HomeMy WebLinkAbout0034 JOYCE ANNE ROAD - Health F314 Joyce Anne Road
nterville P
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No. a 0 l U '� 7 7 fl Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
9 phration for )Disposal *pstrm Construction 3pPrmit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System Vdividual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
Cen u l�� ��v Anne R �tyd�+h C°�ool 3� ®� _e 4nnz/11.
Assessor's Map arcel �v 9 /p � �g�.[o•3 7> .S"o$-1"5-&.07a '
Installer's Name,Address, d Tel.No. D si Name,Address,and Tel.No.
�iciii "-`� ner's-77i-9.399 ��
$���..ry v�• Agars 1•�;�5 ' (6 A.va�1r a r� a
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date OCA-At?f'c�G,,Ro i' Number of sheets y Revision Date
Title v 141-5 6i'k.P6,11 a1k
Size of Septic Tank e v r Type of S.A.S. - �A�U� �l+�y[L�d'S (36.t/4C 6 �'j�(•7S/>
Description of Soil -5®
Nature of Repairs or Alterations(Answer when applicable) c
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 o>the viro ntal Code d not to place the system in operation until a Certificate of
Compliance has been issued by this Board
Si Date %/ J /O
Application Approved by A Date /// I/�o
Application Disapproved by Date
for the following reasons
Permit No. 0 0
Date Issued / 1 'a,11t)
a _
No. a 0�� Fee
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
. PUBLIC HEALTH DIVISION - T6WN30F,$ARNSTABLE, MASSACHUSETTS' es
application for 33isp6sar Opstem Construction Permit
Application for a Permit to Construct( ) Repair VUpgrade\( ) Abandon'( ) ❑Complete System [iXndividual Components
Location Address or Lot No.2�'� nnn� Qd Owner's Name,Address,and Tel.No.
cE��krv�►�� oyce-V�nneA/.
Assessor's Map/Parcel do
Installer's Name,Address,and Tel.No. �5k�- 7r//-� � Designer's Name,Address,and Tel.No. �aFr_334—a
(�r�lc�}}i Cvr��n.�4ioh�'2"rK- �tl1G[.J�[�Ci�E•r��in��/>'r�� y.3i✓1'la i>7 Sl-
4S �us�'.y �• P�la�s 6�,n�n1' i� r�1�-���'& � ,�rrv+tx�+4,no (- � ��
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd__
Plan Date OC+ybe t 3L,,110 ln" _11 Number of sheets /� Revision Date
Title T 44P 661 P�i� 7 C* 1C�� ' 0,00 i2)jj/,V
Size of Septic Tank e v; % - Type of S.A.S. (3b•4l
Description of Soil nr,,o i- 4,, 50� latm
Nature of Repairs or Alterations(Answer when applicable) _9)v,C)1G c 1m Lack �R;4=
' 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 Enviroonnme tfi al Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healti'i.
Siv�IZ-AV-2—ples
,� Date // /2 /U
Application Approved by ( Date //1.2
Application Disapproved by Date
i
for the following reasons
Permit No. U/D - /L/ Date Issued l i h o
.- --- ---------------------------------------- ----------- ---------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(11-< Upgraded( )
Abandoned( )by bob -"I 7T1 l_ I UCA i ntn . 1—oc-
at3q-16LIee__ Inc,rti LYA- (2&_M �A;'i (e_ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.
.�0/0- V dated //L.) jQ
^
Installer ,r �, �i,,���;i�!(n C Designer l.,DC,)r\ ai 99f2. prtC-,,,s Tnc
#bedrooms Approved design flow ? > d
� gP
The issuance of his p' it shall not be construed as a guarantee that the system r*11ct pn as designed.Datebit -
Inspector
----------------------------------------------------------------------------------------------------------------------------- ----------
No. U/0 11-W Fee /00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal �pstem Construction hermit
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located atj (j ('(�1 ��
f and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or,special conditions.
Provided:Construction must be completed within three years of the date of this per it.
