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Home My WebLink About0245 OLD CRAIGVILLE ROAD - Health "L45 Old Craigville Road c Centerville A:=-247— 1,1.1 i llln *�`Q®)) UPC 12543 �o- Now VOW HASTINGS,MN I I aye- lil Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road _. Property Address JOANNE OBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. City/Town 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 A. Inspector Information filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not. S.M.Jones Title V Septic Inspection use the return Company Name 4 key. 74 Beldan Lane 0 Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonesbtle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10/20/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. l5insp.doo-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner Owner's Flame information is Centerville Ma 02632 10/8/2020 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 245 Old Craigville Rd Centerville is served by a Title V septic system consisting of a 1500 gallon poly septic tank, distribution box and 3 3050 Infiltrators. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Passo 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System•Page 2 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. 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: l5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 245 Old_Craigville Road Property Address JOANNE OBRIE_N Owner owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityrrown ^ _ State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.MAWS Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN _ Owner Owner's Flame information is Centerville Ma 02632 10/8/2020 required for every — page. CYRown State Zip Code Date of Inspection C. Inspection Summary (cunt.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I I of a public water supply well t5insp doc.,ev.7p1612078 Title 5 Official Inspection Form:Subswface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Crai ville Road Property Address JOANNE OBRIEN Owner Owners Name information is required for every Centerville Ma 02632 10/8/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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? ® signs for inspected Was the site ins of break out? ❑ P ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doo•rev.MAW 8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner Owner's Name information is Centerville Ma 02632 10/8/2020 required for every page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 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: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate t5msp.doc-rev.7f26/2018 This 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner Owner's Name information is Centerville Ma 02632 10/8/2020 required for every _..._ page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes.❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: tank pumped after inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? size of tank Reason for pumping: to determine structural integrity of poly septic tank t5insp.doc•rev.7/2612018 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts --� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner Owner's Name information is Centerville Ma 02632 10/8/2020 required for every ._.._. page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: system installed 10/25/2006 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 P 9 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.): Joints in good condition, no leakage, vented through roof. D'Disposal stem e9of18 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage �spos Y eg Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner Owner's Name _ information is Centerville Ma 02632 10/8/2020 required for every - State Zip Code Date of Inspection page. Cityrrown D. System Information (cont.) 6. Septic Tank(locate on site plan): 1 Depth below grade: 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: 1500 gallons 5" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' 2„ Scum thickness 7-1Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" Opened covers and took How were dimensions determined? 