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HomeMy WebLinkAbout0047 SEA MARSH ROAD - Health 47 Sea Marsh Road A= 227-127 Centerville I S M E A D No.2-153LOR UPC 12534 emead.com • Made in USA y amtn®wnasoaooixruf SFI �� " �° WWWSFPRV--PAKOW IZZ- 53 v_ 1 Y Mar 26 14 09:46p p 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owners Name information is required for every Centerville MA 02632 3-21-14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms \`��utnwltl(jj on the Computer, `\����`��N OF Moe i1126� use only the tab 1. Inspector: I �� :����'� sr� •` SG key to move your p cursor-do not dames D.Sears = JAMES :m use the return Name of Inspector keys co CapewideEnterprises,LLC rr I„. 11 Company Name 153 Commercial Street ��'o� 5•INSPEG,.�``�� Company Address trrlhtltttffl V Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 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 16.000). The system: Q" ® : Passes a Q Conditionally Passes ❑ .YF its ❑ Needs Further Evaluation by the Local Approving Authority -ca 3-22-14 I ctors Signature Date r.w 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. Lz e'its 3l13 Title 5 OUidel is orm:Subsurface Sewa a D'g rsposal System•Page {of 17 f Mar 2614 09:46p p,19 T < Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owner's Name required for is Centerville MA 02632 3-21-14 required for every page. city/Town State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for`yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined,'please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): ,Sins-3l13 Tdle 5 Offlcial Ins pecfian Foins Subsurface Sewage Disposal System•Page 2 of 17 Mar 26 14 09:47p p.20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owners Name requir atifo is Centerville MA 02632 3-21-14 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alairms 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): J ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s)_The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(S)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water i ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3113 Title 5 Offidal utspedion Form:Subsurface Sewage Disposal System•Page 3 of 17 Mar 26 14 09:47p p 21 N Commonwealth of Massachusetts �a Title 5 official Inspection Form Su - � Subsurface Sewage Disposal System Form Not for Voluntary Assessments 47 Sea Marsh Road _ Property Address Aimee Papavasiliou _ Owner Owner's(dame information is Centerville MA 02632 3-21-14 required for every _ _ page. Citylrown 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 clo99ed 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 is less than 6' below invert or available volume is less than V2 day flow X EACy/tiG t5ns•3r13 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17 Mar 26 14 09:47p p 22 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owners Name information is required for every Centerville MA 02632 3-21-14 page. Cityrrown 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. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 51ns•3+13 T fle 5 Official Inspection Form:Substfaw Sewage Disposal System•Page 5 or 17 Mar 2614 09:48p p.23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owners Name information is reequiredquired for every Centerville MA 02632 3-21-14 page. cityrrown state Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? CR ❑ 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 sae 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 151ns•:3f13 Title 5 Official fnspeclicn Form:Subsurface Sewage Disposal System•Page 5 of 17 Mar 26 14 09:49p p.24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owner's Name information is required for every Centerville MA 02632 3-21-14 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. tank D Box and field. Number of current residents: 4 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2012-169,000Gal 2013-135,00OGaI s Detail: Y Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) tsasls or aeslgn now(seatsipersonsrsq.n., 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: isi�s•3/73 Tntle 5 CMal Inspecibn Fo-n swhswface Sewage Disposer system•Page 7 or.7 Mar 26 14 09:49p p.25 Commonwealth of Massachusetts Title 5 official Inspection Form 61 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owner's Name J information is required for every Centerville MA 02632 3-21-14 page. Cityrrown State Zip Code Date of Inspetdion D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 05/08111 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•3113 Title 5 Official Insp ection Fomr.Subsurface Sewage Disposal System•Page 8 of 17 Mar 26 14 09:49p p,26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owner's Name information is required for every Centerville MA 02632 3-21-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: 1999 Permit # 99-497. