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Commonwealth Of Massachusetts
Executive Office Of Environmental Affairs
Department Of Environmental Protection
• TITLE 5
Official Inspection Form -Not For Voluntary Assessments
Subsurface Sewage Disposal System Form
Part A
Certification
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis ` .
Owners Address: 393 Main St Centerville Ma.02632
Date of Inspection: 6/30/2008 i
y
Name of Inspector lease print)Sean M.Jones#SI4522
P (P P )
Company Name: S.M.Jones Title V Septic Inspection = `
Mailing Address: 74 Beldan Ln. r-
UD
Centerville Ma.02632
Telephone Number: 774-2484850 rn
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 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:
X Passes
Conditionally Passes
Needs further evaluation by the Local Approving Authority
Fails
Inspectors Signature Date: toh 0 c�®�
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.
Notes and Comments:Dwelling is served by 2 cesspools and a 1000 gal.pre-cast leach pit.This inspection is for the
main.house located at 393 Main St.. The property also has a 2 bedroom apartment that has its own complete septic
syste ,this system was not inspected.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 1
a
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(commuED)
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis
Owners Address:393 Main St Centerville Ma.02632
Date of Inspection:6/30/2008
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
B.System Conditionally Passes:N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or
Repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the_for the following statements.If"not determined"please
Explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
Unsound,exhibits substantial infiltration or exfiltration or the 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 structurally sound,not leaking and if a Certificate of Compliance
Indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
Obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
Approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(S).The system will
Pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis
Owners Address:393 Main St Centerville Ma.02632
Date of Inspection:6/30/2008
C.Further Evaluation is required by the Board of Health:N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
Is failing to protect public health,safety or the environment.
1.System will pass unless Board of health determines in accordance with 310CMR 15.303(1)(b)that the
System functioning in a manner that protects the public health,safety and the environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
Surface water supplyor 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 less than 106 feet but 50 feet or more from a
Private water supply well**.Method used to determine distance
- f
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
Bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
Failure criteria are triggered.A copy of the analysis must be attached to this form.
3.Other:
-- a
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis
Owners Address:393 Main St Centerville Ma.02632
Date of Inspection:6/30/2008
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of cesspool or privy is within Zone 1 of a public well.
X Any portion of cesspool or privy is within 50 feet of a private water supply-well.
X Any portion of 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 pp,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
X (Yes/No)The system fails.I have determined that one or more of the above 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:N/A
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
Yes No
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well ,
If you 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
CM15.304.The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis'
Owners Address:393 Main St Centerville Ma.02632
Date of Inspection:6/30/2008
Check if the following have been done.You must indicate"yes"or"no"as to each of the following_
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X _Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X_ _ Were all system components,excluding SAS,located on site?
_X_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? .
_X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
X _ Existing information.For example,a plan at the Board of Health.
_X_ _ 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(3)(b)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis
Owners Address:393 Main St Centerville Ma.02632
Date of Inspection:6/30/2008 i
FLOW CONDITIONS
RESIDENTIAL '
Number of bedrooms(design):-3— Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203 (for example): 110 gpd x#of bedrooms):
Number of current residents:_2
Does residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no): no [if yes separate report required]
Laundry system inspected(yes or no): n/a
Seasonal use:(yes or no) no_
Water meter readings,if available(last 2 years usage(gpd):
Sump pump(yes or no): no .
Last date of occupancy/use: current
COMMERCIAL/INDUSTRIAL:N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): Rd
Basis of design flow(seats/persons/sgtetc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons--How was this quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
_X_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 the system owner)
Tight tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)pre cast overflow pit installed 1986,
Were sewerage odors detected when arriving at the site(yes or no): No
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis
Owners Address:393 Main St Centerville Ma.02632
Date of Inspection:6/30/2008
BUILDING SEWER(locate on site plan)
Depth below grade: 2`
Materials of construction:_X_cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
Joints were in good condition,no sign of leakage.
5
SEPTIC TANK: N/A (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: t
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:Opened covers and took measurements
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: N/A (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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of leakage,etc.):
,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis
Owners Address:393 Main St Centerville Ma.02632
Date of Inspection:6/30/2008
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglasspolyethylene
other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: '
Comments(condition of alarm and float switches,etc.): I
F
DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
Leakage into or out of box,etc.):
PUMP CHAMBER: N/A (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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis
Owners Address:393 Main St Centerville Ma.02632 `
Date of Inspection: 6/30/2008
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X Leaching pits.Number: 1_
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternitave system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
At time of inspection the leach pit had 4'of available leaching,with no signs of past hydraulic failure.Vegetation
was normal and soil was drv.
