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HomeMy WebLinkAbout0109 OLD STAGE ROAD - Health IV 7 Old Stage Road Centerville A= i 0 a I SIII�__ aECYUEp No. 152 LOR YAiT1Yi�i.MY y i • ^tea/ / � �' No. V"+t Vr �(Y 6 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for �Diopooar bpgtem Construction Permit Application for a Permit to Construct( . j Repair(Q( )Upgrade( )Abandon( ) Complete System El Individual Components Location Address or Lot No. i0°q 0 I J S -2 O—A Owner's Name,Address and Tel.No. Assessor's Map/Parcel ^ �. /51 �r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W CA10' S�k��t2�o•�d7d4c� S'�r zo/O EASTS'Alid F33 217-7 Type of Building: Dwelling No.of Bedrooms�— Lot Size�sq.ft. Garbage Grinder( ) Other 71�pe of Building S f �L //t No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow gallons per day. Calculated daily flow -6-6d r0 gallons. Plan Date -3 0 Number of sheets / Revision Date /UW4! Title Size of Septic Tank 1 Type of S.A.S.30.5-D Description of Soil P14-el 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 not to place the system in operation until a Certifi- cate of Compliance has been iss this B lth. Signe Date Application Approved by Date Application Disapproved for the following reasons Permit No. a0c) [o — /6© Date Issued 1 rc)— 5 a � i i �•:. No. / Fee a Y 1/ THE COMMONWEALTH OF MASSACHUSETTS t',,. Entered in computer: /O Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01ppYication for Mi$poiaf 6potem Couotruction Permit Application for a Permit to Construct( . )Repair C )Upgrade( )Abandon( ) ii Complete System ❑Individual Components Location Address or Lot No. d R 0 1 d E4-A c,�,_ 6LJ Owner's Name,Address and Tel.No. Assessor's Map/Parcel Can rJ _-Vew e(I Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. Bpu5�;.e Q SAnff V BC eA/U Type of Building: Dwelling No.of Bedrooms Lot Size 7/Ac sq.ft. Garbage Grinder( ) Other 'Type of Building `ti lC /fir No.of Persons Showers( . ) Cafeteria( ) Other Fixtures Design Flow . b gallons per day. Calculated daily flow gallons. Plan Date _3 o Number of sheets / —Revision Date /UaV/- Title Size of Septic Tank S6Y?� Type of S.A.S.3aSv Description of Soil See to Nature of Repairs or Alterations(Answer when applicable) ,ee�D�� '(� ��r �e�✓ �lSS��/S' Date-last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until.a Certifi- cate of Compliance has been issued-by this B .-Of alth. rr Sign Date Application Approved by Date w Application Disapproved for the following reasons Permit No. 0© (C - O Date Issued L �' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired )Upgraded( ) Abandoned( )by �e u5i2 s��i�dt� SC?ro r c. eivC at a q ��d r�i�s p C�v� �u Ile— has been construct d in ac ordance with the prov ions of Title 5 and the for Disposal System Construction Permit No. dated y � 'a �P Installer dyS�/� �d Designer /06 Cry The issuance of this permit shall not b d/onstru as a guarantee that the sys em-will f n io a designed. Date I Q Inspector 1 No. —/�Q -------------------- -----Fee 0 U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS �Disspoq;al *pztem Con5tructiou permit Permission is hereby granted to Construct( )Repair, Upgrade� )Abandon( ) System located at 4 0 0/ ©/c/ 5S7.�he "C C P,-7 A�l�L�� 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 conditions. Provided: Construction 7ust be completed within three years of the date of h si pe .`it. �f )Date:_ / b Approved bye.._ �_ Town of Barnstable Regulatory Services �. Thomas F. Geiler,Director • swxrasrnst,E, W039.ASS. �0� Public Health Division rFD1AP�A. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: ��.0 b� - -T Designer: Installer: ouSJ� Address: 4� 5 7 � � I C Address: RD e y9-2 On `/'�d 'o bu �e �� �7� ✓�was issued a permit to install a (date) (installer) " septic system at /o 9' old SA'C/wc(e, A based on a design drawn by (address) , Oz'e zky dated (designer) V111"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 of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10': lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local R `'^ns. Plan revision or certified as-buil,�t by designer to follow., Z k OFA4 --41 A�1/// 5, 5 0. Gi (Inst er ignafure) P TS 4 sgNtrAIR\P�' (Des' er's Signature) (Affix ..e) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISIuN. CERTIFICATE OF COMPLIANCE! WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, '✓ik)112 r2, MObl)� ,hereby certify that the engineered plan signed by me dated 1 3 Qlo,concerning the property located at 09 I meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering)and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) �o B) G.W.Elevation ZD - +adjustment for high G.W. DIFFERENCE BETWEEN A and B _ 2?2 , 1 SIGNED . DATE: O ZO O NOTICE Based upon the above information,-a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. I 18 gASepfic\percexemp.doc f Af e� 0 2• p JK E)- LUCUS MAP poOT1 _ -i� e. 33 MAP ZOO.,PcL- 36 9 RfcStDEr#LtkZl]It�1l�'� � Z � � CP is • A Q � 9 3 1 9T s N. It ► zz - 4,z s.P. a►.ir, z ,�• �Oq s ✓ $C�J° .�//vents �, - � , �." _ NIL. M pw ' N , O a° S v.y.. W � 0 � s r•. .\5 �p 6 d � � O A� B�ARNSTAB�E p'LAtVWt1a1� go�A2o WE . .CON'TRd_ LAw' +x7[ pj QI-xvrZ, 'fl 'Tr sue, Tp too RND. f v Lines i�.c.c parag4�ll..ot haws ono epee uicauu�i�' rrurn 1 f7/t, V, Ft}e[.T7K (rinf-itch (%70 The plans and specifications for every on-site system shall be prepared as follows: (1) Every system shall be designed by a Massachusetts Registered.Professional Engineer or a Massachusetts Registered Sanitarian provided that such Sanitarian shall not design a system designed to discharge more than 2,000 gallons per day pursuant to 310 CMR 15.203. Any other agent of the owner may prepare plans for the repair of a system designed to I discharge not more than than 2,000 gallons per day pursuant to 310 CMR 15.203 provided ` they are reviewed by a Massachusetts Registered Sanitarian and approved by the approving authority; / (2) Every plan submitted for approval must be dated and bear the;stamp and signature of l� the designer, (3) Every plan for a new system or plan for the upgrade of expansion of an existing system which requires a variance to a property line setback distance,"inust.alw reference a plan which bears the stamp and signature of a Massachdie-tts. Licensed Land Surveyor in accordance with M.G.L.c. 112, $ g 1 D; (4) Every plan for a System shall be of suitable scale(one inch=40 feet or fewer for plot plans and one inch =20 feet or fewer for details of system components) and shall include depiction of: (a) the legal boundaries of the facility to be served: ,N the holder and location of any easements appurtenant to or which could impact the . system; / (c) the location of the all dwelling(s)or building(s)existing and proposed on the facility . and identifrc8tion of those to be served by the system: / -(d) -•the•'iacation of existing or proposed impervious areas, including driveways and parking areas: (e) location and dimensions of the system(including reserve area); (0 system design calculations,including design daily sewage flow,septic tank capacity / (required and provided); soil absorption system capacity (requited and provided); and whether system is designed for garbage grinder; (g) North arrow and existing and proposed contours; (h) • location and log of deep observadon hole tests including the date of test,existing grade elevations marked on each oust, and the natttfs of the representative of the approving authority and soil evaluator; 0) location and results of percolation tests including the pate of test and the names of the representative of the approving authority and soil evaluator; name and certification number of the Soil Evaluator of record; (k) location of every water supply,public and private, 1. within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply wells, 2. within 250 feet of the proposed system location in the case;of tubular public water supply wells,and 3. within ISO feet of the proposed system location in the case of private water supply wells: location of any surface waters of the Commonwealth, rivers, bordering vegetated wetlands, salt marshes, inland or coastal banns, regulatory floodway, velocity zone, surface water supplies.tributaries to surface water supplies,certified vernal pook private water supplies or suction lines, gravel packed or tabular public water supply wells. subsurface drains,leaching catch basins.or dry wells; and the location of any nitrogen ✓ sensitive area ideadfied in 310 CMR 15.215 within which portions of the proposed ttro located. m) location of water]roes and other subsurface utilities on the facility, n) observed and adjusted ground-water elevation in the vicinity of the system, o a complete profile of the system: , � (p) a note on the plan listing all variances to the provisions of 310 CMR 15.000 sought in conjuncdon with the plan; (q) the location and elevation of one benchmark within 50 to.75 feet-of the facility which is not sbbjcct to dislocation or loss during construction on the far .ility, (r) when dosing is proposed.