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HomeMy WebLinkAbout0025 HYDE PARK ROAD - Health 25 Hyde Park Road Centerville F/R A = 173 016009!PCX = - ti tl i ov 11 14 07:41 p p.1 T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information required for every Centerville MA 02632 11-10-14 page. Cilylrown Stale Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. m When A. General Information ���►r1111r11��,,, Flling ng out out forms OF on the computer, `��.`�LZK „ �q use only the tab .` key to move your 1. Inspector: a - • • • 9 c cursor-do not James D.Sears '��;' •JA M ES m use the returnOAT� ,' key. Name of Inspector CapewideEnterprises,LLC •. ��.•0 i Company Name 153 Commercial Street �� n iiiNi mptt�G�\```\ Company Address Mashpee MA 02649 Cityrrown state Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 1 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �-� 11-10-14 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ine-3M 3 Title 5 0M'1 Fomr.Subaufaoe SexeQe Disposal System•Page t of 17 Nov 11 1407:41p p•2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. C%f rown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal.Tank D Box and field. B) System Conditionally Passes' ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): 15ins-W13 Title 5 Official Inspection Forth:Subsurface Sewage Dlsposel System-Page 2 of 17 Nov 11 14 07:42p p'3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information Is required for every Centerville MA 02632 11-10-14 page. City/Town State Zip Code Date of inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation Is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Tine 5 OMdal Inspedwn Fomc Subsurface Sewage Oispasd system-Page 3 0!17 Nov 11 14 07:42p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in4NqjpW is less than 6 below invert or available volume is less than day flow #Sins•3N3 Title 6 Official Inspection Forth:Subsurface Sewege Disposal System-Page 4 or 17 Nov 11 14 07:42p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. CitylTown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fKih. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or°no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•31113 Title 5 OrBdal Inspection Form:Subsurface pe Sewage Disposal System•Page 5 of 17 Nov 11 14 07:43p p.g Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner information is Owner's Name required for every Centerville MA 02632 11-10-14 page. City/Town State Zlp 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 15.3D2(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN Flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 thins.3113 Title b official Irepeciian Fam SutuurfaeeSeaep Diepoae Syelem•Pe pe 6 at 17 Nov 11 14 07:43p p 7 Commonwealth of Massachusetts o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Hyde Park Road f roperty Address Karen Stanc0 Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. Cityrrewn State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.Tank D Box and Field Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2012-93,000Gais 2013-159,O0OGal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercialllndustrial 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: t5ins•3113 Title 5 offidal Inspection Form:Subsurface Sausage Disposal System•Pegs 7 0l 17 Nov 11 14 07:43p p g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w" 25 Hyde Park Road Property Address Karen Stanco Owner Owners Name information is required for every Centerville MA 02632 11-10-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 9130MO 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 Q 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 Q Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5'^e-3113 Title 6 Offi W InspecUan Farm:Subsurface Sewage Dispose!System-Pape 8 of 17 Nov 11 14 07:44p p.g Commonwealth of Massachusetts ROM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 2005 Permit#2005- 114 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 411 eet 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: 1000 Gal. Precast H-10 Sludge depth: 2" t5ins•3113 Tiffs 5 oltidal Inspection Formr Subsurface Sewage Disposal System-Pape 9 of 17 Nov 11 14 07:44p p.10 Commonwealth of Massachusetts MEN Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 25_Hyde Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. Cftylrown State. Zip Code Date of Inspmlion D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8. Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Tape-Plan _ Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank at working level.Tank and covers at 4"below grade. In and out let tee's. No sign of leak age or over loadinq. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3413 Title 5 Official fnspedicn Form:Submdace Sewage Dimposal System•Page 10 of 17 r Nov 11 14 07:44p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. Cftyrroum State Zip Code Date of Irspedion D. System Information (cunt.) 