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0447 PRINCE HINCKLEY ROAD - Health
C447 PRINCE HINKLEY RD., CENTERVILLE i I 'f { { ° z`. {ti e �,j Commonwealth of Massachusetts f� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;'•W 447 Prince Hinckley Rd I Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 page. City/Town State Zip Code Date of InsEe}tion U1 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 4-5-17 nspector'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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 t Commonwealth of Massachusetts ' 1a=1 Title 5 Official Inspection Form a 'A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W� a_;pail 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 ' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E always complete all f Section D A) System Passes: ® 1 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: System is in good working order with no sign of failure. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form 9. :Wlf�;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _�_J,!✓ 447 Prince Hinckley Rd _. �_ Property Address Edward Butler _ Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): I 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts ' .a� zp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 page. CitylTown 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts ^+ f Title 5 Official Inspection Form -I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t s% 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 page. City/Town 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- 1 0,000g pd. ❑ ® 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 31 U CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 page. City/Town 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 _ t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 1 Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form -A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 447 Prince Hinckley Rd _ Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 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? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2017 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts ' :a=1 Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a£, 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 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: N/A 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts a=1 f Title 5 Official Inspection Form ��I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 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: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ® cast iron ® 40 PVC ❑ other,(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 1811 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: 1000 gal 12" Sludge depth-. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts ' :^� f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 page. City/Town 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 20" 1, Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ` �.J!✓ 447 Prince Hinckley Rd Property Address A � Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 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: 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts �+ Title 5 Official Inspection Form J. Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,,_P_44!✓ 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 page. City/Town 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 � _ Title 5 Official Inspection Form:Subsurface Sewage Disposal Systems•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): Leach chambers in good condition and empty at inspection with no visible stain lines. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts ^r ( Title 5 Official Inspection Form ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts :al Title 5 Official Inspection Form f_ �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 page. City/Town 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 Y 00 , 0 '7( t t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts �r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l a&; 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 page. City/Town 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: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 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 447 Prince Hinckley Rd Property Address Edward Butler Owner Owner's Name information is required for every Centerville MA 02632 4-5-17 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOVM OIE EA STAB'LE T S V7LL,p► / I e 74SE5aOR'S MAP&.LATE 777 INSTfL.E 'S AtAl &PiH4IE YVO. SEPTIC '�A1�K CA.IPACrry rt � LILtAtG 1I�C .I'E'Y t ►a) . C,�j r.•��-2/� (size) lap t R QWhT�� colvOtLam Sapa on sWj;e Bstweei e Maxlmuml�cllustcd Gaundwste�Tabletp tltG 13attomoCX•eaahttt l�su:iUty ,feet Piiva6e /Atc:t Su ly dc�!iu�ci Y,.eoc Ing l�acil�ty ( ,y�rpl9s Cxist' alit sate or;wlthia 2t10 legit e�lancli�g frlGiUty) k�aas Ecle c��VVt4and and Ukwfig Rclltyy GYM airy wettand5 exi§t r µ_,^-—Y-= - ee t+ltfa�i�'�QQ feet a' c�t�ng�'mcllicy iCarnlahed by r' 101 a3 ay A 3 TOWN OF BARNSTABLE Pool' LOCATIAN ULI Pri ncc. i Ar-Wr-u Rd• SEWAGE # 07009 - OOCo �*V'ILLAGE C-COISEY I I G ASSESSOR'S MAP & LOT 170 - ?D3 .INSTALLER'S NAME&PHONE NO. B z 13 ExcA✓ATsory ,S63- V*)'?- 0453 SEPTIC TANK CAPACITY /ODO 9a./Jon LEACHING FACILITY: (type) �Soo!jal chwr,-3er5 CZ)(size) 13 x PS x A NO,OF BEDROOMS 3 BUILDER OR OWNER aullcr PERMITDATE: -9 - D 9--COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feei 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- 50'/z 31- z5 '/2� Al- 5z 391{?lb9 �2- 79 C3- 12 ' �)3- z4 cy- 15 ` REAR IA 9 ' .Dy - z5 PC -' U c fl j i No.J00 (/ HE COMMONWEALTH OF MASSACHUSETTS FEE PV4��o BOARD OF HEALTH U[�)(1 OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - []Complete System [-]Individual Components L�Q )cation/ I Ow er's Name Q 03 9`J-7 -Pr'I n(_e_ �rLLk 1 o. Map/Parcel N Address 50� 0 34l Lot Telethoyte,r ny 1 5 DI�enY�l 21�eppr��-;I-��--��p� �I�v�v�� �3t�3IIo--rl �4.►t�1 �"lason - ,(�,� C I ��JselJ—l6 r��1 stalnrs1lNam �eS�C`Cll� �7�(G, Sr)f Sa n(,C�Desil�r'sName _ .Hl 1 � � ress V b �l5 _2_1 1 Address '' Telephone N Telephone N Type of Building: —Qe--al 6=Q:Il c-,— Lot Size Sq.feet Dwelling—No.of Bedrooms Is Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow( in.required) gpd Calculated design flow gpd Design flow provided gpd Plan: Date 7 - 9E, Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed I� ffl/cy FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 j :_ANLAMI� __---- - - ---- ---- _-��- J r is No. 9L-OATHE COMMONWEALTH OF MASSACHUSETTS FEE , BOARD OF HEALTH APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components �-1'-t-7 �I r I��c I I I i��Ie \/ t� �el I I i R e L_�:_J -5 L I LE V ` � 's1 1Name ccation U( t`f R Map/Parcel# Address t ' SU43 �1a0 .�341 LotA F� /� Tele on # �C L, ) staller's Nam Designer's Name u t 1<c_ ct.t C; <. , ; ,t.r At dress ress t (/ r, I Address Telephone# Telephone# Type of Building: k:'e&1 CAL0-h L_L_ Lot Size Sq.feet Dwelling—No.of Bedrooms _3 Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flow gpd Design flow provided gpd Plan: Date 11-7 1 u9 Number of sheets Revision Date j Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation i I DESCRIPTION OF REPAIRS OR ALTERATIONS I The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed �2,ft_b.t'J� � n ,/� D. r„ I �7 '1 G C� /C/Y i Insp c�"t'tons /_ i �j� ` ., � �� i i i FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No.��s�Dr17! THE COMMONWEALTH OF MASSACHUSETTS __y__�FEE"__�._ ---:---_ 1�C11✓IIStG�f��� BOARD OF HEALTH i CERTIFICATE OF COMPLIANCE IDescription of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ` Upgraded( ),Abandoned( ) by: �°)i G ry !