CESSPOOLS: X (cesspools must be pumped as part of inspection)(locate on site plan)
Number and configuration: - 2
Depth-top of liquid to inlet invert: 3"
Depth of solids layer: 1`
Depth of scum layer: 1"
Dimensions of cesspool: 6x6
Materials of construction: brick
Indication of groundwater inflow(yes or no):—no
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Water level in both cesspools was at bottom of outlet invert.Cesspools covers are raised to grade with steel covers.
PRIVY: N/A (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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION(continued)
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis
Owners Address:393 Main St Centerville Ma.02632
Date of Inspection:6/30/2008
SITE EXAM
Slope
Surface water i
Check cellar
Shallow wells
Estimated depth to ground water 5+ feet
Please indicate(check)methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
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:
Design plan dated 6/3/86 shows no groundwater @ 12'.Bottom of leach pit is approx.9'below grade.
r -
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 393 Main St Centerville Ma.02632
Owners Name:John Ellis
Owners Address:393 Main St Centerville Ma.02632
Date of Inspection:6/30/2008
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or
Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building
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Town of Barnstable
OFtHE Tp�
P� o Regulatory Services
Bnxxsrns►e Thomas F. Geiler,Director
y MASS.
w i639. Public Health Division
prFD PAA�a
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not-warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
I
QASEPTIC\Disclaimer Private Septic Inspections.DOC
393 Main Street
Centerville, Ma., 02632
July 31, 2008
Thomas A. McKean, Director
Town of Barnstable Board of Health
200 Main Street
Hyannis, Ma., 02601
Re: Proposed kitchen addition at 393 Main Street, Centerville
Dear Mr. McKean:
This letter is in response to an application for Building Permit that came under scrutiny
yesterday, July 30, 2007, and is intended to provide a brief history of the septic system at the
above-referenced property.
When my wife and I purchased the property in 1986 it was understood the existing septic
system, consisting of two cesspools, would require renovation to be more compliant with
current Title 5 regulations.
John Kelley, Barnstable Board of Health Director at the time, allowed me to use the two existing
cesspools as two septic tanks provided (1) a satisfactory perc test was performed, (2) all piping
was upgraded to schedule 40 PVC, (3) Tees were installed and (4) a leaching pit, designed to
accommodate the four bedrooms currently in place at the dwelling, was installed. The soil test,
witnessed by yourself, was successful, PVC was installed with Tees and a six foot diameter by
six foot leach pit with three feet of stone was installed at the site of the perc test.
I have had the system pumped periodically and have had no problems.
Jaime Cabot, of your office, indicated on June 25, 2008, that if I had a successful Septic
Inspection at the site The Board of Health would sign off on our application. Accordingly, Sean
M. Jones (#SI4522) evaluated and passed the system on June 30, 2008.
The addition proposed at this site is an expansion of our existing kitchen, no additional
bedrooms or bathrooms are to be constructed; my wife and I are the only occupants of the
dwelling and I would anticipate no increase in daily flow from this renovation.
I hope this will satisfy the interests of The Barnstable Board of Health and if you require any
additional documentation or information I would be most happy to comply.
Very truly yours,
. Ellis
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Town of Barnstable Health Inspector
Office Hours
Regulatory Services 8:30—9:30
Thomas F.Geiler,Director 1:00—2:00
+ BARNSTABLE,
9� 039.
. 1�r Public Health Division
ArE p �A Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
I
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE
1. General Information: Size of Property: 0-Q
Address: ?j M'tIP1 S , //� Map M Parcel -Z-j
Name: �) S Phone #:
2a. How many bedrooms exist at your property now?
2b. Are you planning to add any bedrooms? �(7 If yes, how many?
2c. How many bedrooms total are proposed at this property (including the amnesty unit)?
2d. Please include a copy of the floor plans for the entire property - showing the existing
rooms in the home plus the proposed amnesty apartment and/or addition. Please label
each room clearly on the plans.
3. Is the dwelling connected to public sewer? YES or NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE or fO&TSI Zone of Contribution to public supply wells?
