HomeMy WebLinkAbout0561 LUMBERT MILL ROAD - Health 561 Lumbert Mill Road, Centerville
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UPC 12543
No. G.'i OR CONS
HASTINGS, MN
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR-NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office,.1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
/'
� T
DATE t 3 2TtFill in please:
{ r APPLICANT'S YOUR NAME/S:
�" r BUSINESS YOUR HOME ADDRESS: 5"
TELEPHONE # Home Telephone Number Ste• S ao C ��
NAME pF CORPORATION
NAME OF NEW BUSINESS'i TYPE OF:BUSINESS
IS TMIS A HOME OCCUPATIpN? YES.; NO
ADDRE-9 OF t BUSIIUESS � ..�9«' ` . c- :1`� :.�crc env, MAP NUMBER (D:\C7C�
/- .PARCEL [Assessing)'.,..
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. _You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING CO ISSI ER''S FF�This indivi ual en inf rof ny ermit req ireme that pertain to this type of business.
A fioriz Sin e** MUST COMPLY WITH HOME OCCUPATION
c MME s: —� RULE: ..ANC REGULATIONS. FAILURE TO
2. BOARD F HEILTH
This individual has tr i e of the_permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
+
CONTRACT Customer Name
SKETCH Contract Date_
ATTACHMENT Customer Phone�� Contract Price
1 2 3 . 5 6 I 1 9 10 11 12 13 14 IS IB „ I9 19 20 21 22 23 N 25 26 22 25 29 30 31 32 33 31 35 36 32 35 39 00 al 42 43 N 55 40 19. 5, S2 63 51 56 56 57 59 50 60
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30
31
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32
4 � -1 t ' 1
NOTES: 'Each box equals one foot unless otherwise noted.This sketch is a good faith
representation of the work to be done,it is understood that all dimensions
derived from this sketch are approximate,and that all locations of outlets,light
fixtures,plugs,jacks and/or switches are subject to change if necessary.
TOWN OF BAR STABLP _
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Town of Barnstable P 4t
Department of Regulatory Services
naaNsr. s
, ��
Public Health Division Date
ate
lfD MA�h0 i treet,Hyannis MA 02601 /
Date Scheduled Time Fee Pd.
Soil
Suitability Assessment for Sewa a Disposa '
Performed By:_(� �-T7R/�'[t�3�d�., S,. Witnessed By:
LOCATION& GENERAL INFORMATION
Location Address SW LUG�C� ���` � Owner's Nam �� d (�����
\ l9 Zb3� Address Sbt Lvt, Zli
Assessor's Map/Parcel:
f - Engineer's Name
eta �Cc�tw��'(1
NEW CONSTRUCTION REPAIR Telephone# Sa 2 ' 42 2 3 gb
Land Use �(�fiiX.G�Y��tx Slopes('%) Surface Stones
Distances from: Open Water Body Z UD r ft Possible Wet Area_ ft Drinking Water Well �ZaD ft
Drainage Way�ft Property Line ZO'd� ft Other
ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc test�oCl ate wetlands in proximity to holes)
b
03
i a
4
� w
O_
Parent material(geologic) OVA1.4'o r^ Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: N Weeping from Pit Face ��l..•�
Estimated Seasonal High Groundwater l l t
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: 5-a / I b7_( TZ
Depth Observed standing in obs.hole: __ in, Depth to soil mottles: in,
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor- Adj.Groundwater Lzvel, e
PERCOLATION TEST ]Hatt; s 4 Time
Observationr3
Hole# Time at 9"
Depth of Perc 3r-S3 Time at 6"
Start Pre-soak Time O d'O(1 Time(9"-611)
End Pre-soak �' 2 ~°�&"tie &Va%�zo
Rate MinJInch .4
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\,SEPTICIPERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones;Boulders.
o i tency.%Gravel)
to -Ty 7f,,,. L. s to YG V,( v
3 Y-r to C /*Ud fO ,.d z .s-- 61y ,v d C
DEEP OBSERVATION HOLE LOG Hole# Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
onsi ten % rave
p -- off-
L s /0 Y2
?Z-�l0
DEEP OBSERVATION HOLE LOG Hole# 3
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
0 -� d �S o ye6
G'z6 S l0 y'e/� •(/0
z.sy6 Ilen)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other.
