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0051 JOYCE ANNE ROAD - Health
51 JOYCE ANNE ROAD, CENTERVILLE A= 209 016 UPC 12534 ° No.2153LOR HASTINGS,MN f r Bk 31143 Po'74 OL 1 2296 DEED RESTRICT106 WHEREAS,JacquelineJ. Hansen and Mark Jan Hansen, as Trustees of the Hansen Trust u/d/t dated May 20, 2014, as evidenced by a Certificate of Trust recorded in the Barnstable County Registry of Deeds in Book 28153, Page 246, of 51 Joyce Anne Rd, Centerville, MA 02632, is the owner of 51 Joyce Anne Rd, Centerville MA 02632, and being shown on a plan entitled "'Apple-Wood', Plan of Land in Centerville (Barnstable), Mass. for Riverside Building Co., Scale 1"= 40', dated May 3, 1977, Baxter & Nye, Inc., Registered Land Surveyors, Osterville, Mass." which plan is recorded at the Barnstable County Registry of Deeds in Plan Book 315, Page 22. WHEREAS,Jacqueline J. Hansen and Mark Ian Hansen, as Trustees of the Hansen Trust, as the owners of said lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit for a septic system in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction, or alteration of a single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, NOW, THEREFORE,Jacqueline J. Hansen and Mark Ian Hansen, as Trustees of the Hansen Trust does hereby place the following restriction on their above referenced land in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: i l ' 1. 51 Joyce Anne Road, Centerville (Barnstable) MA, 02632 may have constructed upon the lot a house containing no more than three(3) bedrooms. Jacqueline J. Hansen and Mark ton Hansen, as Trustees of the Hansen Trust agrees that this shall be a permanent deed restriction affecting any home located on 51 Joyce Anne Road, Centerville MA, being shown in Plan Book 315, Page 22. For title of said property see the following deed: Book 29049, Page 314. Executed as a sealed instrument this day of March, 2018. By the Hansen Trust: Lc.t2c `�t.C�.�+�..�2 /ru��-c� �z. 5�"Gtrid--�Wit• ' �q4ji.ne .J. H n en, Trustee Mark Ian Hansen, Trustee COMMONWEALTH OF MASSACHUSETTS SS Man c1h l ) 2018: Then personally appeared the above named•—t K— known to me to be the person(s) who executed the foregoing Instrument and acknowledged the same to be - r\ t11- ltJ in free act and and deed, be j me, Not u My commissi n ex Tres: CRISTINA BROWN Notary Public COMMONWEALTH Of MASSACHUSETTS My Commission Expires On. October19,2023 BARNSTABLE REGISTRY OF DEEDS John F, Meade, Register �licationrl�er...B. ................ �o�.. .. :-� MA8t3. P ee �........ .... ..I. s......Other Fee.................:...... TotalFee Paid...................»............................................. TOWN OF BARNSTABLE PeM3itApFa,alby.................................on........................ _ BUILDING PERMIT o�oq.................... M=1......... .......................... lvlap........ APPLICATION Section I — Owner's Information and Project Location Project Address �c v CE -1-t tv M i VMage l V/GLz Owners Name ,VS 67-^ / Owners Legal Address 5/ 126 City. (�O-AI EiZ U-C State M/Z - Zip 0 b3c- Owners cell# 5ng-- c2-qz — 37 37 E-mail Section 2—Use of Structure Use Group_ Commercial Structure over 35,000 cubic feet ❑ ❑ Commercial Structure under 35,000 cubic feet Single/Two Family Dwelling Section 3—Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ©Sprinkler System ❑ Addition ❑ Retaining.wall ❑ Solar Renovation ❑ Pool ❑ Insulation Other—Specify Section 4-Work Description jnJ% J C h - I mt) �i�SG— L Ncle AeO4= f 6�L 7/7ti r . /vojA) PG!-C/�Y,/ 1/ 2 9rzo18 TOWN OF BARNSTABLE LOCATION 571 -,30yef ;:LUNc- SEWAGE VILLAGE e:2/%T2V,11/CG� OV INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY p®d ca A LEACHING FACILITY:(type) �'OD% L �i4A*&' (size) /Z,5 mX 215-1 NO.OF BEDROOMS f / OWNER /,V,4a�LT/�QU�N6 /Y�094,- PERMIT DATE: / COMPLIANCE DATE: 2 / Separation Distance Between the: 'A Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility V /'� Feet Private Water Supply Well and Leaching Facility Of 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) 41 Feet FURNISHED BY Reap, OF: �400&E_- Q. I, 8 pEcK or oZ A q o - Z.-ZD' -5- 53 5 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for ;Bisposalbpstem Construttion permit Application for.a Permit to Construct( ) Repair(( tpgrade(' ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. vim'1 Dy Cf_ AM JF— Owner's Name,Address and Tel.No. MARK i4AN)5 eel Assessor's Map/Parcel MA P W9 $i 'b C iAkm3E 19b Ce-ei—W-U i t t c— Installer's Name,Address,and Tel.No. �d -776- 67-19 Designer's Name,Address,and Tel.No. 77!K YI -1 y($ l,L �'A E t��v�QoNdwENr+�� meye1z. ;6o.