5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER?
6. Is a disposal works construction permit on file? YES or NO
6a. If yes,how many bedrooms were approved according to this permit? Bedrooms.
7. Were any building permits obtained for construction of additional bedrooms? YES or NO
8. Is there an engineered septic system plan on file at the Health Division? YES or NO
9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
------------------------------------------------------------ ------ -�----------------------------------------- --
FOR OFF USE ONt
The Public Health Division has no objecti n to edrooms at this property.
Special Conditions:
Signed: - Date: 1i
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The Town of Barnstable
* BARNSrABLE, +
16 Growth Management Department
3q. ��
� 367 Main Street, 3rd Floor
Hyannis, MA 02601
Tel:508-862-4678 Fax:508-862-4782
January 31,2008
John C.Klimm,Town Manager
Janet Joakim,Town Council President
Barnstable Town Hall
367 Main Street
Hyannis,MA 02601
Re: Susan W. Ellis, 393 Main Street, Centerville; two-bedroom accessory unit
This letter is to inform you that the Accessory Affordable Apartment (Amnesty) Program has
received a request for a project eligibility letter under the Community Development Block Grant
(CDBG) Fund and under Article II of Chapter Nine of the Code of the Town of Barnstable and the
criteria for the Local Chapter 40B Program.
This office is reviewing the request. If the Town has any comments on the project, please forward
them to me so that they can be addressed in the site approval letter. This letter gives you official
notice of our receipt of the above application(s). We will issue a decision as to the acceptability of
the sites and the consistency of this development within the guidelines of CDBG.
Sincerely,
Elizabeth Dillen
Special Projects Coordinator
Growth Management Department
cc: Building Division
Health Division✓
- t
fr
ASSEISORS MAP NO:
PARCEL NO.- 1 1 FEx..,.. -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
v.11V..........OF........ ............................
,� lirttiinn for Diipnsal larks mArtutinn anti#
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System �� math h " ,�
.... .... ....... .. .--••----••--•-----•------••.......... .................................................... -!------...........................---..
Location-Address or Lot No.
_ ....�1�i 5---••-......•...................• ........._.......
weer �yp� �j c
a �.es. . ..-er..1 C�_ L---�C<�.4/►
Installer Address
dType of Building Size.Lot..._...0,,.4 .......Sq. feet
U Dwelling—No. of Bedroo Expansion Attic ( ) Garbage Grinder (Rb
------------ —
pa., Other—Type of Buildin __ .__.... No. of persons............................ Showers ( ) Cafeteria ( )
a Other fixtures ................. ... . . .
W Design Flow...... ...*3.��-gallons per person per day. Total daily flow..._.._. Q.......................gallons.
WSeptic Tank—Liquid capacity. a allons 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 (y4�-:!- Dosing tank ( )
'-, Percolation Test Results Performed by.......................................................................... Date........................................
).4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rx ••c-�..--------------�--.�....�. .-•---------................... --------........----... ............----•-----...............-•---..
Description of Soil - .-•-••CG--•.....••...--e=•-•-�"...... .
x
V -----------------------------------
-------------
•------------------------------------------------------------------------------------------------------------------------------
•---------
•-----------
W ......-----•---- ------- -----------------------------•••--•-----............._......--•-•--•------------------•--------•-----------•-•••--•••••••••....-••••-•••••••---••--••---•---••-•••-•-----......
VNature 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 TITi a 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by oard ea
Signed---- --- --.----•- •-•--••----•-••••---•---••--•--•--• ••--- ....................
Dale
Application Approved By---...•. = ... ............ ...•.•• ......••-•.-•-•-- �f o �'
Date
Application Disapproved for the following reasons:.............................................................................................................._
------------------------------------------•--•--...----------.....--------------••---------•-------......••--•----...•-•-••••••••--••-------------------------------------•-----•-•••••••-••--•-•--•----
Date
PermitNo.................'j n....^�� Issued.......................................................
Date
v '
• ���"?aFxs ..... ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--•-- .VJIV..........OF........ d'1 !ter :...-------•--•-•------•------
Appliration for Disposal Works Cfonotrartion Errant
Application is hereby made for a Permit to Construct ( Repair ( ) an Individual Sewage Disposal
System at
.... .. .��•.•....... 4n ............?-..^.................... .................`... ::'. '_"... � ::... .........•...........-•.....--•-•-......