=mptete design and specification of the dosing system proposed including but not limited to dosing chamber capacity(required and provided), pump curves and specifications,number of dosing cycles and depth per cycle; N,^ (s) when a Recirculating Sand Filter or equivalent alternative technology is required or roposed,a complete plan and specification for the system,including a hydraulic profile; t a locus plan,to show the location of the facility including the nearest existing street; (u) the street number and lot number,if any,of the facility; and TOWN OF BARNSTABLE �► LOCATION 9 Old 5-ha 9 0, SEWAGE #,900(- _/Coo V}I L�.GE10#1 LAA Ile ASSESSOR'S MAP & LOT. 0 S ;r INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY 15-0 0 LEACHING FACILITY: (type) C,- k . 1 o S0 5 (size) 11`� 7,1a..I " NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: '4-la a 0 b COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N P Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) NO Ng Feet .. Edge of Wetland and Leaching Facility (If any wetlands exist within 300 fee,t7@ leachiy /a/E��ility) Feet Furnished by �cl r d i oo ' nor ' q TOWN OF BARNSTABLE LOCATION D 1 d�� S�/ E �� SEWAGE# c�^ VILLAGE C £*7 ASSESSOR'S MAP&LOT 5�'S NAME&PHONE NO. /9 SEPTIC TANK CAPACITY S E l r/C- /ti S f e-C�v N LEACHING FACILITY:(type) (size) NO.OF BEDROOMS .+ BUILDER OR OWNER D £ £f iWINWDATE: f 3' S- C CE DATE: Separation Distance Between the: Maximum Adjusted Groundwat � d Bottom of Leaching Facility Feet Private Water Supply well and Leching 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 O POR`)q r O �' fRUNJ� i Town of Barnstable CF THE tp� P� do Regulatory Services + BARNSfABLE, Thomas F. Geiler, Director 0 3 � Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 12, 2006 Mr Morgan Dewey 18 Fox Hollow Road Worcester, MA 01605 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 109 Old Stage Road, Centerville,was inspected on, December 9, 2005, by James D. Sears. a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system had"FAILED"under guidelines of 1995 STITLE 5 (310 CMR 15.00) DUE TO THE FOLLOWING: Single cesspool—automatic failure in Town of Barnstable You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE H ALTH DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health t SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by rioted Nacf C. DatZ De,livry ■ Attach this card to the back of the mailpiece, /_..4� / or on the front if space permits. / s D. Is delivery a Jiff '* from i 1 Yes 1. Article Addressed to: �' If YES,ente ¢®li a addj�ss bel w ❑No V CO �Lf�•oMor an �Ite?W e y c� PDX Gh oq� MDi s,9 .. eS 4 q/( y ,o 3. Service Type ❑Certified Mail ❑Express Mail ❑ Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service label) J iyt PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 I �rnu►aa�, UNITED STATES POS7AJL*WVWAL MA.0. 5ostage %&Fees ! PM 4 goo I • Sender: Please print your name, address, and ZIP+4 in this box• I I I F IEAI,TH DIVISION r BARNSTABLE STREET IS, MASSACHUSETTS 02.601 I i.��!1!'.lifll�lf'.1�!?fff!�1f1!flilfflF�fllf!tlfi�f!!)iff!flfifi .o 1 CERTIFIED MAIL RECEIPT --n Co i (domestic,Mail Only;No Insurance Coverage Provided) rn =, O FICIAL USE7 Postage $ O Certified Fee `S • Postm r Return Receipt Fee LH(Endorsement Required) • 'y0C3 Restricted Delivery Fee O (Endorsement Required) O '9 Total Postage&Fees $ 0 Sent To --- -rnQrsQ y---------------- Street.Apt.No.; �r or PO Box No.