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.): Tank was pumped for inspection to determine its structural integrity.Tank was in good condition, water level was even with outlet invert. t5lnsp.doc•rev.7I2612018 Title 5 Official Inspection Form:Subsiurace Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/28f21118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road _ Property Address JOANNE OBRIEN _ Owner Owner's Name information equire d for is r every required Centerville Ma 02632 10/8/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.MM2018 TAIe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 < Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN _ Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 - page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 3050 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5lnsp doc.rev.7128=18 Title 5 Official Inspection Form:subsurface sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts WELAW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Crai vilg le Road Property Address JOANNE OBRIEN Owner Owner's Name information is Centerville Ma 02632 10/8/2020 required for every page. Citylro wn State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): s.a.s.was video inspected from d-box and was found dry with no signs of past overloading 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/2612018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner Owner's Name information is Centerville Ma 02632 10/8/2020 required for every — page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7r4W018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner Owners Name information is required for every Centerville Ma 02632 10/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 �AX- 0 v -� �-Z Z z 6 132 0 /-�3 02 AY 30 (3y 13b t5irsp.doc-rev.7282018 Title 5 Official Inspection Forth:SubsLuface Sewage Disposal System-Page 16 of 18 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. City1rown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water:. 12'+ 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7@8/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 245 Old Craigville Road Property Address JOANNE OBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1,2, 3,.or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/W018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18 cc — l�� No. 6 Fee ��O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASGACHUSETTS ' 01pprication for Biro pgtem CCom6truction i3ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. C9 / qR Assessor's Map/Parcel �L �1 1 ��n 1 2 q 5 A t 1 l l l l �Jti U U CrC" Instaaller's Name,A dress,and Tel.,Xo. Designer's Name,Address and Tel.No. Gj Q$ 1 F0 (30� &2_7 �. 1>� oL)kl..ttit.q. 0ZS3�O. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 37 gallons per day. Calculated daily flow 3 3O f C7 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 3 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 n t p ace th eration until a Certifi- cate of Compliance has be inSuO by this of a t Sig ed Date Application Approved by Date Application Disapproved for the following reasons Permit No. rZ k Date Issued No. Fee VO THE—COMMONWEALTH OF MASSACHUSETTS Entered in computer: i NYe PUBLIC HEALTH DIVISION - TOWN OF. 'y BARNSTABLE MASOACHUSETTS }-- • ZIppYication for Miq *raem Congmruction Permit Application for a Permit to Construct( )Repair )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Q �I!)P. F_Q ee.r0 C_ zc,, v P_�6 ' Assessor'sMap/Parcelil�r"1�� Qf�n►� °'^ g Installer's Name,Address,and Tel No. Designer's Name,Address and Tel.No. G)0$ •'D r ` 2�_ t TL9 � (5- ?r �U PO t701< ( ?_—t �. 1r. �c��Elti �AkA• vz53�- . Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) w Other Fixtures Design Flow 3D gallons per day. Calculated daily flow 3 30'C� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 31 Description of Soil; Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: t . 