�('X( CI\t `�`IC,t1 at �� f 111C�' 11t '�i._�( ��\r Q l r :'Sl � j has been installed in accordanc t the visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application NoRT dated Approved Design Flow 3 3 (gpd) ' Installer ,ti�� _ qq � es / Designer: Oc\\1( Inspector I The issuance of this certificate shall not be construed as a guarantee th t the system will function as designed./ FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. � THE COMMONWEALTH OF MASSACHUSETTS FEE w BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair (�) Upgrade ( ) Abandon ( ) an individual sewage disposal system at � }`1-7 Pr i+1 C C I t C_�l l L,u V D as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this per i,,_ itt�'-11y�ca/1 c ditio st be met.u.i, Date Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON /,. Town Of Barnstable �•.��`f"E r Regulatory Services Thomas.F.Geiler,Director + BAFtN.STAtBE E. a Public Health Division Thomas McKean,Director 200 Fain Street,Hyannis,MA 02601 Office:.508-862-4644 -Fax: 508-790-6304 Installer &Designer Certification Form Date: I IZ 2p0 Designer: °d AV l Installer: B j-A E CAVA=00 _ Address: . ��� �7L4-�-I ��i� Address: J y �T7 crr� Fores4d6)c /►114� On_ 9- O 9- O 9 R*B EXcAyAr=q,%J was issued a permit to install a (date) (installer) septic system at MW W ased on a design drawn by (address) 12 OrO 1 C`�2 dated ZU v Cr (designer) 1 certify that the septic system referenced above was installed substantially accbrding'to ,I,- d design, which may include minor approved-changes such as lateray relocation of the d distribution box and/or septic tank- . < . IF. i _ I certify+'that the septic system referenced above was installd with`nYa1ror changes greater than 10' lateral relocation of the SAS or any vertic1.al jelocati sn of any component, of the.sept(,system)but in accordance with State&Local Regdiations. Plan revision or certified as-budlt by designer to follow. f ID 4,;, (Installer's tore) 1ViASpN m .,� X. �o W6s SgNlT-A (D er s Signature) ( $x er's$tatip Here) PLEASE RETURN TO BAANS E PUBLIC HEALTH.DIVISION CERTIFIC TE OF.: COMP .IANCE WHIM :SE`= SSUED:r BOTH :THI[S FARM BUIELT LARD ARE RECEIVED RY-TH :BAR S'P $L]E PUBLIC E TIH DIVtSI4N TE ANK YOU. t , Q:HeaA/SepticlDesigner Certification Form t< ; Town of Barnstable P# Department of.Regulatory ServicesMOM O Public(Health Division Date MAU& fb q.��e$ 200 Main Street,Hyannis MA 02601 Date Scheduled Time Fee Pd. So Suitability Asse sment for Sewage Di osal 6 � Performed By. A-0 1 Witnessed By: .. �/ LOCATION & GENERAL INFORMATION Location Address 4 yl T4 r1 nc e H t n eY�e Owner's Name E ��{1 Y y yl -Pr t e%ce N I rv- lei C P�1'�Cf V 11 1e_ Address Cen+«v l l 1 e Assessor's Map/Parcel: a t7 3 Engineer's Name JJ tXY f� Q S o rl NEW CONSTRUQ;`I'ION REPAIR' '� Telephone# i Off, W Land Use 1 Slopes(%) b Surface Stones Distances from: Open Water Body ft Possible We Area /^/ft Drinking Water Well / ft Drainage Way ft Property Liae 1 V ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&per tests,locate wetlands in proximity to holes) 1 a i rn CA) -� ^ O o > crr Parent mate (geologic) Depth to Bedrock rial Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face IV14 Estimated Seasonal Yligh Groundwater y y DUTERMINATION FOR SEASONAL HIGH.WATER TABLE Method Used: Depth Clbserved standing in obs.hole: in, Depth to S411 tYiottles: Depth tolweeping from side of obs.hole: ' in, Groundwater Adjustment f Index Well# Reading Date Index Well level AEI,faetor� Adj.(Imundwater Leval, y� PERCOLATIO►N TEST Date..— x4ne Observation !r l Time at 9" �. .------- Hole# ��� • , Time at G' Depth of Perc L Time(9"-6") Start Pre-soak T•ime.@ - 1 End Pre-soak Rate Min./Inch Site Suitability Assessment: `Site Passed Site Failed; Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-------- ***If percola#on test is to be conducted within 100' of wetland,you must first notify the Barnstable C40Servation Division at least one(1)we&prior to beginning. Q:\SEPTIC\PERCF6RM.DOC DEEP OBSERVATION HOLE LOG Hole#�— Depth from Soil Horizon Soil Texture .Soil Color Soil i Other Surface(in.) (USDA) (Munsell) Mottling (Strut re,Stones,Boulders. Consistency.% ravel DEEP OBSERVATION HOLE LOG. Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling ,(Structure,Stones,Boulders. Consistenc %Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent Gravel n ' f 'DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA), (Munsell) Mottling (Structure,Stories,Boulders. onsistenc ra el r Flood Insurance Rate Man: Above 500 year flood boundary No Yes Within 500 year boundary No Ll Y'es Within 100 year flood boundary No✓ Yes Depth of Natut H occurring Pervious Material Does at least fo r feet of naturally occurring pervi uerial exist in all areas observed throughout the area proposed fbr the soil absorption system? .� If not,what is the depth of n turally occurring pemous material? Certification I certify that on. `� (date)I have passed the soil evaluator-examination approved by the Department of tnviro*entat Protection and that the above analysis`was performed by Me consistent with . the required training,expertise a ex . nc de `'bed in 310 CAR 0.017. Signature Date i 200 y Q WEPTICIPERC�.ORM.DOC TOWN O BA.RNSTABLE LOCATION i� n SEWAGE # VILLAGE l 1[J( 1, _�� _ASSESSOR'S Iv1rAP'& I:0 o C, INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY lmz) LEACHING FACILITY: (type) w e 5� Q i,� (size) f 0 NO.OF BEDROOMS _ BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1 h . Isimap 4An g OC �c .� ac PA �a e4 3) < COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 447 PRINCE HINKLEY RD. CENTERVILLE b 'Z0 "Name of Owner MR.RICHARD KIELEY �� Address of Owner: SAME ®d O Date of inspection: 6/1/99 Name of Inspector:(Please Print)JOHN GRACI l am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) fCE�VEO Company Name: n/a 31999 Mailing Address: n/a roftof 64 Telephone Number: n/a y >OMftr f l t 4e CERTIFICATION STATEMENT �� I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evall4atinn By the Local Approving Authority performing at the time of the Inspection.My Inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:612199 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY ONE TO TWO YEARS. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 447 PRINCE HINKLEY RD.CENTERVILLE Owner: MR.RICHARD KIELEY Date of Inspection:6/1/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: Wa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced nLa The system required pumping more than four 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 447 PRINCE HINKLEY RD.CENTERVILLE Owner: MR.RICHARD KIELEY Date of Inspection:6l1/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance Wa_(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 447 PRINCE HINKLEY RD.CENTERVILLE Owner: MR.RICHARD KIELEY Date of Inspection:6/1199 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 447 PRINCE HINKLEY RD.CENTERVILLE Owner: MR.RICHARD KIELEY Date of Inspection:6/1199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal Flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 447 PRINCE HINKLEY RD.CENTERVILLE Owner: MR.RICHARD KIELEY Date of Inspection:6/1/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):2 Total DESIGN flow: IQ Number of current residents:2 Garbage grinder(yes or no):N_Q Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):DLO Water meter readings,if available(last two year's usage(gpd): n& Sump Pump(yes or no): NQ Last date of occupancy: n& COM M ERCIAL/INDUSTRIAL Type of establishment: n& Design flow: n/a gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):JLQ Industrial Waste Holding Tank present:(yes or no): MQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n& Last date of occupancy: Wit OTHER: (Describe) nLa Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS LAST PUMPED TWO YEARS AGO System pumped as part of inspection:(yes or no):MO If yes,volume pumped nLa- gallons Reason for pumping: Wit TYPE OF SYSTEM XSeptic tankidistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: Wa APPROXIMATE AGE of all components,date installed(if known)and source of information: SYSTEM IS 15 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no) 