HomeMy WebLinkAbout0010 HOLLY POINT ROAD - Health L
olly Point Road
rville P233 059
J1QEcvct �
UPC 10259
No. H163OR ��
HASTINGS. MN
I
No, t "" t ' FEE
COMMO. NWLALTH Of MASSA 14USETTS
Board of Health, uf �l d MA.
APPLICATION FOR DISPOSAL SYSTEM CONS UCTION PERMIT
Application for a Permit to Construct( Repair( ) Upgrade( Abandon( - omplete System ❑Individual Components
Location 0 1 � ' Owner's Name
Map/Parcel# `, �� Address
Lot# CE-IA V J L-L� Telephone#
Installer's Name Designer's Name
Address G e,7U Address MiE
Telephone# ZS5 I Telephone#
Type of.Building Lot Size � �a��sq.ft.
Dwelling-No. of Bedrooms Garbage grinder ( )
Other-Type of Building. No.of persons Showers ( ),Cafeteria( )
Other Fixtures
Design Flow�4t)fle—
eq red) Z4Y gpd Calculated desi ri flow Design flow �ow provided / gpd
Plan; Date ®, Number of sheets Revision Date
Title '1 -4
Description of Soil(s) -!6FF,
Soil Evaluator Form No. P & _ Name of Soil Evaluator Date of Evaluation E "®
DESCRIPTION OF REPAIRS OR ALTERATIONSv UI7
1 c_ t� a t
The undersigned agrees to install the above described Indi ' e al Sewage Dispo al System in accordance with the provisions of TITLE 5 and
further agreesko not to pla a the s teiWin opera oaunti Certificate of Co 166ce has been issued by the Board of Health.
Signed `` Date 1;7eDjA
V IV
Inspections
�.�_ . __ ............ ........
No. FEE 1 '
f WMMONWV ALTH�OF MASSAC44USETTS
a Board of Health, ��� �+ ,MA.
APPLICATION FOR DISPOSAL SYSH I CONS UCTION PERM,IT '
Application for a Permit to Construct( Repair( Upgrade( Abandon( - $((Complete System U Individual Components
Location d i ' ` Owner's Name
' Map/Parcel# Address V IL.,
Lot# �F.�.l�� � � Telephone#
Installer's Name � Designer's Name c:,.owI ,
Address Address
Telephone# Z� Telephone#
Type of Building � � !`` ,� Lot.Size Y L/'" 0 sq.ft.
✓` Dwelling-No.of Bedrooms Garbage grinder ( )
Other-Type of Building No.of persons Showers ( ),Cafeteria( )
Other Fixtures 1
' Design Flow (min.required) 44 4/D gpd Calculated deli n flow T� Design flow provided ""7 gpd
Plait: Date Number of sheets_ Revision Date
Title
Description of Soil(s) -!SEP— t ,..,. `„sd �—lf
Soil Evaluator Form No. Name of Soil Evaluator r / y Date of Evaluationor
I r
DESCRIPTION OF REPS OR ALTERATIONS �vf v� ✓1 1�
The undersign d agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to plage tjie sys em in operation untill hertificate of Co't /pli/ance has been issued by the Board of Health.
Signed / Date 1 �. e!,J ,
Inspections.
<,�,VUv',rr,,uvQr -0.•in, 1,�r.t c(. �'c �c:cr.� G.. Jr! U. al,)^ �`t :.^[^!• .L:.. 1 Jr-��'.� ..,rG ^ ,t ^,J i, r1n r/ ,J �',(..e
No. 4,xo(to 1 f FEE l
COMMONWYALT14 OF MASSAC14USETTS
Board of Health, qu l!'-4 ,MA.
C ERTIFICA1 Of CO�'�POANCE
Description of Work: ❑Individual Component(s) (oCom lete System
P Y
The undersigned hereby certify that the Sewage Disposal System Constructed ( ),Repaired ( '),Upgraded +)_ Abandoned ( )
has been installed in accordab ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.,n701fc--001 dated ,rI� -/ . Approved Design Flow '/0 (gpd)
installer +��l.ik�1�3e/,'►,�W,� �
Designer: 1/. ,�1�r1` / Inspect oQ a Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. 26 ib 'F FEE
COMMONWEALTH,OF MASSAC14USETTS
Board of Health, �1. �.� MA.