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 Cod'e�and not-to p ace th ste operation until a Certifi- cate of Compliance has been tasu d by this Bo of Health Si ed Date v 7o v6 Application Approved by Date Application Disapproved for the following reasons t Permit No. `c V6 l - Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( 4_�Pgraded( ) Abandoned( )by 1 -f-4f' . at 24 "w � rs�A. ?�f �/� has been constructed ' acco ante with the provisions of Title 5 and e for Disposal System Construction Permit No. �P 176 dated Installer 0(_3,A,4- e� Designer The issuance of thipermit shall n t be consirued as a guarantee that the system w + function as, esig ed. Date �. � Inspector. r--J-(-'�.Jy �� ------------------------ No. Fee /a0 e THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ligoar *pgtem Con5,truction Permit Permission is hereby granted to Construct( )Repair(�)�Upgrade( )Abandon( ) System located at_ n / L �- c r`7l ITS and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special con.• ions. Provided: Constructio ust b completed within three years of the date of this p it. Date:___ �AApproved by la 001/002 'own of Barnstable Regulatory Services 1 , r' Thomas F.Geiler,Director MIAM s Public Health I)av-lion Thomas Mckean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-46" Fax: 508.790-6304 nstaller&Designer Certifl �tio Form Date: 1015-06 Designer: Shay Environmen S ices.Inc. Installer: I�obert�Services Address: .O, Box 627 Falmouth - --_._..�. Address: 5 Trenton Street_ MA 02536 Yan�riouth MA On 10/18/06 &bert�Septic Service was issued a permit to install a (� ) (installer) septic system at 245 Old Craicryalip Road Centerville based on a design drawn by (address) tel Services tuc 3/17/Qg (designer) ' dated XX I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved-changes such as lateral relocation o f the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (Le, greater than 10' lateral relocation of the SAS or any vertical relocation of any component `t c 56Pti% system) but in accordance with State& certified as-built by designer to follow. Local Regulations. plan revision or ItA OF 4f,4S� CARMEN cG, (Ins ex's Signs h SHAY No. i1al o (Designer's Signature) Alex _stai��p here) _ N Tq BARNSTAB�, PUB CH�+ALTH DI'V�SfG]VDT fGAr OF CUMMI ANC r_ Rik' rm-P ,a 1 8iv_ r p �b �,�`a; wcws se.e L•+.6d eF 4_r !`E4� 5`...a �,ya � • k DL •§'¢ �'ir3>��&4'�r�. rg'4 �F�� Q:lfealth/Sep WDuigner CMiaoation Form h r Bk 20928 P96 =23759 04 —20-2006 a 10 = 28ct DEED RESTRICTION WHEREAS,WE,RALPH M. CROSSEN AND MARY V. CROSSEN are the owners of the land together with the buildings and improvements thereon situated at 245 Old Craigville Road, Hyannis,Massachusetts and more particularly described in a deed recorded in the Barnstable County Registry of Deeds in Book 20457,Page 43 (hereinafter the"premises');and WHEREAS, ,RALPH M.CROSSEN AND MARY V.CROSSEN as owner of said 245 Old Craigville Road, Hyannis,Massachusetts have agreed with the Town of Barnstable Board of Health to a restriction on the number of bedrooms that can be included in any home now existing or hereafter constructed on the premises as a pre-condition to obtaining a Certificate of Compliance for the on-site septic system repair/replacement recently completed on the premises pursuant to State Environmental Code,Title V,310 CMR 15.000 et seq.; and WHEREAS,the Town of Barnstable Board of Health,as a pre-condition to granting the Certificate of Compliance is requiring that the agreement to restrict the number of bedrooms in any home now existing or hereafter constructed on the premises be put on record with the Barnstable County Registry of Deeds by filing this document for registration; NOW,THEREFORE, We do hereby place the following restriction on the above referenced premises in accordance with the agreement with the Town of Barnstable Board of Health,which restriction shall run with the land and be binding upon all successors in title: l. Any home now existing or hereafter constructed on the above-referenced premises shall contain no more than three(3)bedrooms. We agree that this shall be a permanent deed restriction affecting the above-described premises also known as 245 Old Craigville Road,Hyannis,Massachusetts. Four title see deed recorded in the Barnstable Registry of Deeds in Book 20457,Page 43. Executed as a sealed instrument this 19`"day of April,2006. ' RAL H M. CROSSEN v� Q MARY V. MOSSEN COMMONWEALTH OF MASSACHUSETTS Barnstable, SS April 19,2006 On this 19th day of April, 2006,before me, the undersigned No 'YPublic, personally appeared Ralph M. Crossen and Mary V. Crossen, and proved to me through satisfactory evidence of identification,which was MA V C rS 1 I be the person whose names are signed on the preceding or attached document, and acknowledge to me that he/ she signed it voluntarily for it's stated purpose. 