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.
D Xff do
to ti s'6 ti0
zP-tad cd z.ry6 ,-v
Flood Insurance Rate Map:
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 pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Ceitiiation /v /99T
I certifythat on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required tr • • g,exppe- ex rienc escribed in 310 CMR 15.017.
Signature Date S ��
QAS.EPTIC%PERCFORM.DOC
TOWN OF BARNSTABLE
LOCATION SA SEWAGE#
VILLAGEQ((�l,l(A, 111• ASSESSOR'S M1AP&PARCEL I'A,1100
INSTALLER'S NAME&PHONE NO. rn �.V�b U4� �7 83%O-S6Zy
SEPTIC TANK CAPACITY \ GUO PAk6,-N"--1 —(
LEACHING FACILITY:(type) SG- p11en l4-tD L (size) 33 Sx I Z
NO.OF BEDROOMS 3
OWNER.
PERMIT DATE: 5/2,7 12oL"1 COMPLIANCE DATE:
Sepafation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands'exist within
300 feet of leaching faci ' ) Feet
FURNISHED BY
Lpll
^ 33030° f
A -q
0 2-
No. r _ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplitation for Misposar 6pstem Construction hermit
Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. -S(p i l..0 M6 tx-+M v t..I Qj_4 nner's Name,ic
ir
s,and Tel.No.
faf1 Assessor's Map/Parcel 1q� 100 ecAeau i��.e: s(o U m i( ( `� C�'�'rU4 i LQ-rn 14
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 38��
6 1a G��►� D7-(oak �. fln A2�, " Sd,g-y2�-
ed A �n.- rn m i I t6 jam.V4
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 2 2
Design Flow(min.required) `)0 gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature_of Repairs or Alterations(Answer when applicable) 3 — P— l 1> 5 PP70 4 t.M �_e"c klom 6C rzs
W AV�_ Li-5 d4-ca aad A° 34- i 2! & b wp4iv .. ! ll Ado
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 Health.
Signed Date Jr � 241( i
Application Approved by �- - Date — �? (✓
Application Disapproved by Date
for the following reasons
Permit No. C90 ` Date Issued
- - - _ ---- ---- ------ _— ---.---—----_—_--_---=------------- I
No. olQ t ' o f k5 Fee
Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS> .. Yes j
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for Vsposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( Upgrade( )!Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. JSG I Lj_jrnb e;4 M I k Qd. Awner's Name,Address,and Tel.No.
Assessor's Map/Parcel f�(p -' l 00 <!"Rul i�- r)Zo V 1
S401 1_U M r M i I � t'<+ cxN-k ro( LQ f'h a
Installer's Name,Address,and Tel.No. _77 L{ '9_24o-Sda q Designer's Name,Address,and Tel.No. 3gloZ.
VP P L,rs b 1,�.t n n 1�R��,��krti sob-4
Type of Building:
Dwelling No.of Bedrooms e 7 ►1 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons! Showers( ) Cafeteria( )
Other Fixtures F~~ `!
j
- Design Flow(min.required) %3?j'(� �' gpd. Design flow provided gp
i Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) C> 5 A L horn OG/S
1 1A, 6� I vo ke& s ra t t A Qoonc_4
Date last inspected: '
W
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 Health.g ? `- Date 512 //7011
Signed
Application Approved by c Date
Application Disapproved by Date
for the following reasons
Permit No. �� !a S Date Issued - 7 -
x ..,,. ----------------------------------------------
1 — THE COMMONWEALTH OF MASSACHUSETTS
!; BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
i THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded
Abandoned( )by L. i�loll y
at .ifo L-UYY\L_k e- - M.1 l j Pd has been constructed'jq accordance °
with the provisions of Titte 5 and the for Disposal System Construction Permit No. 9 V 11 1(0'5dated
Installer hC) Designer
#bedrooms _ Approved design flow gpd ...