�s �• BPS 360-33�/ P �o• 0ox l Sp#-)DUJtc.H_ MA. Oz�3r7' Type of Building: 7 t Dwelling No.of Bedrooms 3 Lot Size ��jOG�® sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3�ZrZs gpd Design flow provided 'Y2,257 1,330 gpd Plan Date���� �� Number of sheets Revision Date "A16 Title Size of Septic Tank /.ST/%LL'y ®Q� (4ZW, Type of S.A.S. p� 209 A 6—P j e� Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1N 67D 1,1,6 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H ajt . Si - Date a� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 3 Date Issued J Fee THE-COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4' Yes PUBLIC HEALTH DIVISIONM- TOWN OF BARNSTABLE, MASSACHUSETTS 2ppliLation for Misp0$af 6pstrut Construction 30Prtttlt Application for a Permit to Construct( ) Repair 0()' Ups e(°) Abandon( ) ❑Complete System ❑Individual Components ` Location Address or Lot No. j 1 Sbl et= A"WE Owner's Name,Address and Tel.No. p OAP ZOO /llo SI�Toycs Ao C- 1Zb Assessor's Ma /Parcel Installer's Name,Address,and Tel.No. tD7- 76- 6ZI,? LDesigner's Name,Address,and Tel.No. 77r Y/,9-9V 6g ALL �J� l; l�1V 1J 1�0NrN1�Eec1Tt4�- 4EYEt2-b- 66O's ZNC• �vR 366P Z .o• Sox R8I SANDWI-CH OAA• ort5"317 Type of Building: 7 v71< Dwelling No.of Bedrooms 3 Lot Size 16000 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) .�ya�2S gpd Design flow provided gpd Plan Date y�Z6 �� Number of sheets 2 Revision Date Title Size of Septic Tank �iY/.377/L� ��ODq�. Type of S.A.S. o7� DpQAl �:IA:: 'V Description of Soil /��f�/�/ �jil1Q IF Nature of Repairs or Alterations(Answer when applicable) y�PJ d-Aa A' AA16 ,2 5�l�fa,+'�e Date last inspected: tip ,a ;. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H alt . J Signed Date / /a o ' Application Approved by Date Application Disapproved by Date G for the following reasons A // e Permit No. �0l 7 '�f 6 73 Date Issued ------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate Of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired.*) Upgraded( ) Abandoned( )by fi� eAde �;1X Ri9�10,, �j¢� — �J i u SfeN C r'�0 M�I�iJ -at 6'-/ UO-YZ-9: tqIA-46 - A2:PAD has been constructed in accordance ALL ,� with the provisions of Title 5 and the for Disposal System Construction Permit Na /22 `4 3 datte•^d 15l•-r•-5 Installer tPc 97NUi' k)Dk) eA3T.A1-� Designer #bedrooms .3 t:��IZQDlH� Approved design flow 314 Z 25' gpd The issuance of this permit shall noit�be 4onstrued as a guarantee that the system wil fiztc tot as dt ts'gned. Date ! ` Inspector --------- ------ ----------------------------------- No. C: '`l / .,,flV`"f Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS -Mispo8al 6pstem Construction i9ermit Permission is hereby granted to Construct( ) Repair) Upgrade( ) Abandon System located at i4okme P 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 permit. Date ��1 Approved ty k TOWIII of Mirmstable Regidatory Services 1110111"d V. Se"li. listerini Director 1111blic "c"Ith DIVI'Mon Tholums McKenn, Director 200 Main Street, Hyfillnis, MA 02601 011,10o: SOt-962-4644 Fox: 508-790.6304 Sewage PermitO Assessor's Map\Parcel �Z, Designer: 0 IIIr-- C.,Installer: _adf45__!� 1VA3( CLC Address: Address: _A 01cf? RWYLIML Ff AM On 1 nstall was issued a permit to install a 6 er) ,Ce4qc'ro (le, septic system at based on a design drawn by f mdd—rosTs e-*"' dated es er A I ccrti,ly that the eptic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &required) Regulations. Plan revision or certified as-built by designer to follow. Strip out (it equired) was inspected and,the soils were found satisfactory. I certify that the system referenced above was construct e with the terms h, \A appro,4HItters(if applicable) QA c r (15esigner's ignature ere BLEASE RETURN T E ND S- LIAN. �;ARQ A QASapdc\DosISnor Conification Forol ROV 8_14.11doc i Is- Town of BA astable. P it1�ZD� Department of Regulatory!Services Iq ' Public ][ealth Division 'Date , puva� I P� 16.1 200 Main Stree4 Hyannis MA 02601 Ul AlFO pV! I",� 4a l I 4 Date Scheduled l l ' Time Fee Pt'1 I U U i�' Stuitabil'ty Assesset,fog- Sew ge isposar Performed By: Witnessed By �^v' LOCATION & GENERAL INFORMATION Location Address t' l Owner's Name 4 Toyc.E.cll ��� e�p� S Address �' Assessor's Map/P�rcel: a is`J/�� I Engineer's Name C7` I NEW CONSIRU�-nON REPAIR Telephone# K: ' � I i Land Use L Slopes SA- % I! Surface Stones Distances from: ripen Water Body _ft Possible Wet Ar ' " ft Drinking Water Well ft DrainageWay " ft. ProprrtyLine C ID ft Other ft I i • SKETCH:($tree[name,dimensiotis'of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) J"e.-� '`>, S STD✓`—\ i 1 \Q�r lL ta v 1 ��t `motIq • i I I 1 i • I • • I t I i Parent material(geglogic). Wv "'"'VA 1 \ Depth to Bedrock ; Depth to Groundwaker. Standing Water in Hole Weeping from Pit FACe Estimated Seasonal Ii"igh Groundwater D tMIN TION FOR SEASONAL FIIGrH WATL1,R TADLE Method Used: _ 1 Depth dbperved standing" obs.hole: _in. Depth td still mottles: In. Depth toiweeping from sidc of obs.hole: I in, Groundwater Adjustment ft.Index Wel!