Location Address or Lot No.
.................. 'A_... �t� .....----........----------...
caner u Address
W ... r..._ -f O lJ ................ .................
a ...--•------...
Installer Address p
Type of Building Size Lot.......A.,222.......Sq. feet
U Dwelling—No. of Bedrooms-,... � r ....: ..................Expansion Attic ( ) Garbage Grinder (/1/
'4 Other—T e of Buildin ) 1 No, of e'rsons............................ Showers
a YP g -- --- -----------------------•P----- ( ) — Cafeteria ( )
dOther fixtures •----•---------------- ---------------------------------------•-------...----.---•------•------•--------------•-.-
W Design Flow...... ........... ...B----5-•0gallons per person per day. Total daily flow........ 0......................gallons.
WSeptic Tank—Liquid capacity.l'�'.!!t£-kallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (yo!z i Dosing tank ( )
Percolation Test Results , Performed by--•-•---•----•--••-----••••.._.......••-•-•--•-••---•--.....--•-•---•_... Date........................................
aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
:: --- . --•-•--•---•....... ......
----------------------------
.....-----------
O Description of Soil :.:.:.............7M...........�...d'!?.9+1.--•-��s`��� � ���cn�'............ •--
x
U ......_..•-••-•-------•------••-•-•---•-••••=......•.....--••••---•••.....................•---•--
------------------------------------------------------------
----•-••---•----.......•---•-----••-•------••-•-••••---••--•--••-•••••--•--•-•-••---•--....-----•---• --•--•---•--------•---------•-•-•--••---•---•••-------•••••--•-----••--•--•-••-----------•------•-
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 TITL% 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.
Sign d--------------------------- ------ ----
------------•----------
-..---..--------- -------------.---•-•-•--------
Da e
Application Approved By--••--•••••....... _=�- .-- ... .�r"`' = J.�Dat �-
Date
Application Disapproved for the following reasons:................................................................................... .....................
....-•-•---------•........................................•---------.......---•-------.........._...........-•----•-•---•---------------•-----••-•--•-------------......-•------•--•-••••----•••••----
Date
PermitNo................ •------ ---------- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:....1 ...
Trrtif iratr of Tontpltttnrr
THJZLS TO CE. RTIFY, ThaX heIpdividual Sewag Dispo al System constructed ( or Repaired ( )
by -- 4.• . =-------•-------•----------•..........................••--•-•------....--
• Installer
at = .•......---•-•...!' ....---------a..�--`----------------- a1- s?iC:`�.e. ---------------------------------------------------------•--------•---------
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._.....�: ....... _ ___ dated---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCT40Y SATISFACTORY.
DATE............................. �I � .... Inspector................ .- -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD._ OF HEALTH
........ . �N...OF...... .` ...................
No. r am,?_._.. ' F$$.....
Disposal orko_(gonotrurtiort
--------• ....... . _...... rrntit
Z .Permission is h �r1L ......- ---- - ------ L4: ._....
to Construct _ or Repair ( ) an In vidual Sewa a D• posal System
Street
as shown on the application for Disposal Works Construction_Permit_No ;j( .-• ?3. Dated.....��.�.�.......�(r
ull �1 ' '�� Board of Health
DATE......----•-.�
FORM 1255 A. M. SULKIN, INC., BOSTON
-9
ASSESSORS MAP NO: Yb�
N.. PARCEL NO.: 14-I ` ,. FEB
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.-rZ.W4.i—. . ..............OF.......... a IJSP'f'Y' L�..........----...........
Appliration for Uiipnsal Works Tomitru.r#ion Errant
Application is hereby made for a Permit to Construct ( ) or Repair (►<an Individual Sewage Disposal
System at:
.�q. nnA'6i. .C � r f-LC-- ---------------------------------- A.---•-----•-----------....-----------.......---
• ...............•---......... ._ .y...........
f P" Location-Address or Lot No.
..•... . I....- 6............................................................. . .��.....3
a Plc�T'T�= Owner Address
{cam PcAcf� ar � . --••............... . . ! .. ..
c..`?..��
�
QI 7 Installer Address
UType of Building Size Lot........,.................� Sq. feet
,., Dwelling—No. of Bedrooms........HNAA....CA)............Expansion Attic (NfA) Garbage Grinder (w1A)
a'-1 No. of ersons.... I ) Showers �L Cafeteria
Other—Type of Building .&?__�.3. p _... .. �..._. ( ) — (4R)
dOther fixtures ....IJ A--------------------••----------•-----'--------------------'-----------------...............-----------.......---...-----•--..........