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 32-0 Depth below grade: 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.): Peeing is 4" PVC SCH-40. Septic Tank(locate on site plan): Depth below grade: 22"teat 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: 1500 Gal.Precast Sludge depth: 3 15Ina-3i13 Title 5 Official Inspection Form:Subs idece Sewage Dispoeal System-Page 9 of 17 Mar 26 14 09:50p p.27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owners Name information is required for every Centerville MA 02632 3-21-14 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 27" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle Big - Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Tape-Plan Sludge Judge 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 at working level. Tank and outlet cover at 20" below grade. In and outlet Tees_ No sign of leakage or over loading. 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 15ins-3113 Title 5 Official bispection Form:Subsurface Sewage Disposal System•Page 10 of 17 Mar 26 14 09:50p p.28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '~ 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owner's Name information is required for every Centerville MA 02632 3-21-14 page. cityrrown State Zip Code Date of Inspection D. System Information (cons.) 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: Dale Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Sins•all Title 5 Official Ins pedion Fonre SubsuAace Barrage Disposal System•Page 11 of 17 Mar 26 14 09:50p p.29 Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner owner's Name information is required for every Centerville MA 02632 3-21-14 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.): D Box is 16"x16"-38"below grade_ Box is solid w/some scum on wall's. Three lines out. No sign of over loading. 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•3113 Tile 5 Offidal In SpCCtion Form:Subsurface Sewage Disposal System-Page 12 of 17 Mar 2614 09:51 p p.30 Commonwealth of Massachusetts Title 5 Official Inspection Form a - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owner's Name information is required For every Centerville MA 02632 3-21-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number. ❑ leaching chambers number; ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 18"x25' ❑ overflow cesspool number: — ❑ innovativelafternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a three pipe field 19'x25'x16". 4" PVC perforated pipe. Camera out line's little build up, holes open. No sign of holding water. 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 15ins•303 Title 5 Official Inspection form:Subsurface Sewage Olsposal System-Page 13 of 17 Mar 26 14 09:51 p p.31 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sea Marsh Road Property Address Aimee Papavasiliou _ Owner Owner's Name information is required for every Centerville MA 02632 3-21-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cons.) 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.): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Mar 26 14 09:51 p p,32 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r µ 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owner's Name information is required for every Centerville MA 02632 3-21-14 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 ail 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 If AT o JL r� R-3 tSins-3M3 Title 5 Official inspection Form:Subsurface Sewage Dispose;System•Page 15 or 17 Mar 26 14 09:52p p.33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Ass essments 47 Sea Marsh Road Property Address Aimee Papavasiliou Owner Owner's Name information is 1421 Centerville MA 02632 3- - required for every -- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells �p Estimated depth tofhigh ground water: 9'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: 3-25-99 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: T.H.on design plan, no G.W.at 9'+. Bottom of field at 4" below grade. Bottom of field at V above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3f13 TNIe 5 Official hrspectian Fonrr Stbstsfaoe Sewage Disposal System•Page 16 of 17 Mar 26 14 09:52p p.34 J Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Fort - Not for Voluntary Assessments 47 Sea Marsh Road Property Address Aimee Papavasiliou _ Owner Owners Name information is required for every Centerville MA 02632 3-21-14 page. Cityrrown State Zfp Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•3113 Tgle 5 Official Inspection Fomr Subsurface Sewage Disposal System•Pape 17 cf 17 Bk 21 412 Ps 318 4.62576 10-06-2006 Q 1 1 = 55u DEED RESTRICTION WHEREAS, Achilles K. Papavasiliou and Aimee W. Salyapongse, of Centerville, MA are the owners of the property known as 47 Sea Marsh Road, Centerville, MA, being shown as Lot 27 on plan entitled " ' Riverview Landing' Subdivision Plan of Land in Centerville-Barnstable, Mass. For Daniel c. Hostetter et al dated April 9, 1976, Barnstable Survey Consultants, Inc. 411 Main Street, West Yarmouth, Mass.", which plan is recorded in Plan Book 305, Page 42; and WHEREAS, Achilles K. Papavasiliou and Aimee W. Salyapongse as the owner of a home on said lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in the home on said lot as a pre-condition to obtaining a building permit for an addition to the home located on said lot; and WHEREAS, the Town of Barnstable Board of Health, as a precondition to issuing a building permit for the addition to the home on said lot is requiring that the restriction on the number of bedrooms in the house located on said lot be put on record with the Barnstable County Registry of Deeds by recording this document; NOW, THEREFORE, Achilles K. Papavasiliou and Aimee W. Salyapongse do hereby place the following restriction on their property in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. Unless and until the Board of Health of the Town of Barnstable releases the owner of the property at 47 Sea Marsh Road, Centerville, MA from the provisions hereof, the home constructed on the property at 47 Sea Marsh Road, Centerville, MA shall contain no more than three (3) bedrooms. For title see deed recorded.in Book 16942, Page 234. Executed as a sealed instrument this day of October, 2006 AMC Achi s .'Papavasiliou &AA AA AA A A Aimee W. Salya gse State of Massachusetts County of Barnstable On this 5 day of October, 2006, before me, the undersigned notary public, personally appeared Achilles K. Papavasiliou and Aimee W. Salyapongse proved to me through satisfactory evidence of identification, which were: drivers licenses to be the person whose names are signed on the preceding or attached document, and acknowledged to me that they signed it voluntarily for its stated purpose. Nota Public LINDA S. DAVIDSON, Notary Public Name- My Commission Expires March 20, 2009 My commission expires: r,'r,si r: I -� fit .d J ►°+a'! DATE : 2/7/03 PROPERTY ADDRESS: 47 Sea Marsh Road ----------------------- -_ Centerville,Mass_------ �� 02632 ------------------------ On the above date. I inspected the septic system at the above at-A�es,�S]VED This system consists of the following: 1 . 1 -1 500 gallon septic tank. FED 2 5 2003 2. 1 -Distribution Box. 3. 1 -Leachfield 18 ' X25 ' TOWN OF BARNSTABLE Based on my inspection, I certify the following condltlons; HEALTH DEPT. 4 . This is a title -five septic system.._ ----- -- is in proper working order at the present '6. -Pumped'- septic -tank at time' of inspection: - - 7. Heavy scum & solids layers were present. SIGNATUR44V-e 5� Name : _ J ._ P . _Macomber_Jr . ---- Corhpany :�oaeph per_ Son, Inc . Andress :__@Qx ............ --(Z-e-ns2zYiLlP,_ ta-_QZ632- 0066 Pnone : __508- 775_ 3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks•Cesspools•Leachflelds Pumped & Installed Town Sewer Connections P.0 Box 66 Centerville. MA 02632.0066 775.3338 775.6412 �-\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:47 Sea Marsh Road Centerville Mass. 02632 Owner's Name-Ricliard Capen Owner's Address: Same Date of Inspection: Name of Inspector: (please print) Joseph P.Macomber JR. Company Name:J.P.Macomber & Son Inc. Mailing Address:Box 66 Cen yi l l -,wtass 02632 Telephone Number:SfIA_775_j"j-jR CERTIFICATION STATEMENT I certify that 1 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 traiping 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: 