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 ❑fiber lasspolyethylene g ❑ El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No t5ins•3113 Tills 5 Official Inspection Forac Subsurface Sewage 01sposal System•Pape f 1 of 17 Nov 11 14 07:45p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page- 674f own State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is 16"x16"-1'below grade w/cover at 5' Box is clean and solid w/three line's out Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑.No* Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official kropecLon FOmc sWsuAsca Serape DJsposal System•F'epa 12 Of 17 Nov 11 14 07:45p p.13 Commonwealth of Massachusetts Title 5 Offici al I a Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. CItyrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 30'x15' ❑ overflow cesspool number: ❑ innovative/alternative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is a three pipe field 30'x15'camera lines. Clear and dry. No sign of over loading or holding water. 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 Ming•3l13 Titre 5 Omdar Inspedian Form:Subsurface Sewage Oisposet System•Page 13 of 17 Nov 11 14 07:45p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i&ns-3113 TWO 5 Offidai Inspection Form:Subwftce Sewage Disposal SysO�n.Pape 14 of 17 Nov 11 14 07:46p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owners Name information is required for every Centerville MA 02632 11-10-14 page. C4frown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks_ Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below (-1 drawina attached seoarateiv i � I r I i 38 EEK E f � ! � 4 j i ' I j 15ins•W3 Tree 5 Ot6def Inspedon Forth:Stbswfaoe Sewage Disposal System•Page 15 of 17 Nov 11 14 07:46p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 ode Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. Cityltown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells /I.1P Estimated depth to igh ground water feet 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: 3-28-05 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: T_H.on design plan 3-28-05. No G.W.at 11'+. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•W13 Me 5 Official 1 nspxf3on Fomr.Subsurface Sewage Disposal System•Page 16 of 17 Nov 11 14 07:46p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Hyde Park Road Property Address Karen Stanco Owner Owner's Name information is required for every Centerville MA 02632 11-10-14 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked N Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 official Inspedion Fomr.StbsWace Sewage Diapoaal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 1 L le �y Ta h Owner Owner's Name information is J / required for every �t?c l e✓li page. City/Town State Zip Code Date of/InspAction Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, I �� use only the tab Inspector. I key to move your cursor- et not ���A✓'1 �o/sue �/l use the return key. Name of Inspector Company Name y°o /a ye . � Company Address _ '� L 14'7 pa 6�oC City/Town l /� r7 n[�// State tg / / 2�— / / 7 T �,l p Zip Code Telephone Nu ber License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the —a information reported below is true, accurate and complete as of the time of the inspection. The in'spectton was performed based on my training and experience in the proper function and maintenance of,on sites sewage disposal systems. I am a DEP approved system inspector pursuant to'Sectlon 15.3.40 oft Title 5(310 CMR 16.000). The system: -.. , 2 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspect is Signature /� / Date The s stem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""*This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ins-11/10 1"qle 5 Official Inspection Form:subsurt a Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments a S 6/ e /�r4- /,d Property Address / Le V/ Owner Owners Name / information is � 7e 1r vi / required for every N D (2 /o 8 /� page. City/Town State Zip Code Date o Ins ection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 2/1 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11110 Title 5 Official Inspection Form:Subsurface Savage Disposal System•Page 2 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subs urface Sewage Disposal _ g p s/a/l System Form �- Not for Voluntary Assessments , ` �J /7 de r"G✓fir �o� Property Address Caner Owners Name information is required for every Ceram 42 ✓Vi Ile— page. City/Town State Zip Code Date of I s ction B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system Is not functioning In a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a.surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins-11/10 Tille 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 3 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address I e v/ � Owner Owner's Name information is y required for every _ eH ✓ j'%� Ol 6ZL page. Cityfrown State Zip Code Date oVinspikction B. Certification (cunt.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to.a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the.SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all Inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y Property Address Owner Owner's Name information is every C(?O required for eve page. CityfTown State Zip Code Date of 14spedtion B. Certification (cont.) Yes No ❑ 0/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ LJ 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. ❑ Ea' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ An portion o ,�/ y p f a cesspool or privy is within 50 feet of a private water supply well. El ET 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. ❑ Ea 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. 