Design Flow.._.._.. i gallon erso�n per day. Total daily flow___-.- �?••---.-•...............gallons.
WSeptic Tank—Liquid capacity_.... gallons ength___.wj�..... Width..!�JA.__.. Diameter__!-/A_..._. Depth_1-1 .....
x Disposal Trench—No. .�4/A.......... Width
---&.qA........ Total Length...NgA........ Total leaching area....."IA-......sq. ft.
Seepage Pit No.......I------------ Diameter.._. .-4...... Depth below inlet•......4�R.`........ Total leaching area.35 .....sq. ft.
Z Other Distribution box (4a:) Dosing tank (&JA)
aPercolation Test Results Performed by...... ............ Date.... #: ! S .........
a Test Pit No. 1.- �-_-minutes per inch Depth of Test Pit....�'�n.......... Depth to ground water.;A+ . �'r -
Test Pit No. 2................minutes per inch Depth of Test Pit......_............. Depth to ground water........................
------------'----------•-•-------------------------•---•--••......•............-•.•.-- ••--•.........••-•-.....•---••••-'-•---•-•••--.........•---------
Description of .oil :..� ............................. i' - �°Lc-•-�laeAl �t.� 1�
P i
4WOt— / 't'.t .....= ---• -------------•------...---------------------•----------------------.......----•-......--•------.......------------..
W
------'--------------'------•...•'-••'•----'--••••----•••''-------'-••'••-•-•••'•...................--'•"'-•-•'--'•--•"'-----"'-•••-••'-•'---•••--......•---•-•-•'••-••••-...........•-•-•---•..._.
U Nature of Repairs or Alterations—Answer when applicable__Q:D i-i.•—_._-_e.*- .E
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL% 5 of the State Sanitary Code—The unde signe further agrees not to place the system in
operation until a Certificate of Compliance has bee 'ssu by t and ie
. -•---•-• ........ • .... -- --•-----
Da a....••--
Application Approved By-•••---•••-• ..--"•...... = ( .._..
Application Disapproved for the following reasons:..............................................................................................................
-----•---••---•-----•------------•-------------------------------•-•-----------------•--------............_......---•---•-•----------------••-----•-------------....----------------------•-•••-••---•---
Date
E�ePermit No .... .e.--...... Issued--------------------------------•-••-•---------•......--
Date
IL_ __. - - --- = -- --- -- - _ ._�.4____.__--------------- -- -- - - ---—1
No.... ...... Fxs..... . ..,�=
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TJW ..........................iJ"s L....................................................
App iration for Dispoottl Marks Tonotrurtion Permit
Application is hereby rn.4&,for a Permit to Construct ( ) or. Repair (V#Y"an Individual Sewage Disposal
System at:
`l 1 ..: .................................•..................
-Location-Address or Lot No.
------------------------•--•---• ---------
... 9"✓ AA Al MJ ' 1 g�r�...... ]mot i C...`....
Owner Address
W i�yc��..........................
a ..... ....
Installer Address
Type of Building Size Lot..44,91.5..-.Sq. feet
U Dwelling—No. of Bedrooms....._. ........"...Expansion Attic (w/4) Garbage Grinder (N,A)
pa, Other—Type of Building ._ :�•� •�. No. of persons...5F! -0!.).. Showers (/L) — Cafeteria (41A)
p' Other fixtures ....WA---_-._
Design Flow......_. I 1-® al sj4n per day. Total daily flow_...........................................' gallons.
W. �. s i, '" i'«.�i. ..
WSeptic Tank—Llqul c�pac> y._... _gallons Length.-.� A..._.gWidth.�1•i11A..... Diameter..glA...... De th YJ q.....
nch
th
x Disposal
el Pit o__...... Diameter la ..4_�..De t Total
belown inlet��....... Totallleaachin area
area.� ....s -ft.
� P� P g q.
Z Other Distribution box (ao) Dosing tank (KIA)
aPercolation Test Results Performed by.... -1 _ ..1* j+-<<-+ ±" ............ Date...5- ..........
a Test Pit No. L. ...minutes per inch Depth of Test Pit-- ! •_'........ Depth to ground water.. -' T'•
fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....