10 Danielle Suzanne Iadonis ,Notary Public j, .,;cosy°,. 'O My Commission Expires: Danielle Suzanne ladonisi NOTARY PUBLIC Commonwealth of Massachusetts My Commission Expires March 2,2012 BARNSTABLE REGISTRY OF DEEDS TOWN OF BARNS ABLE LOCATION 0 I CrAl V�� SEWAGE # VILLAGE- ' �'Q � 1�A SSESSOR'S MAP & LOT' 4 � INSTALLER'S NAME&PHONE NO. , SEPTIC TANK CAPACTTY SI FIw CQ SSP(b LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 FAILED INSPECTION BUILDER OR OWNER PERM TDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by G AL� a� 3 � TOWN OF BA ST, BLE LOCATION �' /` �1G SEWAGE#f C/! '� �D VILLAGE S ASSESSOR'S ;�P&PARCEL . INSTALLERS NA E&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY. (type)/Alo / �� (size) 0 t r NO.OF BEDROOMS ° OWNER { PERMIT DATE: � /� COMPLIANCE DATE: , Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY / 31 Rfi nn U N ii Town of Barnstable p l sa39. Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D Sumner Kaufman,MSPH May 5, 2006 Mr. Carmen Shay, R.S. Shay environmental Services Box 627 East Falmouth, MA 02536 Itg- RE: 245 Old Craigville Road, W A= 247-111 Dear Mr. Shay, You are granted conditional variances on behalf of your clients, Eleanor Bacquelod and Loretta Reed, to construct a replacement septic system at 245 Old Craigville Road, Hyannis. The variances granted are as follows: 310 CMR 15.211: The soil absorption system will be located five (5) feet away from the southerly property line, in lieu of the ten (10) feet minimum separation distance required. 310 CMR 15.211: The soil absorption system will be located five (5) feet away from the slab foundation, in lieu of the ten (10) feet minimum separation distance required. 310 C310 CMR 15.211: The septic tank will be located seven (7) feet away from the northerly property line, in lieu of the ten (10) feet minimum separation distance required. MR 15.211: The soil absorption system will be located fourteen (14) feet away from a foundation, in lieu of the twenty (20) feet minimum separation distance required. These variances are granted with the following conditions: (1) No more than three (3) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and ShayBacquelod2006 similar-type rooms are considered "bedrooms" according to the MA Department of Environmental.Protection. (2) The applicant shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County-Registry of Deeds restricting the property to three (3) bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. (3) The septic system shall be installed in strict accordance with the revised engineered plans dated April 7, 2006. (4) The designing sanitarian shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the revised plans dated April 7, 2006. These variances are granted because the physical constraints at the site severely restrict the location of the soil absorption system due to small size and shape of the lot. The proposed soil absorption system appears to meet the maximum feasible compliance standards contained within the State Environmental Code, Title 5. Since ly yours, W yne iller, M.D. C airman ShayBacquelod2006 pf DATE: '�44v v7 � . FEE:' MARS. A i639 t�� REC. BY I(� Town, of Barnstable SCHED. DATE: Board of Health 200 Maim Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION , Property Address: Z4S G\d Crq\G,V i>>#— Assessor's Map and Parcel Number: 2 4 {/ ( ( ( Size of Lot: Wetlands Within 300 Ft. Yes Business Name: No_ ' Subdivision Name: N(q APPLICANT'S NAME: Som cSacS Phone SOS 39-+9 w,, Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PER ON r'm Name: p n or � D t]�OC'� � Name: CAQ.M£*3Ler- �• ,SI.1A'I' �.TTA- E 