15Ins•11/10 - Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments as ���✓� r�� �� Property Address Owner Owner's Name information is �� ✓�f /� � required for every "/ b o� page. CitylTown State Zip Code Date of I spe ion C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No d ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ L"J 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? d ❑ Were as built plans of the system obtained and examined?(If they were not .,/ available note as N/A) L� ❑ Was the facility or dwelling inspected for signs of sewage back up? E ❑ Was the site inspected for signs of break out? L�1 ❑ Were all system components, excluding the SAS, located on site? E ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ©/ ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms n desi : ( 9 ) Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �J O 15ins•11/10 Title 5 Official Inspection For m:rm.Subsurface Sewage Disposal Sysfem•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C�s Al Property Address Owner Owner's Name information isV,� required for every T Oa page. Cltylrown State Zip Code Date of rnsp4ction D. System Information Description: (0 /000 6-- qh Sp 4Ic If Trt E�w�(Dn go x SZe-tc-4 7rt e- -,z Number of current residents: t2 Does residence have a garbage grinder? ❑ Yes S No Is laundry on a separate sewage system?[if yes separate insp ection required] El Yes D'No Laundry system inspected? ❑ Yes a'—No Seasonal use? Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? Yes No Last date of occupancy: Ica A'111'K Date Commerciallindustrial 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: ISins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 7 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is /yJ J required for every CeN '`'�V e /%y opt q - a v page. Cltyfrown State Zip Code Date of Inspe on D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: � / -7f Source of information: /"i°* �`^''"✓k �y-�`�s — O(� � 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 S 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection form:Subsurface Sevsge Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • ' Cj ID14- R Property Address / L 10 ✓J Owner Owner's Name information is 1 —::: required for every e f e F-Z+— �olpage. Cftyfrown State de Date of I pe ion D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: a007— /kct l le.,4 e �p/ 1 ,4, a..,d Z2-1 D/1151✓�aL Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: Elcast iron 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Materi 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: Sludge depth: —2 15ins 11/10 Tille 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address -evl�4 Vr Owner Owners Name ) information is CQv+'!C✓!/�/required for every /%N oa 6 IfIll page. Citylrowm State Zip Code Date of In edfon D. System Information (cont.) Septic Tank(cont.) 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 Ole. 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.): �Q ze Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address // L-evr Owner Owner's Name information is required for every — 1? y N Ile- page. City/Town State . Zip Code Date of In ect on D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•11/10 Tine 5 Official Inspection Form:Subsurface Sevrage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C"2S A cue Q�� R� Property Address Owner Owner's Name information is 1 required for every (/P✓t J e✓V//e Qa 6 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert FVe 1-7 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.): /fro Sal, J Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System'(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address e o el k Owner Owners Name / information is �►�e✓d! / required for every ` //0 Oa-6 3' 101- ; 11 page. Cltyfrown State Zip Code Date of In pecti n D. System Information (cont.) Type: ❑ leaching pits number ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: leachingfields X y`sX � 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.): oe a N� G H , 0 VLC 07Z Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal m /System ForQ- Not for Voluntary Assessments Property Address v Owner Owners Name � information is o� ll /� required for every �� o� 8 // page. City[Town State Zip Code Date of I spection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts _ - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1 r C;�s Property Address Owner .Owners Name information is 11 l required for every Ceo�e✓l�f Ile- �� �a�` 3� page. City/Town State Zip Code Date of nspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately x 1 III- 3s. 6 J 7Q r r 15ins•11110 Title 5Ofricial Inspection Form:Subsurface Sewage Disposal system.Page 15 of 17 Commonwealth of Massachusetts - ---- Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address -e v1 71:v7 Owner Owner's Name information is required for every QI^->�✓vi /� Q] 3� a g �� 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. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) L� Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: ✓t-ee r- e2 V1 /2 fo/ z Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•11/10 Tale 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 18 or 17 II commonwealth of Massachusetts k Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments j � 4 C/-e j . Property Address -- Owner Owners Name 1 information is every ,� ✓ ✓/ �/ )� c, 6 required for eve e � /=—�/�r' V page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist 53 Inspection Summary:A, B, C, D, or E checked inspection Summary D(System Failure Criteria Applicable to All Systems)completed [ �stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•11/10 Title 5 Ofrrcial Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ` ?a"'re i0 0i 1 OFFICIAL Io SPECTIO> FOR1g_XO T FOR -VOLI., T_PY ASSESS� Tc SUBSURFACE SEN GE DISPOSa-7C SkSTE:�i I1SPEr"i IO\ FORI 1` ,. . PART C SYSTEM EN ORMATIO'N Property address: C?s /T -ev�-lG ,- v,., Date of Inspection: � C ' SKETCH OF SEV _AGE DISPOSAL SYSTEM ?reside a sketch o_`".:e ser ace uis^osai u2 s; -5 ."1;IlC1 C1 S i0 i i�2ci=cQ ei _ cc C'P.aaiKS. OCaie �I'S ._« w Lei. LOCcte`,rhe a r S yu0i:.. w2:� upp-; C_z rs e OutL Qiu� A 1� �/ - 35, 6 4 / J � Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: __ 25 Hyde Park Road Centerville, MA Owner: John Hales Date of Inspection: October 19. 2004 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. B I 8ACk I O a 3 � Q a 3 W 31 y SS Ss 10 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town(which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1 FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: 03 �31 lrt(D Fill in please: APPLICANT'S YOUR NAME S: 3AM,95 0 CA 1)et 7i,3, BUSINESS YOUR HOME ADDRESS: 41S RvOP P-,r� Fz r P -1 ax T TELEPHONE # Home Telephone Number 5 S- $4� 1375 NAME OF CORPORATION: MzM SF C N s tJ NAME OF NEW BUSINESS TYPE OF BUSINESS Colu-5011015 IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS let (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. . -1. BUILDING COMMISSIONER'S OFFICE This individual has been i ed of ,a permit requirements that pert W§fh66W YPPNOME OCCUPATION Au t orized Signature* RULES AND REGULATIONS. FAILURE TO COMMENTS: COMPLY MAY RESULT IN FINES, 2. BOARD OF HEALTH This individual ha e n info m of the per it re irements that pertain to this type of business. '7'�MWCOW LYWITHALL Authorized nature**COMMENTS: HAZARDOUS MATERIALS REGULATIONS 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: No. 2UGa �.� 1 FEE lU U Board of Health, \e MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) RepairxUpgrade( ) Abandon( ) - ❑Complete System,)-4j' ndividual Components Location 7-5 0 Owner's Name Map/Parcel# 1 nuo IonaAddress Sf4M Lot# Telephone# Installer's Name Designer's Name Address Addres fop �l e l� Telephone# ` Telephone# Type of Building �Sl `k1�.\ Lot Size /LP 1 b;;kJ sq.ft. Dwelling-No.of Bedrooms ``ThC"+2e �?]� Garbage grinder W4 Other-Type of Building N Owe No.of persons Showers (V,Cafeteria (vr Other Fixtures LAtt Design Flow (min.required) gpd Calculated design flow Design flow provided gpd Plan: Date aCl 16S Number of sheets Revision Date I Title CD c i Description of Soil(s) 'e~Q- ��A Soil Evaluator Form No. ��— Name of Soil Evaluator Eq. &j)[j Date of Evaluation 3 a Ia 5 DESCRIPTION OF REPAIRS OR ALTERATIONS SL71C'1 The und, signed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a ees tor�ot to place to eration until a Certificate of Compliance has b n issued by the Board of Health. Signed (X/ Date goH 3 —3i-0:.S7 Inspections -- ---- ---- — ----- -------------� V 4- r � •' • � -rrl', ° -.;: �• P 'I-Q 1-r i ,.._+.r.�w �_ 1'.. r . • .., L '. �!E" - tw ADO .-COM NWLALT14 OF MASSACAS#TS t Board of,Health ���a•��e MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT ' Application for a Permit to Construct( ) Repai Upgrade( Abandon( - ❑Complete Syste ndividual Components Location ZJ� �P � Q��, C,eVt11 Owner's Name Map/.Parcel# '4 3 1 oti ( 0 Address M Lot# Telephone# Installer's NameS�S \-'�C C Designer's Name Address �f A ew l)0.114 Address^+t Telephone# ��L) _ ��^'3 O Telephone# C "Type of Building `Jl �1 G\ Lot Size ►b o�S M yp g sq.ft. Dwelling-No.of Bedrooms \'Tk 1c-�� �J� Garbage grinder�54 Other-Type of Building t dC7�' t_ No.of persons '�i Showers (yrCafeteria (K Other Fixtures L. )-\1 Design Flow (min.required) gpd Calculated design flow 330 Design flow provided gpd �• Plan: Date 3 I a4 I b5 Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator 1=tl SM(-A Date of Evaluation 3 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a ees to to place a VAeration until a Certificate of Co plian has een issued by the Board of Health. Signed Dat 1 ' (J Inspections No. FEE �00 COMMONWEALTH OF MASSAC14USETTS Board of Health, �Z&AB �/✓l�___�_, MA. CERTIFICATE OF COMPLIANCE Description of Work: �Individual Component(s) ❑Complete System The undersigned hereby certify that the Swag DDispo/sa�ll S tem; Constructed ( ),Repaired ( ),Upgraded�,Abandoned ( ) at - cx,15 Q c od - has been installeA in accorda cc with the provisi ns of 310 CMR 15.00 (Title 5 and the approved design plans/as-built plans relating to r application N Urs/ , dated l U Approved Ders}ign Flow U (gpd) Installer .�� / t ! 1 / Designer: Inspector: _/"c 1//1/U.e <� Date: t The issuance ofJ this /permit shall.-not be construed as a guarantee that the system will functionas designed. No. U of I / FEE �y y COMl'l ONWFALT14 OF/MASSAC14USETTS Board of Health,_�.