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HomeMy WebLinkAbout0063 PRINCE HINCKLEY ROAD - Health IM 63 Prince Hinckley Road , Centerville A= 172-189 � I it cc�� No. 9 O!r 0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS RpPliLation for Vspoeal *pstem (Construction Permit Application for a Permit to Construct( ) Repair(Vfl"U'pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address o Lot� . ri v-it i Rc-Uey Owner's Name,Address,and Tel.No. Assessor's cel I U 112�4 act' I 5 I O4 f E y k- let 'Tev5 "('— talle ' N e,Address,and Tel.No. Designer's Na e,Addre s,and Tel.No. + x savor t n SDR-477-D65 Mown , �,9;n-e"I SaB 362-4.5 4 I Type of Building: FL' Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3.3 0 gpd Design flow provided 3,33 gpd Plan Date 9/1`f/ 1 0 Number of sheets � Revision Date Title Size of Septic Tank 2X IS♦I f1Q I OQU QaA 1,Q0 Type of S.A.S. 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 not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed 0. Date Application Approved by - Date Q ���� Application Disapproved by Date for the following reasons Permit No. p2��y 375 Date Issued '7—lq`f t� 4 No^ O` �� ^ . .�..,�.,.ka,. "r 't t � j Fee /VV THEE O MONWEALTH OF MASSACHUS.TTS Entered in computer: PUBLIC HEALTH DIVISION,­TOWN OF BARNSTABLE, MASSACHUSETTS S; 1 2ppYiration for Disposal *pstem ionstruction 3permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address of Lot N,p. �(j 3 nir, C e' H i rL c— �e Owner's Name,Address,and Tel.No. �— , IgNCy �r sr Assessor's IapWarcel ` 1_7 Z_7Pq r t 1 9 _I Pr Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �k ctl\/a. 4 n SG�S W 77-065 -3 Dcwr--, Cady, <fncj, rti ,rl o ra � t 5GR 3 �i5 1 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(min.required) 330 gpd Design flow provided 333 gpd Plan Date { 1 () Number of sheets Revision Date Title Size of Septic Tank eX 161 I i 1(' 1(}boortdoo. Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) I r L � y} { - 1- Date last inspected: t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date �I f_4 1 1 o Application Approved by Date Application Disapproved by Date for the following reasons Permit No. jQd(0-- 3 7:5 Date Issued '07'N y 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 7R-f 6C&c(,ya1 i6) at (o ' has been constructed in accordance ( rl with the provisions of Title 5 and the for Di posal System Construction Permit No.L>9610—3 75 dated Installer�15' O hER V_ L EC�4 Designer #bedrooms 2 Approved design floe gpd _ The issuance ofTspe it shall not be construed as a guarantee that the system l c n as Inspector de d. Date 5 1 ---- ------ N _--------- ---- ------- Fe �0 0,r e THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Wrmit Permission is hereby granted to Construct( ) Repair( Upgrade.( ) Abandon( ) System located at (a �,�' i i r)r UP, r"1 f 'i�l'f t� l and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this per , Date 1 — 14—10 Approved by 7 FROM :down cape engineering inc FAX NO. :15083629880 Sep. 16 2010 01:26PM P1 ° Rw.C;;�l�� 1F?��� =�9G��E�:F'.•7 6Thornas F. C. l 4 L�P.4ifdH'dAKYx, b i �'��sa �%',� 'Tl�l���s i�i1d•11�.d��nll, fiIli<>re�:>tallr :7,041 Main H yuirsno 02601 ()t{icc: 508-86').-4644 1 ax: i0$ '190-hJ0�1 lllstWllcr 6A lfhlemi;>aaia:r Fom Date. 1 V vG"@dcd d°1�Q'L+JIIDIll��J oIV T Agsc>;"dt;or',�1VgiUpTar'ee I(yn:sngane>r•. t�nwl^, Address- Addms. On — _ �v�t:;issood s pexj-7 t to instal) a selltic rysteial s.t 63 /%l�I.�Q.