DISPOSAL SYSTEM CONSTRUCT10 PERMIT
Permission is hereby granted to;—Construct(
—) Repair(
�)�^�Upgrade(Y Abandon( ) an individual sewage disposal system
at: j o HyUA � "1"b)k 1 45,, A ) as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local cokldidons must be met.
t
Form 1255 Rev.5/96 A.M.Sulkin Co.Chadeslown,MA Date -3 I X Board of Health (n.zC.X`.YIE V
V
5
7
Town of Barnstable
Regulatory Services
Richard V. Scali,Interim Director
• aAeersrnOM ,
� Public Health Division
RFD Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: 2�� Z� ewage Permit# Assessor's Map\Parcel
Designer: �� Installer. d a�
Address: Af;j"f' Address: _ IMq
M I�6,.:�,, �
On `���IY `t _was issued a permit to install a
( a ) (installer)
i
septic system at 11ZP based on a design drawn by
( ddress)
dated
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constru �__.��liance with the terms
40te IAA approvalletters (if applicable) `OAV OFADAVIDer's gnature) o ho.1066ASON m
;v ,� No.1066
f1:
��(Desi s Signature (Affix Designs S p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION
THANK YOU.
Q:\Septic\Designer Certification Foffi Rev 8-14-13.doc
TOWN OF BARNSTABLE
LOCATION /P,D SEWAGE# o20/8— 00/
VILLAGE 7ney"/le— ASSESSOR'S MA�Pv�&PARCEL,;?33--dy'
INSTALLER'S NAME&PHONE NO6X6,,;J4 L T
SEPTIC TANK CAPACITY /5CV 44/I0n
LEACHING FACILITY:(typ<5--) p� ci§01 (size) j J')e l,3 /X 192 '
NO.OF BEDROOMS
OWNER kal ovi D
PERMIT DATE: /�,3//�' COMPLIANCE DATE: 020 /
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
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i
i d•
,ciYcGC
j/e v7
TOWN OF BARNSTABLE
LOCATION & 4" �13/,�►�� ", SEWAGE# 02018- 00/
VILLAGE eJU. 7e4CVi/Ce- ASSESSOR'S MAP&PARCEL4933-0,51
INSTALLER'S NAME&PHONE NOeAgO j" T�j
SEPTIC TANK CAPACITY /5ZV
LEACHING FACILITY: (typ<'j) �ql �' e� /S(size) 5�
NO.OF BEDROOMS '�
OWNER
PERMIT DATE: //3 8^ COMPLIANCE DATE: D /
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
ve-,v
a
Town of Barnstable P# �
Department of Regulatory Services
Public Health Division Date /J� l
t6sq ��s� 200 Main Street,Hyannis MA 02601
Date Scheduled /,! Time Fee Pd. 00 f
y
Soil Suitability Assessment for S age Disposal
Performed By: • l n `�\ Witnessed By: �.
LOCATION& GENERAL INFORMATION _
Location Address 10 1( ) Owner's Namet/� 1p►�„{A'�
Y I Address
Assessor's Map/Parcel: 01V�*/ Engineer's Name g�� )* Im
NEW CONSTRUCTION REPAIR Telephone#
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
� I
• 1 1.
Parent material(geologic) Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE ,
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
----- -- Depth to weeping from side of obs°hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
_ _ _ _ PERCOLATION TEST _ _Date Time
ObservationV
Hole# __..�._. _ __ Time at 9°,
_ II
Depth of Perc Time at 6"
Start Pre-soak Time @ Time(9"-6")
End Pre-soak I Y`
Rate Min./Inch L A (-` 1
17
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
0
DEEP OBSERVATION.HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent ° Gravel
v
V
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling, (Structure,Stones,Boulders.
Consistency,%Gravel)
W
f;
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
_ _ DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
Flood Insurance Rate Map:
Above 500 year flood boundary No` OYes
Within 500 year boundary No Zes
Within 100 year flood boundary No_ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of aturally occumng pe 'ous material?
Certification
I certify that on ID (date)I have passed the soil evaluator examination approved by the
Department of Enviro a al Protection and that the above analysis was pefforrqed by me consistent with
the required train4exin ex e ' nce described in 310 CMR 15.01 i.
