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0129 ROLLING HITCH ROAD - Health
129 Rolling Hitch Road Centerville A= 192 - 105 lIl1 �QEcrccFor J n, ti UPC 12543 No �'srco ` HASTINGS,NIN TOWN OF BARNSTABLE ✓✓�� a LgCATION 1Z 1 RcsIft ?y Rf �4 4 K) SEWAGE# 0 6 Z- VILLAGE C4-4f--1J "Of ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 13 rq LEACHING FACILITY.(type) 5-3-0 !16A— ze) 37 rX NO.OF BEDR OMS OWNER PERMIT DATE: Z����l f COMPLIANCE DATE: 3—� 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 110(`4"Y` z`f 2 Ys 1 t�2 ? y6 r LD 1 f� Po l `�T/WN/OOF BARNSTABLE ,LOCATION k%l1n �yLL SEWAGE VILLAGE� 1't� �' SSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO.` ,. I SEPTIC TANK CAPACITY JOB LEACHING FACILITY:(type) (size) 2 Y� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No M2 vZ 1Ti' l9 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppfication for Disposal .6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Lo���Address o r`o�o. /2 j oi'/it'✓` i i K k • Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 2 2 r,<C, F� Installer's Name,Address,and Tel.No. (--jef- 9 Designer's Name,Address,and Tel.No. / �`G.i �!? ! ew/i it. �j✓r✓✓ �N G d li S�Ult Type of Building: / Dwelling No.of Bedrooms `/ ! Lot Size sq.ft. Garbage Grinder( ) Other Type of Building J No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) cyIeId gpd Design flow provided y� y gpd Plan Date s�L�`l7 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Za S 6 411a it CXt�mi,-,5 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 a not to 1 the system in operation until a Certificate of Compliance has been issued by this Board of Health. /G SigLied Date —/5! Application Approved by Date ;�' (5-j Application Disapproved by Date for the following reasons Permit No. 9 0 C — Date Issued 2 No: ArW� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: S Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYicatiou for -Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair'( ) . Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lott No. /?5 �of/j�.,y A i f-C f� )( Owner's Name,Address,and Tel.No. Assessor's Map/Parcel f Installer's Name,Address,and Tel.No.P �' ?�6!� 9 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 11 Lot Size sq.ft. Garbage Grinder( ) Other Type of Buildings S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 4/4-'D Ad grL ow-pzovAed y�/ gpd Plan Date '7-l�/�/� Number of sheets "2 Revision Date Title Size of Septic Tank U ')yffype of S.A.S. g )o 4L/a" (LiC„r1e.f Description of Soil Nature of Repairs or Alterations(Answer when applicable) Ae 4 4 e 2�f 2 3 ! t 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 �""�- Date Application Approved by �- Date Application Disapproved by Date for the following reasons i Permit No. t7 ( 0 Co Date Issued << +' 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 ���19G,d✓n D ey, ee!62.� at Z r has been constructed in accordance with the provisions of Title 4nd the for Disposal System Construction Permit No.,901 - -dated ;t ��i r Installer h4 Designer #bedrooms 2f Approved desig ow p gpd The issuance of this permit shall of be construed as a guarantee that the system ill fun 'o (�d igned. Date / Inspector ---- -----------------------------------------------------------------------------------------------------------------tK/ -------- Na o'�©( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstrm Construction 3perutit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at Z cJ y�p l�i w;l h ' �C C C A fit/✓,w e 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 permit. Date ;t " /s r Approved by U Regdfatt—,"'Sor ices R,tchard V::Scali;,.Intierin�„1),ixt�ctut' Public health:&D;<AsW6, T hotllas:M,Kean .Directoi ?00 AlainzStfeet,Oyl flats,YIt1,f)?601 Office; 508-56?-'!.(it4 508 790 4 Install`er,.&Designer Cerfification Form 'Date.:, Sevna,gpe:.Pei refit#. Assessor's NI p�Pai cel � •,���.. � ' it..S�f�S�4't� Itistallei:> �!l�i�'r��y :�`e�-� ).��'�'' -^� Address:, 1Z W Cs `�-lcJ 92t Address:' - -- _ Oil DI j3 0✓!iS was issued a petii�it to install a (date' {iristalle) Sep"'tic systerri,at � l���5 ¢'('.� ELr r^ basc,d on a design drawn by (address) � � 14 19 trltc r t'i���i/1 ! lticsJ+�r dated ;.