMENT ' Q 14.0 X 32.0 LEACHING FIELD: (CAPE COD COMMISSION METHOD) O O O PROPOSED 1500 GALLON SEPTIC TANK a v� u_ J ❑ DISTRIBUTION BOX \70 w J SIDEWALL CAPACITY DEPTH TO WATER OBSERVED: 87" 4"SOLID SCHEDULE 40 PVC PIPE Z T\ I O INDEX WELL: Al W-230 \ W O NONE DEPTH TO WATER: 22.2'(JUNE 2003) - - - - - - 4"PERFORATED SCHEDULE 40 PVC PIPE = N/3 ZONE: D 191.00, , 3 / BOTTOM CAPACITY ADJUSTMENT: 2.3'(28") 91.0 � -- DEPTH TO SEASONAL _ 14.0' (LENGTH) X 32.0' (WIDTH)= 448 SQ. FT. HIGH GROUNDWATER: 59" D 448 SQ. FT. X .74 GAL/SQ. FT. = 331.52 GAL. LEACHING/DAY PINE 'NE TOTALS: REV. DATE BY APP'D. DESCRIPTION (1919 STATE L.0., 40_FT) STREET" _ PROPOSED SEPTIC SYSTEM UPGRADE TOTAL NUBER OF DISTRIBUTION LINES: 2 TOTAL LEACHING AREA 448 SQ. FT. PREPARED FOR: MHB TOTAL LEACHING CAPACITY 331.52 GALJDAY FND MR. KERRY SMITH LOCATED AT 15 HOLLY LANE CENTERVILLE, MA 02632 RESERVED FOR BOARD OF HEALTH USE SCALE: 1 INCH = 20 FT. DATE: AUGUST 1, 2003 0 10 20 40 80 FEET \H OF y,`C u�° JOHN L. ?w PREPARED BY: CHURCHILL JR. MILJC ENGINEERING, INC. No 41807 2854 CRANBERRY HIGHWAY SITE PLAN- FF`° EAST WAREHAM, MA 02538 SCALE: 1" =20' 508.273.0377 ° Drawn By: SJ Designed By:SJ Checked By: JLC JOB No.484