__ d basal oil�.d.esiep drawn by (address) dated I cr.,ttify tlial.i.h.e scutic systf:m.refeTZ 31.oed ,fl)ove W"rIS ITISLifflCdl substutta:i.Iy accol-ding to the design, which.may lrl.cludc TmWr approvcd ch,5ag•es `?lid:.h as lateral relocation of isle dl:tstribulion bux and/der septic tank. I cerhfy that. tl_Ze selll:ic syslum rc.f'crcncud above was in ,q led With majur chiuigc,s (i._e- greater. than 10 latcra.l.rnl.ourtioi).of the ,A,, d>- UTly Veyfi al re.locatioll.of any wTupoiie.W. (if ilio.sop c systelu) but With State :4z T,dl(:al Ruplations. PJan..revisidm or cc:rtifiul as-huilt by designer to folJ.pW. dtl OF Mqs DANIEI_A, ©JALA ` (Iatsfiallcs's'�lfmaluTt. _ 47 CIVIL, No.46802 (T)e,igrlcr's 5i iafiue} (Affixl)ss.irsiier'S F'Aamp Hcic) .-„lin'oal-15 O BARNSTSU'Oli; :e.'�iT�F,lfa: K1FA_n•.'TH ,WVISIO.N. d::EP2TrFTCA E+T OF a'aglo`oi"a,TANov6;, "vViLt.1 .i.Vtpa v,a+_aS,hN.I;)r QIN.0 f, d:v'.a TrTS F6 ANP .dA.j�i-�1•lUlf'� CARD AJA:�', --... --- 1hp!;4::FB�IlD%�y'A':t-G1F 1Fc�TtI�4?�.'�J.�9,.K�;n°IlJl`�I d:d:F1fV+,�#T,'�'_�f-�V��b�➢I'�}. 'Il'lfl�l'a)E�_'�'GDTJ. Q:HrKllJj/Srj°ticll)csignrr CvrEi icatimi Form 3 26 04.dor Town of Barnstable P# l 3o 5-1 JDepartinelet of Regulatory Services '. / 1p n UAMETABM : Public Health Division Date 200 Main Street,Hyanuis MA 02601 s0191 . • �APfa PM'1 A � /' Date Scheduled I b Tinie�� Fee Pd. YA yo ' �U f� -,�S'oil Suitability Assessinent for assuage � sposall Performed By: �C1 d..S° Witnessed ey: Location Address Owner's Name T_" I ►rlv1C�: ��nclCl,7.y 2�. t�2s��e�►� Address � n p Assessor's Map/Parcel: /a/�0 9 Cngiucer's Name 0 W C-Af e NEW CONSTRUCTION REPAIR 7Telephone If Land Use N�� +��8iACL__ Slopes(%) A,* !C Surface Stones Distances from: Open Water Body ">-�61 ft : Passible Wet Area YYV4 ft Drinking Water Well ft Drainage Way S ft Property Line ft Other ft .SYj,_ETCHC (Street name,dimensions of lot,exact locations of lest holes&pert tests,locnte wetlands�In pronindly to holes) c _I A c o ♦x�� G Z t� O 1--� n CC) f�7 t' 3 V) oo cA W Parent material(geologic) ON'F<4"+ Q�. Depth lu Bedrock, Depth to Graundwatcr: Standing Water in Hole: Weepilrg I'rati)Pit Pflee _ __. — �T Estimated Seasonal High Groundwater > 7.Q DETII NATION FOR SEASONAL HIGH WATEIt TABLE Method Used: lk Depth Observe standing in obs.hole: In, Depth to 5QII mruttlts: Ill. Depth to weeping from side of obs.hole: -- I!1, cJrtrullrlWuttlr Adf uslment Index Well I# Reading Date: lndcx Well level A tj,ftwtor— A01.Oroundwater Level PERCOLATION TJ I ST Datu Time ----- n ervatio Hole# 'Time.at 4" Depth of Pere Tlme at 6" Start Pre-soak Time @ _ Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed_ 5it�Failed: Additional Testing Needed(YIN) Original: Public Healer Division Observation;dole Data To Be Completed on Back----------- ***If percolation test is to be conducted Witilin 100' of Weiland,you must first notify flat. Barnstable Conservation Division at least olle (1) Weelc prior to beginning. Q:\SEPTIC\PERCFORM.DOC DE Depth from 1P.OBSER`Y.4TION I-TOLL LOG Hole# �Soil Horizon Soil Texture Surface(in.) Sdil Color Soil Other (USDA).. (Munsell) Mottling (structure,Stones;Boulders, Con istenc %a" ravel o , DEEP 0139 ,RVATI®N HOLE, LOG�,®� Depth from Soil Horizon Soil Texture IIole#_ Surface(in.) Soil Color Soil Other (USDA) (Munsell)N ) Mottling (Structure,Stones,Boulders. Al. ® Consi ene %Gravel r 1 Lam(" �o &i D EL1P OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture a10le# SirrFace(in,) Soil Color Soil ther (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Co siste c O vel a DE EP OBSERVATION HOLE LOG y Depth from Soil Horizon Soil Texture �01e# Surface(in.) Soil Color Soil Other (USDA) (Munsell) MOtuln g (Structure,Stones;Boulders, t O A Consi ten c a �_ i Gt . Flood Insurance Rate ma Above 500 year flood boundary No ±t Yes Within 500 year boundary No Within 100 year flood boundary No Yes ..