2/— Passes — Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: i Date: -7�-8� The system inspector shall mit 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. Notes and Comments r L ""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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 or I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 Sea Marsh Road. Centerville,Mass Owner:Rir-hard Capen Date of Inspection: 2 /7/0 3 Inspection Summary: Cbeck A,B,C,D or E/ALWAYS complete all of Section D A• asse • - I have not found any information which indicates that any of the failure criteria described in 310 Ctv>3t 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Cotntnenu: Thp iC S stem Is In p le— at the present time. 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 statemenu. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structural) 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: �e 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 pipes)arc replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: 2 Page 3 of I 1 .r' OFFICIAL. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Proper) Address:47 Sea Marsh Road Centerville Mass Owoer:Richar Ca en _ Date of laspectioo: 2 7 03 C. Further Evaluatioo is Required by the Board of Health: _P 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 orihe environment. i. S,stem -A-ill pass unless Board or Health determines In accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a maooer wbich will protect public bealtb,safety and the environment: AM Cesspool or privy is within 50 feet of a surface water Cesspool or privy is witbin 50 feet of a bordering vegetated wetland or a salt marsh I. 2. SNstem 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: tia 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. VO The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supple 42n The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. .UD The system has a septic tank and SAS and the SAS is less than 100 feet b 50 feet or more from a private eater supple well'' Method used to determine distance •'This system passes if the well water analysis, performed at a DEP certified laboratory, for eoliform 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 anaehed to this form. 3. Other: 3 Page 4 of I 1 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 Sea Marsh Road Centerville.Mass. Owner:_Ri_�hard. Capen Date of Inspection:2/7/0 3 D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each of the following for all inspections: Yes No ackup 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 /F"'A/6-1'1 e-4c,44.,i,d Liquid depth in.cesspeel is less than 6"below invert or available volume is less than ''A day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number /of times pumped�,lx �/ y 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.] 10 (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. 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. 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) yes nof. !/ 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 2the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:47 Sea Marsh Road Centerville,Mass_ Owner: Richard Capen Date of Inspection: 2/7/0 3 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 d Was the site inspected for signs of break out ? ✓ _ Were all system components,a eluding the SAS, located on site? y _ 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: Yes no / _✓ 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 47 Sea Marsh Road Centerville,Mass. Owner: Richard Capen Date of Inspection: 2/7/0 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_�_ Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 4>IO Number of current residents: &J Does residence have a garbage grinder(yes or no):A65 Is laundry on a separate sewage system yes or no): 4.b [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):Vd Water meter readings, if avaylable(last 2 years usage(gpd)):2001 =1 45, 000 gallons=3 9 7. 2 6 GPD Sump pump(yes or no): t" 2002=21 9, 000 gallons=600. 00 GPD Last date of occupancy:7l,� Sprinkler system is present. COMMERCIAL/INDUSTRIAL Type of establishment: ,kJ14 Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): 1,4 Grease trap present(yes or no):Z/f Industrial waste holding tank present(yes or no):4# Non-sanitary waste discharged to the Title 5 system(yes or no):,4R Water meter readings, if available: IV14 Last date of occupancy/use: 4)1? OTHER(describe):. 