The issuance of this permits all no be construed as a guarantee that the syste `ill.fun'o ,esigned.
Date InspectoF
--- -------------- --------------;------- -----------.----- -- -
1 Fee 1
THE COMMONWEALTH OF MASSACHUSETTS -
PUBLIC HEALTH DIVISION-BARNSiTABLE,MASSACHUSETTS
t
t
�isosaf �pstern Construction Permit
Permission is hereby granted to Construct(t ) Repair( ✓j Upgrade(L,,,� Abandon( )
System located at la4✓i�l( � prd
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 rj ' -7 ( Approved by
Town of Barnstable
901 Regulatory Services
Sl, Thomas F.Geiler,Director
•
• Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: y Sewage Permit#:�?bLl- L!off Assessor's Map/Parcel
Installer&Designer Certification Form
Designer: Installer:
Address: 9 ze-AY L Address: y 1-7 Z Z.
.�ov�.b{�-►)�%`�Z� Vwl4-5 MAW,
On '5.24 / I n ti c wA-Q 1-41 w`k-L was issued a permit to install a
(date) (installer)
septic system at SSG/�c�,be v' 41,%/C&,, c,,' a based on a design drawn by
(address)
(designer)
/1'1�certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State&,Local Regulations. Plan revision or
certified as-built by designer to follow. Stripout(if require cted and the soils
were found satisfactory. OFGLEN
MgS�9
C ERIC
(Installer's Signature) HARRINGTON to
NO.1070
At.lei rill
(Designer's' i ) (Affix ere)
LEASE RLTM TO ARNS ABL PUBLIC HE TH DIVISION. CERTIFICATE
OF C MPLIANCE WILL N T BE ISSUED UNTIL BOTH THIS FORM AND AS-
CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoPfice fonm\dwiper=fifwadon form.dw
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Commonweafth of Massachusetts `
Executive Office of Environmental Affairs I/
Department ofY Nov 2
Environmental Protection
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Gorsma esepuy
A W Paul Celluocl S1tu s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
proppty�d 561 Lumbert Mill .Rd. , CentervilleAddressofowner Victor Mazzarella
Date of Inspection: 1 0—1 0—9 6 (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
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 se age disposal systems. The system:
t
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: � t �Y= Date: lo —/0—
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.
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.
Bl SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,poem
es
r
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, cracked,structurally unsound, shows substantial infiltration or exSltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a yonforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street 9 Boston,Massachusetts 02108 a FAX(617)SW1049 a Teephone(617)292-5500
` Prn ted on Recycled Paper
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinusd)
PropatyAddress: 561 Lumbert Mill Rd. , Centerville
Owner: Victor Mazzarella
Date of lnwwti°n: 1 0—1 0—9 6
B CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution boa is due to broken or obstructed pipe(@)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
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 pas@
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C1 THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require ltuther 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 FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
INES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
S AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is f"
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3)
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
ProPeityAddlv" 561 Lumbert Mill Rd. , Centerville
owner. Victor Mazzarella
Date of Inspection: 1 0—1 0—9 6
DI FAIIB:
I determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16"3. The basis for.
determination is identified below. The Board of Health should be contacted to determine what will be necessary to oor- the
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(*).
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 aceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE TEM FAILS:
The fo wing criteria apply to large systems in addition to the criteria above:
The in serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
and safety and the environment because one or more of the following condition*exist:
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 of any such system shall bring the system and facility into AM compliance with the groundwater treatment program
requirements f 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for ftuther information..
(revised 11/03/95) 3
L •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PeOp rt7Address: 5'61 Lumbert Mill Rd. , Centerville
owner. Victor Mazzarella
Date et bspeodon: 1 0—1 0—9 6
Check if the following have been done:
ping information was requested of the owner,occupant,and Board of Health.
LNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
dyring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
AZ 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.
system does not receive non-sanitary or industrial waste flow
lllnhe site was inspected for signs of breakout.
✓All system components,excluding the Soil Absorption System,have been located on the site.
septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of ba8les or
tees,material 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 existing information or
app ' ted by non-intrusive methods.
` The facilityowner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 56i Lumbert Mill Rd. , Centerville
owner. Victor Mazzarella
Date of Inspection: 1 0-1 0-9 6
FLOW CONDITIONS
RESIDENTIAIA
Design flow: lions
Number of bedrooms:.
Number of current residents:,
Garbage grinder(pee or no):_& b
Laundry connected to system(yes or no):—Y�;S
Seasonal use(yes or no): /L- b N/A well
Water meter readings,if available:
Last date of occupancy:
C0MX=L4kL/INDUSTRIAL:
Type of establishment:
Design flow:�gallons/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 INFORMATION
PUMPING RECORDS and source of information: ® � _ r A-,S
System pumped as part of inspection: (yes or no)` a
If yea,volume pumped: gallons
Reason for pumping:
TYPB gr SY87'EM
I.- Septic tanWdistrbation box/soil absorption system
Single cesspool
Overflow cesspool
Privy attach previous inspection records,if any)
Shared system(yes or no) (if yes,
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: —!+�=y+----
b
Sewage odors detected when arriving at the site: (yes or no) A- O
(revised 11/03/95) a
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PopertyAddeess: 561. Lumbert Mill Rd. , Centerville
Owner. Victor Mazzarella
Date of In"Notiow 1 0-1 0-9 6
SEPTIC TANK
_-Z
(locate on site plan)
Depth below grade: /
Material of oonstr ction:_/concrete_metal_FRP--other(explain)
Dimensions: `r
Sludge depth. /D ,
Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness: f ' ,
Distance from top of scum to top of outlet tee or baffle: 4
Distance from bottom of scum to bottom of outlet tee or baffle:-
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of ligpd level in relation to outlet invert,structural interfty,
evidence of leafage,etc.) �/'.o 4'. ['/c= �-C-f A %i 4z- r
Rti Q t.) -d-- 7
G E TRAP:_
(locate site plan)
Depth low grade:
Mate ' of construction:_concrete_metal_FRP—other(explain)
�.
Scum
!7&
top of scum to top of outlet tee or bafflance bottom of scum to bottom of outlet tee or baffle:
tionfor pumping,condition of inlet and outlet tees or banes,depth of liquid level in relation to outlet invert,structural intep*,
n of leafage,etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddres: 561 Lumbert Mill Rd. , Centerville
Owner. Victor Mazzarella
Date of Inspection: 1 0—1 0—9 6
TIG OR HOLDING TANK:_
(boats site plan)
�h it &:
Material ocnsttvdion:_concrete_metal_W_other(e:plam)
Capacity ons
Design sallons/day
Alarm le
Comments:
(condition o inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP BER:_
(boats on plan)
Pumps in king order.(yes or no)
Comments:
(note con1lion of pump chamber, condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGk DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 561 Lumbert Mill Rd. , Centerville
Owner Victor Mazzarella
Da*of Inspection: 1 0—1 0—9 6. /
SOIL ABSORPTION SYSTEM(SAS):v
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type. leaching pits,number:
leaching chambers,number:_
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number: n
Comments: (note condition of il i of hulic failure, level of ponding,condition of vegetation,etc.)
CESS LS:_
(locate site plan)
Number d contiguratioa:
Depth- of liquid to inlet invert:
Depth of solids layer.