Date //.1 b n Approved by
FROM :down cape engineering inc FAX NO. :150836298eO Nov. 22 2010 12:33PM P1
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(date)
septa;sysLea.Tult tJ D CQ_�!t,�1 VlE'._.._N`-Ou. UBSed on a t•esi.i7n,dramm by
1 /� r(address) +
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.l cerfif'v Llitit the septic system refere-aced above Nwls i;astilleai subsLuIlliduy ac'rsordi_uc' to
hz, �I.,,si�i., which may i=lt►d(: ':nit:or appruvcd ehttugos srach -).s latmal relocitliOTI of the
distribution box algid/c►r selitic link.
I i-eitify ihaL tho septic >.;ystPtn. .referezt�erg 'i.bove was U.].stallul wl:d1 Illaalor changes (i..e.
grc'itrr tbfln 10' IaLe'--tl fclocittion,of the, SAS or auy vcxtical xel.nctiiion of Lny cc�r.Y�prrui'i�t
of f:lie seq)tie systei2t) bit in.acumdimce wiLli yLate 8s Local R pilatiao.3, Plmn rezrisirtri or
certilic,r.1 , a. : by d6siglicr to 7011ow,
����rc qi MASEI
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u L1LA T; � 6 i7[tail. TO . .OU-4STABL>R...PT3� ;Y�' h3fSAL;Q',Q�9 iJJLVI�D.aJ�1'i._ t_C`t'd'Y ilFT0.:Pa 6 -- `�J�+
2;iyA!6P.Lf1 �1a::@? WILL N(D'A .��nr ,9,5fTFj) T11�Ia l.t, i�4ArH TFYg� O RM. AM) ,��-1�k-1[Y,'6: C:Alr D ARE
TIE(;'EIVEJI)JIfY THE B[jK[al,S'h'A'RUP g'4JBLTC TTEALTILT!)TVT rGI'T. TIUNK bT4;D'i J,
f!:tir..�.ilt1/SrliLiC(rleSiRur,[Gnfli-Cc.iiliu,,.ftiim 3 26 U4.doc
TOWN OF BARNSTABLE
LOCATION ; 5/ T_07lt Ave AJ SEWAGE# d'O/O-yy/
VILLAGE C+rn ASSESSOR'S MAP&PARCEL v;?O9AaY
INSTALLER'S NAME&PHONE NO. Z1 V
SEPTIC TANK CAPACITY /040 C C z'xi. &r
LEACHING FACILITY: (type) - '1"i/ /_ ;Frw (size) /off- TO,
NO.OF BEDROOMS 3
OWNER G L
PERMIT DATE: //-o?/d COMPLIANCE DATE: o
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r71' 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 /�6yd eOa A% .,_,y
�3y
a3G` a'6K
0
f7G A
3q's
'dlrybIC4CU0 l(
Town of Barnstable P#_1�3/o V
oFIRE Pb
@v� ]Departmcnt of Regulatory,Services
J(/ Public Health Division Date
L tAttt EMAEM 4
MAB& 200 Main Street,Hyannis MA 02601
t6y 9. ti�
APED PAA�A
te� )C+eepd.
Date Scheduled Tin
_ l l
`oil Suitability-Assessrizent for Sewage Disposal i
_- --- . --n �• '.�'^�"'�R�r�'.� try^;,....r^ - ; -
Perfonned By: �w �{ Witnessed By;
F� ]LOCATION & GENEI RAJL IN OJRIVUTION
e ^yet, av> Cgcc��l.
Location Address 7^^L� (I Owner's Name �
Address
Assessor's Map/Parcel: 6WOOJ engineer's Namc
NEW CONSTRUCTION REPAIR Telephone IFJ
f A /o NG
Land Us'. Slopes(%) 0 ��J,� Surface Stones /V S
Distance's from: Open Water BodyA/ (�A ft Possible W@ 'reo /Vft Drinking Water Well ft
Drainage Way-de��%�ft Property Line ier ft
t *+ L.,
(
S ICE TCH., (Street came,dimensions of lot;exac ttons of lest holes&pert tests,locate we(lai sin proxinuty to holes)
Cx)�zCj
174Z\3��
yIle
Parent material(geologic)_�U` W V` Depth to Bt;drock 352D
s iI j SEP 2 3 REC'D
Depth to Groundwater: Standing Water in Hole; U Weeping('raid Pit PIICc_ A, I�ti/ L'd _.