(desigiiei) — I certify than the septic sys(ein referenced abov e`Maainstalled substantially act ordiilr> to the desrgil, 'which may inc ude minor approved_changes such as later,-d eel cation of"the di5nibtitioii.box anet/or septic tank Strip. out (if'required) was inspected and; the soils'. ti�eie.0Lind satisfactory. I certify that the septic system referenced ab ve eras installed with triiijpr changes (i.e. greater than I Iaterid relocation of thc. SAS or any vertical reloc.atiofIi of and%comhoi ent ' of the septic system) but in accordatlt-e Wiitli State Local iZeg rlatt_ons_. .Plan.ie�risioil or' c rtifsed as-built by designer to follow. Strap out('!f retluii-ed) was inspecti d<and the soils 'were sati;;Factory,, - C certify that the system reter�eaced abovle was coilstructed wr;l the terms of the T1�1.appro�rri rs ` applicable). 'TE (,istaller's Signature) M�NIt E - �p'.;351ti9 ( esi>n ir's Si nature g .° g ) (Affix Designe : ere) x PLEASII RETURN TQ BAkNS'IABLP PUBLIC HEALTH DIVTS:ION. C.EI2TIFICf11'k,', DE :CO1vTPL;IANCE �ti ILL NOT BE :T"SSUED UNTIL BQ'TtI T.E1I;S :FOR tit AND AS_ 13UILA-CARD ARl RECL•IVED BY TTIE BARNSTABLE PUl3L.IC HEAL'I'II DIVISION'. TIIA:NII, l'UU_ Q Sopti;;Desi-no r;Certificeti on.Fomi Rev 3-14-11doe Engineers note:This Ceriiicauon is+limited to"an,as=built itspebtion of system "components as installed price to backiiil.The ngineer dtd nat supervise const uction,,of the.system.;The installer assumes respo tsibilitysior'all'materials,workrnanship;'backfiliing Io,speciriod9rades'with proper compactio:i and setting rise,rstcuveis as shoiyn.on tF;e deskn.plan. Town of Barnstable p* Department of Regulatory Services s „ 14 Public Health Division Date , p 1639 tea .. 200 Main Street,Hyannis MA.02601 t ; L0 Date SchedWed Time��_. Fee Pd. .� (a d l�� ,j T ail Suitahility Assess enit jor Se, age Disposal Performed By: I ✓ CG"t p(/ SL�i—fZ �;Witnessed By: LOCATION& GENE, INFORMATION Location Address `Zt� /Zo YtV79 P `4-c1, jr-M Owner's Name 15, r i<A,, Cep ✓ v' 11-� _''' �- Address--Iz9 -fZa1.1ih5. ./-4=1-c_1,-J- C'eh�,e r 10 kr MA C Z(D3 Assessor's MaplParceL. , q Z _1 v� Engineer's Name ``ete,—.;w7y We t" NEW CONSTRUCTION �� RE/PAIR X Telephone:# .5 0 $-14 77—5 313 Land Use'_. )—CppS/r� e l W ( Slopes(TO) — W Surface Stones a Open Water G� L Distances from: Q p y ft Possible Wet Area�3 ff Drinking Water well 7 1� ft Drainage Way Aj� 1� ff Property Line Z t.—€t Other ft SKETCH:(street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) ............ �(tiw'e t Parent material(geologic) ®J Depth to Bedrock Depth,to Groundwater. Standing Water in Hole: Weeping from pit Pace �'`� f�` ©` 1a2 Estimated Seasonal.Hgh Groundwater. �3 q r,%-ckx DETERMINATION FOR.SEASONAL HIGH wATE,R TABLE Method Used: Depth Observed standing in obs.holes _._—_. _ in, Depth to Soil mottles; in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adl,factor y r Adj.firout dwater Level PERCOLATION TEST Dote. Thtte .�._ Observation (n� Hole# �er(� ®r\ t�b Time at 6" Depth of Pere 4 z (V 1 111101 Time at 6" Start Pre-soak Time 0 1 �G 'rime(9%6") End Pre-soak Rate Min:/Inch. Site Suitability Asscssrnent: Site Passed / Site Failed: Additional Testing Needed(YIN), Original: Public Health Di9ision Observation Hole Data To Be Completed on Back----------- ***If percolation testis.to be conducted.within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:GS EPTIC\PERCf,ORM.DOC 4 DEEP OBSERVATION HOLE LOG Bole# Depth from Soil Horizon Soil Texture .Soil Color" Soil Other Surface.(in.) {.USDA) (Munsell) Mottling (Structure,Stones;Boulders,. o i tenci Gravel) =lZ F)L.Q z-)-7 A qua S4,,J to`tf,`i/z -C 2 s DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil. Other Surface(in.) (USDA) (Munseli) Mottling (Structure,Stones„Boulders. Consistency.% rave w-1 16 Low", 5,-4 tayGL b —yo (S ark .i -4 aU`fVZ- s/F M-C�-al 2-s`C I-IL cr ` d (l DEEP OBSERVATION DOLE LOG Hole Depth.from Soil Horizon Soil Texture' Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistency. Gravel) . DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA), (Munsell) Mottling (Structure,Stones,Boulders. Consi ten 'j 2LQra. Flood Insurance:Rate.Map: Above 500 year.flood'bound6y No—. Yes Widen 500 year boundary No Yes: Within 100 year flood boundary No Yes �.j. Depth of Naturally Occurring Pervious Material Does at least.four feet of naturally occurring pervious material exist all areas observed throughoutthe area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification l f , I certify that on 1 _(date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was:pe rformed by me consistent with the required train' ,expertise and experience described in�10:CMR 15.017. Signature y..�1� _ Date Q 1S,EPTICIPERCFORM:DOC YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town.