Depth scum layer:
of cesspool:
Ma of construction:
of groundwater:
(cesspool must be pumped as part of inspection)
Comments: ( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:
(locate on plan)
Ma construction: Dimensions:
Depth of so
Comments: note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
(revised 11/03/95) 8
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PmP*rtyAddF*" 561 Lumbert Mill Rd. , Centerville
O"O'! Victor Mazzarella
Da"of'n*Poc"cOD 1 0-1 0-9 6
S OF SEWAGE DISPOSAL SYSTEM:
indkids tin to at 1oaat two pormansnt references landmarks or benchmarks
Ioeate all well within 1t>0'
r
DZM TO GROUNDWATER
Depth to ponndwater j � feet
matbod of ddtermination or approximation: 1 J 6 1i�1
(revised 11/03/95) 9
6-rao
rD CATION riB°� .5�1 SEWAGE PERMIT N O.
'VILLAGE
INSTA LLE)R'S NAME i ADDRESS
U�
010 a UILDER OR OWNER
�4-
DA T E P E R M I T ISSN E D
DAT E COMPLIANCE ISSUED -7Ir �
T
N.
j7 /
1 I
a
�Y AJ
No.__ .:�...... Fxs:.................. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-------------- -OF..........................................................................................
Appliration for Disposal Works Tnnstrnrtiun Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: _
Locationwoe'dr s. -•..__. :.:...`s S_ o AddreNo. .............
ssyt
a •-•-----------•----------••••-.... .�lJ .......... -e./ 91V•••••--................................................
Installer Address
d . Type of Building ` Size Lot..t ...Sq. feet
Dwelling—No. of Bedrooms..........- 3.........................Expansion Attic ( ) Garbage Grinder
Other—Type T e of Building .__.... No. of persons............................ Showers
(� yP g ---------------••---- P ( ) — Cafeteria ( )
Q' Other fixtures ------------•-----------•-----------------------------.-••----•-•-----•---•--•-------•---••-•••-•.
d
W Design Flow............................................gallons per person per day. Total daily flow............ _ ._............gallons.
WSeptic Tank=Liquid'capacitylOa .gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width—................. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter............._...... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank
~' Percolation Test Results Performed by__________________ ............................._...... Date.........
,.a Test Pit No. 1.� minutes per inch Depth of Test Pit.................... Depth to ground water........................
f3 Test Pit No. .'Minutes per inch Depth of Test Pit.................... Depth to ground water........................ F
a •--••--•••-•---•••-•••-•......--- _ _
-------------- ------ --
O Description of Soil...................................................
-------•.......................................... •--.. •-------t..... U ........................................................
x
V --------------------------------------
-----------------------------------------------------------------
•------------------------------------------------W
UNature 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 iITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
o ratio it a erti of dance has been issued b the board of h
`� Signe ------------------ --- ••-----• ---------
-----------a; .... ..
Date
ApplicationApproved By--•-- -•--•-• ----•--------••--•----•-•--•-----------• .........._...•---
Date
Application Disapproved for the f o ing reasons------------------------------------------------------------------------------..................................
-----------------•---------••••••-------...---•------------••'------•---•-•------•...---•--...............__........_._....------•--------•••------------•----=-----••••-----------•-•----•----•...------
Date
PermitNo......................................................... Issued.......................................................
Date
No................_....... FEs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
x, ............. ........_...-----•------.OF.........---...................._.........................
ApplirFa#ilan for Disposal Works Tunitratrtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
....... -`.:._T: .....'. .C. ..........c X........ . :✓. ......422a..... . ----....� =L _J..........................••...........
Location-Address r Lot No.
Address ...^
-"-"•.................•••-•......., -----......
Installer Address
Type of Building Size Lot_..;_. _:69....Sq. feet
Dwelling—No. of Bedrooms.......... ..........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building No. of persons............................ Showers
� YP g -------------•-•---"•----... p ( ) — Cafeteria ( )
dOther fixtures .........---"-----"---"......------""------"""""---"------"---"-"--"-•---•--"-----------"-""---"---"-"-------------"----....._._......._.............
W Design Flow............................................gallons per person per day. Total daily flow...........= _ ...............gallons.
WSeptic Tank—Liquid capacity: ..gallons Length................ Width................ Diameter................. Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( _)
Percolation Test Results Performed by.................�sz"-•.4_. _� Date...... _ /.