Estimated Seasonal High Groundwater /t By
DE,TERPvJINATION FOR SEASONAL HIGH WATER TABLE
E
Method Uscd:
Depth Observed standing in obs.hole: — In, Depth to soil Itlaltle(S: �III.
Depth to weeping from side of obs.hole: _ III, Oroundwater AdJuslment m��,.•._ft'.
Index Well 8 Reading Date: Index Well levni_ AdLI,factor A01.Groundwater Level e
]C'JC+RCOJ[.rATI.0�171']CST � Dat�c'�.7.5 l'Lulo
Observation
Hole# Tinto tit V
Depth of Perc Time at 6"
Start Pre-soak Time @ i Time(9"-6")
End Pre-soak.
Rate Min./Inch L 7i
Site Suitability Assessment: Site Passed_ _ SiIG-Failed: Additional Testing Needed(YIN)
Original; Public hleal(h Division Observation Hole Data To Be Cointtteted on Flack-tf - --
***If1)ercolatiou test is to lie coladucted vvitillla 100' of wedand, you m St lfiirat U91lify C11C.
Barnstable ConserV atlon DivISi011 at least 011C (1) weelc prior to begiull lug.
Qas EPTlC\PERCFORM.DOC
I
IDI]C1E]P.® SR](t VA TI O aC.E G G
Depth from ��g®� t Hole �. ! ,
Soil)Horizon Soil Texture Surface(in.) Sdil Color Soil �—
(USDA).. (Munsell) MottlingOther
(structure,Stones;Boulders.
Con istene %a' ravel
/ns A
��s Z,s y-7yy
A16 e,
-- ----------
DEEP
0-B-0,P-RVATIONTIOLE LOG
Depth from Soil Horizon e m xt Hole # —�—
• Surface(in.) oi! .eure Soil Color
(USDA) Soil
her
(Munseil) Mottling (Structure,
Stones, Boulders.
SL /YC�/ Consis enc %Gravel
� _
Depth from
DEEP OBSERVATION HOLE
Sojl7-Horizon LOG
Surface(in) Soil Texture Soil Color.
(USDA) Soil) (Munsgll) Other
Moaling (Structure,Stones,Boulders.
Co siste cy %(3r,vel)
T DEED Q7BSIERVA7t'ION T OLE, �'®�
Depth from Soil Horizon ]Bole#
Soil Texture _
Surface(in.) Soil Color 5'cll
US
_ ( DA) (Munseil) Mottlin Other
— —_ g (Structure,Stones;Boulders,
Consi ten %Orav—
][�Wd r nsuR aance)Bate M nor
Above 500 yea r.flood boundary No Yes
Within 500 year boundary No Yes '
within I00 year flood boundary No— Yes
Depth of Naturally 0Ccalrr!nl Peu'vious Materlal
Does at least four fe0t of naturally occurring pervious ma
area terial exist.in all areas nbserved throughout the
proposed for the soil absorption system?
At not, what is the depth of naturally occurring pervious matol'ial?
Ceutl�cation
1 cerdfy that on 4Gl'7.7 (date)I have passed the soil evaluator examination approved by the
Department of Environmental.Protection and that the above analY.-is was performed by me consistent with
ilia required training, expertise and experience described in �10 CMR 15.017.
Signature �d (s1� Data
1 . .
Q!\S,V,?TIC\PERCrORM.DOC
I
COMMONWEALTH OF MASSACHUSETTS
i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
LRECEIVED
tVJ t,RC EE
LOT �. 2 4 2004
TITLES F BARNSTABLE
LTH ) T
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address- 3 4 Joyce Anne Road.
en ervi e
Owner's Name: Judith Caccioli
Owner's Address:
Date of Inspection: — —Q
Name of Inspector:(please print) Wi 1 1 i am E_ .Robinson sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P 0 Box 1089
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
I certify that 1 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 15340 of Title 5(310 CNIR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: r/x Date: / f
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanh-or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the.buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5Inspection Form 6/15/2000 page I
Page 2 of I 1
a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)-
Property Address: 34 Joyce Anne Road
Centerville
Owner: Judith Caceioli
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst 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 arc indicated below.