(which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: 3� Fill in lease: ' � '� �+ APPLICANT'S YOUR NAME/S: Rr;�lr► 1C,nfl_t1 p � �` teTy YOUR HOME ADDRESS. BUSINESS1077 try` � Cria$--73-7--7773 �;�� TELEPHONE # Home Telephone Number NAME OF CORPORATION: NAME OF NEW BUSINESS Kill Il!s /I d ki. TYPE OF BUSINESS ;oN- IS THIS A HOME OCCUPATION? ✓ ES NO ADDRESS OF BUSINESS I - 014 MAP/PARCEL NUMBER 1 1 2 iCff (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST -GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual as b Z? ermit requirements that pertain to this type of business. " -Authorized Signature* MUST COMPLY WITH ALL COMMENTS: * �IVARDOUS MATERIALS REGULATIrw. 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of th e licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: + ' Date: 3 /t S" /i�00 i' .TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: l�nellS FA►'►1r` Y BUSINESS LOCATION: J29 Ifir4f A` i/) T IM4 r1. VZ INVENTORY MAILING ADDRESS: /29 krtly 84P ZJ CUT- P"4 ouz TOTAL AMOUNT: TELEPHONE NUMBER: J-6 - 72-LU79 CONTACT PERSON: Vri,4ej ky�n EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: -��� A��°°`�" -- 0 INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW i USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) _ Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Not for Voluntary Assessments �;M a Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer,use 129 ROLLING HITCH ROAD, CENTERVILLE only the tab key Property Address to move your MARY GLYNN cursor-do not Owner's Name use the return key. 20 CYPRESS ROAD Owner's Address MILTON MA 02186 City/Town State Zip Code Date of Inspection: 5-7-06 Date < 2. Inspector: MR. ROBERT A. DRAKE, P.E. Name of Inspector f KCJ ENGINEERING Company Name 66 GREENVILLE DRIVE I - _ Company Address r f FORESTDALE MA 02644r i City/Town State Zip Code 508-477-5048 Telephone Number Certification Statement: certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true accurate an d 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: 7 ® �( M'Passes ❑ Conditionally Passes ❑ P H OF p� RD�6Ef?T �y ❑ Needs ,Further Evaluation by the Local Approving Authority DPAKE N 5-08-06 ° 642, y m Inspector's Signature Date 9a t�TEP �/ The system inspector shall submit a copy of this inspection report to the App SON L ty(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. ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 129 ROLLING HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D-or E/always complete all of 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: B) System Conditionally Passes: ❑ One or more system components.as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the.Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined,".please explain. ❑ The septic tank is metal and over 20 years old*o.r the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Page 2 of 16 I - Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 129 ROLLING HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: i ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments a, Subsurface Sewage Disposal System Form M A. Certification (cont.) 129 ROLLING HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) y determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is.within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: ROLLING HITCH CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Page 4 of 16 Commonwealth of Massachusetts - Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 129 ROLLING HITCH ROAD Property Address , CENTERVILLE MA 02632 City/Town State ZipCode MARY GLYNN 5-7-06 Owner's Name Date of Inspection 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 ❑ ® 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must.be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails:The system owner should contact the Board of Health to determine what will be necessary to.correct the failure. ROLLING HITCH-CENTERVILLE-GLYNN-T5lNSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal.System 11/2004 Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A.. Certification (cont.) 129 ROLLING HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's Name Date of Inspection 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. ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Page 6 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form' Not for Voluntary Assessments Subsurface Sewage Disposal System Form B: Checklist 129 ROLLINGHITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's Name Date of Inspection 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? Z ❑ 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? ® El 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(3)(b)] t ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection.Form:Subsurface Sewage Disposal System 11/2004 Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 129 ROLLING-HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 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] El Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ 'No Water meter readings, if available: last 2 ears usage Z°o y ` I PD . , ( Y 9 (gpd)):Zoo S- : 7/ G Pb Sump pump? ❑ Yes ® No Last date of occupancy: SUMMER 2004 Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A 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: Last date of occupancy/use:. Date Other(describe): ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 sur Page 8 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form G1M C. System Information (cont.) 129 ROLLING HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's-Name Date.of Inspection ' General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow.cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other.(describe): Approximate age of all components, date installed (if known)and source of information: HOUSE BUILT IN 1990. HOUSE IS USED ONLY OCCASIONALLY NOT SINCE 2004. WATER USE IS FROM WATER SPRINKLER SYSTEM. Were sewage odors detected when arriving at the site? ❑ Yes ® No ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 129 ROLLING HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: APPROX. 2 FEET feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): SEWER PIPE APPEARS TO BE IN GOOD CONDITION, NO SIGNS OF LEAKAGE, TEES ARE IN PLACE. Septic Tank(locate on site plan): Depth below grade: 0.75 FEET feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,500 GALLON TANK INSTALLED IN 1990, ALL COMPONENTS APPEAR TO BE IN GOOD WORKING CONDITION. If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,500 GALLON Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness 0,! Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? MEASURED IN FIELD ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Pagel 0 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 129 ROLLING HITCH ROAD Property Address CENTERVILLE MA . 02632 City/Town State Zip Code MARY GLYNN -5-7-06 Owners Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ALL COMPONENTS OF THE TANK APPEAR TO BE WORKING PROPERLY.WATER LEVEL IN TANK APPROXIMATELY 1.7 FEET. LOW WATER LEVEL COULD BE ATTRIBUTED TO VERY LITTLE SEASONAL USE AND EVAPORATION. NO SIGNS OF CRACKS IN TANK. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): ROLLING HITCH-CENTERVILLE-GLYNN-T5lNSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments w Subsurface Sewage Disposal System Form C. System Information (cont.) 129 ROLLING HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN. 5-7-06 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: N/A . 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.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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 SIGNS OF BACK UP IN D-BOX. WATER LEVEL IS SLIGHTLY BELOW OUTLET PIPE.THIS COULD BE ATTRIBUTED TO.VERY LITTLE SEASONAL USE AND EVAPORATION. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Page 12 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments .c Subsurface Sewage Disposal System Form . C. System Information (cont.) 129 ROLLING.HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's Name Date of Inspection 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: LEACHING PITS LOCATED ON SITE PLAN AND ALSO IN THE FIELD. Type: ® leaching pits number: 2-6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: - 0 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.): PITS ARE LOCATED IN LIGHT BRUSH AREA. NO VISUAL SIGNS OF PONDING OR HYDRAULIC FAILURE. ROLLING HITCH-CENTERVILLE-GLYNN-T5lNSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal.System 11/2004 Page 13 of 16 I Commonwealth of Massachusetts _ Title 5 Official Inspection Form o Not for Voluntary Assessments �,M •..