--•---•-•--•.......---•-•--•-•-
14 Test Pit No. minutes per inch Depth of Test Pit.................... Depth to ground water........................
f, ;i p
fs Test Pit No. 2_f,A�'?:�'..nunutesper inch Depth of Test Pit.................... Depth to ground water........................
Descriptionof Soil --•-f---•••-•••••....... ...4 --------•---"---------------------"-•--•"-------"---------""
x
w
--.------""-----------------"--"--------------"-"------------------"-"-----"•---------...•"----"---------------"---"-•-------------....---"------.---"----------•----------------------------------•-•-
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 Code—The undersigned further agrees not to place the system in
o Derrattio til a erti" of dance has been issued by the board of health:
Sin ' �-,
Date
Applicationpproved BY """"-----•--••....•................ --•--------•-------- ..............
Date
Application Disapproved for the f l wing reasons:-------"""-----------------"-""-"•---"-"------"----"------•---"---"---"-"-------..._........•-•---•--..._------.
•-••--••----------•---•-------•••---y;••--••-•-••----•••-•-•...---••--------•-••-•-----......-
Date
PermitNo.......................................................... Issued--•--------•--•-••-•----•......---- ..------------•----
Date
THE COMMONWEALTH.OF MASSACHUSETTS
BOARD OF HEALTH
.............I............................OF.....................................................................................
Tntifirtttr. ,af ToutpliFatta
THIS IS TO CERTIFY, That theIndividual Sege Disposal stem constructed (, ) or Repaired ( )
bY-----------------------�2:.! r2�,E_= Z...... ` =_. x f >en2..........................................................
Installer
at -. %. ?�`, ' '�!C: .,......%`s [_ ----ld'e-------------------•-•-•-----------"-----------------•----"-------------------
has been installed in accordance with the provisions of TITI E 5 of The State Sanitary Code a described in the
application for Disposal Works Construction Permit No.___-_�.5.-.` Q............ dated----- �_R�NTEE
_ .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUED AS A G THAT THE
SYSTEM WILL FUN TION SATISFACTORY.
DATE----------- .......................................... Inspector------------ ------------•.� . • ......._. ----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
•-• .........................................OF.....................................................................................
No......................... FEE........................
MgivsFal Workv T>anitratr#ion nuti#
Permissionis hereby granted..............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
f
at, No...............................................................................................................................................................................................
Street
a shown on the application for Disposal Works Construction PeriniNNO..................... Dated..........................................
rr , q Board of Health
R;
DATE .............................................
,FORM 1255 A. 9tjLKIN, INC., BOSTON t$
ti�
I
N B.M. - 100.00 ASSUMED ON CORNER �y�
OF CONCRETE RETAINING WALL 9Q419a0s��e� �° L P nd t
�. �T GENERAL NOTES
SITE PLAN �"
.o . ... ; ' �: �/<< 1 . ADDRESS: #561 LUMBERT MILL ROAD, CENTERVILLE t M'� Rd.
SCALE: 1 = 40 s° 97.73' "Qo 2. ASSESSOR'S NUMBER: MAP 146 PARCEL 100
CONTOUR INTERVAL=2' R'B fn 95.75' 98.74 3. DEVELOPER'S LOT: LOT 4
�O #
4. TOPOGRAPHIC INFORMATION WAS COMPILED FROM AN ON THE SITE
x99.55 GROUND INSTRUMENT SURVEY. Flowing
,��
5. WELL & TOWN WATER IS PROVIDED TO THE SITE & SURR011 LADING PROPERTIES. Pond �oromoc Rd'
3' a,h 6. REFERENCE PLAN: LAND COURT PLAN 37432E SHEET 3 OF 4
7. UNDERGROUND UTILITIES LOCATED IN ACCORDANCE WITH DI( SAFE #20111901405
104.5' 8. NO WETLANDS OR POTABLE WELLS ARE LOCATED WITHIN 1 �O FEET OF SAS. ROUTE 28
9. THIS PLAN SHALL BE USED FOR THE SEPTIC INSTALLATION DNLY.
X1o0.62 :;. '•`••.••;....•• 10. THE EASTERN ONE-THIRD OF THE SITE LIES WITHIN A GP GROUNWATWER PROTECTION ZONE.