Signature Date 1 I
Commo v EALTH of MAssAmuwrrs
EXECUTIVE OFFICE OF ENVIROINTMENTAL AFFAIRS
D
DEPARTMENT OF ENVIRONMENTAL PROTECTION
O"
O �
V
n1LE S
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM
PART A
CERTIFICATION y,S SLA
Property Address: 10 Holly Point Road
Centerville
Owner's Name: Robert Kelland
Owner's Address: 10 Holly Point Road
Cent ry• _
Date of Inspection: a Co
Name of Inspector:(please pprmt) Sean Jones C-1 Z-
Company Name- WM. E. Ro inson, Sr. Septic Service
Mailing Address: PO Box 1089
Centerville ,
Telephone Number: 508-775-8776 C=
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 die inspection.The inspection was performed based on my
training and experience in the proper fimcdon and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to n 15-W of Title 5(310 CMR 15.Oi ). The system:
Passes
Conditionally Passes-
Needs Furthe uation by the Local Approving Authority
Fails
Inspector's Signature: Bate
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 thee 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 dies 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 6/152000 page 1
Pace 2 of i 1 • ,
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 10 Holly Point Road
en ervi e
Owner: Robert Ke land
Date of Inspection: i _- `
Inspection Summary: Check AAC,D or E 1 ALWAYS compteteall of-Section D
P rY
A. Syst Passes:
° I have not found any information which indicates that any of the failure criteria described in 3 l0 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 descxrW 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,iV,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 structura*
unsound,exhibits substantial infiltration or exfiluation or tank failure is imminent. System will Pass inspes ion ifthe:. .
existing tank is replaced with a complying s-�nby=lte Boar'd ofHealth.
*A metal septic tank will pass inspection if it is structurally sound,not bmlring 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 tick out or high waw knel in the drst nbution 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):
brokeapipe(s)are replace
obstruction is removed
distr&wton 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 Healthy
broken pipe(s)are replaced
obstruction is removed
ND explain:
I
r
f � ,
Page 3 Of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 10 Holly Point Road
Centerville
Owner: Robert Kelland
Date of Inspection: 5_1Q
C. Further Evaluation is Required by the Board of Heahh: IVIA
Conditions exist which require funther 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 teet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the S"is within a Zone l 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
Page4ofii
OFFICIAL INSPECTION FORM:NOT'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION'[(continued)
Property Address: 10 Holly Point Road
Centerville
Owner: Robert Kelland
Date of Inspection:
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
_ �!lLiquid depth in cesspool is less than 6"glow invert or available volume is less than ifs 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.
YAny portion of cesspool or privy is within 100 feet ofa surface water supply or tributary to a surface
water supply.
;d Any portion of a cesspool or privy is within a Zone I of a public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.
Y/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 eoliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogemis equal to or fen than 5 gpst,prov Fdmtaoatker�faBore_eriteria
are triggered.A copy of the analysis w6st he 2ttsellsd to this farm.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CUR 15303,=therefore the system fails.The system owner should contact the Board of.
Health to determine what will be necessary tor. xtite fattt€e.
E. Large Systems: jV A
To be considered a large system the sys nust-cove a faeiflby wAth a design flow of f 0,400 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 H 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
I
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B -
CHECKLIST
Property Address: 10 Holly Point Road
Centerville
owner: Robert Relland
Date of inspection:
Check if the following have been done.You must indicate"yes"or`lto"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant:or Board of Health
_ V W 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?
_./,/J A 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?
s _ 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
c� Existing information.For example,a plan at the Board of Health.
Determined in the field(if any ofthe failure criteria related to Part C is at issue approximation of distance
is unacceptable)P 10 CW 15.302(3)(b))
S
Page 6 of i
OFFICIAL INSPECTION FORM--NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;`
PART C
SYSTEM INFORMATION
Property Address: 10 Holly Point Road
Centerville
Owner: Robert Kelland
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 'I Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15-203(for example: 110 gpd x#of bedrooms): 1-/Y o 6
Number of current residents: v4-
Does residence have a garbage grinder(yes or no):A4
Is laundry on a separate sewage system(yes or no):AV [if yes separate inspection required]
Laundry system inspected(yes or no):_!!�LA
Seasonal use:(yes or no).— 2006 — 84,000
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): //W , 0 0
Last date of occupancy: C y r A&,.,
T COMMERCIAL/INDUS RU1L
Type of establishment: N A
...