#_� Reading Date Index Well level Ad factor_ Adj.droundwater Level • I V PERCOLATION TEST . Date TIM, ; Obserntion. - I - I Hole# Time at 9" Depth of Perc II 'lime at 6" l�0 Start Pre-soak Time.0 IL 'rime(9"-601 ); End Pre-soak l Rate M12:Inch Site Suitability Asse4sment Site Passed _ Site Failed: Additional Testing Needed(Y/N) Original:.Public HeMth Division Observation Hole Data To Be Completed on Back--- i ***If percolali0n test is to be conducted within 100' of wetland,you must first notify the Barnstable N#servation Division at least one (1) wedk prior to beginning. t DEEP OBSERVATION HOLE LOG Hole# _ Color Soil Other Depth from Soil Horizon Soil Textuu, S Mottling (Structure,Stones,Boulders. Surface(in.) (USDA) (Munsell) Consistenc %Gravel 12,w L 17)1, 2 DEEP OBSERVATION HOLE LOG Hole# Other Depth from Soil Horizon Soil Texture Soil Color S odin Structure,Stones,Boulders. Surface(in.) (USDA) (Mansell) g Consistency,%Gra el 1► [,Are A R-3 -V t ti' r�W-0 j -1/ (AwA DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Surface(in.) Consistency,%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (USDA)A (Munsell) Mottling (Structure,Stones.Boulders. in. ( ) - Consisten ra I Flood Insurance Rate Ma I p J Above 500 year flood boundary No Yes Within 500 year boundary No Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring:Pervious Material Does at least four feet of naturally occurring pR' us material exist in all areas.observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurringus material? Certification G I certify that on ` (date)I have passed the soil evaluator examination approved by the Departure . nviron ental Protection and that t above analysis was performed by me consistent with the required trai ng,ekpe tise and xperience des ribed in 310 CMR 15.0 7. Signature - Dat eq Q:\SEPIYC\pERCFORM.DOC � 7 Commonwealth of Massachusetts (P �' Title 5 Official Inspectiono rm F ! � day, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments p y� ``�1 " M 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is CENTERVILLE ✓ MA 02632 5-13-15 required for every page. Cityrrown State 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. Important:When filling out e A. General Information forms on the � �� onlycomp the tab key uter,use 1. Inspector: to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name �I P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection -was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of 'title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-13-15 "eg�atui,6—, 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 insp9ption,.doe�s no address how the system will perform in the future under the same or different con,,,et�q�r s oif u . �b t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page t o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Cityrrown 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: AT TIME OF INSPECTION SYSTEM MET ALL MINIMUM PASSING REQUIREMENTS THE SYSTEM IS LOCATED IN THE BACK YARD IN AN AREA COVERED WITH IVY. I WOULD RECOMMEND REMOVING THE IVY BECAUSE THERE WERE ALOT OF ROOTS ENTERING THE COMPONENTS . THE HOUSE HAS BEEN VACANT SINCE OCT OF 2014. FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED FROM THIS REPORT. HOUSE WAS OCCUPIED BY ONE PERSON FOR QUITE SOME TIME WITH LITTLE WATER USAGE 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms 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 Boarq 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts, w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 '/2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w ,0 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 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 11 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 1 1 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. CityrFown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage di5p�osat 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(design): 3 Number of bedrooms(actual): 3per town DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: A 1000 GALLON TALKED'-BOX AND LEACH PIT WERE LOCATED IN THE BACK OF THE PROPERTY Number of current residents: 0 I, 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)): Detail: HOUSE VACANT MINIMUM USAGE Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: OCT 2014 Date Other(describe below): General information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No ' If yes, volume pumped: . gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1998 PER AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: LIGHT t5ins-3113 Title 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 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE 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 WAS STRUCTURALLY SOUND AT TIME OF INSPECTION