. 10 9&•iii`•
,a4.99' Design Calculations FOCUS
.::..................................... N 0 SCALE
T.H. _. {}'.{�!{+'•;,'•` 98.10' Number of Bedrooms: 3 EXISTING
Proposed SAS T.H. ....'.'.z;....;;,;;:``''`'9813' Garbage Disposal: Not allowed with this design
With Install 3-500 gal H-10 ehamban ... Bp�'U V of atom all wand. a`f' ;• T.H. try 98.20'
ab.aa. . a�� a�&29, Septic Tank Capacity Required: 1 ,500 gallons (Utilize existing 1 ,000-gal. tank)
:.r:.•'��.:. •:::jr Pam,"F ,4 ...........::. . �adota I
>' Application Rate for <2 min./inch - 0.74 gal/sq. ft.
150 footat#577%u,lRd ICJ919
Leaching Capacity Required: 330 gpd/0.74 gal per sq. ft. = 446 sq. ft.
10103 . Prop osed Leaching Structure: 1 -33.5 f x13>x2> Leaching
Trenc
h
gas , ........... L ..... Bottom Leaching Area Provided = 435 Sq.Ft.
101 •:•rrrr:•::98.85'•rr::•i::.•:i"•
Side Leaching Area Provided = 186 sq. ft.
99 0° .........�ti Total Leaching Area Provided 621 sq. ft. > 446 s ;. ft.
„' LeachingCapacity Provided =621 s ft X 0.74 al ft.=460 d. > 330 d.
s
p y q• g ' q• gp gp
97
p90.
r
"PIP
o �'
g e5.e5'x p �p 9s �3� ,�s LOT5O � CONS RUCTION NOTES
9 REA= 1.6t Acres
3 1 . Contractor is responsible for Digsafe notification
za5'x
�--�\ and protection of all underground utilities and pipes.
2. The septic �tonk and distribution box shall be set
PIPESALL OUTLET E
level on 6, )f 3/4 - 1 1 /2 stone.
S DISTRIBUTION BOX HALL E
Af 94. AgyQo SET LEVEL FOR AT LEAST 2 FT. 16" CONCRETE COVER 3. B a c kf i l l should„ in size.
be clean sand or gravel with no
A '�� � 3 stones over•
3c , 93.11' 9 KNOCKOUTS
5 - 5" OUTLET '' j Fr 2' 4. This system is subject to inspection during installation
A_ 93.94w o WELL TO #557 15.5" OUTLET I
12" INLET
� to Glen E. Farrington, R.S.
6• B" •:.
'� :;:.,:..�::. . 2• 5. The contractor shall install this system in accordance
AL AL ,� 20' 2• with Title V of the Massachusetts Environmental Code.
A_ AL PLAN-SECTION CROSS-SECTION and local Board of Health Rules and Regulations.
H- 10 5 HOLE DISTRIBUTION BOX 6. If, during installation the - contractor encounters any
�A_ NOT To SCALE soil conditions or site conditions that are different
USE WIGGIN PRECAST OR EQUAL from those -4>hown on Lhe soil log or In our design
`�- the installer shall halt installation and immediately notify
G
W//V SOIL EVALUATION Glen E. Harrington, R.S.
Date of SOIL EVALUATI04r MAY 4, 2011 7. No vehicle oi- heavy machinery shall drive over the
Pv
OI /D Evaluation Performed By: Glen E. Harrington, R.S. septic system unless noted as H-20 septic components.
Excavator: M.P. LABUTE SEPTIC & EXCAVATING
Witness: DON DESMARAIS, R.S., BOH AGENT 8. Install Tuf-Tice gas baffles or equal on septic tank outlet tee.