16/14 GENERAL INFORMATION Pumping Records Source of information: .dam Was system pumped as part of the inspection(yes or no): S If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: Heavy scum & solids layers were present. TYPiE OF SYSTEM ✓Septic tank,distribution box,soil absorption system Single cesspool IPF 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) 4�O Tight tank Ab Attach a copy of the DEP approval tk) Other(describe): Ap roximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):�v 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Sea Marsh Road Centerville,Mass. Owner: Richard. Cape Date of Inspection: 2/7 f o BUILDING SEWER(locate on site plan) tl Depth below grade: / Materials of construction:�i cast iron �'40 PVC,4/dother(explain): ,c/A Distance from private water supply well or suction line:/,/�r Comments(on condition of joints, venting,evidence of leakage,etc.): Tni ntiLc ;appear ti ghi- LTn eyi d a of--lraakage SEPTIC TANK: Z(locate on site plan) /mod�Av':S-0S >l Depth below grade: J� Material of construction:_concrete,,/ct metaWd fiberglass�ePolyethylene Ud other(explain) -00 If tank is metal list age:.-f,2� Is age confirmed by a Certificate of Compliance(yes or no):-vd (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: O Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Pumped tank at time 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.): Pump the septi r tank annual 1 y C'arha i Gnncz=1 i G p rac2_IIt_ `'T_nl at R niit 1 a- t'-Pq are in nlac No evidence of leakage.The . . e_. septic tank is structurally sound. GREASE TRAf>�'//d�(locate on site plan) Depth below grade:�J// Material of construction;W concrete,4o metal,41 fiberglass/�olyethylene/1 other (explain): X)>Q Dimensions: tiA Scum thickness: Distance from top of scum to top of outlet tee or baffle: /W Distance from bottom of scum to bottom of outlet tee or baffle: ,e, Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Greasp trap ig not prPGent 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Sea Marsh Road C entPrvi 1 1 e,Mays. Owner:Richard Capen Date of Inspection:2./7/0 3 TIGHT or HOLDING TANK�i_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:,concrete metal,�)4_fiberglass,&, Aolyethylene,jO other(explain): AM Dimensions: j,l/4 Capacity: ,,)A gallons Design Flow: 4M gallons/day Alarm present(yes or no): Alarm level: A)A Alarm in working order(yes or no): A09 Date of last pumping: Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not present. DISTRIBUTION BOX:Zif present must be opened)(locate on site plan) Depth of liquid level above outlet invert: I)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.): Di Gtri but-inn hay bnq 'I-1 ai-oral c ]NngV�dgn6.Q of solids G� ---- 1]v r�wr NO o��i onno �� 1 eEakage rote 9F g t—ef the—be . PUMP CHAMBERt(j_ (locate on site plan) Pumps in working order(yes or no): e 4 Alarms in working order(yes or no):Z Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): Piimi cbamhAr J-s n8t_ esei�t� 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Sea Marsh Road Centerville.Mass. Owner: Richard Cap2en Date of Inspection: ZL l l n-i SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan,excavation not required) 18 'X25 ' Leaching field. ( 3 laterals) If SAS not located explain why: Located; See page 10 Type deD_leaching pits, number: O ,f,ob leaching chambers, number: a Alb leaching galleries, number: Z) VZ) leaching trenches,number, length: Kleaching fields, number,dimensions: -00 overflow cesspool, number: 0 ��---- UD 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.): Loamy sand toboney medium sand to fine sand No signs of hydraulic failure or ponding Soils are dry Ve etation is normal. SAS is three years old. CESSPOOLSf�� (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 Depth-top of liquid to inlet invert: i1/r9 Depth of solids layer: AIA Depth of scum laver: ,yq Dimensions of cesspool: ,y,0 Materials of construction: Indication of groundwater inflow(yes or no):, Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): C'Pssnc�ol S are not present PRIVY,(locate on site plan) Materials of construction: 161)X Dimensions: Depth of solids: WX Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is not present 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:47 Sea Marsh Road Centerville.Mass. Owner:Richard Caoen Date of Inspection: ? /7 /0 3 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. 