+). If�ep�t➢n 0� f NatHra!j Qc�n�ketYious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? „If not, what is the depth of naturally occurring pervious atarial Cee'te- ficatlon I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above a,nalytsis.was performed by me consistent with the required training, expertise and experience described in�10 CMR 15.017. - Signature Date Q:%SEPTIC\PERCFO RM.DOC E' Town of Barnstable Barnstable ti Regulatory • Re ulator Services Department O micacftv &RNSTABM 1 i ;9. Public Health Division 6 A,O� ii i). 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#70083230000251783180 9/09/2010 Sidney Kessler Trust 0 p� 63 Prince Hinckley Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 \ The septic system located at 63 Prince Hinckley Road, Centerville MA was last inspected on August 8, 2010, by Ricky L. Wright, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH as , c can, R.S., CHO Agent of the Board of Health r �l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 `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 General Information A. � / filling out forms A F �/ on the computer, / use only the tab 1. Inspector: key to move your D � Cal (� cursor-do not Rick L. Wright �jj I key the return Name of Inspector i y B & B Excavation, Inc. AUG G 6 RE CUD r� Company Name /d 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S 14595 Telephone Number License Number 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. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority r 8/9/10 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 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. LID 41� V t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. Citylrown 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: 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•09/08 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 °M 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. Cityrrown 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. Cityrrown 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 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C G M Prince Ince Hinckley Road Property Address p Y Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. Cityfrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 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? i ® ❑ 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. City/Town 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 years usage d n/a Detail: Sump pump? ❑ Yes ® No Last date of occupancy: July 2010 Date 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. City/Town 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: 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1976 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 19"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 70 feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good working order- no signs of leakage Septic Tank(locate on site plan): Depth below grade: 10"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: 8'6"X 5-2"X 512" Sludge depth: no sludge t5ins-09/08 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 °M 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. CitylTown 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound 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 l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. Cityrrown 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: Capacity: gallons