Percolation Rate:< 2 mEli assumed, 24 gals applied during presoak
9. All piping shill be SCH 40 PVC.
N� Test Hole Test Hole Test Hole Test Hole 10. Puns d backfill existing leach it.
No. 1 No. 2 No. 3 No. 4 p an geac p
DEPTHI SOILS ELEV. IDEPTHI SOILS ELEV. DEPTH SOILS ELEV. DEPTH SOILS ELEV. 11 . The Contractor shall notify the Board of Health and the Designer
0 103.0' o 102.0' 0 / 100.5' 0 / 99.5' at least 24 ,lours in advance to inspect and certify the system.
V oaloAan oarfiy San loafiy san �•
10YR6�1 1OYR6/, 6" 10YR6/1 8" 10YR6/, PERK TEST #13252 12. Provide one v g g i n Precast H- 10 DB-5 distribution box and three
ry 10" 8" DEPTH: 35-53"
gw Bw Bw Bw BEGIN SOAK: 0:00 Wlggln Precal:t. H- 10 500-gal. chambers or equal.
oamysan oamy san oamy san oamy san END SOAK: 9:00
34" 10Y5 6 00.17 32" 10YR5 6 9.33' 26" 1OYR5 6 98.33' 28" 1OYR5 6 97.17,
35" TIME: 9 MIN.= UNABLE TO SOAK,
C PERK C1 Ct
USE G2 MPI FOR DESIGN PURPOSES
C
medium medium 53 mediudm medium
san San san san
2.5Y6/4 2.5Y6/4
2.5Y6/4 2.5Y6/4
120" 92.0' 1321 189.5- 120" 1 89.5,
No Observed Ground Water No Observed Ground Water
l09 89
Sol Evaluation Certification
I certify that on October, 1995, 1 have passed the soil evaluator
examination approved by the DEP and that the analysis was performed by
me consistent with the required training, expertise and experience described
in 310 CMR 15.017.
GLEN E. HARRINGTON, R.S.
SYSTEM PROFILE
Existing Dwelling
Not to Scale
5 HOLE H-10 PROPOSED SEPTIC SYSTEM REPAIR/UPGRADE
DIST. BOX Provide 4 dia. observation port PREPARED FOR
Existing Grade = 103f Finished grade over system=2% slope away Existing Grade = 103't t:) 3 of grade
LEGEND
CELLAR Septic tank covers must be D-Box cover shall b Min. 2"-1/8"-1/2" Double-Washed Stone Approximate location B R IAN Z U G E L ET U X
One chamber cover shall be A i
WALL S = .02 within 6 of finished grade within 6 of finished grade within 6" of finished grade or geo-textile filter cloth gas IIne
• To of Peastone Elev.=100.6't - Approximate location A
S=.01 T
Level for 2 S=0.01 ft/ft a er line
' EXISTING -
561 LUMBERT MILL ROAD
10 15 0 Invert Elev.=100.08 -18- Existing contour BARNSTABLE CENTERVILLE MA
1 ,000 GAL. .'.. 20'
SEPTIC TANK 24" o Ex.1,000 gal. '
- P=100.28 0 0 0 0 0 septic tank location PREPARED BY:
Inv. elev.= 101 f H-1 0 Inv. EI. 100.60 0 Bottom of Leach �K c� $
Install Gas Baffle 33.5' Facility Elev.=98.08' spy Glen E. Harrington, R.S.
_ � . 9 Leda Rose Lane
Inv. elev.=100.85' or equal P=1O0.45 p Existing Leach Pit y ,
3/4 -114 Double-Washed Stone 5' Min. RIN Marstons Mills, MA 02648
6" OF 3/4"-11/2" STONE L LA C H I N v C H A M BERS t f T � ��� Tel: 508-428-3862
,�+ � °�'� � Fax: 50$-428-3862
6" Cis•` :3/4"-11/2" STONE Hole #3 Elev.=89.5' ITA
S =20' DRAWN BY: GEH DATE: 17 MAY 2011
DATUM: ASSUMED FILE: ZUGEL SHEET 1 OF 1