Comments:
B. yytem Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repair d.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.
Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, khibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing is replaced with a complying septic tank as approved by the Board of Health.
•A metal eptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating at the tank is less than 20 years old is available.
ND expla'l:
Ob ervation of sewage backup or break out or high static water level in the distribution box due to-broken or
obstruct pipes)or due to a broken settled or uneven distribution box.Sy
stem em will pass inspection if(with
approval f Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND expia :
Th system required pumping more than 4 times a year due.-to broken or obsis xlcd pipe(s).The system will
pass inspec ion if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rMoved
ND explain:
Page 3 of 11
r'
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 34 Joyce Anne Road
Centerville
Owner: Judith. Caccioli
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Con itions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to otect public health,safety or the environment.
1. Syste will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system 's not functioning in a manner which will protect public health,safety.and the environment:
_ Ces pool or privy is within 50 feet of a surface water
_ Ces ool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System wil fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is funct ning in a manner that protects the public health,safety and environment: .
_ The sy item has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface wat r supply or tributary to a surface water supply.
— The sy tem has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
— The s stem has a septic tank and SAS and the SAS is within 50 feet of a private water supply.well.
The stem has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more froal a
private w ter supply well•• Method used to determine distance
"This stem passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteri and volatile organic compounds indicates that the well is free from pollution from that facility and
the pr ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure iteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address• 34 Joyce Anne Road
Centerville
Owner: Judith Caccioli
Date of Inspection:. 9—dL —6`-
D. S. stem Failure Criteria applicable to all systems:
You m st indicate'Yes"or"no"to each of the following for all inspections:
Yes o
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 IA 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 I00.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%-Ater
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds
indicates that the well is free.from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.1 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.
Large Systems:
be considcrcd a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
g
Y •must indicate either"yes"or"no"to each of the following:
(TI following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone I of a public water supply well
If yo have answered"yes"to any question in Section E the system is considered a significant jhrcat,or answered
"yes"in Section D above the large system has faikd.The owner or operator of any large system considered a
signil scant threat under Section E or failed tinder Section D shall upgrade the system in accordance with 310 CMR
15.3 4.The system owner should contact the appropriate regional office of the Department.
4
I
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 34 Joyce Anne Road
Centerville
Owner: Judith Caccioli
Date of Inspection:
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
Pu
mping information was provided by the owner,occupant,or Board of Health
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)
�t' 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?
—baffles
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?
_ LWas the facility owner(and occupants if different from owner)provided with information on the.proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes 7/ Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance.
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 34 Joyce Anne Road
Centerville
Owner:
Date of Inspection: — c
FLOW CONDITIONS
RESIDENTIAI.
Number of bedrooms(design): Number of bedrooms(actual):_
DESIGN flow based on 310 CMR 5.203(for example: 110 gpd x#of bedrooms):-76
Number of current residents:
Does residence have a garbage ' der(yes or no):
Is laundry on a separate sewage system(yes or no):,Z,�J [if yes separate inspection required)
Laundry system inspected(yes or no): /ri<I
Seasonal use:(yes or no):�L U
Water meter readings,if available(last 2 years usage(gpd)): 2003 — 102,000
Sump pump(yes or no):o 2002 — ,0 0 0
Last date of occupancy: 4�
COMMERCIAlent:
NDUSTRIAL
Type of establis
Design flow(b ed on 310 CMR 15.203): gpd
Basis of desi flow(seats/persons/sgft,etc.):
Grease trap esent(yes or no):—
Industrial ste holding tank present(yes or no):—
Non-sani waste discharged to the Title S system(yes or no):—
Water m er readings,if available:
Last dad of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 4
Was system pumped as pad of the inspection(yes or no):_
If yes,volume pumped:_Jgallons--How was quantity pumped determined?