�il r-a,5 `,(mil Aa— -- , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is here b g�nte to; Construct( ) Repai ( ) Upgrade) Abandon( ) n individual sewage disposal system at � �• �� ; � � s� described in the application for Disposal System Construction Permit No.o2(TS dated l 11 U i Provided: Construction shall be completed within three years of the date oft•'s pey 6iit All 1 cal conditions must be met. Form 1255 Rev.5/96 A.M.Sul kin Co.Boston,MA Date 3!, 1/ l/ Board of Health � - r1" /� v Town of Barnstable �tHE ip� do Regulatory Services Thomas F. Geiler, Director + BARNSTABLE, 9�A MA �m� Public Health Division rE1639. A Thomas McKean, Director 200 Main Street,Hyannis,NIA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 5/27/05 Designer: Shay Environmental Services, Inc. Installer: Robert Septic Services. Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street MA 02536 Yarmouth, MA On 5/24/05 Robert Septic Service was issued a permit to install a (date) (installer) septic system at 25 HYDE PARK ROAD, CENTERVILLE, MA based on a design drawn by (address) Shay Environmental Services, Inc. dated 02/29/05 (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. NOTE: VERIFIED REMOVE AND REPLACE PRIOR TO INSTALLING SAS. 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. ` I -iN OF MASSq o CARMEN cti� staller's nature) o� E. a SHAY Cn No. 1181 &O/STEREO ooj� a/ S (Designer's Signature) 0 (Affix 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:Health/Septic/Designer Certification Form TOWN OF BARNSTABLE lr LOCATION SEWAGE # L '[ VILLAGE A SESSOR'S MAP & LOT l73 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY c,7-t — \ C) LEACHING FACILITY: ((type) NO.OF BEDROOMS BUILDER OR OWNER t`eC*k— PERMITDATE: -3 COMPLIANCE DATE: S ®� 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 IAI v Af �S ' TOWN OF BARNSTABLE -LOCATION SEWAGE # `f �{ VILLAGE ASSESSOR'S MAP& LOT_i73 -016"Ord INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ;E cl q wkkC A , �! LEACHING FACILITY: (tyPe) G t4,C—Q—� (size) c 7e NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: S-2 °S 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 .. w ii 14, It O v p1� '�'` _ 0m 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, C -.1 - ,hereby certify that the engineered plan signed by me dated ' '�c I06 ,concerning the property located at 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). 91 u CC- B) G.W.Elevation 3 +adjustment for high G.W.4. 1. _ DIFFERENCE BETWEEN A and B SIGNF,D : 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. gASeptic\percexemp.doc Permit Number: Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location:_ i � Cef ,t\k-e Lot No, c� Owner; 17- )P5E--V -\ Address,_ Contractor: ��;. '��_` Address: :i . �,x C`c, 1�_ 4"> !1�,�,;• t { Notes:_ STEP 1 Measure depth to water table tonearest 1/10 ft. .......................... ................................ .Date � q of a month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... o1S• OWater level range zone .. STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ....................... ... 5 month/year STEP 4 Using Table of Water level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ......................... .................................... 1; Figure 13,--Reproducible computation form, 15 ASSESSOR'S MAP NO. V 1 3 PARCEL LOCATION � ��� SEWAGE PERMIT NO. VILLAGE/,"' I N S T A LLER'S NAME ADDRESS ce) Sots I U� ILD E R OR OWNER � ER DATE PERMIT ISSUED (0 q / �7 DATE COMPLIANCE ISSUED �� z 3� yf Z� 3b L �3 i Fss .�J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .O.I�t A............0F.:.� .1bT I. ..................... Application for j3iipnsttl Works Tonstrnr#iun rrrmi# is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal �yjje_::A�pppficatiofi steal at: p J46... �.5� . ................................1�.......................................... cation Address � y�•�— AA '' ... .. . .....or Lot No..........................«....«.«..... .. .... ......... wner Address w � ---•---••--•• ....-••-•-••--••-••...----••......••-•••................................................. Installer Address Type of Building Size Lot..Lki.O20....Sq. feet .-� Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No.. of persons............................ Showers a YP g ...........................• P ( ) — Cafeteria ( ) WOther fixtures ..--••-•---••---........-•---.................................•-•--....--••--••--•----....................•--....... ....... W Design Flow............J JO.....................gallons per person per day. Total daily flow...........„?0.... ............gallons. WSeptic Tank—Li ui ty-I00-Ogallons Length.g-0! WidthA!7.Idbiameter:—.:-..--..... Depth. .-M4.kt x Dispo —. o..............a_ Width......el......Total Length....Z.45.!...Total leaching area.?7 .C)sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box 0J Dosing tank ( ) Percolation Test Results Performed by......�'I--41. r ..14.�................. Date ��'S .... ... ......................... Test Pit No. 1..G ...minutes per inch Depth of Test Pit.....LZ.= Depth to ground water......... T'.i... fro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ............................................. ..... .••• ............ .... ............................ O Description of Soil..........2... S...o... .......................... .............G.,r i r _.....1`-i ce �r.