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HomeMy WebLinkAbout0773 OLD STAGE ROAD - Health 773 Old Stage Road Centerville A= 191-168 KM EAD No.Z-1UWR UPC IM" smssd m • Hub In UlA 4 ' ssu��>smuau� � SFI �� . �t TOWN OF BARNSTABLE LOCATION -71 Z5 Qt_�S,—,fir AZT SEWAGE# _-�6ld6- 465 ILLAGE �FN�.� v c I IA ASSESSOR'S MAP&PARCEL tq 1 - 1,6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 6 i n(11(4 000 .41-i0 LEACHING FACILITY.(type) �` ' (size) 1 NO.OF BEDROOMS OWNER PERMIT DATE: /11-14—(A, COMPLIANCE DATE: 2 Gj 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 77 De r a. '3 7 :�f -773 olds+Ieo TOWN OF B STABLE •LOCATIOr1 o1c�,5� h j p . P1 S/ .VILLAGE� rew� AS SSOR'S &PARCEL NAME&PHONE NO. S TANK CAPACITY Qr�LEACHING FACILITY:(type) 'T (size) CDCa& NO.OF BEAROODdS OWNER ®-so PERMIT DATE: DATE 1I, t 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 an ands exist within 300 feet of leaching facility) Feet FURNISHED BY i ti 4 \ ♦ '\ 4 \ \ \ ♦�4�♦!\l\ ' ! f f 1 1 J J ! •L1 y!�f 1 1 J 1 / 1 • f f f- 1 f / • r 1 / 1 f / • f / J • r • f • r ', 4 k \ 4 4 4 \ \ 4 \ \ t \ \ 4 ♦ t ♦ \ ♦ ` f / f ? f J f r f f f f f f J f J f f • f ! ? ? ! • f f J J r F f f r 1 " r r r • • ! / r • • 22 f f f f f f f f J f 28 t \ \ \ \ \ t \ t b Back Yard 44 17 .. w s �� No. CA016 Fee /00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppliLation for MispoSal *pstrm Construction permit Application for a Permit to Construct( ) RepairX Upoade( ) "Abandon( ) ❑Complete System [�Individual Components Location Address or Lot No. t old S OO�wn"er._',sName,Address,and Tel.No. �5 09-6�70-W2DL �s.ccxc�0 CL4,f��oSD Le°7 �iold� Sf"' Assessor's Map/Parcel/g/11a Installer's Name,/A�ddress,and ��/Te�l.No. )p�_S/�8_ �9�� esigner' Name,Address,and Tel.No. b�Z'-34 a ` , D4010 C-"0n64fC4r'On irl� GYeY)� g � 4.34 rat ft Sf- s. W p Type of Bui mg: Dwelling No.of Bedrooms 3 Lot Size 16, 344 — sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 3.99 gpd Plan Date r76ADL,, 'n 070/& Number of sheets / / �RYevis/ion Dr/ate Title 7 5 IGt//in � 913 Old Si6ge /� /1�)G� (1,�7Y2f f� Size of Septic Tank i S'►7� Type of S.A.S. /0?1 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 Co not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date // Application Approved by Date Application Disapproved by Date for the following reasons Permit No. f ��� Date Issued A ' ► 9 P"�/ Fee ��✓ "'No. (Q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Di8tlo!a; a Y 6psiem Construction Permit 1 ✓[� ` 1 Application for a Permit to Construct( )'� RepairAly`Upg 0,dti ❑Complete System [/Individual Components Location Address or Lot No. I?/'�3 V�� S� 2 f'�C� • Owner's Name,Address,and Tel.No. Y US•SDI rJ- '2ya; �vLuxcEd CG{('GQOSO !.e r1 ,C.��-f-r1 Sf'• Assessor's Map/Parcel H/h68 Cf/7 f-ul E— rrn�s I/4 Gaya/ Installer's Name,Address,and Tel.No..�`-od-V,)S- esigner's Name,Address,and Tel.No. -rl- fiX'�I IICi' l ,— �93c t n St dv�}o(Uc4i r'��t r,lzcY?�lc/A�' � u Type of Building: Dwelling No.of Bedrooms Lot Size 15 34/ sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( )" Other Fixtures Design Flow(min.required) .330 gpd Design flow provided 39 gpd Plan Date0c A o27, av/& Number of sheets / Revision Date Title T,r& a1 ! lk n 4 213 Old 5)66e 1&d 444a,Ak � n Size of Septic Tank. 5 4' , / Type of S.A.S. lo?•S3 X Description of Soil 5W 4a�,,A)P,� J ' I Nature of Repairs or Alterations(Answer when applicable) Date last inspected: (- Agreement: - The undersigned agrees to ensure the construction and maintenance of the afore describe'd-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code an not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. r / Signed Date /h 9/ f(„ Application Approved by Date Application Disapproved by Date for the following reasons ! Permit No. S, (a Date Issued I �i -------------------------------------- - ---------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS eertifirate of Compliance THIS IS TO CERTIFY__,that the On-site Sewage Disposal system Constructed( ) Repaired(AK) Upgraded( ) `Abandoned( )by i�f �l�(.L ��rn<,�'ri is 