6" Garac'e 10 Page I 1 of 11 OFFICIAL INSPECTION FORM —.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Sea Marsh Road CentervillefMasy, Owner:Richard Capen Date of Inspection: 2/7/0 3 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water f�L feet Please indicate(check)all methods used to determine the high ground water elevation: ny0 Obtained from system design plans on record- If checked,date of design plan reviewed: .�.G Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: NA Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain:http: //town,barns table.ma.us. You must describe how you established the high ground water elevation: tsed: GahrPt= & Millar Mod 1 . 12/16/94 Ground water elevations above sea level. ' ised: USGS•ObsPrvation well data-June 1992 Ised: USGG'Tarhni real Rut 1 att-i n 92 000 1 P1 ata #2 Ann ial angP�pf ground water nc _ Tani 1 qc 2 unar �' - -eet 771 Groundwater Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frim p pter Method Therefore, the vertical separation distance between the bolt m f Of the leaching pit and the adjusted groundwater table is — feet. 11 a•wRf{A.—n r�r-•rT s�sr.—mr•nnn.rlrn rs+r.+•r*.f-.r+T.'�ert�r�*ww.n rR'n`Y srR7�1 p7`I Y T7PrTT�.11�TI�..�..r•' TOWN OF Barnstable BOARD OF HEALTH SUDSURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION ^•rr•f^r••.-: r•-a r.^.---rim rm•n.�•a-rarrar+rarnmr.---•trmrrn�armvr`.•+nn+e�ne�'wmr�+�t•.�� tin .. -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 47 Sea Marsh Road Centerville,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # 227/127 OWNER' s NAME Richard Capen PART D - CERTIFICATION NAME OF INSPECTORJoseph P.Macomber Jr. COMPANY NAMEJ.P.Macomber & Son,.Inc ram ` COMPANY ADDRESSBox 66 Centerville Mass. 02632 Street Town or City state-tip COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at ftlomplete his address and that the information reported is true , accurate , and as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : .� System PASSED ; The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or, the. environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have con\-d-LTcted has found that the system fails to protect the jiublic health and the environment in accordance with Title 6 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection orm . � - Inspector Signatur - Date ti'II��i�3TiT�. ..�. copy of this ert.ification must be provided to the OWNER, the BUYER Ownhde ere applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or,,operator shall u within one year of the date of the inspection, unless alloweddortrequiredhe m otherwise as provided in 3,10 CMR 15 . 305 , partd .doc No. d Fee z .� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Miopozal *pwm Construction Permit Application for a Permit to Construct(X )Repair( )Upgrade( )Abandon( ) XComplete System Q Individual Components Location Address or Lot No. 47 _5�& 1TIa.sh +.v Owner's Name,Address and Tel.No. Cc nka ua Ita RPcl o.-A s SAa-rn C.espen Assessor's Map/Parcel ,f.,k i/9 &06 r/rno�Ne .PO �c„ltrdi/� PKAP Z27 1 c%, 1Z7 i i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ���-yi✓'/ ,64iCTc�?f V e6o o'vG 8i1 6J7�i�o S QS/zrdi//r� iY1�l OZIvSS Type of Building: Dwelling No.of Bedxooms 'I h rrcc Lot Size 5. .L2 sq. ft. Garbage Grinder(/�) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 116G cQ Oeclvesdm . Calculated daily flow _ _33 o gallons. Plan Date Jk>^v- ® , l ct 4 q Number of sheets one Revision Date J o,,A. 24, 1li9`! Title _ S,lz P I. - 47 5c.,, M-mk 6a Size of Septic Tank icc�e S„Ilrxa Type of S.A.S. Lc Qrh F',4L-S)_ 10'x25' ci Description of Soil _nlc.gw mvjr..- Ja max-;;1 Jor cr, jgIr,., tv P—q3c13 Nature of Repairs or Alterations(Answer when applicable) MRIGNING ENGINEER MOIST SIIPFRVIRF INSTALLATION AND CERTIFY IN WRITING Date last inspected: THE SYSTEM WAS INSTALLED IN STRICT Agreement: ACCORDANCE TO PLAN. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y this Bo alth. Signed 14 Date Application Approved b Date rf — Application Disapproved for the following reasons Permit No. V Date Issued ` s THE COMMONWEALTH OF MASSACHUSETTS t,.,J BARNSTABLE, MASSACHUSE;1�jJG ENGINEER MUST SUPERVISE !m !