�-t aa: �e.......................... ............. ..... ...... ...... w ..........................................l A- = �/�oc�,�tr�,��� , . Gj rp�r»�- -- •............................. ......................................................... V Nature of Repairs or-Alterations—Answer when applicable................................................. . . ........................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:I':I• he State Sanitary Code— The undersigned further agrees not to place the system in operatio . n ' Certifi a Compliance has been i by the boar lth. igned. .. :.... ........ .......................................... 1Z,ZDat r . Appli ion Approved By.......... ........ '�`.................................. - �..........1..9...�....... Date Application Disapproved for the following reasons:............................................................................................................ «.. ...........................................•-•------..............---..............-----..........-----................--•---.................--•---..............••--•--•----......................... Date PermitNo........................................................ Issued................ .....-••----............... Date TH.E.COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - .Vl� ... ............OF.. !.�.�t .!.�rC . Appliratiun flax 11ispusal Works Tnnsirudion Vrrmft Vgat Application is hereby made for a Permit to Construct (1/) o r Repair ( ) an Individual Sewage Disposal System at: /�. y�� �.ocation Address�j or Lot No. ». `f �11 Akr; °. �4�:��,,- K;:.�,gin;,- A4.�..... .....--•................................... .-».....-^---........................_..... -- -- rOwner -- Address --^--- ......... ns•-, ................ ^---..... -•----............................ ddre...................... ........... Installer _ Address ppqq Type of Building d2.............Sq. feet U -^--�, Size Lot................ ., Dwelling—No. of Bedrooms.":': .." /. .:.........................Expansion Attic ( ) ` Garbage Grinder ( ) Other—T e of Building .............. ........... No. of ersons__..........__._............ Showers — a Other—Type g -•- p ( ) Cafeteria ( ) Other fixtures ...................••-•-•-••--........_....._....-----... W Design Flow:.........1(�n............ ...gallons per person per day. Total daily flow............ 1" ....... ............gallons. OG Septic Tank—Liquid capacity 100gallons Length..--r'-�r"--- Widths 1 Dia'meter.":.•.------... Deptht?.1.-., .» W Disposal Trefiffi No ...... Width.... ....... Total Length....?!... Total leaching area. `Z�s.Qsq. ft. x 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. .: Z -,Other Distribution box (7,, )" Dosing tank ( ) Percolation Test Results Performed by....., r. A/ ..... Date... `,��-�� Test Pit No. 1..rG ...minutes per inch Depth of Test Pit....Z-: Depth to ground water......q-.F:?:::a--. Gti Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ....-•---•...................... ... . ----... .... ._ VO Description of Soil..........2..r-T�, O� 1�A A f -•------ ---------------•--•:------•--....................----•- •-h--t z� ..G.......�.. T�.,..................................-.-.- Adx-/� � '. ! -••--•..............•-----•----....----•-•----------.....-----•--•--.............., ....---•--------------•----........................--...... UNature of Repairs or Alterations—Answer when applicable............................................................................................... . ........ ... . .................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 1. the provisions of TITLE eeo the State Sanitary Code—The undersigned further agrees not to place the system in operation,until�a CertificCompliance has be�ssued-'by the board.of health. Signed.. .... '... : `. ......................... ........ !. ' ZDat APPlicationApprov>ed-By................................................................ . .......................... .................1.................. Date Application Disapproved for the following reasons:....................•---•-------...-•----.........................------••--•-----............................. ` Date PermitNo...................................................__.. Issued.----..............••.................................. Date __. �'a- r~ -- .- _,__ _... - \ - _.. ....� __..._...- .._ to F •_ ------------------------- THE COMMONWEALTH OF MASSACHUSETTS t -----''' BOARD OF—HEALTH .. ... Wl\j...........OF.................. .............................................................. Trrtif irate of Tompliitnrr THIS-IS-TO-C-ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.................. ......... „R , �, �;C, -, .�; c .._--........----.............---.......... ................................-.....................-- 1 _ �� lnstaller ' at....................2 ......`..............._.._.....::f-�M r .......:.-='....i:. .--•--. ..-.. ........�t _s. ............................................ ,has been installed in accordance with the provisions of TITLE of The State Sanitary Code as de cribed in the application for Disposal Works Construction Permit No.............a ?........ ��. dated........L ..?. 6................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. -- DATE.............•-- .... ....'�....................... Inspector...... ............................