THERE WAS ROOT INFILTRATION FROM THE HEAVY BED OF IVY IN THE AREA OF THE SYSTEM. RECOMMEND REMOVING THE IVY BEFORE PROBLEMS START WITH CLOGS 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-3/13 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 GM , 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM , 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every 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 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.): 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 Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): PIT WAS EMPTY AT TIME OF INSPECTION WITH A SLIGHT STAIN LINE AT ABOUT 18 INCHES FROM THE BOTTOM 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. City/Town 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.): t5ins•3113 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 �M 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Cityrrown 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 ® drawing attached separately t5ins•3113 Title 5 Official 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 �M 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Cityrrown 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: GREATER THAN 5 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). ❑ 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: PROPERTY SITS ON A HILL HIGH ABOVE ANY GROUND WATER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts o- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 51 JOYCE ANNE RD Property Address GEORGE Owner Owner's Name information is required for CENTERVILLE MA 02632 5-13-15 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 2 of 2 I� http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=209116&seq=2 5/14/2015 Assessing As-Built Cards Page 1 of 2 i TOWN OF BARNSTABLE LOCATION SI ,)Q a kbaeg_ v SEWAGEM vn.LAGE Or q 2u,\\.c ASSESSOR'S MAP&LOT 91�,IL 6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACrrY I OCX��yg 'LEACH NG FACQd'1•Y:(type) D T (size)_r`1 n Pr) • � ,NO.OF BEDROOMS. 3 T. BULDSR OR OWNER T'ERARC DATE: LQN%lR�)_CON PL LANCE DATE: I Separation Distance Between the: Maximum Adjusted Grmmdwater Table to th �3 I Fat Ptivate Water Supply Well and Leaching Facility (If any wells exist on site or within 200 fat of leaching facility) k Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of lathing facility) 1J`P. Feet Furnished by OA 63 i � t L Ix 3- 3o'16'1 83_ N i http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=209116&seq=2 5/14/2015 ' _ i TOWN OF BARNSTABLE h' SEWAGE # .VELILAGE ASSESSOR'S MAP & LOT 20� %IV 6 INSTALLER'S NAME&PHONE NO. SEPTIC 'YANK CAPACITY KQQ!�I V LEACHING FACILITY: (type) (size) WnaT_� NO.OF BEDROOMS BUILDER OR OWNER av\\Z----Yt TERMI T DATE: ION%�Jb COMPLIANCE DATE: Separation Distance Between the: 1 Maximum Adjusted Groundwater Table to th y Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) PtA Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 4��114, Feet Furnished by Xx� i i n 0 I a 3_ 36�I bar �`A—36 WA w p tl 'a. COMMONWEALTH OF MASSACHUSETTSAla O EXECUTIVE OFFICE OF ENVIRONMENTAL AF O�� o DEPARTMENT OF ENVIRONMENTAL PROTECo� ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 Y",q kft WILLIAM F.WELD XE Governor retary UIV ARGEO PAUL CELLUCCI D D B. STRUHS Lt. t�(�r1 Governor Commissioner MO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A LO'I `` o CERTIFICATION Property Address: .5i ���e,Z f�N�� Qs CA �'�� Address of Owner: 5t�,lly�ew,�o2� Date of Inspection: i G (If different) . nTa� Name of Inspector: M ar's r`e\ k`t1C} - \ 7tJ 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: 'r `� L k , Mailing Address:—p i_) Telephone Number: n --�l`11 1 y,ZC CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer. if applicable, and the approving authority. T INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. Indicate yes, no, or not determined (Y. N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25197) Page I of 10 w � i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Pr perty Address.- Owner: r ; Date of Inspect on: + B] SYSTEM CONDITIONALLY PASSES (continued) Of 1p Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health. safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONTN4G IN A • MANNER WHJCH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AN'D THE EINVIRONNIEI\"T: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for colifotm 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 if SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system, violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for eoliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 U of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 SC;•+� � Owner: �l V.'