` Subsurface Sewage Disposal System Form C. System Information' (cont.) 129 ROLLING.HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Numberand configuration N/A Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of.groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage.Disposal System 11/2004 Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4'IM SV 0 y,•w _ C. System Information (cont.) 129 ROLLING HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN _ 5-7-06 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or.benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Z. A 6 3 Z y Lf y 4 ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System- 11/2004 Page 15 of 16 Commonwealth of Massachusetts Title 5 Official In section. Form p ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'M C. System Information (cont.) 129 ROLLING.HITCH ROAD Property Address CENTERVILLE MA 02632 City/Town State Zip Code MARY GLYNN 5-7-06 Owner's Name Date of Inspection Site Exam: Slope ol® Surface water N Q N G Check cellar PS Shallow wells NaANE Estimated depth to ground water: 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: 9-28-89 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: ACCESSED 1992 GW CONTOUR MAPS You must describe how you established the high ground water elevation: 1992 GW CONTOUR MAPS: GROUNDWATER ELEV, IS APPROXIMATELY ELEVATION 35' ABOVE SEAL LEVEL.FROM BARNSTABLE GIS MAPS INDICATE GROUND ELEVATION 69.2 FEET NGVD:Also CHECKED ORIGINAL SEPTIC DESIGN PLANS DATED 9-28-89. ROLLING HITCH-CENTERVILLE-GLYNN-T51NSP.DOC.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System 11/2004 Page 16 of 16 r , j I f j ; ` f i Lr� i S � P �,�: _ l�,!f`^A'1d1t b .. � � � 1 _ � cP .-�.�4 P 2 ~•^ ft`9 d�'1 tew i'�, , J yA. a i a 4 Cw I cb� f i , r ) ;r �,i � L.S ..a✓"( .��i:,. �II ..��� �� t w'Y �I,A a i�, ... ..Y. ..�'i ���� �� - . 77 I I 1. P i j J 1 1 t - i 19C? _ X on No ...... Fps ,.. THE COMMONWEALTH OF MASSACHUSETTS 4)A _ BOAR® OF HEALTH ..............OF..... 1•T � '��- ..... ....................... Appliration for Dispefial Works Tnnuarnrnnn rami# Application is hereby made for a Permit to Construct (✓1'or Repair ( ) an Individual Sewage Disposal System at: n _....-•-•--------------------------L: -- ................... Location-Address n nLo r�N Q✓=7°cC_ !=a�i 7�`I-8 ,��_Q k V, ...1� ?r N �� y.S?.......... _� ..._.--•---- ......_._... .. ........_.._ .... - t 1 Address .................................... _............... ---- ........ ..... ...... Installer Address Type of Building Size Lot... �_!9 .......Sq. feet Dwelling—No. of Bedrooms............ ..............Expansion Attic (I-JA) Garbage Grinder (No) '4 Other—Type T e of Building +-�1�.............. No. of personsWA G.� yP g -•--•---- p .............. Showers (�,/,a.) — Cafeteria (+-JA) Other fixtures _.... ``'LA......................... n per day. Total daily flow......`f::.................._............••gallons. WSeptic Tank—Liquid capacity!! .gallons Length._l o�::.. Width..!�...... Diameter_-"/A..._._. Depth-.!��:?-.... x Disposal Trench—No._ /!' ......... Width. .ulp....... Total Length....•L6........ Total leaching area...-Ab.....-_..sq. ft. Seepage Pit No..... ..2..... Diameter......4�!_�..... Depth below inlet... ................ Total leaching area---:In_!......sq. ft. Z Other Distribution box Dosing tank (-/A) Percolation Test Results Performed by.._.�!-�!s--�-��!-!!--►--,-_l_! ................... Date.. .�_...IB,_!gS�-_. Test Pit No. 1...4_.'L....minutes per inch Depth of Test Pit...�?.:S_...... Depth to ground water..�t�......... f� Test Pit No. 2.H f t.......minutes per inch Depth of Test Pit....!4......... Depth to ground water..!—:.�........ 04 ..............•••••--••••••••••••-•-----•-••••.....•...............•----......--------.....----------.....••---............••-•--....._.__...------- p TPA 1 �'-�L.s� D��F, Noy � �,aS,ti�A Description of Soil /...................• -------------._... --------------- .-------------- ------------ U � ..... -r L sty r �. .............................................n.t c-� s✓t�.. �►r� 5..-- ---..-.�........................ �J PFt_Skt!rA1° r�''�R� �t 2.5-- $•--�`�C Jrt T�-S)t_r f 14 AAC-0 �rO Nature of Repairs or Alterations—Answer when applicable.... ________________'_'b`'i°� ---------------------------------------•------•........---•--------.......------............----•--•------------------------..•...--------...-•----......-------•--....................•-----.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11 5 of the State Sanitary Code—The undersigned further agrees not he s} tem in operation until a Certificate of Compliance ias been is dobytAthe board of health. l�-, .