111Q revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 447 PRINCE HINKLEY RD.CENTERVILLE Owner: MR.RICHARD KIELEY Date of Inspection:6/1/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 22: Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: 16" Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No nLa Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: Z" Distance from top of sludge to bottom of outlet tee or baffle: M Scum thickness:Z" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: JE How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY TWO YEARS, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) Wa Dimensions: Wa Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:-nLa Distance from bottom of scum to bottom of outlet tee or baffle nfa Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n& revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 447 PRINCE HINKLEY RD.CENTERVILLE Owner: MR.RICHARD KIELEY Date of Inspection:6/1/99 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n1a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n(a Dimensions: nta Capacity: n[a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:ji/a. Alarm in working order:Yes_No_: NO Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NIQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 447 PRINCE HINKLEY RD.CENTERVILLE Owner: MR.RICHARD KIELEY Date of Inspection:6/1/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: _WA leaching galleries,number: jaLa leaching trenches,number,length: WA leaching fields,number,dimensions: n& overflow cesspool,number: n/a Alternative system: n& Name of Technology: -a& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT WAS 3/4 AT THE TIME OF THE INSPECTION RECOMMEND PUMPING NOW. CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: D& Depth of scum layer. n1a Dimensions of cesspool: nta Materials of construction: Wa Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:Wa Depth of solids: Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) D& revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 447 PRINCE HINKLEY RD.CENTERVILLE Owner: MR.RICHARD KIELEY Date of Inspection:611/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a v A D6c AA 31 X s� N a� 13C 3) revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 447 PRINCE HINKLEY RD.CENTERVILLE Owner: MR.RICHARD KIELEY Date of Inspection:6/1199 NRCS Report name: nta Soil Type: nLa Typical depth to groundwater: nta USGS Date website visited: n& Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 �70/aa-5 At0CATION- �SEWAIGE PERMIT NO. VILLAGE I N S T A LLER'S NAME A ADDRESS C . r S U LDE R OR OWNER oa �SDATE PERMIT ISSUED �< DAT E COMPLIANCE ISSUED 4 7 0 Y3� .............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........................................OF.....................I.................................................................. _. Appliration for Dhip a al Work.5 Tnnotrurtion Prrutit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System ..... ........ ......1 .: u< ......... .......... ....._..._..........••-------•---•-...----- .......--------••--------------....------ Location-Address or Lot No. ............ ... . .... ............................................... .................. ..................................................................................0............... Owner ................•-----..Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ____________________________ No. of persons---__---_---____-_-_-------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ...................•--••-----•• - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid*capacity------------gallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_---------------- Diameter.................... Depth below inlet.................... Total leaching area............___.__sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by............................•...........................