�- Date of Inspection: c o Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. , _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, naterial of construction, dimensions, depth of liquid, depth of sludge. depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- �( Surface Disposal System. f\ _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 ill SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Proper"dress: Owner: (�rtAA6-(� Date of Inspection: i O FLOW CONDITIONS RESIDENTIAL: Design flow:.n0 Q.p.d./bedroom for S.A.S. Number of bedrooms:C). Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or no): Seasonal use (yes or no):_k=� Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):�_ Last date of occupancy: A ka COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_ allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL IINFORti1ATION PUMPl[NG RECORDS and source of information: Po System pumped as pan of inspection: (yes or no)_ If yes, volume pumped: eallons Reason for pumping: T E OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: v Sewage odors detected when arriving at the site: (yes or no)_ (revised 04/25/97) Page 5 or 10 A., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S l SLef'e— Owner:I�LVIJ'Nalv(L Date of Inspection: �0\'bh� BUILDING SEWER: (Locate on site plan) V� Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:Wk( ' (locate on site plan) k Depth below grade: t b Material of construction: 11concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list ace _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: kt,) Li C1 Yy Sludge depth: 2;t " ,t �z Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 6„ Distance from top of scum to top of outlet tee or baffle: 1 Z• � Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: CA- Comments: (recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet 'oven, structural integrity, evide ce of leakage. etc.) % S OU�"Ca VC_ k GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity. evidence of leakage, etc.) (revised O4125/97) Page 6 of 10 r. ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property dress: Owner: kutn��C Date of Inspection: ) TIGHT OR HOLDING TANK: /0-0(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order _ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches. etc.) tISTRIBUTION BOX:Ut S (locate on site plan) S n Depth of liquid level above outlet invert: Comments: (note if level and distribution is a ual, evidence of solids carryover, evidep a of leakage into or out of Pox, etc.) PUMP CHAMBER:ILCL� (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.) (revised 04/ZS/97) Page 7 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �y Owner: k e,l/,/�1g \'\ — Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavatiorf not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: I�p leaching chambers, number:_ leaching galleries, number: leaching trenches. number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil. signs of hydraulic failure, level of ponding, co dition of v etatio etc.) CESSPOOLS:. (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 (cesspool must be pumped as part of inspection) 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.) (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property g¢dress: Owner: �� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) � 51 3 1. 1 t 30 601 t (revised 04125197) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address- SA 3G`Ic-'�-, Owner: Date of Inspection: l V 60 i Depth to Groundwater��� Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) (revised 04/25/97) P2ge 10 of 10 THE COMMONWEALTH OF MASSACHUSETTS BOAR® F� HEALTH 7........................................OF....... !c !.e..`'.dS (• .......... i Appliration for Uispooa1 orkii/Tongtrnrfion ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual. Sewage Disposal ystem at: r , L ca'on Address or Lot R1V�r � c� J h �Ow erXJ v•V �YV �v..dft�/ Installer Address UType of Building` Size Lot_..._L_ 9.�?...Sq. feet Dwelling No. of Bedrooms_.........................................Expansion Attic ( ) Garbage Grinder (kj)o aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures -----------------------------------8 W Design Flow-------- S.............................gallons per person per day. Total daily flow____-_33Q.........................gallons. W &q Septic Tank—Liquid capacity ...gallons Length________________ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. ..... ........... Width.................... Total Length............____... Total leaching area.___.. ._ ........sq. ft. Seepage Pit No.�_.._.. _-__.Diameter.___-___-_r_..... Depth below inlet___....__.___._ Total leaching area._ a.it..__sq. ft. z Other Distribution box ( ) Dosing ank ( ) T dfo.by 0-4 Percolation Test Results Performed by ..