�Y Ox u r, �O ------------------------------- City,State ZIP+4 - worCeStrh h?p w(p s Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece o A signature upon delivery o'A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail or Priority Mail:' o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of `delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 381,1)to the article and add applicable postage to cover the fee.Endorse.rfl'ailpiepe,'Return Receipt Requested".To receive a fee waiver for, a duplicate refurn receipt,a USPS postmark on your Certified Mail receipt is required. o For an additional fee,`delivery•may. be restricted to the addressee or addressee's authorized agent.Advise-the clerk or mark the mailpiece with the endorsement t'Restricted Delivery". F: n If a postmark'on the Certified Mail.receipt is desired„please present the arti cle at the post office for postmarking. If,a postmark on the Ceitified Mail; receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it When making an inquiry. PS Form 3800,April 2002 Reverse) i.- 102595-02-M-1133 COMMONWEALTH OF MASSA01USETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS M o DEPARTMENT OF ENVIRONMENTAL PROTECTION a� CIGgM cVOy 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 208—PARC 159 Property Address: 109 4lLD STAGE ROAD J �"i�c�✓� CENTERVILLE,MA 02632 Owner's Name: DEWEY,MORGAN Owner's Address: 18 FOX HOLLOW ROAD WO'KESTER,MA 01605 Date of Inspection DECEMBER 9,2005 Name of Inspector:(please print` TAMES D.SEARS Company Name: A&.B Canco Mailing Address: 350 is-Iain Street Wes' Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally i i,pected the sewage disposal system at this address and that the information reported below is true,accurate and com, ,-�as of the time of the inspection. The inspection was perfonned based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes Conditionally Passes Needs Further Evaluation by the Loca;A pproving Authority �J Fails Inspector's Signature: Date: 12-9-05 The system inspector shall sub I it a copy of this inspection report to the Approvi�i r Authority(Board of Health or DEP)within 30,days of comple ing this inspection. If the system is a shared syster i or has a design flow of 10,000 gpd or greater,the inspector and the ,stem owner shall submit the report to the approl,late regional office of the DEP. The original should be sent to th:;system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments 'This report only describc5 conditions at the time of inspection and under She conditions of use at that time. This inspection does not addr,+;.s how the system will perform in the future under the same or different conditions of use. i Title 5 Inspection Form 6/1 }/,;000 1 r t Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 109 OLD STAGE ROAD CENTERVILLE_MA 02632 Owner: DEX7,TY,MORGAN Date of Inspection: DECEMBER 9,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/A I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 of nt 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 tank failure is inmlinent. System will pass inspection if the existing tank is replaced with 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 t]uan 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: Title 5 Inspection Form 6/15/2000 2 r{+. r Page 3 of 11. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUI D) Property Address: 109 OLD STAGE ROAD CENTERVILLE,MA 02632 Owner: DEWEY,MORGAN Date of Inspection: DECEMBER 9, 2005 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 310 CNM 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 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: � I 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 lone 1 of 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: Title 5 Inspection For-in 6/15/2 DUO 3 f Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1.09 OLD STAGE ROAD CENTERVILLE,MA 02632 Owner: DEWEY,MORGAN Date of Inspection: DECEMBER 9, 2005 D. System Failure Criteria applicable to all systems: ./ You must indicate"yes" or"no"to each of the following for all inspections: NOTE: SEE ATTACHED BARN.REG.—SINGLE CESSPOOLS. 