O ---------------•....... ....--......
Description of Soil.... ? ,►,' t- ar4 v► - "roe". x 1+5�----•-} c .......................................V►
VW -•-••••-•••••----•--;....--•-•-•--......_--••-•-••-••--••-•--•••---•---•.............••...._.....----••.._.....--•-
Nature of Repairs or Alterations Answer when applicable...�►.6.1 4.e C 1 K-t4s- . t-' A-5,
"... C__ i. ht-A �/ Ia5 t 7?t(t.. sE'a.� ca' 4 V, Gq ' L.,P "i fT•H .. ......... .........
-•- •-•-•-._----_••• ..........._••--••...... •-•.................. .•••...._....--•-•---------..__....__.............._.._._.......•••.............
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
operation until a Certificate of Compliance has been issu by the board of health.
Sred� .......................... ..........•-.._....... .................._....
}} t
Application Approved By............. 11...:.
Da e
Application Disapproved for the following reasons:................"."....._._._................_____._........."..........._.___................_.........:..—
.."--•"•.................•---"-"•-----""--....•..-•----"....--------"-""•--"--•"--"---------------------•••-•-•-•-•••-•-••________.__..........___----•-•••----••--_...--•---•.....-••......•---•....._.
Date
Permit No........`.. ............ •-...._ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
,,��•^�^- BOA fALTH
.......)...'.alb.... .. .OF. ................. ...............
(Inrtif iratr of Tompliana
THIS �RT , T e 'dual Sewage Disposal System constructed ( ) or Repaired ( )
by---------------- 3� -•"•-- .b. -�.'��gta "-•- -----.-..................-------------------------------------------- ---------
at------ _.... 1.q_....••... ............... :.._..
p 5 of The State Sanitary C,,ode as de rib in the
has been installed in accordance with the provisions of TITLE �
application for Disposal Works Construction Permit No"`�._ .. dated........... ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU A ANTEE THAT THE
SYSTEM WILL FU,JICTION 4ATISFACTORY.
DATE......--••-••....... �. ....-- Inspector
.__.•• -•......••••.............. ••..........................................................
THE COMMONWEALTH OF MASSACHUSETTS
( BOARD OF HEALTH.. ,
N ... ,,,��^^� ..............1.. Py)......OF.... ' .rE! - .................. i -
Rovosutlorko Ton fr ion Permit
Permissionis hereby granted................................................. •• -- --..... -"------...."-----•"..................•.....---...........................
to ConstK_ucL� Repa• ) an W!*!M ual Sew Di tem
- I ; Z
Street
----
as shown on the application for Disposal Works Construction Permit Nco' � - . Bated_- ... ............77
.
`���� Board of Health
DATE............. . ..---• ....-•............... ............
FORM 1255 A. M. SULKIN, INC., BOSTON
N
-'LOCATION SEWAGE PERMIT NO.
�3q3
VILLAGE
ALL E 'S NAME i ADDRESS
8 U I L D E R OR OWNER
Mli/_ 1�
DATE PERMIT ISSUED j
DATE COMPLIANCE ISSUED �t ` -�
II
1
3`s,�
l'0 C`K"T ION SEWAGE PERMIT NO.
343
VILLAGE
INSTALLER' NAME j ADDRESS
G'
S U I L D E R OR OWNER
`liky �a
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
d
lei /000
r
►'
co Gf•1-,
.Proposed New Construction- in Centerville, MA.
Prepared For: Susan W. Ellis
Assessor's Map: 208 Parcel: 121 - Baxter Nye Engineering & Surveying
Community Panel Number 250001 0005 C N Flood Zone C Registered Professional
Plan Reference: Plan Book 109 Page 107 Engineers and Land Surveyors
Deed Book 9145 Page 168 78 North Street, 3rd Floor
Owner. Susan W. Ellis Hyannis, MA 02601
Address: 393 Main Street Phone — (508) 771-7602 Fax — (508)-771-7622
Centerville, Mo., 02632 Job Number. 2003-088 Scaler It) = 30' Date: 07-18-2008
Np��s�, ?2v
0.
cT •';r 5 N/F STEWART MALCOM REED, ET UX.
ti MAP 208 - PARCEL 120
PLAN BOOK 79 - PAGE 39
DEED BOOK 9,650 - PAGE 29
� G
-1p3 78,
AlN7 •
A 4 40'18„ W ?