�►D ••• • .--•••- Application Approved By.... �.. 7 _ Date Application Disapproved for the following reasons:................................-----------.........------................................................. -••-•••--------••-•-•---•----••••.............••--•••-•••-•-••-`•......: � Issued_..._...!._....---•--------••••--•-•--•.••----••-•--•-••-•--••-•---••••••-••••--•-•-••--••...•--••-•.. Permit No....--••---- - � ------ --- j/ 2 � ._ .___.._ _._ -Date.-'__- Date -------------W--__-____------------- No.a_.._..__ / Fss � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............OF.... Appiiration for Disposal Works Tonstrurtion P.rrutit Application is hereby made for a Permit to Construct (✓f or Repair ( ) an Individual Sewage Disposal System at: n,t�, C ?�r��L !-d S nn Location-Address or Lot No. - !::. _E:=..•-•-..-.n: -�--•Y.1wPCrz.l» ........................ne; --. ----•---.-.. Owner Address W �•t� �.�,r.r� CIC� Installer Address Type of Building Size Lot--- -,..!`l .......Sq. feet Dwelling—No. of Bedrooms............ ..............................Expansion Attic ("1.�) Garbage Grinder (Na) Other—Type of Building .... JA_•............. No. of persons.....ly lf........__.___. Showers (tiIA) — Cafeteria (..!A) P4Other fixtures ............ 1 ---••----•-----------------•---•-....---------•-•-••-----•-----•----------------------•-------._.........-------•-•.........----- W Design Flow...........L_!.52.........................gallons per person per day: Total daily flow....._.�1.._......._......_.._......gallons. WSeptic Tank—Liquid capacity.1...0..gallons Length..!?'s7.,._'_._ Width_.-=,'n".... Diameter.tµh.__.... Depth_s::2_'.... x Disposal Trench—No. .......... Width..... /.n........ Total Length....Mlf--------- Total leaching area..._"jo........sq. ft. Seepage Pit No._- 1..x.2___-- Diameter.....k�t'R...... Depth below inlet_._ ?.:...... Total leaching area-- ......sq. ft. Z Other Distribution box (✓) Dosing tank (!A) aPercolation Test Results Performed by.... !-1-.�-5..-. r?±�.� ►..,. :��................. Date..'.SQp-!-...!- .!_ ! D__. Test Pit No. L..<ln....minutes per inch Depth of Test Pit..??: ....... Depth to ground water..!-«r:ti;-;.......... 44 Test Pit No. 2.t-J.A........minutes per inch Depth of Test Pit....4:.......... Depth to ground water..f%tC:1.M=....... . x ..............•----------- O Description of Soil_.__ `_► - 2:s' ��FF + �t)7 Lc�ffiAn �.2: ..+..............................••.-- V �QA.. �-:TL_ .SILT , ....rQ �t...rd f ..rt.� v:ah1�—......�_1...5..--•-•-...........�P.::.-�....�....t_.. r ..... SA.fJ U Nature of Repairs or Alterations Answer when applicable...1ts�-J.P..........................................................`r' 'A r E= `- I4� - ............................................................-••-...-•------._......---.....••••---••---•--------•-•-•---•----•-•••---------••----•-----••--•-••------•-•--•---•-••---•-------•......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'AI TIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ued by the board of health. Application Approved By.......C---------------------------- r -------------- / D Q Date Application Disapproved for the following.reasons:--••--•---------------------•-------..............--•-----------------------•-•-----------------..............» .................................................. .............................................................................................. � � -- � Date ``• Permit No.. ............:_... - ..... _._. Issued. .. ..................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH £:+ O ............................................. (9rrtifirtttr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) by..» V.Z. ..... ......._f .�_. . .-` - -k •-• ...................•----•-••--•........--•---------.......•--•------••......---•-•-----••--- Installer at----- ._..�......---• t? .._. a'X fit... ..........C.t4rier.N1 ...._... has been installed in accordance with the provisions of TITIE 5of T 'State Sanitary Code as des ribed in the application for Disposal Works Construction Permit No....._____� . �`j--------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR�NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No E�� '.�?1e9�.O..................OF... � ��.W!�'1 - .......................................... �J � ;)....1...... �. FEE._......1..�..... Oiopouai Works Tonstrurtivit Prrutit Permission is hereby granted..... --.. ..S C_ditV ...-----•-----•....................................