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 N/A 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%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 well �— Any portion of a cesspool or privy is within 50 feet of a private water supply well —T 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 or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CNIR 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 service 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 loge 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'ry significant threat,or answered "yes"in Section D above the large system is 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. Page 5 of 11 Title 5 Inspection Form 6/15 2000 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 109 OLD STAGE ROAD CENTERVILLE,MA 02632 Owner: DEWEY,MORGAN Date of Inspection: DECEMBER 9. 2005 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 Bored 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 Vol Lines of water been introduced to the system recently or as part of tlus inspection? N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facifita or dwelling inspected for signs of sewage back tip? ✓ Was the site inspected for signs of break out? ✓ Were all system components located on site? ✓ Were the manholes uncovered,opened,and the interior inspected for the condition of the tees,material of constriction,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)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the Held(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 109 OLD STAGE ROAD CENTERVILLE,MA 02632 Owner: DEWEY,MORGAN Date of Inspection: DECEMBER 9, 2005 FLOW CONDITIONS RESIDENTIAL.( Number of Bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 550 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes,or no): YES Seasonal use(yes or no): NO 1 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRJAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,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: 2005 _ 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—NOTE:TWO(2)SEPARATE POOL'S. 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: N/A Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 OLD STAGE ROAD CENTERVILLE,MA 02632 Owner: DEWEY_MORGAN Date of Inspection: DECEMBER 9, 2005 BUILDING SEWER(locate on site plan): ✓ Depth below grade: LEFT' l'—RIGHT 2'. Materials of construction: Cast iron _ 40 PVC ✓ other(explain) CLAY PIPE Distance from private water supply well or suction line: Continents(on condition of joints;venting,evidence of leakage;etc.): SEPTIC TANK(locate onsite plan): N/A 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 the 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 deternuned: Cotmnents(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(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to to( of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping reconnntendations,inlet and outlet tee or baffle condition,structural integrity;liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 �i f f - Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 OLD STAGE ROAD CENTERVILLE,MA 02632 Owner: DEWEY,MORGAN Date of Inspection: DECEMBER 9,2005 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 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: 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): Conunents(note condition of pump chamber,condition of pumps mid appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 I , ....................................................... ........................................................ Page 9 of l ITEE I ��E. .....................::...:.....:.:............. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 OLD STAGE ROAD CENTERVILLE,MA 02632 _ Owner: DEWEY,MORGAN Date of Inspection: DECEMBER 9, 2005 SOIL ABSORPTION SYSTEM(SAS): N/A (locate on site plan;excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Continents(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) NOTE:SYSTEM IS FOR(2)BATH'S,WASHER,SHOWER. Depth—top of liquid to inlet invert: 4" Depth of solids layer: 4" _ Depth of scum layer: V _ Dimensions of cesspool: 6' Materials of construction: BLOCK&BRICK Indication of ground�vater inflow(yes or no): NO Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): SINGLE POOL,MAIN POOL IZIGHT SIDE,TREE LINES IN—TWO LINES TIED INTO HOUSE,STEEL COVER AT GRADE.ONE LINE 2'BELOW GRADE,ONE LINE AT 3'—6". WATER AT 4"BELOW LOW'f_,R LINE,NO IN TEE'S—NO OUTLET LINES. PRIVY: (locate on site plan) Materials of Construction: _ Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,cond�.tion of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of 