-................. Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water-----------------------. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------------_----- ....................................................................................................--••----•-------------------•-•-•-•-•--•-...__......_-......----••----------•---••------------------....... ---------- ------------------•------•--•-------- --- 0 Description of Soil........................................................................................................................................................................ x U •••-•-----•--••---••----•----...••---•-------•---------------••--•--••---•----•••--•-----------•--._...-----•--•-•----------------------•------•••---•---•------------•-----------...------...__._..__.. -•------------------------------------------------------------------------------------•------------------------------------------------------------------------------------••----••-••---------•-----•- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -----------•------------------------------------•-•--------•------------------------._..........•-••-----....--•------. .•------•-------------••-------•--------------...----------------._.------_-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. etfollowing ned....................•--------------•-------••----------------._.....-------•------ -•-•-- D Application Approved By Date Application Disapproved reasons-----------------•------------------•-----------...-------------•--------------------------D---- ------------ ------------------------------------------------------------------------------ Date PermitNo..........................-............................_ Issued........................................................ Date wFEB t' ��jj � THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............. ............................O F....................................... Appliration for Bispaaai Works C onstrurtinn rumit Application is hereby m de for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System.fit`-`' -• :.... .. -----------. ....... -•-- --------- -- ------------•-•-•--•........-•----•--•--••-•------....--•--•.•--- Location-Address or Lot No. ............................•... ................... ._...........---._...---••-••....................__... ......_......... W Owner Address a --------------- ..---•--------------....... Installer Address UType of Building Size Lot__--------•----------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a � Other fixtures -----••--------------------------•------•-------•-----�--•--------------------------------------------------------------•-------------•-•---••---•---- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 0-4 Gir Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 9 .......--•--------•-•----••--•---•-------------•-•--••-••--...•--•--•----•-----•......-•••----•.............••••--.........•-•-•--•••-•-•--------.........--- Description of Soil........................................................................................................................................................................ x V ....................... ...............................................................-.................................................................................................................. W x -••-------------•---------------•••-------•---•---•--•--•------•-•--••••--•-- -•-•--•-•-------•--••----•-•---•------•-----•---------•-•-••---•---•--•---•---•------••---•------------••-•--••---•--•--. U Nature of Repairs or Alterations—Answer when applicable................................:.............................................................. -------------------------•---•--------•------------•--•-•--•--••-----••---------------------------•-------------------------------•-•----------------......_....---••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igned................••------....