� r INSTALLATION AND CERTIFY IN WRITING �Cl.ertif icate of IMI KYSTEM WAS INSTALLED IN STRICT THIS IS TO CERTIFY, at the On-site Sewage Disposal System ConsstCruQc e�C9 a ( )Upgraded( ) Abandoned( )b at has been constructed in ac ordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2,9 ted 'Installer Designer The issuance o pe 1 not be construed as a guarantee that theft it functio d signe . Date Inspector / No. 9M sJ / - Fee ^ _ THEE COMMONWEALTH OF MASSACHUSETTS a Entered in computer: 'PUBLIC HEALTH DIVISION-TOWWO BARNSTABLE' MASSACHUSETTS S X < pplication for'bJi5pogat *pgtem Congtruction Vermit Application for a Permit to Construct(< )Repair(`•)Upgrade( )Abandon( ) )KComplete-System ❑Individual Components Location Address or Lot No. 47 5r4 YI Icrsk AW Owner's Name,Address and Tel.No. Cen Izr ui Its �Pciwr./t Skw-�.r lopr., Assessor's Map/Parcel V"A r ?2 7 er 1. 127 S�,fs /�f �6qp Fs/Maaf�l LCNftY!//�� Installer's Name,Address,and Tel.No. Designer's Name,Address;and Tel.No. 44'u-&-v! Vxggo I•vG Type of Building: Dwelling No.of Bedrooms Th rcc- Lot Size A 3�sq. ft. Garbage Grinder(/�) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ll-pc0 t 13u1vwn rdary. Calculated daily flow 33 O gallons. Plan Date :1 og. ® . 1945 Number of sheets &yw Revision Date Jana Z-4, 1549 Title Sot= P l,_, _ 47 Se. mam4 W Size of Septic Tank ' 1 p l��lu.�a Type of S.A.S. hc�cl+ FicicQ� Ig tr25 CJ Description of Soil j21r4ste t Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y this Boar. ealth ; Signed ` - Date Application Approved b ��� ' �� ��Llilr Date 1-I Application Disapproved for the following reasons Pernut No. 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( rby� at ha een constructe in ccordance with the provisions of Title 5 and th for Disposal System Construction Permit No. " dated Installer Designer , /1© The issuance of pe h 1 not be construed as a guarantee that the ste .-wil functio as signed. �r Date If Jr/ nspector / 1 _S No. �/ ---------- —=-------------Fee /f t"' °'. �o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS '=igpogaf *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upg de )Abandon System located at a r_�'a"� � and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. - N 1 1 Provided: Construction must be completed within three years of the date of this permit., Date: t/ / I) �7 ("/ A roved . / ( PP by /�`1 y r ' BAXTER & NYE, INC. Professional Land Surveyors and Civil Engineers 812 Main Street•Osterville, MA 02655 Tel. (508) 428-9131 Fax. (508) 428-3750 WILLIAM C. NYE, R.P.L.S., President STEPHEN A.WILSON, P.E.,Vice President- Engineering RICHARD A. BAXTER, R.P.L.S.,Vice President JOHN R. ELLIS, R.P.L.S. November 10, 1999 Board of Health Town Hall 367 Main Street Hyannis, Ma. 02601 Re: Permit#99-47, Capen Sea Marsh Road, Centerville Members of the Board: I inspected the above noted system on November 5, 1999 and found that it was constructed in substantial compliance with the approved plans. If you have any questions or comments please call me. Very truly yours, Baxter&Nye Inc. ephen A. Wilson, P.E. V.P. Engineering cc: Conservation Commission- SE3-3546 #99025 MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS SEWAGE INSPECTIONS LTA77QN 47 Sea Marsh Road DATE 2/7/03 VII.LA(E Centerville,Mass_ ASSESSOR'S MAP & LOT fNS'�ECTOR Joseph ?.Macomber jr. SEPTIC TANK CAPACITY 1 500 Sat ons + nox LEACHING FACILITY: (type) 1 3 ' X25 ' Leachf ield(size) NO. OF BEDROOMS 3 BUILDER OR OWNER Richard C'annn OWNER 6iAILING ADDRESS Same y� Sep t. Z6 - - -PC;eh_ — - - - - 6,3 yQ TOWN OF BARNSTABLE A, h 9 ON '�-12 Sc" YI &'CA Rd SEWAGE # t VILLAGE C Pw& y ASSESSOR'S MAP & 0 INSTALLER'S NAME&PHONE NO. 91 T ��d,��Fr.c•� e�� •F33-��'� SEPTIC TANK CAPACITY LEACHING FACIL=: (type) 4e`lc-A AC Afr/ (size) _ 1X A9 XA.s NO.OF BEDROOMS BUILDER OR(CMtR fd caOeev 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 Al 6 ® / IT S _s3 � S-.?6 Y 67 r rrl 5.2 ZONE 0 SEES MARSH RD i A � 5.4 AP • LQg1S f, 4.9 OLD G OG �- 17.2 CENTERVILLE �, A 0- ZONE m 4.8 co RC � ti L0.r d23 A3 co GV w 6.1 86, -`FNp, \ ` y o ShAi MINIMUMS / 9:2q.) 7.6 _- A2 r ,F`� o x AREA = 43,560 S.F. C A x � � �/SIN '; 17.6 �c� FRONTAGE 20' N R N ,�� G ,, -'' "`� � I���� WIDTH "s 00' • H f 7.8 o f ti i C) 21, �,..,- �S9r0 •--...._..- r--"� , ������/f ./ /,,' OCJS� �,, � ry ��, ) /_,�. �� - -: ,_ � ,FRONT SETBACK - 20' �c 6.4 p 4 x 3 P\� , ;� 20.6 0.0 17.1 SIDE SETBACKS = 10 ot`�� O A 7 /� 184�, e Q �'� '� 21.4 rp a O y O r' � , ✓ z REAR SETBACK - 10 LOCUS MAP � .TKO 00 /,, LO%j {�n cs ��. i ,- - / �l �C,g• 17.9BUILDING HEIGHT = 30 2� x 7.7 . �, �, �P SCALE 1 1 25,000 FND.OF'" 6 /' � / / Off\ / 39.7 ASSESSORS 21. , O�F,� / X 19.7 / 8.0 1a1 MAP 227 PARC[L 127 ! , x 8.7 ;.