Reason for pumping:
!I%/CF SYSTEM
ptic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
—_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date in called(if known)and source of information:
L � g �
Were sewage odors detected when arriving at the site(yes or no):,�J
6
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properly Add ress:34 Joyce Anne Road
Centpryill
Owner: Jnrli th car ci nii
Dale of Inspection:
BUILDING SE ER(locate on site plan)
Depth below gr de:
Materials of c nstruction:_cast iron _40 PVC_other(explain):
Distance fro private water supply well or suction line:
Comments( n condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: !/
(locate on site plan)
Depth below grade:
Material of construction: %ncrete metal fiberglass_polyethylene
--Other(explain) _
If tank is metal list age:_ Is age confumed•by a Certificate of Compliance(yes or no):
certificate) 1 , _(attach a copy of
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: ;L
Scum thickness: �I r
Distance from top of scum to top of outlet tee or baffle-
Distance from bottom of scum to bottom 9f outlet tee or baffle: Ij�Z
How were dimensions determined: f jr�.-►✓ e a�,�`�—
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leaka etc.):
1�
GREASE TRAP:_(Ioc tc on site plan)
Depth below grade:
Material of eonstruclio :_concrete_metal fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thicknes
Distance fro top of scum to top of outlet tee or baffle:
Distance fr bottom of scum to bottom Oro
f outlet tee or baffle:
Date of las pumping:
Common (on pumping recommendations,inlet and outlet tee or baffle conditions,structural integrity,liquid levels
as rclat d to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 34 Joyce Anne Road
en ervi e
Owner: Judith Caccioli
Date of inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(Iocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity; allons
Design Flow: allons/day
Alarm present(yes o no):
Alarm level: Alarm in working order(yes or no):
Date of last pump' g:
Comments(coed' ion of alarm and float switches,etc.):
DISTRIBUTION BOX: zafpsent must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.).
PUMP CRA51DER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
f
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 34 Joyce Anne Road
Centerville
Owner: Judith Caccioli
Date of Inspection:_ —A/-0 �z
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,ezcavation'not required)
If SAS not located explain why:
Type
c/ leaching pits,number:
leaching chambers,number:
leaching galleries,number.
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
,'nor s 3
CESSPOOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and con guration:
Depth—top of li uid to inlet invert:
Depth of solids ayer:
Depth of scum ayer:
Dimensions o cesspool:
Materials of onstruction:
Indication o groundwater inflow(yes or no):
Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY (locate on site plan)
Mated s of construction:
Dimen ions:
Depth f solids:
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 34 Joyce Anne Road
Centerville
Owner: Judith Caccioli
Date of Inspection: -- o tz
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.
LIU
A �
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b
10
f
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 34 Joyce Anne Road
Centerville
Owner. Judith Caccioli
Date.of Inspection:
SITE EXAM
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to ground water6v feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
yChekd with local Board of Health-explain:
d with local excavators,installers-(attach documentation)
ed USGS database-explain:
You must describe how you established the high ground water elevation:
10!q.P GQ2,
11
i
TOWN OF BARNSTABLE )Q
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
(�f
NAME ✓✓t �' 'c�L �0 �X Z Z t�
ADDRE S VILLAGE -C.Pn t P rvi 1 1 P
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE:
OR CHEMICAL
Rear of building 500 Heating oil 1981 Steel
(Give same information for any additional tanks on reverse side of card)
DATE OF PURCHASE OF EACH: 1. 8/10 f 81 2. 3. 4. .
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED:
PASSED DID NOT PASS
A P P R O V E D
Flo Cnno$vation COMIS830A
No.6 Fps....
f!.
THE COMMONWEALTH OF MASSACHUSETTS
� BOAR® F HEALTH
4.. 4*04)...................OF....4D ...............................................
s , ppfiration iur M.6pusal ark�orRepair
nn�trurth rn rrmi#
Application is hereby 'made for a Permit to Construct ( ( ) an Individual Sewage Disposal
Sys .. ........ � _. Lot N o
----- -
_._ LoIcat i Ow nerI.v, / i
.® � ... ..................... .. ............... .................