----------•-------....----...._.....--•••----•-•---•- Application Approved By;t-.'--:... . ----------------•--•---•--•-•--•---•-•---•----- -- - - ...... Application Application Disapproved or t following reasons:-------•------••---------------------------------------•------...---------..................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF........................ Trrtifir'd a of TI-Im littnrr TnO ,..S T CERTIFY, That the Individual ewage Disposal System constructed ( Repaired ( ) by..... /9257 /F Instiller at °I - .................. has been installed in accordance with the provisions of TIT 5 ofTate Sanitary o �cr,��ed in the , application for Disposal Works Construction Permit No.___.__ ""_ 44.GC_________________ dated__..<.:____.__ .___....Y___. .._ ` s�� ....THE ISSUANCE THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM WILk FEU�j ION SATISFACTORY. DATE.... .......y� :..rl....................................................... Inspector --•----- i= .....--....••-•-....-----••---•••---•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No....................... FEE.:......... ........ �a. k� �nn�#rnr�irrn rrnti� Permissionis eby granted......... ,-----•------------ ---- .-• - ------------................................................ to Construct Re ( ) Individual e Dis System at No Street as shown o/thea n for Disposal Works Construction ermit _.......•........._ Dated•......................................... ------. ---•--.' --•----------------------------------------•-••----••-----••--•----...---....... Board of Health DATE---=7 �-------••---- FORM 1255 A. M. SULKIN, INC.. BOSTON 5I►J6LG- FAMII-`( ►JD GAZaAGE- 6Qjw0ER ti p/a►LY FLOW = 110 X 3 Pn , SEPTIC TA►.iK = �'s•3nw15o% = A95G.P. q �JS� l000 GAL. I ► s,L43 ot5Po5At_ PIT USE Iaoo Gal-. �j►D�Y�(AlL AQ6a = I JO S.F �,P u �50 5.F• X .2.5 - 37 i, G.P C� AQeq PQo BOTTOM AQR A: .. �0 5•F, _ 1 . Plr 5� s.� x I• o 5o G.P � -TOTAL. DA I L`Y 330 G.Po _ ;` e PE2�o1_ATIoN RATE ; 1"IM ?PAIN oP--LC--55 N, p� '9 �TN 41_ ---- I-I LF Ef:! '�, P�1N OF Mq DAVIDC. �yG 'r:` �t• `-,~ THULIN gfL�NcE N�►iCKL �/ f+G• BAY•TER Z'-i'' L.) No. 29976 v fdi 27(Y18 9 O F CS S 7 f( s 5� TOP FWD=55 TE f `�T P Zags -zF �`r/`>' 1000 INV. a I�irl MST.ST. �j' ii S�aso�c `P`. _ 0uX INS. 5 E Pr�G `Sv -- -� �' I Ooo INV. 5^O G TA►1K /0 s �Dy INV.p IT r ,j 7 VJASNt:D . 670HE it ------------------- F►G p P L•o-T P 1_A 1J C L� � P R U F I L� L o C A•-T I O N C��'r�L'�,/1 LLb. 11 I �1v l w O CAL a Ill `�D �AT � 4 ;Vp V14 7-ffZ tl-1 R E F E 2E N G� �. �OtJW►�P'1�o� SNawN i CE czTI�Y -THAT 'TNT L I{EREaI.I GOMPt_�(5 rlITN "THE Sto�LItJ >= fJr '(otrV►J O� �..,A�C�7TA(% N� IS IJU1� /� I {�!•� �� L0CP.TE0 WIT Q ND GLOoD PLAIN • PAT 1r A� � ,.}c�.ti�r••-- g A-AT E Q. REGI��i✓26�'I-Auosuev�Y�es . I "Tins PLati t s Nort 4n5c T,'-) C>►d AN os F-rGQ-V1LL - M�•ss 1Nc�T _UM6NT SVeVe`( �-TNE pl=F-SETS SUOuI,� APP�-ICP.r-IT l�loT DE USEDTd DE7E.R1^ T Itit� L. I 1IdE J I I ��I►J6,LL FAM1L 'Y - gCDR�oM I ► 1D GARBAGE 6QIWDEW- 'L ,.�3 C' p Q pAILY FLovv II U X 3 = 5EPT%G TP►-JK ='4Z3Uxi5o01' - A "6-Pp U5� l000 GAk-. , it S ,143 o15Po5AL PIT v5E IooD GaL. S t D�r(ALL Peon 50TToM AQ2-: A .. Ico 5F - Pi 5a S.P X 1• 0 r7o � P�� - t 'ToTA GN 1- o�SI ° ;g-2�j c7.PD. -ToTAt- DA I �Y F�-ov! = 33o G.Po ,N Tc�i � A- -41 - e PE2CoL-ATIo�1 RATE ] I''IN ZMIN c)P-Le55 '� to • C1 — �► Li ri..�.,• g.,� LPLOF -9Sf $�j.�'•� � As i DAVIDC. •'l:; ��• I• THULIN P Y I1AXTER Z', c�� No. 29976 y (... A es S/O_ /4 f; LLL• �`. 5�z TOP FND =SS z d I. n�►yl �� loou 1Nv. GG.t_. MST. ST. 1► Sv$SO/� 0Ux INv. SEP7IC I. 3 I o0o S�o Gc 1N�• , 50 S�uD� LCAG11 INv INt/. p IT I I �.-IJA✓�z, W u SDI 2 Sa•�L I 7 v!A SNG D �; 6TvNE CC-- sZ-r 1 F 1 e D P L o-r P L a►.a PRUFIL� toCA7lotJ s_ ( �r � P.Ta 4 N o S CAL E I � V/Q 7-eZ PL_p,h-! REFSIZEN G�p CEczT�Y THAT TNT �pvIJDPTIOt� SNoVYN NE2Eo_ti GoMPI-`(5 YJITN T HE S I D�L1tJ L 19 t_ -rowN o;:-- LOCp.TED \41 1J NE G1-ooD PLAIN! - t �-- D ATE: A� GZ ..)t� "-'`-'�-..•- Bp,XT E Q.