•-------•-••-----•---• S Date . ..... -------•---•--- � Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil......0.' -2: - � - -- d '- w ----------------------------------------------------------------------------•-----•----••---- -------------------------------------••-------••--••-------•----•------•-•-•-•---•---•-----....._...... U Nature of Repairs or Alterations—Answer when applicable---------------- _..:�._._.�...._..._..____._.._..__.__... -------------------------------------•---••------ -7 � Agreement: �lr, .j _...�.- �,. ,a•-� �✓-----•-----•...................'. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I'Ma 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig - ----.. - -------------•-------•---.......----....-----•-------.•.---...-- •-----•---•--••-.-••----•---•-•- Date q Application Approved BY r 1•d ............. ---- �- Date Application Disapproved for the following reasons:____________________________________________________________________ ........................••------•-------•-•-•--•---•••--••---•--•••----••--------•----•-•--------------••---•---------------•-------------•------•----•----•------..................................... Date _ ._� ' / �, .^• Permit No......................................................... Issued_....: - Date No ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD-OF HEALTH ....................OF........ ...f ............... Appliration for R"aaal V U trurtion 1hrmit 'T o Application is hereby made for a Permit to Construct o ) or Repail! an Individual Sewage Disposal stem at: A ..... el ---- .0 L _..! Q........................................................ .. Q—ca Addres or Lot ............. ....... jer Addiets . .............. ........ .........................................!.. ........................................ Installer Address I �_ Type of Building Si,e Lot____ 9.03?...Sq. feet U Dwelling No. of Bedrooms_________Swa ..............................Expansion Attic Garbage Grinder (AJ)C) aOther—Type of Building ............................ No. of persons_._....________.________.__. Showers Cafeteria Otherfixtures ----................................................................................... Design Flow______.3*17........:....................gallons per person per day. Total daily flow.....3'50. ............ ............gallons. 9 Septic Tank—Liquid capacity/494...gallons Length________________ Width______.____._.._ Diameter.....____._.____ Depth_._______.__._.. Disposal Trench—No . ......... Width-- Total Length_________ Total leaching area Sq. f t. ............. . .... .. Seepage Pit Diameter......... ........ Depth below inlet......-.4 .......... Total leaching ar;�:._,P. 1:::.sq. ft. z Other Distribution box DosmMank Date.... ............ Percolation Test Results Performed by___P.Eir- ............ .... Test Pit No. I________________minutes per inch Depth of Test Pit_.__._.___.__._..___ Depth to ground water_.___..____..___......_. f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.__.____.__.___.__._.... P4 ........�; t..........j------- ----------------- ............I.............. 0 ..... ... ...... .... .. .. .. Descriptiop of oil..--- ---------------- alv ................AkAltKcr.............. .......... A. . .... .............................................................. ............... ---------------------------------!�....................................................................................................................................................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 TITLE 5 of the State Sanitary ode— The undersigned further agrees not to place the system in �. operation until a Certificate of Compliance,has been issued by the board of health. S ra ,Y;I- Date -- o -i�- .--------------- ,� ;--- ---------*--------------------------*------------------------ ........---------------...... Application Approved By----- L.. Date Application Disapproved for the followingV reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................! ................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .......... ..........OF...16..................................................................... (9rdifiratr of Toutplitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (j410'or Repaired ................................................. .......g.,------------- ----- .. Installa.. Y7 -------------------- at--. Xw, ------- ---------I/ 6i has been installed in accorda ce with the provisions of T 5 of The State SanitaryCode as described in the application for Disposal Works Construction Permit No_&-----7Y.1......... dated_../ ............ THE: SSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIC�!4 SATISFACTORY. — — 1 41 r....... ....... -------- .......7-------------------------------------------- Inspecto `_____ ---------------------------------------- DATE...... 3 ------/u U THE COMMONWEALTH OFMASSACHUSETTS BOARD OF/ EALTH 07� .. ............... V-3 ... ....................0 F............./0........................................................... No......................... FEE... .......... utopsal or v Tonotrurtion Virrutit Permission bsAwfo by gr anted..........6 -V-112.,......................................................................................... ...................to Constriec,..... o/ e it iliai,�r ev,61)is sal system a .. $--�z . . ...... _---------------------------------------------------------------------- ................ Street as shown on the application for Disposal Works Construction Per 0.- ated,4. ... .... ..... -Board of Health DATE_-.-. ...................................................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS cr,1i.lC�L GA�I;yCL_�� 3 i3m2ro0 "0 GArZBAC-C- C,-(ZI 4.MV=P-' St Sao G•P•V. �(0o ca ---- ��T'rC �30� U Ste- l UcxC� G,4L_. }} j P0S A.L F',T - vSE t Dc�o GAL-: 1151000 ��xwa.L1_ AeE.Q : LSo S.t;. TOTAL -DeSl6W = 42S G.P.D. -T-OTAL- "Ow Lam( FLDtit./ = 330 &PD. 1of Pmec.t>l..a-noQ O&M ; 1",u 2Mtu• om LLs,S. ri �p �_ PL'X � N F TA.IGt 0 Qw 1.4 LOAMIW- loan iuv. SASOIC., 4'pv� V� f "Sox �,•5' 5c-pnc ,� ' Ta�tK aSSarty 1000GAL Lei QG ( GG CoAtSg 'PIT "�+t1 1' w w WASWaD 1.1 IST06.4f_ I Na p �� !o� I .o• � �I y to Ci✓�TLFIED pL.bT' PL �41J Gt?E��L Ptw�-t1_. LbC.AT1O" C,s3S(`mk/"t 6 �e•O �..!o SG�.L,� �C.AL C �h � L AT[_ �D� (q �-�`'�� � G G tz-r t 1=-{ T t-1 A l- T t4 V-- 70 U�pA- '1 o l� 5 N� ( ,W WF_L'L LSt.J Gc>AAPLklS W Irk T";1� ►:• �jI VE U G= I I A► t:> SETVAGLG VGQUI9ZEME-+-ITS 0 TNT rr -'Q W u or- '�EA2�4 }�`T S K P P LE';'t.l o D't C>aIM .fin I l f~3 A.XTC>Z. 4-, Uqc t2EGtS Cr_IZ6D 1..A.Wo uzvaKo�S T141-5 pLA1J ('S LIOT ?:,&SGV 064 AN aSTEt~V1L,.I.G a 114-grC'J."✓lCW i >L�t �1L_�{ . Tali : G3Fti; T , �il•1GWLD APPLI GA-"-r ,'•kit tJr u�ycc, T�, ��r_reetirt�N� t.r��c' L_Iw�s LO CAT 10 SEW GE PERMIT NO. Je c -- 7' 3 V LLA— Ce Z L GE I N S T A LLER'S NAME i ADDRESS rC O B U I L D E R OR OWN ER / �-�-- of�1'" t/ I/ �rJ � � •B / r DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED e w j7 /a 6 � n Q z �` -� 1 p �.-....-.�:'z'--S".'^."�2'�:.�`.'tW'+F".'+'arm";'�':';'�'—` �"�y�"Ki.%""'�!"••`..,-.e_"Yt.�p"�r`_"- �'"'w� , Ll �bCt IW /-TheVI L � Coves . Pi tLN4E ; Pool - _ yROD A, �N g } � P lit ce� PAHTW OFFUMUNCO Hill if 1�wAlBiOVAIED FLOOR PLAN PAGE IS FOR w a,00, oasroam c/oei ro [ r roAEAaw t � �3 REFERENCE ONLY. HOME OWNER TO PROVIDE DETAILED FLOOR PLAN PAGES INCLUDING DIMENSIONS, g z P WrNb0W/DOOR UNITS,AND TOWAA P� FLOOR FINISHES Q STALt4 7$ �„r w,eoYv� Npw/PBr0YA7� E1G'ETLiVAidOD1A TO WA=A uaeis ro eeaAna aca wAus PO FW `' ro w"r wAus��cw.aem�" fEWAWEn00M � N WA01 Scale: 1/4" i !ST FLOOR PLAN 'I Y �20 Pa S , P49V 4 OF 8 >. .. _.., s. .. ..:.,. �r .•x.s - "�). Ys:^.�,A�'M.Ik'.4'.�;A'-.q'. r.f-9.'.'j. .:�.'+e!:!..•.�?'.-.sv.�' .�n.�.`'!3Y 1�r:e F:.. *.,z'-.` n �,:-5�'��t�:_cui.:�".SW _Y'Y-,•.y'"� •:3'§.K'•y_,.t.L.',1•+Y�_n*. ..Le.:,. ..:�=�:.,�r l r.SS�. r"3;M.:.y. ...L""& L I c Plan 1 T 2nd Floorcao (C-X Lv r r f o s 4 f ,z Ln ai " Gci igle C 0 0 0 w a 16' 11'8 1/2" v ru 2' 5 1" - 5'2" 12' 5'5 1/2" E X O Q rZ BATHROOM v Olfu O L 5' 10" x1 ' 0 y � BEDROOM A oaj HALL BEDROOM o 18 x15 4 14' 8" x13' 8f' � Y A 5' 2 1/2" x 1 �_ In N L � . — LA - E O ET 0 o v 5' 11'9" CLOSET Ln 18' (10 7'3" 13'8" r N {. to Statistics f r 3162 sq ft f 00 3 Floors 3 Bedrooms 3 Bathrooms j 13 �..�...^^-?^�.t:+"^-�+a'�"""=.a:.Y.'�^"'..5�'�.'.-�,"*."""`°a�,'.`-t"i�!"7S.".} ... - �-.<. _ r_� � _ '�'."'..`-r"::'�",'�'pC�"-"."a.,."�,'*— - lc^^'Kt*-'..'^'.^�' �"^"'.�'r"'�'�y,�`.�'�""'t �'Z•^+'�'�+,,._..,_.�q,. ...a=�3' r - M' S VVA J ULRATH muow A FLOOR PLAN PAGE Is FOR REFERENCE ONLY. HOME OWNER TO PROVIbE 2 TONEVAoaoC aK —i DETAILED FLOOR PLAN PAGES 701FM"'1NDOMN�' �7 INQ-UDIN6 bIWt1ENSYOhls, + WIPlbOW/DOOR UNITS,AND fee O �x}", FLOOR FINISHES �1 3 <i S Date; 12-4-12 Revisiortz a S NEW 2ND FLOOR PLAN prc,) Page: 3 OF S "•,x-'x.;�,r. ,_:f' .,�,�y'L- „:r6 y..:,:> ..�..�. ... ' .,,- ..- .. � „ ..- :a w-.. � r��1��e��;..af' Y.3k�.• _ LEGEND CENTERVILLE PROPOSED CONTOUR 179-8-1 PROPOSED SPOT GRADE -- 98 -- EXISTING CONTOUR ' CATCH + 96.52 EXISTING SPOT GRADE �o r ,SIN yy— EXISTING WATER SERVICE CB TEST PIT 2a H '` �` N , , SCALE: 1"=20' �Qv PINS , LOCUS ., 0 ,t 04 04 04 M LOT 18 N50 LOT 17 ���e G'�� t <� LOCUS MAP AREA=15,000 S.F. 3� z' t �� PLAN REF: 315/22 BENCHMARK: TITLE REF: 29049/314 �\ '`t COR BLHD ____ _ � PARCEL ID: MAP 209 PAR. 116 EL=50.0 =_- — ZONING: "RC" 20710-10 /WIND EXPOSURE "B" _ _ t MAX. BUILDING HEIGHT: 30' •1� `'� _ = W ',t \,t �O NOT IN STATE ZONE II /SALTWATER ESTUARY FLOOD ZONE: "X" % COMMUNITY PANEL: 25001CO563J DATED:07/16/14 TOP TANK - - moo:✓"�. SEPTIC SYSTEM ' �6 � - OEL=48.10 ; #51 W 0 ! ° t% REPAIR PLAN 1 , = TOF=50.66 = �'t, LOCATED AT: I-V 5 i \ - - -- 'f ,,r, ��CATCH 51 JOYCE ANNE ROAD CB DH pUN tt ` % BASIN CEN TER VI LLE, M A. / O \�� PREPARED FOR >� \�� OF ��P .