----------.
---•--•........... ..................... ....... ............................ -----•......................._...................................Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers
a YP g ( ) — Cafeteria ( )
Otherfi s ....•••-•-•----•......•-•---•-•----•--•••. •--....-•--•-•-•••---••-• -•...............••-•--.......
W Design Flow--... ... . .....................gallons per person per day. Total daily flow...........�r?,?�..._._..........gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter----..........-- Depth................
x Disposal Trench—N .................... Wid h . .......... Total Length........._ .. Total leaching area....................sq. ft.
Seepage Pit No----------------- Diameter. .X�... Depth below in __.. Total leaching area..Q�41.0....sq. ft.
Z Other Distribution box ( ) Dosin ank ( )
`" Percolation Test Results Performed by-- f_��C_� ..`�-� &•...................... Date....SO t ?( -.........
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..--....................
0-4
4= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of oil------Q Zi......_._.. ?..9Z'..... . ..t. a ...
x �/L-----------------�.......1�, .12. d .
W l,�.s� sly --G�c�1r�- 1" - ..
x ---
U 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 ofIT:LE 5 of the State SanitaryAis
The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beby the and of health.
Date
Application Approved By__.......-- � • %� --------------- .......
ate
Application Disapproved for the following reasons--=---------------• ----------------•-------•----------•------•-•---------••----•-----.........._..._.....-••_..
....-•-•------•-----•-••---...---•-----------------••-------...----------------------•-----•-------.............--•---------------•-•-------------------------------------•-•--•-•----••---••--•--._.....
Date
PermitNo........................................................ Issued-_.......------•----------------......--•- -
Date
.T4
No. FEE.............. ....:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'...... � .........................
Appliratiun for Uiupuiial Works Cnunitrtirtiun rautit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Syst�m at:
--..... .......................•------•-- ......................
Locat' ddress Lot No.
. r: SIMP u ? . ........... c .............................................
....�
Own r Ad ss
_• ......................................................................................." _ '----•..........................•--- -•--•--•---- e �/ .......................................
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other s ••-•••-••-••-•-••--•-•-•-•••-•-•-••-•-•----•----•. ••
W Design Flow........... _ _. .......................gallons per person per day. Total daily flow..........,,,, -----------------gallons.
9 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter.-----.......... Depth.............:.-
Disposal Trench—Ng. .................... Width.._._ ..__........ Total Length.......__. .. Total leaching area....................sq. ft.
Seepage Pit No........ ........... Diameter..G.+�. ..._ Depth below inlet......- >....... Total leaching area.,r'�.0..._.sq. ft.
Z Other Distribution box ( ) Dosing4ank ( ) f
aPercolation Test Results Performed by...� /4:Y' r. ' C�." t...................... Date._..f%:(*a ..........
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.----................--.
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
_.
............#L------- .. ..................................�e...........
"
O Descr tnf oil---•- I ! Ca ii ..........................................
----------------------------------------1A..--- > - _ - - <...................................................................
U 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 T?TI,;,:. 5 of the State SanitaryAis
The undersigned further agrees not to place the.,system in
operation until a Certificate of Compliance has beby the and of health.
d ----- DateA lication A roved B „ �br� CirY a C y ? .PP PP Y � ate
Application Disapproved for the following reasons:...............................................-------•-----•------------------•----------•--•-•---•----•-•-•--
-------------------------------------------------------------------------------••---•--------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALT
�f......6 ..�
Trrtifirttte of Toutpliattrr
THI. I 0 ERT e Y T ndivid 1 Sewage Disposal System constructed or Repaired ( )
at
�.. ' ue �
t.
by. - r - ----------------- ---------------------------------•--------------
has been installed in accordance with the provisions of r of The State Sanitary Code as described in the
m
application for Disposal Works Construction Permit N _ _... ---------- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SAT SF?CTORY. �3 /} �................. Inspector-•••--••----•- "
DATE......................................... .. .....� t�5... _. .._....._...._....--•------•-------••----•-•-•--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTJH
4.................OF..... ---
C? _ FEE..-_.-•--•..............