� 1�•I`{{= I N C R E 6 I.S-T j-Z F,D t1aQ o s U Izv V-- S -fu►S PLo ►.I 15 ti1oT 4�5�c� p►d Ar1 o5"rEIZVILI� INSrR�MEt�T Sv2V�`( "T1tE UI-FSETS 5u0uL.D ri rr- Z �1ti1� L.oT �_ II-1E.-j • APPLICA►w!T �j►►•I G LL F A M►l.�f- :3 B C.O2 o F M 3111 uO 'GARBAGtr 691WDER .p A►.I.-Y F 1-o W .: 11 O X :;5 �: 7 30 6 P. ©• SE.PTLG 'C'lP►,�K..= 3.3ox.l5o%.=�95G. � . • � _ 115.43 _ D15Po5At_ P1'T' vSE.' ►Q GAL• �50 5.1= x a•5 - 3�5 G:Po A teeA- Pao U BOTTOM 5 F � 'TOT A 1_ 42 - -roTA1- pA►LY F%__0W = .33P-6P0. T4 0 PE2CoL.AT►ON RATES 1'�► 2MrN o�t_E5$ N iT ,N OF M .� RICHARD DACVID v\r THUIIN `�. Tt'�t VA Nt►.JCk LF_Z Rp �ti. (3AY.TER a. ; v. No 2:497..6 o` �. w `� 4C/s DER ld¢ 'Po.�FC1 STD SUA1� Ss/ON-AV'E. / To P FND:-5} -r E��T �Z�3 S , fG • 5� ,,,,,,, S o'rST. a :INd: G t_ sb, SEPTIC c�3 6�.X ',�D•G -ra NK �0' IOoo INY, LSA,CN PIT INV. INS/. r �7 WASNGD / 6TvN� tLr y� Q--r I v- I c P P42UF11-� �.. I. . ;JOJA P1_.AN : �ZI✓FENGE I GERT1FY TNET TN"�: OrJWDs'i 1r PwN A IJ D 5.6T E G K 2.6 Q U 1 R_i✓M I=N'1" F 'T 10�' -TOWN oF:l `�WIKOAnat.: ANl> lS I•ldr P��.1 N VIL- ., (_�► �{ �k� L.OG P.TE O -\NIT. ?J.. 1.1 E G y � D AT 1✓ "A•'Z cl _ _ Gl r'.'�✓t..- B A XT t✓ a h1 Yx 1`N L•: . REG I S'S�Q•Erp 1.AN��:-�11zY���5�5 I TGOS � V f L _ 15 •PL 5-W, OrT IuSTR�M�►NT 5V2v�Y �.-rNE-�1=FSE'T5 :��v�? _ T �E..�U 5 E-p T d O.E`C>r•�f^1#mil E �.oT � {�E5 -.. _ �P..P-1~I G;;P. ,. ...... d ASSESSORS MAP : TEST HOLE LOGS NOTES: PARCEL : 2C FLOOD ZONE AlD% SOIL EVALUATOR - i L� 1) The installation shall comply with Title V and Town of Barnstable Board of WITNESS : Owls�A Health Regulations. REFERENCE: G277JD 151/ DATE: U 2) The installer shall verify the location of utilities, sewer inverts and septic _ - ~ / 3 components prior to installation and setting base elevations. )(]�� � � � ��47�'/.:� -yt 2. -. �' ^ _ _- PERCOLATION RATE ,G, �41 � 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot r.-.__.. ..__. ._ -. _ -...._ �d' p . The first �' --� two feet out of the d-box to the leaching shall be level. TH- 1 TH-2 4) This plan is not to be utilized for line property determination nor any other A5►q..i►J 14w1 I � w '^!C� #� purpose other than the proposed system installation. �' I n' V- /- ' td `� 7 5) All septic components must meet Title V specifications.p ations. �� bV1,3 Lv M (D 5�p t� 6) Parking shall not be constructed over H 10 septic components. 7) The property is bounded by property corners and property lines. ! 8) The property owner shall review design considerations to approve of total LOCATION MAP design flow and number of bedrooms to be considered for design. Receipt J"t of payment for the plan and installation based on the plan shall be deemed Gapproval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per d Title V specs. 10 System components to be 10 feet from water line. Sewer lines crossing the - - water line shall be sleeved with 4 inch SCH 40 PVC with ends route g d if l -- - `- - - applicable. The proposed SAS is being installed below the water service SEPT I C - SYSTEM DES I G N line. The line is to be sleeved as aforementioned and maintained in place. ` 11) If a garbage grinder exists it is to be removed and is the responsibility of the .,� owner to ensure such. % ------ � - -------� ""-�"- � �1 FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line. lD Mill, 13)The installer shall verify the location, installation.quantity and elevation of the sewer j BEDROOMS AT I I GAL/DAY/BEDROOM - �I�DGAL/DAY lines exiting the dwelling prior to the nstallat n. oFIE" SEPTIC TANK 1 Mid I �"D GAL/DAY x 2 DAYS - GAL USE GALLON SEPTIC TANK Iwlt� ,O OIL ABSORPTION SYSTEM ���H9Mgs - .. rm VIASON �G SIDE AREA: Z�X 2-q �` 1�✓ 2•-X +1 J ' sgN1TAA�!' A/' BOTTOM AREA: ! 4�5EP " I C SYSTEM SECT I ON a or 0 ) I wIN 0 I I , IND GAL 1`,II �2DV/+ r SEPTIC TANK W v33Z _gTGt4rZ 7 ItjLC I4iN01bf Va r SITE AND SEWAGE PLAN LOCATION : A q -a-iw �I iw 4,�o PREPARED FOR : T26 -0 M � 19'� SCALE: I ' a w DAV I D B . MASON V-4 DATE: t � z DBC ENVIRONMEN AL DESIGNS EAST SANDWICH . MA 3 DATE HEALTH AGENT ( 508 ) 833- 2 177 w Z