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No.., " �.�. ...rlr� -?, 5 .................... . ...........:.................... Street r as shown on the application for Disposal Works Construction Permit Now 7_..7-1. Dated....... a� i ....... Board of Health DATE................................................................................ `�... FORM 1255 A. M. SULKIN, INC.. BOSTON 4 1 1 _it ♦.�� . — 97——EXISTING CONTOUR Co n crosb Rd N CATCH BASIN x 100.98 EXISTING SPOT GRADE W EXISTING WATER SERVICE �a 97,20 G EXISTING GAS SERVICE oo� Pen Ln + 98.42 —$.H. bb.--- OVERHEAD WIRES 0 Posthn9 �? 97.42 UGVW— UNDERGROUND WIRESMoshe O CURRANT TEST PIT 0 <� r od Ln BENCHMARK O `Q� CORNER OF DECK ® OLD TEST PIT (9/18/89) a �a mq, y PK SET y EL.=99.42 1 1 < r� ell 97,66 BENCHMARK o F v LEGEND 97,88 \ ��� Q. EXISTING SEPTIC TANK �j Q. TOP OF TANK, EL.=97.52 �` LOCUS -J \ N IN V.(OUT)=96.30E w y LOCUS MAP 2� �� \`00 S EXISTING LEACH PITS NOT TO SCALE (� x 98.(,2� '��� S�Stj, CONTRACTOR SHALL PUMP, 98,0 '�� �6`8 SS,, FILL WITH SAND & ABANDON -----� + 98.59 �O• F 98,19 -f 98,79'' 99,33 ��� BH GENERAL NOTES: ` ) 0 N ^N \\ \�� x 98�1 f��ce 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL Y BOARD OF HEALTH AND THE DESIGN ENGINEER. �P 2• ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS n OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE \' LAMP LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: 98,6c� C)� EXISTING 1t ix -310 CMR 15.405(1)(b): 1) A 3' variance to the 3' maximum cover requirement, for up HOUSE(J129) x �1 --•97,53 to 6' of max. cover. S.A.S. shall be H-20 and vented. T.O.F.-99.64E VENT 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 9,2 98,64 �1 — — LOCATION TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE o ( MAY VARY DESIGN ENGINEER. '.o :''.'.;`:�'•. TP-2 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING / " :: ':' : :.• ;. O I ° ..,.,,� I FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 96,19 x ST KE ENGINEER BEFORE CONSTRUCTION CONTINUES. 7 qy x 98,34 9� `��TP-2 �• .3 S. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. 98.85 / `` GARAGE / :.' O 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF / , / 100,�I�i \�� •'., ;;:.'; ; 97, Q I THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF T -1 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. PLAY 7. WATER SUPPLIED BY TOWN WATER SERVICE. .` �., DECK LJ 98,44 � �<v irk 96,82 AREA 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. �... . .. ' jg;66c. 1 O ,Q, / 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS \ LOT 53 :. ,'� / AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE I. ( 96,59 DIRECTED BY THE APPROVING AUTHORITIES, 16,193 ±SF x o 0 � � � �.,.:• I -N 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY -9iM5_ x 98.60 \ + f ?8, I �/� � THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 99.23 fence line �� �� 97.73 ` 110 CONSTRUCTION. SHED 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS [ G Z IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND — 174.86' ,�,� REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). S 83• 98,34 �\\`\ 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE 27 37 _ 97.70 / INSPECTED BY A LICENSED SOIL EVALUATOR PRIOR TO BACKFILL. E 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND i IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. Of Mgss9CyG � PARCEL ID: 192-105 o PETER T. n PROPOSED SEPTIC SYSTEM SITE PLAN M CIVILEE N 129 ROLLING HITCH ROAD, CENTERVILLE, MA No. 35109 Prepared for: DiBuono Sewer & Drain, 35 Content Ln., Cotuit, MA 02635 RfG/STE OWNER OF RECORD F /ONAL E � KNELL, BRIAN D & MARY C TRS Engineering by: SCALE DRAWN JOB. N0. KNELL NOMINEE TRUST Engineering Works, Inc. 1'1=20' P.T.M. 117-19 129 ROLLING HITCH ROAD 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. CENTERVILLE, MA 02632 (508) 477-5313 2/14/19 P.T.M. 1 of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL:92.9 SEPTIC TANK FOR A DISTANCE OF 15' AROUND THE INSTALL RISERS & COVERS OVER INLET PERIMETER OF THE S.A.S. POSED AND SET TO 6" OF FINISH GRADE. PROPOSED D-BOX PRO S.A.S. DECK BACK INSTALL WATERTIGHT RISER & PROVIDE TWO ACCESS MANHOLES TO WITHIN 3" OF FINISH GRADE FOR INSPECTION PURPOSES T.O.F.=99.64t COVER SET TO 6" OF GRADE a CHARCOAL F.G. EL.=98.6t F.G. EL.=98.3f F.G. EL.=97.5t F.G. EL.=97.3t VENT O f f MAINTAIN 2% GRADE (MIN.) OVER S.A.S. ��';� ►�v o ' L = 30' L = 23' � cn S=1% (MIN.) B S=1% (MIN.) 4"SCH40 PVC 4"SCH40 PVC SR (.4 �. 