-
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 EIWORP ATION
Pumping Records
Source of information:
was system pumped as part of the inspection(yes o=4�Lpw
If yes,volume pumped: •°o co gallons--Ho*.was determined_? 6-.�z CIA °?•�
Reason for pumping: I eSOLI
TYPE OF SYSTEM
-Septic tank,distribution box,soil absorption system
✓Angle cesspool
"/Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Altemative 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:
Were sewage odors detected when arriving at the site(yes or no):AX-'
6
Page 7 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SERFAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM INFORMATION(continued)
Property Address: 10 Holly Point Road
Centerville
Owner: Robert Kelland
Date of Inspection: !i I s k LILA.,7
BUILDING SEWER(locate on site plan)
Depth below grade: � + */' - L`R' �� �• �- !�`r
Materials of construction: ; c 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:h/ (locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass___polyethylene
other(explain)
If tank is metal list age:— Is age confrrined by a Certificate cif Compliance(yes or no):—(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP!V _N(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 primping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of I r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION{+continued)
Property Address:1 0 Holly Point Road
Centervi e
Owner: Robert Kelland
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_Polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: alionVday
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.):
�1/.4
DISTRIBUTION BOX. (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 art equal, y evidence ofstslids carryover,any evince of
leakage into or out of box,etc.):
sv�
PUMP CHAMBER: (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 primps and appurtenances,etc.):
8
Page 9 of l i
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Holly Point Road
en ervi e
Owner: Robert Kelland
Date of Inspection: 41/)1 0—7
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. p
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.):
eks5,zl,ei b- 3 4,-e-.5 A,04 E'ti[ mac. t`rsS�J�1 3 �^-H s jd +-vas
do" bele,.-
CESSPOOLS: (cesspool must be pumped as part of inspectionXiocate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert 1 S
Depth of solids layer: j d ��;AF
Depth of scum layer. i riii 3vz
Dimensions of cesspool: os 46A Y
Materials of construction: t p-w is co%eze%
Indication of groundwater inflow(yes or ): ^,c, —.1
Comments(note condition of soil,signs of hydraulic faihure�level of ponding,condition of vegetation,etc-):
a" h a �
Sol 1 �� � d S}�e l i •� d� 1)rt��, - :$7n�c, �f y .5�:..r�- r..-{.�1- /�' r e� �
4a.�:
} by✓c�t
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_):
9
Pase 10 of l '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART_C
SYSTEM INFORMATION jconfinued}
Property Address: 10 Holly Point Road
Centerville
Owner: RnhPrt nd
Date of Inspection:_ d 144oe 7
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.
Lee-,1.
43
a 4p)7. ,a
ro
tad r+
?3��.A
I
Page I i of I s
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Holly Point Road
en ervi e
Owner: Robert Keiland
Date of Inspection:
SITE EX
Slope �/ 1
Surface water✓
Check cellar
Shallow wells
Estimated depth to ground water jJ 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 Iocal Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground waterelevation_
Gbyvc NPc :X
11
Town of Barnstable
OF 1HE 1p�
Regulatory Services
BABNSTABUM ; Thomas F. Geiler,Director
MAS&
9`�Ar16 9.
� Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
a
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 10 Ho U'V go i V :c.�l
owner's name
Date of Inspection Or. S; ,� �y Ste, f V,,rjn
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
10 None of the system components have been p um ed for a least two
and the system has been receiving normal flow rates duringthat weeks
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site.
N119 The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM 'IN SPECTZON FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
q number of bedrooms
6 number of current residents
yes garbage grinder, yes or no
ES laundry connected to system, yes or no
E S seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: 991/ _ ?Vt 0t3U
c Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
/ 1
I-- L Iry J rJ N1 A !` W r N Sr�n
No System pumped as part of inspection, yes or no
if yes, volume pumped
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)
Other (explain) C���,o�,
Approximate age of all components. Date installed, if known. Source of
information: ,,11 1
�a Sewage odors detected when arriving at the site, yes or no
{
a
,`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
f SYSTEM INFORMATION continued
SEPTIC TANK
(locate on site plan)
depth below grade:
material of construction: concrete metal FRP other(explain)
dimensions:
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
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
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
DISTRIBUTION BOX: /a?