Ropu�l ku nu#r iun rutit
Permission i ereby granted-• -• -t ........ 9t� lK '1 }
to Constuct J Rep ' A') an Individ . Sewage D�8Sys
atNo...... ...................... r - . rM-.....-- '1 fir-. ------- ...- f . ............................
Streer
as shown on the application for Disposal Works Construction�t No..................... Dat d..........................................
B Health
DATE.....- ...........-..........
...............................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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VI l lAG E C"e. _
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I N S T A LLER'S NAME i ADDRESS
8 UILDE III / OR OWNER
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DATE PERMIT ISSUED -7-- — 1
DATE COMPLIANCE ISSUED
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SKETCH ADDENDUM
Borrower/Client
Property Address _
City County _
Lender
Appraisals
' Certified Real Estate Appraiser•MA License#4354
Judith A. Caccioli Phone: 508-775-6092
34 Joyce Anne Road Fax: 508-775-3949
Centerville,MA 02632 email:CCrose96@aol.com
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FW-73A ®1980 Forms and Worms Inc.,315 Whitney Ave.,New Haven,CT 06511 All Rights Reserved 1(800)243-4545 Item N 112900
I,.ov,
ALL SSTEM
S SHALL
SYSTEM PROFILE M RKED WITH CMAGNETIC TTAPE OR BE NOTES
(NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. APPROX. NGVD Ped
1. DATUM IS
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE
2. MUNICIPAL WATER IS EXISTING Phi
\ TOP FOUND. EL. 55.0' PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE
53.2' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTE d
PRECAST H-10 UNI4. DTSSIGN LOADING TO BE AASHO HR 1A0LL PROPOSED PRECAST Old ocu
RISERS (TYP.)
p 0 52.1 4"OSCH40 PVC ��
PIPES LEVEL 1ST 2' 5. PIPE JOINTS TO BE MADE WATERTIGHT.
_T: 2" DOUB�F WASHED PEASTONE
OR GEOT TILE FNBRIC 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE
10" EXISTING 14" 50.6 WITH 310 CMR 15.000 (TITLE 5.)
TEE SEPTIC TANK TEE
f*50.7 000000000000 0oo�$s 0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND
GAS BAFFLE oD 50.1' NOT TO BE USED FOR LOT LINE STAKING OR ANY
50.27' 50.1' OTHER PURPOSE. �o`c
0 2' o
6" MIN. SUMP o000 000 48.1' 8. o
PIPE FOR SEPTIC SYSTEM TO SOH. 40-4" PVC.
12" MIN. INT. DIM.
H-20 3050 INFILTRATORS cooL
9. COMPONENTS NOT TO BE BACKFILLED OR
CONCEALED WITHOUT INSPECTION BY BOARD OF
6" CRUSHED STONE OR MECHANICAL 3/4" TO 1 1/2' DOUBLE WASHED STONE HEALTH AND PERMISSION OBTAINED FROM BOARD
COMPACTION. (15.221 [21) OF HEALTH.
( 1 % SLOPE) ( 1 % SLOPE) OVERALL DIMENSIONS TO OUTSIDE OF STONE: 30.4' X 10.25' 51
C!
10. CONTRACTOR SHALL BE RESPONSIBLE FOR
CALLING DIGSAFE (1-888-344-7233) AND
LEACHING VERIFYING THE LOCATION OF ALL UNDERGROUND &
FOUNDATION- EXIST. SEPTIC TANK 45' D' BOX 2' FACILITY OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. LOCUS MAP
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED NOT TO SCALE
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON H-10 SEPTIC TANK IF NOT SUITABLE (OR H-20 BOTTOM DWA & FOUND
43.1 ' SHALL BE REMOVED 5' BENEATH AND AROUND THE
SEP11C TANK IF IT WILL BE SUBJECT TO VEHICLE LOADING). NO GROUNDWATER FOUND PROPOSED LEACHING FACILITY.