=' MARK & JACQUELINE erns H A N S E N OAKS ,, �� �� APRIL 26, 2017 Ta-z G� OF _ __ Qo R PARCEL ID: NITAR�a� 209/067-002 LOT 16 MEYER & SONS, INC. P.O. BOX 981 I GRAPHIC SCALE EAST SANDWICH, MA. 02537 20 0 10 20 40 s0 PH: (508)360-3311 i FAX: (774)413-9468 meyerandsonstitle5©gmail.com ( IN FEET ) 1 inch = 20 ft. SHEET 1 OF 2 J#1886 ELEV. TOP FOUNDATION NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (49.0-50.0) 50.66 F.G.EL- 49.5 F.G.EL: 49.10 F.G. EL: 48.50 VENT a MAINTAIN 2% MIN SLOPE OVER LEACHING AREA 2" OF 3/8" DOUBLE WASHED F.G.EL: 48.10 STONE OR FILTER FABRIC 3/4" - 1-1/2" +' DOUBLE WASHED STONE 4" SCH 40 PVC :a to"I (MIN. MMErER®®03E30E®® A: TEE'S ARE TO BE 14, s S= 1% ) :4 4" SCH 40 PVC INV.46.40 2' EFF. DEPTH ®®®®®®®®®® INV.46.80 INV.46.20 1 ` 4' 2 X 8.5' 4' EXISTING ouTLEt BAFFLE PROPOSED DB-3 EFFECTIVE LENGTH = 25' LE ••. .. DISTRIBUTION BOX INV. 47.05 (1-120) INV. ELEV.= 44.10 EXISTING 1 ,000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON ���`� OF MAssq BREAKOUT OUTLET TEE AS MANUFACTURED BY 3`` ELEV.= 45.10 TUF-TITE, ZABEL, OR EQUAL o ARE E M �, TOP CONIC. ELEV.= 45.10 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING 1 4 �' INV. ELEV.= 44.10 •EM E3 PIPE INVERTS PRIOR TO CONSTRUCTION ®®®®®®® 2) D-BOX SHALL BE SET LEVEL AND TRUE TOG/$TES ®®®®®®® ®®®®®®® GRADE ON A MECHANICALLY COMPACTED SIX SANiTAR��`� BOTTOM EL.= 42.10 INCH CRUSHED STONE BASE, AS SPECIFIED IN ,9 �b ; 3.75' 5 FT. 3.75' 310 CMR 15.221(2) W� 1 - 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK SEPARATION 5.10 FT. EFFECTIVE WIDTH 12.5' WITH GALLON SEPTIC TANK IF FAILED, SEPTIC SYSTEM PROFILE DAMAGEDED,, NOT H2O LOADING, OR UNDERSIZED. SOIL ABSORPTION SYSTEM (SECTION) 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 37.00 e GAS BAFFLE AS REQUIRED (500 GALLON H2O LEACH CHAMBER) GENERAL NOTES: SOIL LOGS P#:15205 DESIGN CRITERIA **NO PROPOSED INCREASE IN FLOW" 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL NUMBER OF BEDROOMS: 3 BEDROOOM DESIGN BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: NOVEMBER 14, 2016 SOIL TEXTURAL CLASS: CLASS ( (0.74 GPD/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614 - 310 CMR 15.405 (1) (e): WITNESS: DAVE STANTON, BARNSTABLE HEALTH DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. 1) A 1.90 Fr. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING GARBAGE GRINDER: NO (not designed for garbage grinder) TO BE 4.90 Fr (MAX) BELOW GRADE VS REQ'D 3 Fr. (H2O/VENT PROVIDED) SEPTIC TANK: 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFIL.LED PRIOR Elev. TP-1 Depth Elev. TP-2. Depth 330 gpd x 200% = 660 gpd, USE EXISTING 1,000 GAL. SEPTIC TANK TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. 48.30 0" 48.0 0" LEACHING AREA REQUIRED: (330) = 445.94 S.F. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FILL I FILL 74 FROM,THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 46.63 A 20" 46.42 A 19" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. USE TWO (2) 500 GALLON H2O PRECAST LEACH CHAMBERS W/ 4' LOAMY SAND LOAMY SAND 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 10YR 3/2 1OYR 3/2 STONE ON ENDS & 3.75, STONE ON SIDES: 25 L X 12.5 W x 2 D THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 46.14 26" { 45.84 26" HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. B g BOTTOM AREA: 25 x 12.5= 312.5 SF 4 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. LOAMY SAND LOAMY SAND SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 1OYR 5/8 10YR 5/8 TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE 44.30 48"C 44.17 C 46" DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING PERC 0 MEDIUM- MEDIUM- CONSTRUCTION. EL. 42.9 SAND SAND 10. EXISTING LEACH PR TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 2.5Y 6/4 2.5Y 6/4 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 37.30 132" 37.00 132" 51 JOYCE ANNE ROAD, CENTERVILLE, MA 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY <2MIIN/INCH IN "C" SOILS AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY Prepared for: Hansen 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. NO GROUNDWATER OBSERVED 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. Engineering and Survey by: SCALE DRAWN ' MEYER&SONS,INC. N.T.S. DMM 15. ALL PIPING TO BE 4" SCH 40 ® 1/8-/FT (UNLESS SPECIFIED) ' I, Darren M. Meyer, R.S., CSE, hereby certify that I amicurrently approved by MADEP pursuant to 310 CMR .15.017 PO BOX981 to conduct soil evaluations and that the above analysis has been performed by me consistent with the DATE CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October, 1999. EA,362-2 DW/CH,MA 02537 _�22 04/26/17 DMM 2 of 2