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
PUMP CHAMBER: N/A
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions 6 4.,tod' x 46 '
overflow cesspool , number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
5condition of vegetation, recommendations maintenance or repairs,etc. )All 5ia - 3 a1 144 .rn ,jl • c. - ', u -e Lo-cL L Gld , S7-i ,.,f , Lc OF
ke-
nrvtid . :So, ' A-' ' $ X t'v-e- o' / ✓ oG.k is G.&A iMK G JeS�.ti,as -
04. -�4i c U( '7
CESSPOOLS (locate on site plan) :
number and configuration On Czs, bv� f
depth-top of liquid to inlet invert 7 '
depth. of solids layer y "
depth of scum layer "
dimensions of cesspool ���� ,�,� i Li r":
materials of construction t c s�as c, i b /o t k
indication of groundwater
inflow (cesspool must be pumped as
part of inspection) C45's /V00 S , �-�; L-
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
1'1/U 5 i K s � (, G u r� . C.e S vU I ( o �c:1 -c. .. .(✓t�t- 'r. ca n.:sl
CA �"S-� L
AIVY: IV14 hof' c;S � crl ',s�°so� I � ��oSsrio/t
(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, recommendations for maintenance or repairs,etc. )
' 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
/A\
2q
DEPTH TO GROUNDWATER
depth to groundwater
method of 1determination or approximation:
0 -A h Z7 v/- � , I/ G i '
.;-%1' . Y Vh 1 'T>(�� L �^.� �L /�G ✓l dl
0 U 'Ad�' �d� �� [� fd
'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or -not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 de.
flow?
Required pumping 4 times or more in the last year?
number of times pumped d
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well .water analy
for coliform bacteria, volatile organic compounds, ammonia nitrogen'
and nitrate nitrogen.
o �
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspectors
Company Name L'// ,• .M.S S � 3�'; G �n s C_c �70�a S
lrm� G� II � � •
Company Address �o t ��5 S J�:v
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Che k one:
I have not found any information which indicates that the system fail.
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature
Date 1 ��s
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
30, '�S
f I i
COMMONWEALTH OF MASSACHUSETTS
Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
t d DEPARTMENT OF ENVIRONMENTAL PROTECTION
d
F
Q
OW
v�
M she
�43
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTE +
PART A RAC€iV�ED
CERTIFICATION
Property Address: 10 Holly Point Road Centerville MAR 2 6 2002
Owner's Name:A.F.RIndustries Inc. TOWN OF BARNSTABLE
Owner's Address: 5 Blue Water Drive HEALTH DEFT.
Date of Inspection:March 11,02
Name of Inspector: Timothy Lovell
Company Name:Accurate Inspections MW
Mailing Address:550 Willow Street ,��
W.Yarmouth,MA. PARCELzI
Telephone Number:508-771-3700 LOT LC
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:
x _Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails—
Inspector's Signature: G Date: 3/11/02
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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 10 Holly Point Road Centerville
Owner:A.F.R.Industries Inc.
Date of Inspection: 3/11/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
x_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:
N/A 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.
_N/A 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 infiltration 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:
_N/A 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:
_N/A_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
I
ND explain:
Page 3 of ll
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 10 Holly Point Road Centerville
Owner:A.F.R.Industries Inc.
Date of Inspection: 3/11102
C. Further Evaluation is Required by the Board of Health:
_N/A 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:
_N/A_Cesspool or privy is within 50 feet of surface water
_N/A 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:
_n/a 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.
_n/a The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_n/a^ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
n/a_ 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:
Page 4 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 10 Holly Point Road Centerville
Owner:A.F.R.Industries Inc.
Date of Inspection: 3/11/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for aIl inspections:
Yes No
_x_Backup of sewage into facility or system component due to overloaded or clogged SAS,or cesspool
_x_Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_x_Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_x_Liquid depth in cesspool is less than 6"below invert or available volume is less than I/ day flow
_x_Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_x_Any portion of the SAS,cesspool or privy is below high ground water elevation.
_x_Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_x Any portion of a cesspool or privy is within a Zone 1 of a public well.
