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HomeMy WebLinkAbout0601 HUCKINS NECK ROAD - Health (2) 601 Huckins Neck . Centerville A=234 044 g I e i T _ Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments M 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name //�� information is Ce .tiNe �Vt s t.� (y�luOMa. 02632 9/08/2008 required for every 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini � cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 rerun City/Town State Zip Code (508)428-4028 S 14454 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 v.: -� '✓ 9/08/2008 Inspector's Signature Date ;• The system inspector shall submit a copy of this inspection report to the Approving uthoritoal' of Health or DEP)within 30 days of completing this inspection. If the system is a sha ed system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall ubmit 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. 601 Huckins neck rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 601 Huckins Neck Rd. M Property Address Maureen Joseph Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 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 601 Huckins neck rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2 r Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M ...... 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 — -- -- every 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)(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. 601 Huckins neck rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 every 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 ❑ E 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 1h 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. 601 Huckins neck rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.)' D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 601 Huckins neck rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 . 1 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 601 Huckins neck rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 e Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 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 ears usage d 2008:37,000 g ( y g (gpd)): 2007:125,000 Sump pump? ❑ Yes ® No Last date of occupancy: 9/08/2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 601 Huckins neck rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is Centerville Ma. 02632 9/08/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: System installed in 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No 601 Huckins neck rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20'+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the leachfield. Septic Tank (locate on site plan): 2' Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ® polyethylene ❑ other(explain) If tank is metal,.list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0 7" :. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 601 Huckins neck rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 every 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.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. 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): 601 Huckins neck rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 601 Huckins Neck Rd. Property Address Maureen Joseph . Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 every 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 No. 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.): Box is level.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 601 Huckins neck rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is required for. Centerville Ma. 02632 9/08/2008 every 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.): Soil Absorption System (SAS)(locate on site plan,•excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5-Infiltrators ❑ 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.