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.��............. _. Fn........................ Rappal Marks Tans#rurtiun ramit Permission is hereby granted....................--'......`.-,�..-� ..!.�:;....b-.....-..........•...................... to Construct ( ) or repair ( ) an Individu� Sewage Disposal System at No....................... '.�.:.---.--t�...` ..... .. -........� :�..�G � .._.. `r nS :.: .............................•-•----............. Street as shown on the application for Disposal Works Construction Permit No.�-.L.-_ D ...22 .21. ........... Board of Health =-----------------•• ...................................._ r 362-4541 926 main street yarmouth mass. 02675 down cope engineeiiflg civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys site planning August 5, 1986 sewage system designs Barnstable Town Hall inspections Board of Health South Street Hyannis, MA 02601 permits Gentlemen: Please be advised that on August 10, 1986 Down Cape Engin- eering inspected the septic system installation located at Lot #8 on Hyde Park Road, Centerville. We hereby certify that the installation complies with Massachusetts Environmental Code Title V, Town of Barnstable Health Regulations, and our approved site plan # 84-198-8 dated December 26, 1985. Sincerely, Arne H. Ojala, P.E., R.L.S. AHO/amp Inspected by Timothy Covell L R.200 pp ArBp.63 N !� K ,y 3, C"4c O1rL.&;,T Ff�I .FO�►JDAT isy: Fo�N�q ,q4. �- p OF Pi PE) 66 Lo-r 9 s aNII\ m Lo-r 7 Iti1lJE'r'(O Sf�G CTOP OF PI I o -gox II��E-rTo'D'-WX (TOP OF PI Pb ' 771 pt1tI.ET PI�D'M �I�t'IG ��(DP OF PI PE� _ Ut.X�E-r 'r0`D-r✓oX C'(bP OF PI P�� � 0P OI.:: PI PE� . -rpP�-,WD OF P1,0�-4 DI FFJ601;l6 Pam-.= Co4.17' -. 108.00 Joe # 84-198 CERTIFIED PLOT PLAN it ��A�"�i�II.T hEr"rIG � PREPARED FOR: LOCATION: LOT-8 BARNSTABLE SCALE. 1 "=40 ' DATE: 05/30/86 REFERENCE: PB 406 PG 8 BAYSIDE BUILDING . CO . . I HEREBY CERTIFY..THAT-THE BUILDING SHOWN:ON THIS PLAN :IS LOCATED ON THE Zµ OF M GROUND AS SHOWN HEREON o -:ARNE :i. H. a j. OJALA ti down cape engineering , No.26348 CIVIL S LAND SURVEYORS , ROUTE6A�z*� , YARMOUTH r� tMA. Y r� , DA, Ear u AEG, L'ANO RVEYOR r g 7 ifa ,i". .e� ;1 e+Ry+pS+H .f: tti !°_!. __ .�s•?i- _ 's:.�e�.- 911ANTP%ttNAUY ALL OUTLET PIPES FROM THE 4 a 10' min. from *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. DISTRIBUTION BOX SHALL BE Ik :l Existing Foundation house to septic tank 12" CONCRETE COVER 9 Septic tank corers must be SET LEVEL FOR AT LEAST 2 FT. Grade owx Septic Tmk g D-Box cover must be FFnished grade over system= 99.00 r_• -< v �S1 Within 6 In. of finished grade within 6 in. of finished grade '��` ' y 2 Grade Doer D-Box 99.00 OUTLET 12• INLET '' ipta rSst<Rd"'.. S - 0.02 s=o.o1 0 3 HOLE H-10 TOP OF SYSTEM 98.25 _ ! ! ,�. z, * ,29Hy�de P.* ,.,,,i+ DIST. BOX 5-.005 II EXIST. Greater t.2s s tI .vor� c EXIST PIPE � 10' t` 1,000 GAL. S- 0.01" per foot 4• Perforated P.V.C. Distnbution Lines. r2•-t/8•-tf2' Washed Stone 15.5•^- 4". - SCH. 40 Te �OM$tagBRd �'t - 4�_... Co a cv 2o' R'te FRW FOUNDATION rn SEPTIC TANK a tz" Elev. = 97.60 H-10 aj s PLAN SECTION CROSS-SECTION n' a-0,,N. rn � ro a/i•-1k•Woshee stone Bottom of Leach FacilityElev.= 97.10 U SB/CRAWL FOUNDA ayi _ _ n I� a� - y .^ N N > h a. e LEACH FIELD per'" 6 In.of 3/4--1 1/2• � 3 HOLE H-10 DISTRIBUTION BOX ,* SYSTEM PROFILE 5 STRIPOUT ALL-AROUND 5' PROVIDED � n compacted stone p NOT TO SCALE Not to Scale - e u 11 ®:ps Rmd et?rary 8 Canosr mT4°<iF NAWTEO r ^. - > j Adpsted ESHWi ELEVATION 92.10 aI ---_ - --- - _Bottom_ of-Test Hole_t Elev_.- 88.00 ^-- �v- 6in.of3/4'-11/2' 5 vObs. Groundwater - Test Hole 1 Elev.= 88.00 (Adj. Per CAPE COD COMMISSION = ELEV. 92.10) GENERAL NOTEScompacted stone v PROJECT ADJ. Groundwater = ELEV. 92.10 _ 1. Contractor is responsible for Digsafe notification LEACH FIELD CROSS-SECTION and protection of all underground utilities and pipes. *NOTE: ALL PIPES ARE TO BE CAPPED 'AT ENDS. 2. The septic tank and distribution box shall be set level on 6" of 3/4"-1 1/2" stone. 3. Backfill should be clean sand or gravel with no 3'-6" on center 4'-•0" on center 4'-0" on center S-6" on center stones over 3" in size. Note: Remove soil down to med sand layer & replace with 4. This system is subject to inspection during installation (elev. 96.50 ) & replace with clean coarse sand w/perc: by Carmen E. Shay - Environmental Services, Inc. . .......... ..`"-1 8'-i 2" rate less than or equal to 2 min./in. before & after placement :.... ..:..:..:.::..... :. :. ...:: . ........::.:._:::.-:::: :.::::-.: :: .:::::. 5. The contractor shall install this system in accordance as a one I with Title V of the Massachusetts state code, the approved plan _ 12"Min. _ and Local Regulations. 3/4"-112" Washed Stone t Min. �\ p 6. If, during installation the contractor encounters any � soil conditions or site conditions that are different I`, from those shown on the soil log or in our design 15' j �`.