1`(C"'bi 1Y1 c-- at f / /rE° has been constructed in accordance with the provisions of Ti le 5 and the for Disposal System Construction Permit No 5�-elt- "14 3 dated Installer'30f tz>J� \�z}2S C��Uf'�Ti'rL Designer to 0/.e ae ���U19PA #bedrooms Approved design flow n-t/Ci A gpd The issuance of this pe it shall not be construed as a guarantee that the system will ction a�esigned. r Date '� 6 Inspector �n/ ✓ 1 ---- 3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *Vstrm Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) ii Abandon r ( ) System located at 77 ��� �V_ �Ro� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following,local provisions or special conditions. Provided:Construction must be/com/pleted within three years of"the date of this permit. Date I I I`7 /I Approved by Town of Barnstable �tHE ti Regulatory Services o� Thomas F. Geiler,Director 'AM MAMg Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: A 6 j 6 Sewage Permit# o20/6 " Assessor's Map\Parcel IflZ6� Designer: 0 WtA_ � r AU� Installer: 160��/�tl 1 -olwtmch i-A--- Address: ��! ' Address: On "11� 14zl , S S�' •was issued a permit to install a (date) (installer) septic system at 7 7 JvC e based on a design drawn by (ad ss) At-.4 �- d� J, �1-1 dated /0 (d goer V I certifythat the septic stem referenced above was installed substantially according to p Y 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 syste but in accordance with State&Local Regulations. Plan revision or certified a - designer to follow. yL'�N�9 (Installer's Signature) O.ALA "t 46502 S�ONA (Designer's Signature) (Affix DeRAME�S Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. 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 3-26-04.doe _3c�7 Town of Barnstab ;Ple # �5 �ir � partmentaof Healti�i,Ssa-fg aff �E��n�v nm, v7ces_ ' . .:, . Public , ia'1`t)h DUMIS ©n Date: 367 Main`Street,Hya:anis MA'02601' s aaa`"nu a ram' a0 RI OrE�µ�Yw`� Bate Scheduled U Time Fee Pd. ��� "Q 11] Soil Suitability Assessente f®r Sews e Dasposal l �J a Performed By: Dan,�.1 �o `� Witnessed By: (/"'� n "'r ACl ... Location Address 77�3 Owner's Name �Addrress. Assessor'sMap/Parcel: ��/ �6�• Engin"eee's"Name �bo`^� �e / # NEW CONSTRUCTION REPAIR Telephone /J Q Land Use I"6L Wr7 ,J Slopes(%) 7 Surface-Stones /J�/ Distances from: Open Water Body >/G y It Possible Wet Area >lacl It Drinking Water Well ;>16 it Drainage Way ft Property Line � 3� ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of lest holes&perc tests,locate wetlands in proximity to holes) )A( IX v �o ��1 gym✓ • Parent material(geologic) �j t6LC 61 . - t I Depth,to Bedrock ZOr,/ Depth to Groundwater: Standing Water i/n�H/ole/'�/� Weeping.from Pit Face Estimated Seasonal High Groundwater_ :;:; Method Used: /U6 (;V - Depth Observed standing in obs.hole: in. Depth watei Adjust in. p in. Groundwatee Adjustment �• Depth 4o weeping from side of obs,hole: ,l u. :Ad Groundwater Level Index Well#_. ._ •Reading Date:_•___ Index Well level•.•__ Adj,factor j:�' '.'•> D nd.... Observation I , Hole#' t Time.at.9'v Depth of Perc Time aY`6"' Start Pre-soak Time® Timet(9"-6") r q; End Pre-soak " Rate Min./Inch Site`Sui[ability'Assessment: Site`Passed ��' -Site Failed:�� ---Additionaah,�Test ng•Needed:(Y/N), -� Original' Public Health Division Observation HolelD to`I O 9$C-C..6in Ieted'6n ac'k � i Copy: Applicant `C V� It lam ................ 4S. )'e from Soil Horizon So'ilATewture si I'It fSoil,Color' Soil Other (USDA). (Munsell) . Mottling (Structure,Stones,Boulderes. Surface(in.) o Mtn a MEOW >:.......:.;:::.::....::> Depth from Soil Horizon Soil Texture Soil Color Soil Other 'Surface(in.) t'i (USDA) (Munsell) Mottling ` '(Structure,Stones,Boulderes. onsistency,°oGravel) 777 Our Vdpth from Soil Horizon Soil Texture Soil Color Soil Ogler Surface(in.) (USDA) (Munsell) 1,3bttling (Structure;Stones..Boulderes. Consistpripy,°o r el . Depth from . Soil Horizon Soif4 e,xture Soil Color Soil Other Surface (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,°o Gravel) A[61 6dAnsur'JTjce Ita•te IVJ[aw:_ M Above 500 year floodtboundary,-No_ Yes *Iihin-.500.yeanboundary No Yes t willi1ii1.10'0 yeaf'flo'od1boundiuy'No,, es- ' Mi Math of Naturally®ccurrin9 Pervious iVlaterial Does at least four feet of natilri lly occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If<not,what is the depth of naturally occurring pervious material? C-ertification certify that on �/ I Z (date)I fiave passed the soil evaluator examination approved by the D'epartmenf'of-Erivirorfine^ntalz,Pfotection_and,that•the above analysis was:performed bydme consistent.w;ith µthe required training,expertise andbexperience described in 310 CMR 15.017. Date Signature e. — �Z W Hazardous Materials Inventory Sheet Checklist Date i�F'hysical Street Address-Check database to ensure it exists Working Phone Number i--,Actual-Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials) Storage Information - location of storage, how long is storage for? � If none, note that. Disposal Information -where and who? If none, note that. Applicant Signature - understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? - provide a vehicle washing policy and explain it - note that it was given _Attach the Business Certificate with your sign off and comments "The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: 0 J a Fill in please: APPLICANT'S YOUR NAME/S: V e-f _J Q, r t . p - �t ' } BUSINESS�n YOUR HOME ADDRESS: Dick \I h. s: �` , n �� bf� TELEPHONE # Home Telephon umber x qq p j;' ` �NGtiii:lliuli i SulSP' NAME OF CORPORATION: 55 op=11f/Iv o3\4 el �� 3 NAME OF NEW BUSINESS Ce,C TYPE OF BUSINESS CleaVA i Y1G IS THIS A HOME OCCUPATION? YES ADDRESS OF BUSINESS MAP PARCEL NUMBER f Assessing] When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: n 2. BOARD OF HEALTH This individual h be n i forme.o h mit re icemen that pertain to this type of buses -Y OATH� HAZARDOUS MATERIALS REG" Authorized Sign e* COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Date:US�/oZ TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS , NAME OF BUSINESS: l uc;'S BUSINESS LOCATION: ��- 0 Sq E, fe,(vi I` INVENTORY MAILING ADDRESS: OaC D� TOTAL AMOUNT: TELEPHONE NUMBER: ��- CONTACT PERSON: _ y-a\/\A\0L P,C C\ ("'( 0 00 kcc EMERGENCY CONTACT TELEPHONE NUMBER: oZ g C'� �I MSDS ON SITE? TYPE OF BUSINESS: C C1 \A-A'`-,n INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product,: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants J Motor Oils Pesticides V ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) 4 Gasoline, Jet fuel,Aviation gas Photochemicals (Pikers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW Q�USED Miscellaneous petroleum products: grease, Photochemical''(Developer) ( lubricants, gear oil ❑ NEW ❑.USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's -. Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers,deglossers-- — hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash b�,k.d-W. i�Qf1Lf �R WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials �.\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is required for Centerville MA 02632 July 13, 2011 every 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 filling out A. General Information Iforms on the computer,use 1. Inspector: (A5 only the tab key to move your Patrick iVi: O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 nne» Cityrrown State Zip Code 508-428-1779 SI 12855 Telephone Number License Number C B. Certification --, I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. Theanspecti n was performed based on my training and experience in the proper function and maintenance of.on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.`-A0 of"' Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails Needs Furth aluation by the Local Approving Authority @z�� July 13, 2011 Job# 11-120 I ctor'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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is required for Centerville MA 02632 July 13, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching pit was empty at time of inspection with a stain line at 2/3 capacity. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is required for Centerville MA 02632 July 13, 2011 every page. City/rown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the 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 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is Centerville MA 02632 Jul 13, 2011 required for Y every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is required for Centerville MA 02632 July 13, 2011 every page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 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. t5ins•11f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is required for Centerville MA 02632 July 13, 2011 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage 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)] D. System Information 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 l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is Centerville MA 02632 Jul 13, 2011 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d None 9 ( Y 9 (gp ))� Detail Sump pump? ❑ Yes ® No Last date of occupancy: Vacant 2 or moreyears. I Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is required for Centerville MA 02632 July 13, 2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is Centerville MA 02632 Jul 13, 2011 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1975 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction.- 9 cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 3" 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is required for Centerville MA 02632 July 13, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1 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? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found slightly below outlet invert due to vacancy and evaporation. Baffles were intact and tank was structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: I Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is required for Centerville MA 02632 July 13, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: I Capacity: gallons Design Flow: aeons per da 9 P Y Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes [] No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is Centerville MA 02632 Jul 13, 2011 required for Y every page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.).- Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is Centerville MA 02632 Jul 13 2011 required for � every page. Cityfrown State Zip Code Date of Inspection D-System Information (cont.) Type: ® leaching pits number: One 6x6 pit. ❑ 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.): Observed a well defined high stain line at 2/3 - 3/4 capacity. No signs of surcharge or hydraulic failure. i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M . ' 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is required for Centerville MA 02632 July 13, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name ----------_._.._-------- information is Centerville MA 02632 July 13, 2011 required for ---- ------------------------ -------- -- — every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below f 1 drawina attached separately \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 22 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ++ 28 ! / Back Yard 44 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 773 Old Stage Road Property Address Gerald Cardoso Owner Owner's Name information is required for Centerville MA 02632 July 13, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20 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: pate ❑ 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 35 and topo map shows property above el. 50. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 773 Old Stage Road UIV. Property Address Gerald Cardoso Owner Owner's Name information is Centerville MA 02632 Jul 13, 2011 required for Y every page. City[Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ALL SYSTE SHALL SYSTEM PROFILE MAR ED WITHCMAGNETICTTAPE ORBE NOTES Sheet (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. ook PROVIDE MIN. 20" DIAM. WATERTIGHT 1. DATUM IS NAVD '88 Ponds ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2" PEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3" GRADE Three TOP FOUND. EL. 58.8' FILTER FABRIC OVER STONE 2. MUNICIPAL WATER IS EXISTING \ 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 2% SLOPE REQUIRED OVER SYSTEM 56.5 9Shie MINIMUM .75 OF COVER OVER PRECAST a. � •i , NOTE: 2" MIN. WALL 4. DESIGN LOADING FOR ALL PROPOSED PRECAST i`� o PRECAST H-10 THICKNESS REQUIRED BLOCKS OR UNITS TO BE AASHO H- o� U� � RISERS (TYP.) PRECAST RISERS 10 r a ° _ oo .. • 2'o 55.9E 4"bSCH40 PVC MORTAR ALL H-10 c a e� PIPES LEVEL 1ST 2' [ COMPONENTS 5. PIPE JOINTS TO BE MADE WATERTIGHT. �° Kok �r ENDS (TYP.) 3 SIDES 53.96' 10" EXISTING 14" poo oo oa o a 1 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE fir` ° WITH 310 CMR 15.000 (TITLE 5.) ** TEE r �0�� ����rmm O- ---�E2 0� '°°°°°°°° s� TEE SEPTIC TANK ° ° ° ° o°o°°oo° 54.5t. o 0 0 ° ° ° 1�," MIN. INT. DIM o ;°o°o °o ==mmmoaoo® �aaaoaoa 0 0 0 0 0 0 0 0 0 0° ° ° ° ° ° 6 MIN. SUMP ° ao�oaaaaoo� ooaaoo�o ° 7. THIS PLAN IS FOR PROPOSED WORK ONLY ANDGAS BAFFLE::' ° ° ° °OQQ ��0 NOT TO BE USED FOR LOT LINE STAKING OR ANY 53.38' S3.21 0000a000 51 .13 OTHER PURPOSE. •" • LH-10 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. 500 GAL LEACHING CHAMBER BY ACME PRECAST OR EQUAL ALL AROUND PRECAST STRUCTURES (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR PPa 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.83' CONCEALED WITHOUT INSPECTION BY BOARD OF COMPACTION. (15.221 [2]) M HEALTH AND PERMISSION OBTAINED FROM BOARD ui OF HEALTH. - 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP ( 2 % SLOPE) ( 1 % SLOPE) CALLING DIGSAFE (1-888-344-7233) AND 46.0' BOTTOM TH-1 VERIFYING THE LOCATION OF ALL UNDERGROUND & NOT TO SCALE LEACHING NO GROUNDWATER FOUND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF FOUNDATION- EXIST. SEPTIC TANK 56' D' BOX 10' WORK. FACILITY ASSESSORS MAP 191 PARCEL 168 11. ANY UNSUITABLE MATERIAL ENCOUNTERED *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL SHALL BE REMOVED 5' BENEATH AND AROUND THE UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS PROPOSED LEACHING FACILITY. PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM 12. EXISTING LEACHING FACILITY SHALL BE PUMPED **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT AND REMOVED OR PUMPED AND FILLED WITH CLEAN 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE SAND. WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE CONDITIONS IF NOT SUITABLE SYSTEM DESIGN: TEST HOLE LOGS GARBAGE DISPOSER IS NOT ALLOWED DANIEL E. GONSALVES, SE 13587 ENGINEER: # DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD LOT 2 WITNESS: DAVID STANTON, RS 15,361t SF �J� USE A 330 GPD DESIGN FLOW DATE: 10/25/16 / PERC. RATE _ < 2 MIN/INCH 58 SEPTIC TANK: 330 GPD 2 = 660 pp **RE-USE EXISTING 1000 GAL. SEPTIC TANK CLASS I SOILS P# 15180 LEACHING: ELEV. ELEV. '� � � SIDES: 2. 25 + 12.83 2 .74 = 112 GPD oil56.5' p» 56.5' �`�� BOTTOM 25 x 12.83 (.74) = 237 GPD A A ° SL SL �G�, 8 / o/ TOTAL: 472 S.F. 349 GPD 10YR 3/2 10YR 3/2 �`� 5 PAVED USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) 8�, 8., EXISTING DRIVE ° WITH 4' STONE ALL AROUND B B �> OF 58.8'LLI N / SL SL �`., ,/ o 18" 10YR 4/4 55.0' 18" 10YR 4/4 55.0' S� f \\v PATIO ° 57 APPROVED DATE BOARD OF HEALTH MA C1 C1 + %P9ti Si LOAM Si LOAM 24" 10YR 5/6 54.5' 24" 10YR 5/6 54.5' Fyo� TITLE 5 SITE: PLAN \ 57 PERC > C2 C2 + TH 2 + OF M/CS M/CS \TH , 773 OLD STAGE ROAD \ F + 2.5Y 5/4 2.5Y 5/4 + '�`� 126" 46.0' 126" 0' \ \ o CENTERVILLE 46. p -/- �, PREPARED FOR NO GROUNDWATER ENCOUNTERED O\ BENCHMARK: USE CORNER BORTOLOTTI CONSTRUCTION/ OF PATIO AT EL. 58.3' CARDOSO OCTOBER 27 201,.. off 508-362-4541 A' ' fax 508-362-9880 OFAfIS )F'�'tis, downcope.com © DANlELA OAN!'E 00WI! C4'p8 eft IIMFOBll � ift. a� O CIVIL A A. - CIVIL ' C �' Scale: 1"- 20' g No.40G3 civil engineers �o�� �s land surveyors `sS�oNAL ENS G sUR 0 10 20 30 40 50 FEET 939 Main Street ( Rte 6A) YARMOUTHPORT MA 02675 �-�2� DATE DANIEL A. OJALA, P.E., P.L.S. .