6" agVEDTH " 14" e" aaEXISTING 48" LIQUIDLEVEL ADD INV.=94.22 PROPOSED INV.=94.05 4'GAS BAFFLE INV.=96.30f D-BOX EFFECTI = 12.8' INV.=92.40 T 3-500 GALLON LEACHING CHAMBERS m i EXISTING SEPTIC TANK bo PROPOSED S.A.S. SURROUNDED WITH STONE AS SHOWN H-20 RATED I --- TOP CONC. ELEV.= 93.5t I-----33.5'- �i NOTES: BREAKOUT ELEv.=92.90 SEPTIC LAYOUT INV. ELEV.=92.40 P63ase easesaaa 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE 6aa9666 INVERTS, PRIOR TO INSTALLATION. BOTTOM ELEV.=90.40 8.5' = 25.5' F4!' 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE 4' MIN. OF NATURALLY OCCURRING PERVIOUS MATERIAL EFFECTIVE LENGTH = 33.5' STONEA MECHANICALLY COMPACTED SIX INCH CRUSHED 5' MIN. ABOVE GROUNDWATER LEACHING SYSTEM SECTION ®®®® O STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 3) INSTALL INLET & OUTLET TEES AS REQUIRED. BOTTOM OF TP, EL.=85.8 .- I- ®®®®®® ® ®®®® 37" 4) CONTRACTOR SHALL INSTALL A GAS BAFFLE ON EST. HIGH GW BELOW EL.=85.0 3/4" TO 1-1/2" DOUBLE �F W ®®®®®® ® ®®® THE OUTLET TEE. WASHED STONE cv Z ®Qom® 3" LAYER OF 1/8" TO 1/2" SEPTIC SYSTEM PROFILE DOUBLEwASHL sTaTER FA (OR APPROVED FILABRIC) 102" DESIGN CRITERIA SOIL LOG 4" KNOCKOUT DATE: FEBRUARY 3, 2019 (REF#15,891) 20" DIA. COVER NUMBER OF BEDROOMS: 4 BEDROOMS SOIL EVALUATOR: PETER McENTEE PE(SE#1542) WITNESS: DONALD DESMARAIS R.S.HEALTH AGENT 4" KNOCKOUT / 4" KNOCKOUT 58" SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) ELEV. TP-1 DEPTH ELEy. TP-2 DEPTH DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 440 GPD 97.4 FILL 0 97.3 FILL 0 DESIGN FLOW: 440 GPD 96.4 A 12" 96.5 A 10" 4" KNOCKOUT LOAMY SAND LOAMY SAND GARBAGE GRINDER: NO-not allowed with design 96.0 10YR 4/2 17" 96.0 10YR 4 2 16' LEACHING AREA REQUIRED: (440 GPD) = 594.6 SF BLOAMY SAND BLOAMY SAND 500 GALLON CAPACITY, H-20 LOADING .74 GPD/SF 93.9 10YR 5/8 42" 94.0 10YR 5/8 40" CHAMBERS EXISTING SEPTIC TANK: 1250 GALLON CAPACITY C1 C1 SILT PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED 5Y 5/3 60"M SILT 5/3M N.T.S. USE 3-500 GALLON LEACHING CHAMBERS IN SERIES 92.4 C2 92.5 C2 El PERC PROPOSED SEPTIC SYSTEM UPGRADE PLAN SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES M-C SAND M-C SAND 30/48" 129 ROLLING HITCH ROAD, CENTERVILLE, MA 2.5Y 6/6 2.5Y 6/6 SIDEWALL AREA: 2(12.8' + 33.5') X 2 = 185.2 S.F. 10% GRAVEL 10% GRAVEL Prepared for: DiBuono Sewer & Drain, 35 Content Ln., Cotuit, MA 02635 BOTTOM AREA: 12.8' x 33.5' = 428.8 S.F. Engineering by: SCALE DRAWN JOB. NO. 85.9 138" 85.8 138' NTS P.T.M. 1-17-19 TOTAL AREA:....................................... """""""'.. 614.0 S.F. NO GROUNDWATER, PERC RATE: <2 MIN. IN. Engineering WOYks, Inc. 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET N0. DESIGN FLOW PROVIDED: 0.74 GPD/SF(614.0 SF) = 454.4 GPD OLD TEST PIT LOG: NO GW AT 12.5' (TP-1), NO GW AT 14' (TIP-2) 2/14/19 P.T.M. 2 Of 2 BARNSTABLE G.I.S SHOWS GROUNDWATER 30' BELOW GRADE (508) 477-5313 pop C B- ?R M e r+rDQrinrr , DESIGN DATA STRUCTURE DESIGN FLOW 4 P ti 00� 4 K t o �P D i f3QQ M 440 G D Z 44,0 x 1 , = Co Coo GPD r SEPTIC TANK r LEACHING RATES : SIDE AREA Z ,S GPD/SF BOTTOM AREA GPD/SF LEACHING FACILITY / c.e. �, 2 .f► X Co 7 ( 7T•, 4' ) F `Y Z) � T f\" x � 2, S) + ( Ic>o c ► . a� _ �S2 ADD ,� � y .,� �� PLAN REFERENCE : 3q _ 2 G C� BA/�NST�LjLE 2i� n°���-� \ � � �':;�o / ��E�s , � �i✓ �3oc�� z�,6 .�'r4 G� i z'7 4 o ` i o`r= ASSESSORS LOT N0. MAP # i�l�L Gc-�. o5 NOTE: 40 I. ALL MATERIALS AND CONSTRUCTION METHODS ¢ Y /p " O�A TO CONFORM WITH COMM. OF MASS. TITLE SC ENVIRONMENTAL CODE A L-� A C C t.-4-r' L-,�i C_lt-D 48 4rn t1a Cv _ 7f �� (� / IN OF M9ssq �p�'0 OF AAs r DAVI 'yG H �r C. u g R o rHUI ^' g v No. 2 76 874 fGIST 9E��� Q14' L LA�O i' PLAN � % SCALE T ,� _� EST PIT NO. ► TEST PIT NO. SOIL OBSERVATION PITS � 45 -I•�' _-___ _ _ _ _ -- ELEV. 4� . 4 _ ELEV. �5 . 2 ES _ L f F s •� �A r L>Y DATE 0 T ENGINEER ice/, �/ „C: _. N1 uf�Sc ( LcSA NA 43.5a �'LSoc�t_ 715 3.os i B.O.H. AG E N T, . i 42.�, } j , EXCAVATOR M_____ � L3A�.�flaE S,�RY/�� D. I. i M�D t..1tvt '�rtly b ` M D '��ru-C Ali I J �eA � - - .SIFT S - _T fi- 7-5 r PERC RATE IN T.P. NO. AT�FT. ,2 MtN.11N• . . � • � � I e --- C . w • L-o�Dom__._-_ ,�=\ ���i�- ------ n -------- ---- *-•--- t � ! I �'`''`'U - __—_ ;--+---.�I �-k... / I L.L.L. /�i�:7� . Nip bt-Jm I _ ELLIS & TH UN IN t I Llo cti�ca ►.,OW AT' iZ- E L ! ..,.3G,... r�►t>w A T'-ia. A SURVEYORS AND CIVIL ENGINEERS EAST SANDWICH, MASS. SECTION THRU SEPTIC SYSTEM _J -T �,--A., SCALE I tom' HORIZ. I „= S' V ERT.