_x_Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_x 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 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•
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
Page 5of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 10 Holly Point Road Centerville
Owner: A.F.R Industries Inc.
Date of Inspection: 3/11/02
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
_x_Pumping information was provided by the owner,occupant,or Board of Health
x_Were any of the system components pumped out in the previous two weeks?
_x Has the system received normal flows in the previous two-week period?
_x_Have large volumes of water been introduced to the system recently or as part of this inspection?
_x Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_x _Was the facility or dwelling inspected for signs of sewage back up?
_x_ _Was the site inspected for signs of break out?
_x Were a system components,excluding the SAS,located on site?
_x_ _Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the ba es or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_x_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.
x_ _Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) 1310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 10 Holly Point Road Centerville
Owner: A.F.R.Industries Inc.
Date of Inspection: 3/11/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_4_Number of bedrooms(actual):_4_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_440
Number of current residents:_0
Does residence have a garbage grinder(yes or no):—yes--
Is laundry on a separate sewage system(yes or no):_no_ [if yes separate inspection required]
Laundry system inspected(yes or no): n/a_
Seasonal use: (yes or no):yes_
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):_no_
Last date of occupancy: Nov.2001 .
COMMERCIALANDUSTRIAL
Type of establishment: N/A
Design flow(based on 310 CUR 15.203): 2Dd
Basis of design flow(seats/persons/sgft,ctc.):
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;No record of pumping at Barnstable sewer facility
Was system pumped as part of the inspection(yes or 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
x_Other(describe): Cesspool to a leaching field
Approximate age of all components,date installed(if known)and source of information:
1969
Were sewage odors detected when arriving at the site(yes or no):_no_
• Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Holly Point Road Centerville
Owner:A.F.R.Industries Inc.
Date of Inspection: 3/11/02
BUH.DING SEWER(locate on site plan)
Depth below grade: 2'
Materials of construction:_cast iron _x_40 PVC other(explain):
Distance from private water supply well or suction line:town water 15'
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_N/A (locate on site plan)
Depth below grade:
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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_N/A (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.):
Page 8 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Holly Point Road Centerville
Owner:A.F.R.Industries Inc.
Date of Inspection: 3/11/02
TIGHT or HOLDING TANK:_N/A (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:_N/A (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:_N/A (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.):
Page 9 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Holly Point Road Centerville
Owner:A.F.R.Industries Inc.
Date of Inspection: 3/11/02
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Located 6x401eaching field,excavated small hole to determine it was a leachfeild
Type
Leaching pits,number:_
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
_x_Leaching fields,number,dimensions:_6x40
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.):
No sign of hydraulic failure soil gravel and bony
CESSPOOLS:_x (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 1 cesspool empty from none use at time of inspection looks in good condition
Depth—top of liquid to inlet invert: 0
Depth of solids layer: 0
Depth of scum layer: 0
Dimensions of cesspool: 6x8
Materials of construction: Block
Indication of groundwater inflow(yes or no):_No_
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
No indication of hydraulic failure
PRIVY:_N/A (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.):
I
` Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Rolty Point Road Centenille
Owner:AXX Industries Inc.
Date of Inspection: 3/11102
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.I,oc'ate where public water supply enters the building.
as �,
a�
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10.11olly Point Road Centerville
Owner:A.F.R Industries Inc.
Date of Inspection: 3/11/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_16.4_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:
Checked with local excavators,installers-(attach documentation)
_x Accessed USGS database-explain:Map provided at B.O.H with adjusted ground water
You must describe how you established the high ground water elevation:
a
9 TOWN OF BARNSTABLE
T.00ATION /U �v<<}' �o s" �� SEWAGE #
VILLAGE CEni TEZV I L Ldr ASSESSOR'S MAP&LOT 7-33 OS 9
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
_
BUILDER OR OWNER A�✓ �"�`'u"' /��3 P�vN>"�
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by Z.v, Tiy a0
i
4N AA
! portch' •�
i 20 �
�c//St BLS'
TOWN OF BARNSTABLE ,
LOCATION /a W-11V Af l oAd 'rr f SEWAGE #
VILLAGE C e419 V,11 e ASSESSOR'S MAP & LOT-I:�—Z 9
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY CeS,5 Pot I—
LEACHING FACILITY: (type) L%.4C,N1AVel, �/y� (siZ04 /G.t
NO. OF BEDROOMS
BUILDER OR /1 I'R 21V!)0 S%205 ZW
PERMITDATE: COMPLIANCE DATE: /�16/` NG o /��✓►f�
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) 20 Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
C�SS�oo� �N 4)R�'ve VYAY L�aP /2 �P %� 6R-4A�
o � I� ullb MUM-
MCI I -AZ4-hTEOT HOLL LOOS.