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil. 601 Huckins neck rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 every 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.): 601 Huckins neck rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Map Page I of 2 . Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out 'I, J M J 1In ' � r � r , � r r � r r r 'r r r r o �! - r ! z r r t -�Y .................... ". t R + !1 F' r • F� 2OW Feet F Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER rnn„rinhf 7nn9_7nOA Tn...n of Pnrncfohlo KAA All rinhfa reeen., http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=234044&mapp... 9/8/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M s 601 Huckins Neck Rd. Property Address Maureen Joseph Owner Owner's Name information is required for Centerville Ma. 02632 9/08/2008 every 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: Bottom of infiltrators 55' 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. 2005 Date ® Observed site (abutting.property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As-Built Card ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. I I 601 Huckins neck rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 a `` / No. . c0 �"O(D a f Fee /66 ^ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: T PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for �Biooq;al i§raem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(.Abandon( ) U Complete System ❑Individual Components Location Address or Lot No. fxi�� G�j 1115 Owner's Name,Address,and Tel.No. 9. 3c N fLjA t� j2:s o Assessor's Map/Parcel L� o�.q I C, Ins 's Na e,Address,and Tel No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms -�3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) .tither Fixtures Design Flow(min.required) o gpd Design flow provided 3 gpd Plan date s�^ �' 8 Number of sheets Revision Date Title Size of Septic Tank I ' 0 T Type of S.A.S. vl d LT�GcC'b Q Description of Soil l/V1� `JJ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b this Bo f SE Date all(7 I _ Application Approved by Date d J )"] 6 Application Disapproved by: Date for the following reasons Permit No. aen(o ' 0 to O Date Issued !� & --0106 , _,:. ,., Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ' Z[ppYication for Migpogar *pgtemc Congtruction' Permit Applicatiori`for�a Permit to Construct O Repair O Upgrade(.Abandon O LJ✓ Complete System ❑Individual Components Location Address or Lot No.'6 a/ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 9. 3 Ins 's Na e,Address,and Tel No Designer's Name,Address and Tel.No. Gx SS f/ Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of.Building No.of Persons Showers( ) Cafeteria( ) ? 06er Fixtures t.. Design Flow(min.required) --3 3 0 gpd Design flow provided gpd Plan date Number of sheets Revision Date Title Size of Septic Tank 1!)D p v� ._ Type of S.A.S. Description of Soil t-0 VA Nature of Repairs or Alterations(Answer when applicable) 1r\C(,JC . z)k ✓� 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 Certificate of Compliance has been issued by this Boa_rd4LHeAjth. S' ned Date I i7 Application Approved by Date d / 1 /)k Application Disapproved by: Date for the following reasons Permit No. ( (o '"-0 too Date Issued a -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS 4� BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Dis j osal System Constructed ( ) Repaired ( ) Upgraded Abandoned( )by at D v 1,4 G k-- C eN"��f V has been constructed in accordance ) l with the provisions of Title 5 and the for Disposal System Construction Permit No. 