Design Flow: gallons per day 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. Cityfrown 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.): no d-box 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): At time of inspection water level was at top of leach pit which was 7' below grade- inlet pipe piped into riser at 3' below grade 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. CitylFown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. Citylrown 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 ❑ drawing attached separately A � al = loov _B1= z3 ' al Bz= z9 Ac3. 51 ' � 3. 39 ' �oov 3 3a -P1� t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 63 Prince Hinckley Road Property Address Sidney Kessler Tru st Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. CitylTown 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: > 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: spoke to local health agent ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 63 Prince Hinckley Road Property Address Sidney Kessler Trust Owner Owner's Name information is required for every Centerville MA 02632 8/9/10 page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 __ I TOWN OF BARNSTABLE LOCATION G3 Pr;ncc. 9 nc)<1cu R4 SEWAGE# _o�OfU "37S VILLAGE CcnAcrv;11 L ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 40 r)- o/-.S 3 SEPTIC TANK CAPACITY /ODO 9cx I LEACHING FACILITY:(type) ','e.I of (size) /D x ys' NO.OF BEDROOMS 3 OWNER PERMIT DATE: 9"1 y- /O COMPLIANCE DATE: 9 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 AI - 2 Li AZ _2�►, 82 B3 -55 C-3 0 A I. �ca� IVY LOC&TION ' G% SEWQGE PERMIT UO. VILLAGE INSTALLER 5PJIE� ADDRESS bU1LDER ' AA � D D E — — — —5 V4A E A R SS — — — ZZ�f - ��— — — — — — DATE PER"VT ISSUED : D ATE COMPLI &MCE ISSUED ; /� � I . �17 ALL TEM LL LEGEND SYSTEM PROFILE MARKED WITHCMAGNETICTTAPEAOR BE NOTES SYSTEM DESIGN. NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 99 - EXISTING CONTOUR PROVIDE MIN. 20" DIAM. WATERTIGHT � 1. DATUM IS APPROX. NGVD � GARBAGE DISPOSER IS NOT ALLOWED ACCESS COVERS TO WITHIN 6" OF FIN. GRADE F PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE 2. MUNICIPAL WATER IS EXISTING X 99.1 EXIST. SPOT ELEV. \ TOP FOUND. EL. 60.4' DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD 1 c 99 PROPOSED CONTOUR MINIMUM .75'L COVER OVER PRECAST 2% SLOPE REQUIRED OVER STEM 59.0 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. �° Locus o USE A 330 GPD DESIGN FLOW ft 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS e Z� PRECAST H-10 I I TO BE AASHO H-LQ p O �98•4] PROPOSED SPOT EL. RISERS (TYP.) lb SEPTIC TANK: 330 GPD (2) = 660 2'0 4"2SCH40 PVC 2" DOUBLE-WASHED PEASTONE o c TH 1 PIPES LEVEL 1ST 2' I I 5. PIPE JOINTS TO BE MADE WATERTIGHT. TEST HOLE **RE-USE EXISTING 1000 GAL. SEPTIC TANK OR GEOTEXTILE FILTER FABRI OVER STON td Y ADD 1000 GAL. H-10 PUMP CHAMBER 10„ 14„ _ 57.34 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH 2> SLOPE OF GROUND EXIST, TEE - o 0 0 0 0 ° o ° o o ° ° o ° o ° o ° o 0 0 0 0 0 ° ° ° ° 0 31D CMR 15.000 (TITLE V.) TEE *57.48f 000 ° 00000 ° ° oo ° o ° ° ° 00000 ° 0000000 SEPTIC TANK** u u u °000000000000000000000 000 0000000000000000000000000000000 0 0000000° °o°o°o°o°o°o°o 56.82 00000 ° 000 ° ° 000 ° ° ° 000 0000 ° ° ° ° ° 000 o°o°o°o°O000°• oo °0000°°000°°000000000000000000000000000000000°°°000 0 0°0°°°0° °00000°o°o°o°o o LEACHING: cnsBAFFLE 0000000 0000a00000000000000000o00o0o0o00 56.13' 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO UTILITY POLE o 0 0 0 0 0 o c o 0 0 0 ° ° o 0 0 0 ° ° o o ° o 0 0 0 ° o 0 0 0 ° ° o 0 0 0000°000°°°°°°°° ° ° ° ° ° ° ° ° °o ° ° ° ° ° ° ° ° ° ° 0000 ° ° 0000 ° ° ° BE USED FOR LOT LINE STAKING OR ANY OTHER FIRE HYDRANT SIDES: N/A 57.01 56.84' � 4" PVC SET AT .005'/' SLOPE � PURPOSE.ry a BOTTOM 45 x 10 (.74) = 333 GPD ON 6" DOUBLE WASHED 3/4" - 1 1/2" STONE NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING 6" MIN. SUMP 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. TOTAL: 450 S.F. 333 GPD 12" MIN. INT. DIM. 