,�f_ I I he inslullu(ion sltull comply tvitll 'I'illt, V uli�l '1'uwu ul' I ualJ u�
-- -- 1 1 C health Regulations. ... '
SOIL EVALUATOfI .
�LooO zoNE: ti �T �P�I,I� � � w�TNEss : !aI,..1 2) 'I1hu inalullol Hhi111 Vul11y ihd ht��Iillnn ul'(1111111�11, Nuwl i Iu�t Ii,l hull lu pll�
� 1 components n for to installation and setting base elevations.
G1 REFERENCE _- /GtQ C % ' �lp`1� 7i DATE 3 C I t 1 l 6
Z.f ERCOLAT ION RATE: -•- I 1
3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first
k4l r5cE- - _. . _�_� L .`__— ___:__ two feet out of the d-box to the leaching shall be level.st COS � '
4) This plan is not to be utilized for property line determination nor any other
TH- I 7H-2 purpose other than the proposed system installation.
(�/��j �\ } ►f1 J +� 5) All septic components must meet Title V specifications.
Iti 1 In ryJ Parking t e constructed over H10 septic components.
6) Pa ki g shall not p P
7) The property is bounded by property corners and property lines.
8) The property owner shall review design considerations to approve of total
design flow and number of bedrooms to be considered for design. Receipt
LOCATION MAP _ of payment for the plan and installation based on the plan shall be deemed i
�iQ ✓' approval of the design flow by the owner:
9) The existing leaching or cesspools shall be pumped and filled with material
�-� per Title V abandonment procedures. Those within the proposed SAS shall
be removed along with contaminated soil and replaced with clean sand per
\) 1 y Title V specs.
10)System components to be l0 feet from waterline. Sewer !ines crossing the
t�Hv * water line shall be sleeved with 4 inch SC1140 PVC with ends grouted if
i
o applicable. The proposed SAS is being installed below the water service
line. The line is to be sleeved as aforementioned and maintained in place.
�t75 j � C SEPTIC SYSTEM DES I GN 11) If a garbage grinder exists,it is to be removed and is the responsibility of the -
owner to ensure such.
12)The installer is to take caution in excavation around the gas line if suh c
FLOW ESTIMATE '
exists. ;: ..,.
j 13)The installer shall verify the location, quantity and elevation of the sewer
BEDROOMS AT �;GAL/DAY/BEDROOM - �GAL/DAY _ R
i lines exiting the dwelling prior to the installation.
(✓� "� U 14)This plan is representative only that a system can fit on a property meeting
SEPTIC TANK Title V requirements.
i
r t GAL/DAY x 2 DAYS .:�C GAL
USE I GALLON .SEPTIC TANK
O1(_. ABSORPTI Off SYSTEM
O�F4DAVID
tq s
--s . ZXs fi Z, X 2 0,� h
s I DE AREA. MASON
I
BOTTOM AREA: (�i = \\v No.tossLO
V i
d
SEPTIC SYSTEM • 'SECTION {
o uwio
10
Li � tf� o� �(�l 1%�1�tl� ��� 3b►�X
O ter:
� /� J / i I � `mil p I �1�01� ; k b l�-�t� ��c ✓ r � �� �� � � � d
r! I OGAL," ✓ C/ : . + ,Fk7��I , v ;��
«JJ��' ;J
O SEPT I C'TANK/
, ' /� �'%i9,s --' io lid, "�� _oi_ SITE AND SEWAGE PLAN
t� <�Zs� L) fr!
LOCATION ' I� l,L
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PREPARED FOR '11�L' I
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M SCALE
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DAV I D B : MASON I DATE: I '
DBC ENV I RONMENtTAL DESIGNS
EAST SANDWICH . MA
5
DATE HEALTH AGENT ( 508 ) 833. 2177
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