11 S. E F >-8 ��! OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION(continued) Property Address: 109 OLD STAGE ROAD CENTERVILLE,MA 02632 Owner: DEWEY,MORGAN Date of Inspection: DECEMBER 9, 2005 SOIL ABSORPTION SYSTEM(SAS): N/A (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) CESSPOOLS: ✓ (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: _ (1) NOTE: SYSTEM IS FOR KITCHEN, UP&DOWN HALL.. Depth—top of liquid to inlet invert: 5' Depth of solids layer: 3" Depth of scum layer: :V'Dimensions of cesspool: 7_ Materials of construction: BLOCK Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): SINGLE POOL,MAIN POOL LEFT SIDE,ONE LINE IN 5'—NO TEE. CEMENT COVER AT GRADE,WATER BELOW INLET—NO OUTLET LINES. 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.) Title 5 Inspection Form 6/15i2000 2 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 OLD STAGE ROAD CENTERVILLE.MA 02632 Owner: DENVEY MORGAN Date of Inspection: DECEMBER 9. 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benclunarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Pe R C/4 as . 35 , ` o rR0 NT Title 5 Inspection Form 6/15/2000 10 Page I I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 OLD STAGE ROAD CENTERVILLE, MA i02632 Owner: DEWEY.MORGAN Date of Inspection: DECEMBER 9. 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 20+ 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: �— Observation site(abutting propertv/observation hole within 150 feet of SAS) Checked Aith 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: AREA HIGH—NO GROUND WATER PROBLEM. t �ooL Title 5 Inspection Form 6/1:;2000 11 h ASSESSORS MAP: 2 - • ASSE - HO• E T T S E LOGSLL_ �- PARCEL: NOTES: a a SOIL EVAt ATOt: 1 FLOOD ZONE: a a WI TNESs Y 1 REFERENCE: L7 DATE: 1 The installation shall comply with Title V and Town of Barnstable Board of 6 Health Regulations. 4 OF '�Gf t.�lL7s' X7L PERCOLATION RATE. .G. t [i, , 2) The installer shall verify the location of utilities, sewer inverts and septic � _ - components pnor to installation and setting base elevations. 1 .,yet t-3` 06 J� ,� TH t TH Z 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8 per foot. The first k ► two feet out of the dbox to the leaching. _ t y � Z 4 ,This plan is not to be utilized for property brie determination nor any other �, ) P p PAY tb ID. Purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. � 6 `Parkin shall not be constructed over H10 septic components. LOCATION MAP Cy ,t,5� w� '✓" The property is bounded property corners and propertylines. T) P PAY y P Ply . 8 The property owner shall review design considerations to approve of total ► ) _. D, .�o -: design flow and number of bedrooms to be considered for design. 'Receipt of - payment for the plan and installation based on the plan shall be deemed . _ 1,1 f > _ � ' �� approval of the design flow by the owner. 9 The existin cesspool(s)l(s) shall be pumped and filled with material per Title V ) g P� P P f1 abandonment procedures. Those within the proposed SAS shall be removed 61�l along with contaminated soil and replaced with clean washed sand per Title V specs. P� 10 System components to be 10 feet from water line. Sewer lines crossingthe water line shall be sleeved with 6 inch SCH 40 PVC with ends outed_ SEPTIC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the .. owner to ensure such FLOW ES IMATE: 1 1C 1 � BEDF,OOMS AT GAL/DAY/BEDROOM 0 GALlDAY .: ---- =y S;EPT I C l"Afl�` t 100 GA1,7DAY x 2 DAYS GAL x USEi, GALLON SEPT I C. TANK t q: SOIL AB30R�SYSTEM HZ A V1,6 �)'Jq�tW4Mat7 30 .0 1 3Tbqt 64 _r S, DE -t / a 7— ,,« k BOT OM AREA: 410,1� 4f 1 I tf Mq cn Ho.1066 t 1JsTe�� _ �. SEPTSEPTI G _ SYSTEM SECTION -yam/.{..//.j�/�J : { t. SL D.BOX *1 I. -V GAL - I, ADo r TOO OLA&I : SEPTIC TANK, / _. I(F jr b000, CMull- 1 t< P AN 2 t SITE AND SEWAGE �. 1 . r Q 1LOCATION . b1-• ' aIF , . yQt ice. 1 _ PREPARED FOR < . , SCALE DAY I D B . MASON >R DATE DBC ENVIRONMENTAL DESIGNS EAST SANDWICH • M A 74 DATE HEALTH AGENT (508) 833 . 2177 - f. .. ,Y::- _. ,- ^,�. -,,. ,>. -L ._ . .✓e ax-.._. _ aa. _ -, .., .. .,r:'-. x .. ,. "u _...,, ,. e.w _.,..,. a..: t ,.. .. ... < ,, , _✓, ..,dM1x<... ... .. _.__ ...s .. .. -.:, V .,...:.,., ,. .,,., ,_.:.... .,,... .:. , ... 4 ::.',. a ..s.>