5.w? qr w. S-4 cs . Addresc' s -62, Ro t a �,. Address: Phone: SO 36Z I +44 Phone: �8—539"1-96�p VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space neelde d) t5.2tt 5,��e-b�c?c -4o LbZ'L��a F'o¢. SAS — LeT �c #o,, srn_elt —l6.2t t ;��eac� -�t'tav*,k -� l.o't Li roE- �• .,_= �► ,,�, c ( .Z11 SPAGk �wc- SAS '�o IFov -�do� NATURE OF WORK House Addition 0 ????? House Renovation 0 Repair of Failed Septic,System i Checklist (to be completed by office staff-person receiving variance request application) 0D Fri Please submit copies in 4 separate completed sets. ZFour(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) (004 VCAMW Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) C:\Documents and Settings\decollik\Local Settings\Temporary Internet Fi1es\0LK3\VARIREQ.D0C -08-2006 WED 01 :00 PM Danny Griffin, com FAX N0, 508 362 1437 P. 02/02 .104/2016 01 :20 FAX I �: 2 002/002 s 4 C,4RmEN E,' SHA.Y (508�548-0796 Environmental Services,Inc. P.O.Box 627,least Falmouth,MA oa536 ,Authorization Agreem mt DATE; March 8,2006 Adross: 245 Old Craigville Road,Hya-Ixuls,MA Authorized By. Bleacaor Baquelod,Property Owner I Authorize Carmen E. ShayEnvironment al Services, Inc. to rl�,,pxesont me before the Town of Barnstable Board of Health for the Variance request relativ, to repair of the Title 'V Septic System at property known as 245 Old Craigville Road,Hyannis , M,y, Agreed and Accepted By:. 1� 7 3 125C Natno IZ�1 L• GnSs�. Aflto: �y i 1 CU v^^' ev C) Z W co rn f .Bk 20457 P043 079095 U...- 1 1-09-2005 & QUITCLAIM DEED We,ELEANOR BACQUELOD of Stoughton,Norfolk County,Massachusetts,and LORETTA REED of Chevy Chase,Montgomery County,Maryland for consideration paid and in full consideration of Two Hundred Seventeen Thousand Nine Hundred and 00/100($217,900.00)Dollars, Grant to RALPH M.CROSSEN and MARY V.CROSSEN,husband and wife as tenants by the entirety of 245 Old Craigville Rd.,Barnstable County,Massachusetts, With Quitclaim Covenants, The land with the buildings thereon known as and numbered 245 Old Craigville Road, Barnstable(West Hyannisport),Barnstable County,Massachusetts,and being LOT 12 on plan entitled"Plan of Lots at Craigville Park,Scale 1 inch=40 feet,April 5, 1926, Harold S.Crocker,Civil Engineer,Brockton and Hyannis,Mass.",which plan is duly recorded with Barnstable County Registry of Deeds in Plan Book 62,Page 145,bounded and described as follows: SOUTHERLY by Old Craigville Road,seventy-one and 25/100(71.25) WESTERLY by LOT 13 on the above-mentioned plan,one hundred (100)feet; NORTHERLY by a portion of LOT 11 as shown on said plan,sixteen and 04/100(16.04)feet;and EASTERLY by land now or formerly of Anita Chadwick as shown on said plan,one hundred seventeen and 25/100(117.25)feet. For title see deed recorded in Book 14001,Page 322. Property Address: 245 Old Craigville Rd.,West Hyannisport,MA 02601 Witness my hand and seal this day of October,2005. TTA REE Bk 20457 Pg 44 #79098 STATE OF MARYLAND Montgomery, ss. October do '2005 10 jD&JL— On this day of ,2005,before me,the undersigned Notary Public,personally appeared Loretta Reed, and proved to me through satisfactory evidence of identification,which was 4 be the person whose name is signed on the preceding or attached document,and acknowledged to me that he/she signed it voluntarily for its stated purpose. Notary Public 'f7 M Commi sion Expires: Witness my hand and seal this—&2cKJ day of�, 5..CNOTN7,'s, M VOLLIAMSON :i =, �j�Gc state of Mar0and Ccusio of Frederi 0,my Commisshn Bites Aug.34,2006 ELEANOR BACQUELO COMMONWEALTH OF MASSACHUSETTS f�D✓ Q Barnstable��,s��s. .Octube� D,2005 On this 4ay ofOA/,2005,before me,the undersigned No he,persona appeared Eleario'• 4�.:fr Bac d d roved to me through satisfacto evide of identification w ' ` 9 �p gh ry y R u to be the person whose is signed on th d' or ttache t.! and acknowledged to me that he/she signed it untarily for its sta purpos r� � r Y•o1 S'`4 j� �/ V� My Commission Expires: I MAT.M.Y^•z ',_.`,W�-4��,. 1 POW ��'frij5.;� ^°•'.