ASSESSORS MAP 209 PARCEL 108
12. EXISTING LEACHING FACILITY SHALL BE PUMPED
AND REMOVED OR PUMPED AND FILLED WITH CLEAN AP DISTRICT
SAND. LOCATION SHOWN PER AS-BUILT CARD. ESTUARINE PROTECTION DISTRICT
LEGEND .3
99- EXISTING CONTOUR SYSTEM DESIGN.
F
X 99•/ EXIST. SPOT ELEV. �'�5$6p SHED
99 PROPOSED CONTOUR 52. GARBAGE DISPOSER IS NOT ALLOWED
6`7 x 53.38
198.4] PROPOSED SPOT EL. 6
�9 DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD
TH1
TEST HOLE 2.59 x 2•82 52.91 USE A 330 GPD DESIGN FLOW
2% SLOPE OF GROUND BENCHMARK: USE CORNER CONC. 53.33 (EXISTING 2 BR PER ASSESSOR'S RECORDS)
S
.- BULKHEAD AT EL. 54.4 52.50 �`, 5�5�04 1 x 53.56 SEPTIC TANK: 330 GPD (2) = 660 �r�'
UTILITY POLE 2
` RE-USE EXISTING SEPTIC TANK**
FIRE HYDRANT 50
3� \ x 5.33
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING p0 53. 54.41 \ 9 �� 16 LEACHING:
O
1p SIDES:2(30.4 +10.25) 1.85 (.74) = 111.3 GPD
TEST HOLE LOGS s .84 54 98 p� x 2�. BOTTOM 30.4 x 10.25 (.74) = 230 GPD
5 .12 x 53.
� 4 ®5 3 LP \�� \ x 53.99
� EXIST. ST ` x 54.15 TOTAL: 461 S.F. 341.3 GPD
2 77
ENGINEER: ARNE H. OJALA, PE, SE 1.08 EXIST. DWELL. ` 53.84
TOP FNDN. _ �� ` x 53. USE (4) H-20 3050 INFILTRATORS,
WITNESS: DAVID W. STANTON, IRS 49 73 Gi"�2 41 ELEV. 55.0' �� `� x 53 x 86 WITH 1' STONE AT ENDS AND 3' AT SIDES
OCTOBER 25, 2010 G/ 53.85 `\X53.55 x 74
DATE: �51.59 xX 533.53 x 3.71
PERC. RATE _ < 2 MIN/INCH x 53.69 x 53.72
.78
CLASS I SOILS P# 13104 \ 50. �o
\ � / 3.75
53 4
ELEV. 2 ELEV. \ / x 53.77 MA
4 (� /� APPROVED DATE BOARD OF HEALTH
v
off 53.1 0" 53.1 O'L_ \ A\ / 53.9 ^1
k 5 0.61 �3.43 Nth
A A � \ /� 67
10YRL4/3 10YRL4/3 \\ � 1 TITLE 5 SITE PLAN
12» 12„ � 6 OF
B B �X0.99
53.02
LS LS _
34 JOYCE ANNE ROAD
„ 10YR 6/4 10YR 6/4 Q k51.16 'ap, 52.34 5z.95 CENTERVILLE
50.6 51.83
30 50.6 30 � 1.24 - - •
52.27 PREPARED FOR
C c BORTOLOTTI CONSTRUCTION/
PERC 51.43 _
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51.40 2� � '�. , �N OF Vj
MCS MCS o� sgc�r�° DANIE=LA.
DANIEL 0 OCTOBER 26, 2010
IVI a
2.5Y 7/4 2.5Y 7/4 } oJA
_ N...,,.::_ o� off 508-362-4541
fax 508-362-9880
downcope.com
DANIELA. �6,
a en Ineerinb Q' Inc
(� OJALA OJALA `'-
At m ((O w II co p
120" 43.1 ' 120" 43.1'
a . 40980� �I���
CIVIL
4 P 9 �N0 465 civil engineers
NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' ® q� FSS o� � ' T�¢ a>�` land surveyors
939 Main Street ( Rte 6A)
10-226 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675