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED 9 6" CRUSHED STONE OR MECHANICAL 7.1 ' 5.1 WITHOUT INSPECTION BY BOARD OF HEALTH AND USE 45' x 10' x 0.5' DEEP LEACH FIELD WITH (3) 4" PERF. PVC IN DOUBLE WASHED STONE. COMPACTION. (15.221 [2]) PERMISSION OBTAINED FROM BOARD OF HEALTH. *THE INSTALLER SHALL VERIFY THE o 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING LOCATIONS OF ALL UTILITIES AND ALL DIGSAFE (1-888-344-7233) AND VERIFYING THE BUILDING SEWER OUTLETS AND BOTTOM TEST HOLE 4 EL. 49' BOTTOM C1 EL 51' LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES ELEVATIONS PRIOR TO INSTALLING ANY ( 1 % SLOPE) ( 1 % SLOPE) LOCUS MAP PORTION OF SEPTIC SYSTEM PRIOR TO COMMENCEMENT OF WORK. 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE MA LEACHING REMOVED 5' BENEATH AND AROUND THE PROPOSED NOT TO SCALE APPROVED DATE BOARD OF HEALTH FOUNDATION EXIST. SEPTIC TANK 47 D' BOX 4' FACILITY LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND ASSESSORS MAP 172 PARCEL 189 REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE WITH 1500 GALLON H-10 SEPTIC TANK IF NOT SUITABLE TEST HOLE LOGS ENGINEER: ARNE H. OJALA, PE, SE WITNESS: DAVID STANTON, IRS DATE: SEPTEMBER 13, 2010 0.23 PERC. RATE _ < 2 MIN/INCH CLASS I SOILS P# 13051 0.01 10' ELEV. ELEV. 4 4 4 ' 4 59' 59' p" 59' p�� 5 59.4' p» 59' 0" p» x 60.14 .... . .. - 6� - TH 5 C/A O/A O/A O/A x 9. 7 9.46 4„ 10YR 2/1 4» 10YR 2/1 41' 10YR 2/1 4" 10YR 2/1 0/A _ LS `n E _ E E _ E - - 4„ 10YR 2/1 -- FS FS FS FS 8.88 x 59.50 x 58. 0 59 10 oa,k » 10YR 6/1 „ 10YR 6/1 „ 10YR 6/1 „ 10YR 6/1 6 6 6 6 E " � B FS c' 4 x 58 9 �° S LS 10YR 6/1 .66 ° LS LS 3 9.35 6 12" OAK 24" 10YR 6/8 57' 24" 10YR 6/8 57' 24" 1OYR 6/8 301s 10YR 6/8 56.5' B x 59.21 C1 C1 C1 C1 LS x MCS MCS MCS MCS 24" 10YR 6/8 57.4' 9.75 x 58.77 7 DEAD P PINE 2 78„ 52.5 72 53 10YR 6/4 10YR 6/4 > 72» 53 9611 1 OYR 6/410YR 6/4 51 ' � T}� 3 14" OAK ' x 59.58 g g 84 60.1 1 Z/1 2 C //2 /C� PERC DEAD P PIN 7 x Si LOAM �'�LOAM Si LOAM Si LOAM Cl 4 59 59 / / / / / ✓ / / / / / / / / � 102" 10YR 5/6 108» 1OYR 5/6 50� 108" 1OYR 5/6 108" 1OYR 5/6 MCS 59 1 x 9.00 WIN 14" OA �5 50 50.0 10YR 6/4 1 OAK x DECK 011 C3 C3 C3 C3 06 ° 60.23 MCS MCS MCS MCS TH 2 DEAD P PINE 1 120" 10YR 7/4 49' 120" 10YR 7/4 49' 120" 10YR 7/4 49' 120" 10YR 7/4 49' 120" 49.4' 8.70 TH 1 x 60.19 x 59. PAVED 59.36 NO GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED I I 6 DRIVE 9.959.35 88 14" OAK EXIST. DWELL. x 0138 TOP FNDN = 60.4 58.93 /j ` 9.81 �\ 59.27 8.79 TITLE 5 SITE PLAN ADO 61 + OF 20 �9\ 59.14 58.70 Cb 8.62 P 63 PRINCE HINCKLEY ROAD BENCH MARK - CORNER CONC. 47 I LOT 95 / CENTERVILLE BULKHEAD ELEVATION = 60.5 23,032 t SF 59.73 158.57 co PREPARED FOR C, 59.59 .48 / B&B/KESSLER 58.91 58.31 SEPTEMBER 14, 2010 � Q �58.22 Scale: 1"= 20' 0 10 20 30 40 50 FEET 1x, H°FMgsS --- of off 508-362-4541 qC� ira``P ss�c ; fax 508-362-9880 DANIELA. G��" 7< DANIEL yUyy downcape.com OJALA - A. " CIVIL OJALA g down cope engineering, inc. �1. No,46502 t.�., q No.40980 v �000,s >>o civil engineers y S�� >NAL � u `q,� o� ,` land surveyors Q --,I `'' \ I 939 Main Street ( R to 6A) DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 > 0- 195