^fit?'L.9�i::C"i12i:1•i'�'� �,`.... j MASSACHUSETTS STATE EXCISE TAX BARNSTABLE COUNTY REGISTRY OF DEEDS Dates 11-09-2005 D 08:49an Ct1f: 123 Doc*: .79098 Fee: $745.56 Cons: $217r900.00 BARNSTABLE COUNTY EXCISE TAX BARNSTABLE COUNTY REGISTRY OF DEEDS Date: 11-09-2005 D 08:49an Ctlr: 123 Doc:: 7909E Fee: $497.04 Cons: $217r900.00 BARNSTABLE REGISTRY OF D A TRUE COPY,ATTEST JOHN F.MEADE,REGISTER COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �� FAILED INSPECTION ; t-'ARCEL i l :OT TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 245 Old Craigville Road Hyannis, MA 02601 Owner's Name: Eleanor Bacquelod Owner's Address: 32 Rosewood Drive Stoughton, MA 02072 Date of Inspection: September 8, 2004 Name of Inspector: (Please Print) James M. Ford - a Company Name: James M. Ford C: Mailing Address: P.O. Box 49 OsterY#14 MA 02655-0049 �- Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the info ation reported below is true,accurate and complete as of the time of the inspection. The inspection was performed b ed on my co training and experience in the proper function and maintenance of on site sewage disposal systems. I am a Dd rn approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Ne s Further Evaluation by the Local Approving Authority ✓ F 1 Inspector's Signature: Date: September 13, 2004 The system inspector shall sub 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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 ' Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 245 Old CraiQville Road Hyannis, MA Owner: Eleanor Bacauelod Date of Inspection: September 8, 2004 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: + 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. 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 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. 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 245 Old Craigville Road Hyannis, MA Owner: Eleanor Bacquelod Date of Inspection: September 8, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 245 Old Craj yille Road Hyannis, MA Owner: Eleanor Bacquelod Date of Inspection: September 8, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 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. [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.] NOTE. SINGLE CESSPOOLS A UTOMATICALL Y FAIL IN THE TOWN OF BARNSTABLE. Yes (Yes/No)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 System: 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: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 245 Old Craizyille Road Hyannis, MA Owner: Eleanor Bacguelod Date of Inspection: September 8, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 245 Old Craigville Road Hyannis, MA Owner: Eleanor Bacquelod Date of Inspection: September 8. 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _______gpd Basis of design flow(seats/persons/sqft,etc.): 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: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Original system-date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION (continued) Property Address: 245 Old Crai-ville Road . Hyannis, MA Owner: Eleanor Bacquelod Date of Inspection: September 8, 2004 BUILDING SEWER(locate on site plan) Depth below grade: None Materials of construction: _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.): SEPTIC TANK: None (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: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: None (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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 Old Crai-aville Road Hyannis, MA Owner: Eleanor Bacquelod Date of Inspection: September 8, 2004 TIGHT or HOLDING TANK: None (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/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.): DISTRIBUTION BOX: None (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: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 Old Craigville Road Hyannis, MA ' Owner: Eleanor Bacguelod Date of Inspection: September 8, 2004 SOIL ABSORPTION SYSTEM(SAS): None (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: i 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.): CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 -single ' Depth-top of liquid to inlet invert: 6' Depth of solids layer: 12" Depth of scum layer: -- Dimensions