'J00(, —O 60 dated a /13 Installer Designer 7 #bedrooms Approved design flow ;}'C> gpd The issuance of this permit hall not be construed as a guarantee that the system will function asp esigned. Date :411 k Inspector ------------ ------- / No. 1. -'� — 0 tl+C Fee 00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migpogat 6pgterm Congtruction Permit Permission is hereby granted to Construct ) Repair ( ) Upgrade ( Abandon ( ) System located at / u K I tis W e Cy- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction ust be completedwithin three years of the date this er 't Date � `� / Approved`by R Town of Barnstable �FtHE Tpk, Regulatory Services O Thomas F. Geiler, Director • BAmsTABIZ,p• y MASS. 0 Public Health Division i639. ♦0 AIEo3`,�A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 21- 2L1- ©(� Designer: Shay Environmental Services, Inc. Installer: Address:. P.O. Box 627 Address: 's i rP_,nA N cS . _East Falmouth, MA 02536 _ �[1e>��, &A0, On Z— ( was issued a permit to install a (date) (installer) septic stem at C)l CANS based on a design drawn b P Y —,� g Y (address) Shay Environmental Services, Inc. dated 2 -J -O Zp (designer) XX_ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' 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. �vZH OF lfqs,N% CARMEN \ c� ; E �.° (Installer ignature) SHAY No. 1181 0 SANITAR\PN (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed ` Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I I, (t� ,�,J l- S t4P� ,hereby certify that the engineered plan signed by me dated Z - l 5- 0 tE , concerning the property located at Ceo ► meets all of the. following criteria: • This failed system is.connected to a residential dwelling only. There.are.no commercial or business.uses.associated with the.dwelling. • The.soil is classified as.CLASS I and the percolation rate is less than or equal to 5,minutes per inch. The applicant may.use historical data to conclude this fact or may conduct deep test holes and percolation tests.at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information). a B) G.W.Elevation '�),s +adjustment for high G.W. IQ DIFFERENCE BETWEEN A 2 Z SIGNFD : DATE: NOTICE Based upon the above information; a repair permit will be issued for bedrooms maximum.. No additional bedrooms:are authorized in the future without engineered septic system plans. t c 3 LZA q:4Septic\percexemp.doc �Ij OWN OF BARNSTABLE LOCATION (J 4 (L�e;^—s e� SEWAGE # "'-"""'—� VILLAGE. t'—O" �T�� ASSESSOR'S MAP & LOT��� ;; C� ----� i,� INSTALLER'S NAME&PHONE ISO. `1 � - -� I SEPT ITY IC TANK CAPAC i`�v LEACHING FACILITY: (type) tT� v_ `L1! (size) �t c NO. OF BEDROOMS BUILDER OR OWNER S PERMITDATE: '�f 7—�� 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 Co �e A ell l _ �y-OYa G�Au E° TOWN OF BARNSTABLE LOCATION /PL-S �C SEWAGE # -�/Gt©—��°_ VILLAGE_ ec V 4v e ASSESSOR'S MAP & LOT+3q—t-) INSTALLER'S NAME&PHONE NO. J SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L (size i f ) mil x NO. OF BEDROOMS ' BUILDER OR OWNER i PERMTTDATE: COMPLIANCE DATE: -? i Separation Distance Between the: i '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 r T fror, .i C -4 �t X, Cie Wz r ous ateria s Inventory Sheetec is -/ Date yPhysical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts -( ie. gas being used to fuel machines,thinner to clean brushes all count as hazardous materials-no blanks) Storage Information -location of storage, how long is storage for? If none, note that. Disposal Information -where and who? If none, note that. 'Applicant Signature - understand what is listed and noted d Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and explain it _Attach the Business Certificate with your sign off and comments "The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. I TOWN OF BARNSTABLE Dater 1) zo TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: / / BUSINESS LOCATION: 90 / . INVENTORY MAILING ADDRESS: Go 1 4� ,' k,,e /o��G���,¢,�//e 4 TOTAL AMOUNT: TELEPHONE NUMBER: 7e- ?2 1 C [76Z CONTACT PERSON: g� �6�,,f/�, EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: (�Lt/] �'✓7� MVIC� [-�i �-�I�U INFORMATION/RECOMMENDATIONS. -w �,'A„ XV ; 1 T Fire District: A4 uz e . Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed_.Ye) No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products,.exhibit�toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum , Antifreeze (for gasoline or coolant systems) MiscellaneousCorrosive'• ; ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) 00 ;a Hydraulic fluid (including brake fluid) Refrigerants E Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers 1 ' (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates COST $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR in (WHICH YOU MUST DO BY M.G.L. - it'does not give you permission to operate). You must first-obtain the necessary sna u1 es on the Town form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1" Fl., 367 Main St., Hyannis, MA 0260(Town Hall)his get the Business Certificate that is required bylaw. �► _ ` ';� Fill in please: DATE: :3 APPLICANT'S YOUR NAME: BUSINESS YOUR HOME ADDRESS: lc— / `3/�• roZ6� TELEPHONE # Home Telephone Number NAME OF NEW BUSINESS —�a.wt� - /�aJL. F A TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES NO J �O"'" �'� C�lA Have you been given approval.from the building division? YES NO ADDRESS OF BUSINESS ,v ,_ ,'L AP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and r Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST. GO TO 200 IM insStf th coornn of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business, in this town. ( er of I. BUILDING COMMISSIONER'S OFFICE This individual has-been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual WAt en infoofthe per it r ements that pertain to this type of business. uhorized gnature* COMMENTS: G 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. OPWIMWILLY E---10' min. from SECTION A -A ALL OUTLETPIBoxPES SHALLFROM THE Foundation house to septic tank PROFILE VIEW OF ADDITION TO LEACHING SYSTEM uvEl FOR AT LEAST FT. 12" CONCRETE COVER TOP OF FOUNDATION = ELEV. 100.00 (Assumed) Septic tank covers must be D-BOX cover moat be HpnNs' within 6 in. of finished grade within 6 in. of finished grade .� Gpn CO Goode over Septic Tank- 98.00 Grade over D-Box- 94.00 over SAS- 94.00 3" of 1/8" - 1/2" Washed Pedston ` "' 3-r OUTLET - ''"`':•1+. 2 _ 3/4" to 1 1/2 " Washed Crushed Stone }' J/ KNOCKOUTS 19 S 5.5' 0.02 3 HOLE H-10 4"PVC(CAPPED)INSPECTON PORT 1D 8E Y, / .• OUTLET ,��s 12' INLET Crarc ^ } - Y, 0 20' NEW S=0.01 or Gr ST. BOX 3' Maximum Cover INSTALLED AND TO BE 1NTHN 6"OF GRADE Y B" p Greater Top OF System-Elev. -89.75 2• i d X,fi0111aeklas Neck Rd EXIST. PIPEZ112 o 0 1,5 00 GAL. Ss o. , 15.5• 4" - SCH. 40 T �- t0 to N 55' 01"Per foot 10"Effective Depth 1.75' �• j FROM EXIST. FI1l1NDATION rn SEPTIC TANK N / /1 n °' ei,aw" ,c o s PLAN SECTION CROSS-SECTION CONCRETE FULL FOUNDATION-' y II H-10 N aj _ i _ - II of m 5 Units E 6.25' - 30' OD 0 0.83' (10 inches) .,4 6 In.of 3/4 1 1/2" a 1 3 31.25' 3 3 HOLE H-10 DISTRIBUTION BOX 1 SYSTEM PROFILE > compacted stone ; • m ad c i u u ao • NOT TO SCALE Not to Scale - e u 37.25 seaev , > 3.5 3.5' II Effective Length o:oesPm sk akv8caoa yo ooSHaviErr -` c " e'r SOIL ABSORPTION SYSTEM (SAS) 6 in.of 3/4"-1 1/2" 0 1Jo3' 0 GENERAL NOTES compacted stone ¢ Effective Vldth 0 INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE Ca 1. Contractor is responsible for Digsafe notification, Verification of Utilities � o z (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. w Bottom of rest Hole 1 ENONE OBSERVED LL HIGHT OF INFILTRATOR IS 18 FFECTIVE HEIGHT IS 10 NOTE: OVERALL " 2. The septic tank and distribution box shall be set Groundwater Observed - NONE OBSERVED level on 6" of 3/4"-1 1/2" stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. PERCOLATION TEST 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance Date of Percolation Test: FEBRUARY 10, 2006 with Title V of the Massachusetts state code, the approved plan Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations. Results Witnessed By: WAIVER (Per Barnstable B.O.H.) 6. If, during installation the contractor encounters any EXCAVATOR: Shay Env. Svcs. soil conditions or site conditions that are different Percolation Rate: Less Than 2 MPI ® 56" from those shown on the soil log or in our design \ installation must halt & immediate notification be Test Hole Test Hole \ made to Carmen E. Shay - Environmental Services, Inc. \ No. 1 No. 2 LOT #2A \ 7. No vehicle or heavy machinery shall drive over the DEPTH SOILS ELEV. DEPTH SOILS ELEV. \ septic system unless noted as H-20 septic components. ; 0 94.00 0 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. � 1 Loamy Loamy 94.00 05 \\ 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Sand Sand \ 10. All solid piping, tees & fittings shall be 4" diameter i 10 Y 3/2 10 Y 3/2 �\ ���' �\ Schedule 40 NSF PVC pipes with water tight joints. A 93.50 0"-6" A 93.50 � 11. Municipal Water is Connected to ALL OF The Residence and Abutting LoamSand Loamy 137.14 \\ Properties Within 150 Feet. 10YR5/6 Bw 91.50 6"- 28" 10 B•� 91.75 6"- 10 5' NEW 1500 GAL. ' \I V� THE PROPERTY LINES ARE APPROXIMATE AND 30" silt Failed SEPTIC TANK ��' � \ r` COMPILED FROM THE SURVEY PLAN GENERATED BY o ED KELLOG OF OSTERVILLE, MA w�C�Y 8/6 w/Cobbles Cesspool 00-, i ► I ENTITLED "SUBDIVISION PLAN OF LAND IN CENTERVILLE, MA, 2 Y s/s 25 Y 8/6 SHED i i _______ o DATED JULY 8, 1963 PLAN BOOK178 PAGE 127 30"-56" c, 89.33 28"-54" C, 89.25 1 i I --"I - � AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Med.-Flue Sand Med.-Fine 10 5' \ 1 1 EXIST. IT SHOULD BE USED FOR NO PURPOSE OTHER THAN obbles Sand \ 1 I 70 2.5 Y 7/4 w/Gobbles \ 1 1 DRIVEWAY THE SEPTIC SYSTEM INSTALLATION. 56'-132 810C 54"-132 C2 83.00 L__--- EXISTING CESSPOOL TO BE PUMPED OUT AND REMOVED. Porch \� D-Box 4 �} NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE PROJECT BENCH MARK EXIST. 1 r,/� / TOP OF FOUNDATION I FROM THE EXISTING CESSPOOL TO BE DISPOSED ELEV. = 100.00 Assumed cARACE I �- \ "•�• OF AS PER BOARD OF HEALTH SPECIFICATIONS. ( EXISTING 1 ._-s• -:._ TEST HOLE ! ✓- o� nM r ELEV.= 94.0 \\Perc #1 3 BEDROOM \ THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY Depth to Perc: 60" to 78" LOT #15A HOUSE' 20 • Perc Rate= 3 MP'I II 1 - 1 GD Groundwater Not Observed 4601 11 1 =r. = 1 \\ /- ASSESSORS MAP 234 PARCEL 044 No Observed ESHWT 37. 5 -; . _ i \' LEGEND ADJUSTED H2O Elev. = None i i w - ' I i \ 11 I yr I TEST HOLE 2 \ EXIST. % i F I ELEV.= 94.00 \\ DENOTES PROPOSED DRIVEWAY � , �; , 11 104X 1 SPOT GRADE 3-2e DIAM. ACCESS MANHOLES LOT #1 1A 1D -6- 15,10o square Feet +/ �i' 1i, �� 4" PVC % i X 104.46 SPOT GRADE DENOTES EXISTING = �i 1 Vent PL m ,ter ham----' i z1' p i PROPERTY LINE ; / ` ou 98---- ------------------------- 147.91' i i 4' -ZP PROPOSED CONTOUR INLET ` PL THE ACCESS COVERS FOR THE SEPTIC TANK, 1 i' - - - - - DISTRIBUTION BOX AND LEACHING COMPONENT �� 1 -97 EXISTING CONTOUR SHALL BE RAISED To "THIN 6" OF 9 �- �:_, s :...._� i'' •_.::.... FINISHED GRADE. ------------------- i� STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITE GAS BAFFLES OR EQUALS ------------`----' ---------------------- ------------------ ---------�'�/ ® DEEP TEST HOLE & PLAN VIEW ON ALL OUTLET TEE ENDS I PERCOLATION TEST LOCATION 3-24•REMOVABLE covERs I 6 FOOT STOCKADE FENCE H UCKIN,S' !V-Jo ; R OA ID 3"min. elearance ��, IISEi •- .....� INLET 8"m � �2"min. tnbt to outlet e.Tti 017�T. NLE ,c.m -_Liqua k„�l�r (40 FOOT RIGHT OF WAY) 5 S _r P LOT P LAN a. ` '°°ept' �o OF PROPOSED SEPTIC SYSTEM UPGRADE J PREPARED FOR I '°'-°" CROSS SECTION END-SECTION g--e" - MR . RICHARD JOSEPH AT TYPICAL (H- 10 LOADING) 1500 GALLON SEPTIC TANK #601 H U C K I N S NECK ROAD NOT TO SALE BARN STABLE, MA Design Calculations PREPARED BY: Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V)Garba Leaching Capacity ciy Proposed: / Y ( ) , ICARM�'N E SffA Y Leachin Ca acit Pro osed: 330 Gal. Da Minimum Min. Per Title V �J� [ `����; e� I n Septic Tank - 2 x 330 Gal./Day = 660 USE NEW 1,500 GAL. Septic Tank. ENVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch Bottom Area: 0.74 gal/sq. ft. x 372.5 sq. ft. = 275.65 gallons F P.O. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 78.72 sq. ft. = 58.25 gallons 0 20 40 50 G'sT- EAST FALMOUTH, MA 02536 Providing: = 333.90 gallons "W ITAR\1i� � TEL/FAX 508-539-7966 Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1 "=2O' DRAWN BY: CES ATE: FEBRUARY 15, 200 TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE ON THE ENDS. NO STONE UNDER. SCALE: 1"=20' PROJECT#SD861 FILENAME: SD861 PP.DWG SHEET 1 OF 1