DRp QED ?,C
A �EwAY APAR
oo
No NT ro 389 J'X
Q� 4.3 W
O
2 v pOpOSED 0Fe 2
ac°� EXjSnN & D fn01V REMo�ED 24,096 SO. FT. t
DWEL G CK de 0.55 ACRES
2� HSE No NG 3,r REP�,gC� , x 6' DEEP
.LEACH PIT W 3 STN
G /�G��e• vV" O� O (�
SB FND/NO DH 00 o o Z d
p HELD 24
0 0 7,2T SB to 4
N O N 81'58'13" SB z
W 247.27' TD
A
5 SB FND/NO DH
' HELD
r"
�a
EXISTING
DWELLING N/F MARY M & FREDERICK A. LOTUFF
HOUSE No. 401
MAP 208.N PARCEL 124
DEED BOOK 18,070 PAGE 94
' EXISTING
t; BUILDING
h=, CB/DH FND
HSE No. 415A CB/DH FND
yF
HOUSE No. 415
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE PROPOSED NEW CONSTRUCTION SHOWN
HEREON IS IN COMPLIANCE WITH THE APPLICABLE BARNSTABLE ZONING DISTRICT SIDELINE AND
SETBACK REQUIREMENTS, IS LOCATED IN RELATION TO THE MONUMENTS SHOWN AND IS NOT
LOCATED WITHIN A SPECIAL FLOOD HAZARD AREA.
THIS PLAN IS NOT TO BE RECORDED NOR IS IT TO BE USED TO ESTABLISH PROPERTY LINES. E s
N
0
REGISTERED PROFESSIO LAND !�RVEYOR N BAXTER NYE ENGINEERING & SURVEYING DATE O"1-15 •O€t
0
N
O
�I qti 1 DESIGN DATA
�p W `JQja M IL
STRUCTURE 'CIF IE�L� -A
��►.�1RjTi=D Lo-r' �°r�: � ; u+ Joy DESIGN FLOW '�1�-MS
4 x I I o G�� M = 44� ESP D
�Q ���IkG1 j D�� �� ���5 ' tj1� Its J. x 4.4o GPD = Cm�o IDD
27A=
�/�i I}1 SEPTIC TANK � I m"e=(L)
LEACHING RATES, SIDE AREA I.o GPD/SF
grab •(�� Y� '� 0` BOTTOM AREA `__5GPD/SF
O LEACHING FACT ITY = p. ,
//�� �T'I•tJ M _TT• &:)
�� I I �� �b, m V' f�L, x 2�Cm + (1.O 'AI l 3
~• + PLAN REFERENCE:
/�• �.�`� '�'. \ /'� s,;r' ►-G y /LAIC` n
w/A
IL
rn �
"' L �9 L ASSESSORS LOT No. MA-P lob 1�_-L At _
P � L f T f+•`+ a ..� � -
� .� w•ZQ 0 N
� OTEi
A �� _� '�•e �j,.P / 5-� �'o �p P•G• C I. ALL MATERIALS AND CONSTRUCTION METHODS
• ( O 1l-IJ' �y TO CONFORM WITH COMM. OF MASS. TITLE SC
, _ � � �f�•sV 'p' �_ o * � �•—� � � ENVIRONMENTAL CODE
/1. ALL
'y i 9 •o�v�l 9 ' O` 4"DIAAAM �r t Lio A.IG
ti
Q 3. 0=-1= F3,4ef•.Is-r-A R.LF- r -LD o�
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oe • sca 2 P�DPm ' �� - N <�LLIs 02.20•8��
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f( `o AVID) JO 2 '
_ C.
u� !=L_= Io�.a Exls-n►�c �f Dom- PLAN �� ( us,
.2 �, o. 29874 o S 6
c
LA SCALE ("=Qo TEST PIT NO. 1 TEST PIT .NO. �4� s '�FCISTER��•�y�'
ELEV. I Qo .a ELEV.
loo � i i r\l E�;�' IQL LRti
1.5
99.3 98.8 -
96.4 _ _ ° _ SOIL OBSERVATION PITS
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LAND SURVEYORS AND CIVIL ENGINEERS
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SECTION THR.U. SEPTIC SYSTEM ., �� �o�T �. EM -