of cesspool: 5'W x 7'T x 9'bottom to grade Materials of construction: Brick Indication of groundwater inflow(yes or no): None Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): The cesspool had 1'ofliauid on the bottom. The scum line was approximately 3'up from the bottom The cover was 20"below grade. Single cesspools automatically fail in the Town of Barnstable PRIVY: None (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.): 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 Old Cra42ville Road Hyannis, MA Owner: Eleanor 6acauelod Date of Inspection: September 8, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 4 I � a� 31 10 Page 1 I of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 Old Craigville Road Hyannis, MA Owner: Eleanor Bacquelod Date of Inspection: September 8, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation.- Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contour maps Checked with local excavators, installers=(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps the maps were showing approximately 25'+1-to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V-C- SECTION A -A 10' min. from °a; / ALL OUTLET PIPES FROM THE r •.;, Existing Foundation house to septic tank PROFILE VIEW OF LEACHING SYSTEM s i>BUTION B�SMALL BE 1r n c;'r' TOP OF FOUNDATION = ELEV. 100.00 (Assumed) Septic tank covers must be 7xrcover moat be tt in. of finished de within 6 in, of finished grade i - Not to Scale :�- Grade over Septic Tank -99.00 Grade over D-Box- 99.00 over SAS- 9t15o J-5'OUTLET . ° s' 2 J•qr f/ll'- f/2' wash"P.A.- }- / KNOCKOUTS V io 1 f/T ' w4aw cr u and St.. \' f v•�•L�to f ^I S 4•PVC-(CAPPED)RVSPEC110N PORT TO BE 7 5.5• f 12• INLET OUTLET ��` r _ 0.02 3 HOLE H-10 g- Ir ; / ST. BOX 3' Maximum Cover INSTALLED AND To BE WITFflN 6•KF GRADE ql,o AKin 10' NEW S=o.01 or Greater - ,� 2• rY�' bti0�tlCr\af�Rla IM �� EXIST. PIPE N O 1.500 GAL S- 0,01• I Top of SAS-Elev. 97.00 1S5• o LO 5• per foot 4• - SCH. 40 T ,, a+d 111 �` �naQe�ae I FROM EXIST. FOUIIDATION a, ^ SEPTIC TANK n f+� �.,•�d� .�,,' tq s PLAN SECTION CROSS-SECTION II o�s.e. Or n Effective Depth 24 s E,fCCLLtJC i n H-10 CONCRETE fIAL FouNOA o ; n cd rn _t SidewcLU - 0) • i l 0 6 in.of 3/4'-1 1/2• d 3 Un(ts E SYSTEM PROFILE ; a 3' 4 3' >' 3 HOLE H-10 DISTRIBUTION BOX Rd'• compacted stone ; o o 4 NOT TO SCALE I " . f - ^- ' 1'" udAri Not to Scale - c o n S0°" �'~ - 10' N 9' em RintlfitW V.J1LC ►e+7,02W-NA Tk c - Effective Vktth ; Effective Length GENERAL NOTES 8 tn.of 3/4'-1 1/2' o compacted stone S❑IL ABS❑RPTI❑N SYSTEM (SAS) NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE m 1. Contractor is responsible for Digsafe notification, Verification of Utilities INFILTRATOR MODEL 3050 (H-20 LOADING)/ SUMNER & DUNBAR and protection of all underground utilities and pipes. Bottom of Test Hole 1 Dev.=87.50 (OR EQUIVALENT) 2. The septic tank and distribution box shall be set Groun De dwater served - NONE OBSERVED level on 6" of 3/4"-1 1/2" stone. NOTE: OVERALL HEIGHT OF INFILTRATOR IS 30' /EFFECTIVE HEIGHT IS 24' 3. Backfill should be clean sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation PERCOLATION TEST by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance Date of Percolation Test: FEBRUARY 21, 2006 Kitchen Bath with Title V of the Massachusetts state code, the approved plan Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations. Results Witnessed By. DONALD DESMARAIS ( BARNSTABLE B.O.H.) 6. If, during installation the contractor encounters any EXCAVATOR: Shay Env. Svcs. soil conditions or site conditions that are different Percolation Rate: Less Than 2 MPI ® 22" Dining Bed Dii from those shown on the soil log or in our design room Porch installation must halt & immediate notification be Test Hole Bed made to Carmen E. Shay - Environmental Services, Inc. No. 1 7. No vehicle or heavy machinery shall drive over the DEPTH SOILS ELEV. room Living septic system unless noted as H-20 septic components. 0 98.50 Bed room 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. Sandy room 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Loam 10. All solid piping, tees & fittings shall be 4" diameter 10 YR 3/2 0"-8. A, 97.831 3 BE HOUSE FLOOR SCHEMATIC Schedule 40 NSF PVC pipes with water tight joints. 