� �, installation must halt & immediate notification be �4Q F ��� made to Carmen E. Shay - Environmental Services, Inc. Sch. 40 - 4" perforated P.V.C. pipe i r y machinery `�-- 7. No vehicle or heavy machine shall drive over the ooseptic system unless noted as H-20 septic components. \ DF Wqy� 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. PERCOLATION TEST r 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Date of Percolation Test: MARCH 28, 2005 10. All solid piping, tees & fittings shall be 4" diameter Test Performed By: CARMEN E. SHAY, R.S., C.S.E. rr "�f �- Schedule 40 NSF PVC pipes with water tight joints. Results Witnessed By. WAIVER(per $ARNSTABLE B.O.H.) r r r��� �- r r al Water is Connected to The Residence and Abutting co _ EXCAVATOR: Shay Environmental Services, Inc. ___ _ Percolation Rate: Less Than 2 MPI 042' -__ _ _ 11. Municipal Properties Within 150 Feet. THE PROPERTY LINES ARE APPROXIMATE AND r J r Test Hole200 ��, COMPILED FROM THE SURVEY PLAN BY DOWN CAPE ENGINEERING ENTITLED No. 1 r �• r �_ ` L CERTIFIED PLOT PLAN OF LOT #8 HYDE PARK ROAD, CENTERVILLE, MA" D O 9999.00TH ...__ SOILS co `� �\ co rr rr `- 80.63' DATED MAY 30, 1986 \ rr 5 r I ` - AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN LOT #8 _ IT SHOULD BE USED FOR NO PURPOSE OTHER THAN FILL J6,025 Square Feet +/ -` ,ys THE SEPTIC SYSTEM INSTALLATION. 97.50 Loamy �� -, EXISTING SAS TO BE PUMPED & FILLED IN PLACE / ABANDONED Sand 10 YR 3/2 r - ` NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE 18"-24" A° .97.00i �\ fr '�96 „ Loamy \�\ __L co FROM THE EXISTING LEACH FILED TO BE DISPOSED Sand OF AS PER BOARD OF HEALTH SPECIFICATIONS. /6 - \ - CO Be 96.50i 24"-42" ASSESSORS MAP 173`PARCEL 0115 009 Fine EXISTING XISTINC \� GARAGE _ ^ LEGEND Sand 3 PEDROOM j � / ,2-5 Y 7/2 HOUSE 42"-132" sa.00! LOT ##9 � DENOTES PROPOSED #25 _ _ 104X1 SPOT GRADE I - --�98 DENOTES EXISTING 5' 0 ALL-AROUND i X 104.46 EXIST. 1000 gal I SPOT GRADE Perc #1 Note: Remove soil down to el. 96.50 & replace ith I Septic Tank I LOT #7 Depth to Perc: 42" to 60" clean coarse sand w/perc. rate less than or O DECK III PL PROPERTY LINE Perc Rate= 2 MPI or equal ;to 2 min./in. before & after placement i PROJECT BENCH MARK SDW252/ZONE B - INDEX = 48.6 for 2/05 n riI I 21,,E P3 TOP OF FOUNDATION �t,r PROPOSED CONTOUR � f- ADJUSTMENT = 4.1 FEET O ELEV. = 100.00 (Assumed) OBSERVED H2O Elev. = 132" or 11' below Grade I D-Box / �� - - - - - -97 EXISTING CONTOUR ADJUSTED H2O Elev. = 6.9' below Grade per Frimpter O / 32' DEEP TEST HOLE & 2-16• aAu. AGaEss MANHOLES �A PERCOLATION TEST LOCATION EXIST. SAS s ,� - 6 FOOT STOCKADE FENCE APPROX. / TEST HOLE #1 98 l\ I I I i I I ELEV.= 99.00 / THE ACCESS COVERS FOR THE SEPTIC TAW, I r INLET /^-1 _..__. /. - DISTRIBUTION BOX AND LEACHING COMPONENT T P LAN .. OU T SET DEEPER THAN ® WCHES BELOW FlNISHmOGRADE SHALL BE RAISED TO WITHIN 6 OF .� FINISHED GRADE k INSTALL TUF-TITE GAS BAFFLES OR EQUALS L _ J / � - ` STEEL REINFORCED PRECAST CONCRETE OF PROPOSED SEPTIC SYSTEM UPGRADE RETE \\ ''--_-�--"J ' � PLAN VIEW 99P z 8, ��'4,�' 4 PREPARED FOR /-3 2a" REMOVABLE COVERS _--____-- , � MS . E L I Z A B E T H G U E R T I N r A INLET _ 3' min. dearance : I �,r N-EJET.".. � -108.0 0' -- # 25 H Y D E PARK ROAD BrmIn 2 min. Inlet to outlet 6•rr -�--- Llquld level OUTLET J I = 5' CENTERVILLE, MA E m I 4'-0' min. .. Ca eom. _ Liq ld depth01 Q) of MgsS PREPARED BY: Design Calculations 0 20 40 50 ME RNE J'1 j E. SHA CROSS SECTION END-SECTION Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 teal./day per Title V) VIRONMENTAL SERVICES, INC. Garbage Grinder: No O• Leaching Capacity Required:330 Gal./Day Minimum ( Title V ) Q P.O. BOX 627 USE EXISTING 1000 GALLON H- 10 SEPTIC TANK Septic Tank : 2 x 330 Gal./Day = 660 USE EXISTING 1,6t� GAL, Septic tank. SCALE: 1 ' =20 G,sTE�`` EAST FALMOUTH, MA 02536 SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch SgNITA?,\ NOT TO SCALE Bottom Area: 0.74 gal/sq. ft. x 450 sq. ft. = 333 gallons TEL�FAX 508-539-7966 Sidewall Area: NOT USED SCALE: 1 "=20' DRAWN BY: CES DATE: f 29, 2005 Providing: = 333 gallons PROJECT#SD71 1 FILENAME: SD71 1 PP.DWG SHEET 1 OF 1 SECTION - SEWAGE T—ar.(p 10 2 -SEPTIC TANK- _„D"BOX - \ mbr!A TOP OF FON �p�'(MSL)• —'?''OF u8TO Vh" WASHED STONE r IN- OUT. IN- OUT- 80.6 i IN- SEPTICTANK TANK ' ELEV. ELEV. ELEV. ELEV. �Z.q m ELEV. ELEV. 8. g, B' \ I . — OF 8i" WASHEDSTONE by a TEST HOLE LOG r liA-4(,4- TEST BY -- TEST DATE (J �OL WITNESS o /� a DESIGN BEDROOM HOUSE T.H.- �► 1 T.H. +� 2 —yt ELEV.�p3,T,I ELEV. NO DISPOSER DISPOSER > PERC RATE MIN/IN. ..... Lp I FLOW RATE 330 (GAL./DAY) 30 GL SEPTIC TANK REQ'D SEPTIC TANK SIZE�' LEACH FACILITY f0 �p b0.11l� SIDE WALL��f'�-f�) Z 7Z1.0(Z,S ) So 1 O .G/D. a �'� I� tj4,5 BOTTOM 2 224,d (I,C� ) _ ?2 4 C� G/D. TOTAL Z`�(o.o SF UID ` _ • L��( '� 144 Lina( D►F4�2ilt�S --''�` f�_� USE: 'zJ _WATER ENCOUNTERED �G -����� NO MS:' (UNLESS OTHERWISE NOTED) �i( 1.DATUM(MSL) TAKEN FROM ` � �-' �O r QUADRANGLE MAP OF I (1J*- 2.MUNICIPAL WATER VAILABLE ( ✓I�I� f }[/] S.M SI GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. 44 A� O ' 1�/� �r LA� 3 PIPE PITCH:VA"PER FOOT Y J .rQ - tt y LOADING FOR ALL PRE-CAST UNITS:AASHOG A%. 6.PIPE JOINTS SHALL BE MADE WATERTIGHT Cl IL �/, -�-�ipX Gp _7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. 30 ��_ ! "�) DE TITLE S ^il5� 1 STATE ENVIRONMENTAL CO L :Q G - n�lv: �C SITE PLAN . . _8,.TkaAS p�-Af�J a=ot Tc� -tea ►��GrC cs.�s��c e.._,�..b ��.'a . •1$i f $� . , LOCUS: {p� T N•I. h - 13�N� R0- �h REG.PROFESSION LENGINEE.R Y�or .: �. ,�o, down ca a en �n�er�n Cs'IZS�- S4.hLb ^n�'. 1��.. d.-L.L- 0 8 PREPARED FOR: ✓�I7�'i o` .. -. CIVIL _ .�BOARD OF HEALTH O.�M LANO SU "r CEO Z AND SURVEY R 11 - CONTOURS (PROPOSED)—O—O—O—O— APPROVED DATA ✓�X -EMx- Y��rI�sX ;..,. SCALE '•I 40 7G � dd" K _ DATE