11. Municipal Water is Connected to ALL OF The Residence and Abutting Loamy sand Properties Within 150 Feet. 10 YR s/6 e'- 22" Bw ess5 THE PROPERTY LINES ARE APPROXIMATE AND M� COMPILED FROM THE SURVEY PLAN GENERATED BY BEARSE & KELLOG OF HYANNIS, MA Sand ENTITLED "SUBDMSION PLAN OF CRAIGVILLE BEACH ESTATES, HYANNIS, MA, 2.5 Y 7/4 22'- 132 C, 97.50 � �O �� DATED DEC. 14, 1964, PLAN BOOK 118, PAGE 133 p AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN to �� IT SHOULD BE USED FOR NO PURPOSE OTHER THAN CB D.H. C ,'� THE SEPTIC SYSTEM INSTALLATION. FNDmooh EXISTING CESSPOOL TO BE PUMPED OUT& REMOVED. le --- �.-..-t Failed NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE EXlS1 LEACH SRENC �` 1• r Y=t`; Cesspool FROM THE EXISTING CESSPOOL TO BE DISPOSED OF.AS PER-BOARD OF HEALTH SPECfFICATIONS. _ Perc #1 0 .- THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY Depth to Perc: 36" to 54" Perc Rate= 2 MPI o SHED �� PROJECT BENCH MARK ASSESSORS MAP 247 PARCEL 111 Groundwater Not Observed ,, _ TOP OF FOUNDATION �9 No Observed ESHWT �� NEW 1500 AL.; SEPTIC TAN ELEV. = 100.00 (Assumed) LEGEND ADJUSTED H2O Elev. = None TEST HOLE #1 . 1 - 7.5' � ELEV.= 98.50 I D-Box --- l 104X1 DENOTES PROPOSED 3-24.OIAM. ACCESS MANHOLES ' • \ 40 POLYETHYLENE LINER FROM ELEV. SPOT GRADE L 10' -6•- - `\ 96.50 to 92.25 AND TO EXTEND DENOTES EXISTING r------t i \\ TWO SIDES AS SHOWN X 104.46 SPOT GRADE LOT 11 I m # #245 �� PL PROPERTY LINE INLET -(XI n ET I I I EXISTING PROPOSED CONTOUR I L j I THE ACCESS COVERS FOR THE SEPTIC TANK, Q Q I I C 3 BEDROOM t; y �- DISTRIBUTION BOX AND LEACHING COMPONENT I I 1 HOUSE - - _ _ _ -97 EXISTING CONTOUR 4,•.r:-. _. = SHALL BE RAISED TO WITHIN 6" OF ` .. e't '.^S..'T„-�-:-;.�..,�,;:��•- FINISHED GRADE. M INSTALL TUF-TITS GAS BAFFLES OR EQUALS DEEP TEST HOLE & STEEL REINFORCED PRECAST CONCRETE I I I o PLAN VIEW ON ALL OUTLET TEE ENDS I Kn i t� 4 PERCOLATION TEST LOCATION 3-24"REMOVABLE COVERS 1r i co LOT #12 6 FOOT STOCKADE FENCE :•:_ .,.. ..:..., 4• 3.500 Square Feet /- u e F 3•min.ctearanae ,r I I -_____-- REV.: 4 4 06 - Corrected Bottom SAS ELEV. Added SurveyStam : :.. INLET B" mfn.T-�2•min. inlet to autiet e. `t I I 71.25' \- / / / P ' INLE L old bvel - OUTLET -ly- ' 1a•mh 1I• UUU t 5' -r L :"s -r I PLOT PLAN I ��_________________________________________ 98 E$ 4•-D•min t\ c v o.ers. ? :• liquid depth ----------------- �- - - 1 i� - -------------- /fir • --------- ------------------ O F PROPOSED P O S E D SYSTEM UPGRADE G R OLD CR-lIG VILLE P SEPTIC SY M DE •10•-0- s-8• PREPARED FOR CROSS SECTION END-SECTION (40 FOOT RIGHT OF WAY) MS . ELEANOR BACQUELOD I TYPICAL (H-10 LOADING) 1500 GALLON SEPTIC TANK OF AT #245 OLD CRAIGVILLE ROAD NOT TO SCALE �� GILSERT �' May Substitute with 1500 gallon H-10 Polyethylene Tank-George O'Brien Co. T. HYAN N I S) MA No co Design Calculations VARIANCES REQUESTED: Og ;' �N o ,q P PARED BY: Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) SUP Garbage Grinder: No p / 1. Request a Variance reducing the setback for an SAS to a �o?BAR E c� �R1Il �N E. AJ HL1 Y Leaching Capacity Proposed: 330 Gal. Day (Minimum Min. Per Title V) Property Line From 10 Feet to 5' and 6.2'. Septic Tank : - 2 x 330 Gal./Day = 660 USE NEW 1,500 GAL. Septic Tank. v E. ai NVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch 2. Request a Variance reducing the setback for a Septic Tank to a 0 20 40 50 O. 1 Bottom Area: 0.74 gal/sq. ft. x 290 sq. ft. = 214.6 gallons Property Line From 10 Feet to 7'. P.O. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 156 sq. ft. = 115.44 gallons ST,rR`° EAST FALMOUTH, MA 02536 Providing: = 330.04 gallons 3. Request a Variance reducing the setback for an SAS to a Foundation from 20 Feet to 14'. A 40 Mil rubber Liner has been proposed. SgNITAR`P� TEL/FAX : 508-539-7966 Use: (3) 3050 H-20 INFILTRATOR CHAMBERS, HAVING A 2' EFFECTIVE DEPTH, (4' W x 7' L) TO BE USED WITH 3. OF WASHED STONE ON THE SIDES AND SCALE: 1"=20' SCALE: 1`90' DRAWN BY: CES DATE: MARCH 7, 2006 ��.✓i5-e� 4' OF WASHED STONE ON THE ENDS. �-� PROJECT#SD872 FILENAME: SD872PP.DWG SHEET 1 OF 1