� / g'3 z Oe 18.1 s /#45 \�P A8 x 10. / X C / f' 20.81 oj00 �� o N� 17.9 tiY �q 1 .5 17.5 20.8 BENCHMARK x 4.4 p , I 00 107 rim NCiB:. oo TOP OF SPINDLE � I� 12.s ► F�1D. EL. = 20.93' N.G.V.D. x N. /J , lY S 42,005 sq. fit. upland o �► / ,�P IMES 1,817 s ft. wetland O: 20.1 �� �, x 1`�3.8 b q , o� 43 822 s . ft. total x 14.8 (1) REMOVE UNSUITABLE SOILS BENEATH PROPOSED SYSTEM, 13ACKFILL ! PJ\ q 4 17.7 x 19.4� - WITH CLEAN GRANULAR MATERIAL FILL TO BE GRADED AS FOLLOWS: NOT.' ! 6 A10 rr�► y x "� \ * �"/ �� 19.4 MORE THAN 15% RETAINED ON No. 4 SIEVE, NOT MORE THAN 909� RETAINED I. x 6.4 t 19.2 C.B. WATER LEVEL ova/ ,� � / `�?/ °' FND. ON No. 50 SIEVE OF FRACTION PASSING No. 4 10% OR LESS TO PASS 'No. • ) ! 0 19.0 100 SIEVE AND 5% OR LESS TO PASS No. 200 SIEVE, SOIL TO BE APPROVED EL. 2.5 '�� �� 1 / � i BY ENGINEER FOR COMPLIANCE PRIOR TO PLACING ON SITE. o\ x5.4rO� x10.3 4 o > I NOT SHOWN ON THIS PLAN AT LEAST 72 HOURS 3 (2) LOCATION OF UTILITIES � , , ,\ 2 y 3 6 6 PRIOR TO ANY EXCAVATION FOR THIS PROJECT CONTRACTOR SHALL MAKE I I GARDEN 7.1 # /� THE REQUIRED NOTIFICATION TO DIG SAFE (1-888-344-7233) AND Zx5 4.1 X `. \ 17.9 z / / / / / / / / / APPROPRIATE WATER DISTRICT TO DETERMINE UTILITY LOCATIONS. _ f x19.1. 16.5 i / / / / / / / / � / �// . A„ \/\/ `Z \ \ \ \ \ \ \ \ \\ \ (3) FOR ALL ASPECTS OF THE SEPTIC SYSTEM THE CONTRACTOR x 5.7 Q4 , °` / = // // // // // // / //� SHALL COMPLY WITH ALL GOVERNING CODES AND REGULATIONS. f O� ,�� �►��` T9� / / / // / IN PARTICULAR 310CMR 15.000 THE STATE ENVIRONMENTAL CODE TITLE 5, ti 9 •; •,.', •. �\ ,.. ; ,.:...; . . , • .. ": •. : : ' .' THE TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS PART VIII: ,. .a .:,.... ..;; j C.B. x 1 ,7 1 G - THE BOARD OF HEALTH '\ 4 `�Q ¢�. / . 4'.�' ON SITE SEWAGE DISPOSAL REGULATIONS AND 9'9 FND. O ti P '. , ?® /� � ��S / � O• '� � '� *� �� "• ' •` �:'" RECOMMENDATIONS FOR ACCEPTED PRACTICE. 12.0 0 #1 -5/4" TO 1 1 2 4 SCH. 40 PERF PVC (4) A COPY OF THE ORDER OF CONDITIONS FOR THIS x / 14.7 / N SITE AT 5.6 5. � 5.9 i/� x IN 1 WASHED STONE ALL O TIMES AND AJECT �ROVEDLWORK LIMIT BE KEPT O/ EROSION Al2 \�P % -�i 9. r / P IN \�� TOPPED WITH 2" OF PEASTONE CONTROL MEASURES MAINTAINED. o �oA / - 4., ° o o / CROSS SECTION (5) THE CONTRACTOR IS TO SECURE APPROPRIATE ,n Z PERMITS FROM TOWN AGENCIES FOR THE A13 ,�S / " : CONSTRUCTION DEFINED BY THIS PLAN. x 5.5 'L�a I / X 13.4 NO SCALE O � (6) ALL STRUCTURES BURIED DEEPER THAN 4 FEET OR s a x 15.� LOADING, NG TO VEHICLE TRAFFIC SHALL BE H-20 4.1 A14 Id x 7.5 14, '6`C 9�9 DESIGN DATA 11.7 � � 23�, 12.4 a� 11 4.7 I 8.�i% �x 12.6 - - - X 129 SINGLE FAMILY-- 3 BEDROOMS NO GARBAGE GRINDER S9, I L WN _ �� THE 200' RIVERS ;ACT QFFSE_' LINE IS PROPOSED DAILY FLOW = 110 X 3 = 330 G.P.D. 4.5 ` 1/1 900, �► �1►, SCALED FROM GIS I,�AP'' 227. A15 ,. .. _:__.. FS I SEPTIC SYSTEM SEPTIC TANK = 330 X 200% =660 G.P.D. -.....r ....: ,... USE 1500 GAL. SEPTIC TANK - �lS • �: 14.1 �O�f G• - ` - _ _ •a• Q a .44. .t ,a e':• J.�CI IM(; FIELD DESIGN GTo� x 13.0 A, . . �a.,,'. d' i 00 A t ' q ALL PIPES TO BE SCHEDULE 40 PVC PERFORATED 4.7 .9 o° ° USE 3 - 4" DISTRIBUTION LINES IN AN ; mP o° . , 18'X 25' WASHED STONE FIELD AS SHOWN �Di;e 'j`' ' ��� `� o' ° . ;o' ° b 3' 330 G.P.D./ 74 = 446 S.F. OF BOTTOM AREA REQUIRED 12.5 C O� 3/4" TO 1 1/2' r r 1470 �'0 USE 18'X 25'= 450 S.F. AREA PROVIDED / NF ND. �' ' WASHED STONE CLASS 1 SOIL PERCOLATION RATE 1" IN 2 MIN. OR LESS A 17 ' fib• ��' � � � .12.o j 25.0' / / � 77, ,\Q- TOPPED WITH 2' OF PEASTONE 3.8 �.; •. PO EXPANSION RE BASED ON N.G.V.D. ELEVATIONS FLOOD PLAIN LINE IS BASED ON e' AREA WETLANDS DELINEATION PERFORMED BY - - - 3 '` o FLOOD INSURANCE RATE MAP K. BARNICLE, ENSR, ON APRII_ 6, 1999. Al ;�a � , COMMUNITY-PANEL NUMBER 250001 0008 D .. -+ 1_ r r, REVISED: JULY 2,1992. �• 8 ' v PLAT OE LEAC14 F EL A�1 _ R r, M SITE PLAN 3 NO .SCALE 4.0 z m PLAN SHOWING PROPOSED DWELLING, A2? .` _ r PLAN - _� y TITLE 5 SEPTIC SYSTEM,& DRIVEWAY w _ 4.1 SCALE: 1 = 20 AT 3.7 0 10 20 40 DESIGNING E"VGINEEFI MUST SUPERVISE 447 r MARSH ROAD INSTALLATION AND CERTIFY IN WRITING f'1 H THE SYSTEM WAS INSTALLED IN STRICT COVERS LOCATED TO WITHIN AcCOR�ANCETOPLAN• 6" OF F.G. - TEST -IDLES CE�ITEF2VILLE, MASS, _ BAXTER & NYE INC. 3/25/99 > ELEV.=16.0' APPLICANTS TOP OF F.c.= 15 f P-9393 FOUNDATION TH #2 F.G. =14'f SHARON & RICHARD CAPEN F,G .� i5'f TH #1 ELEV. = 16.5 INv. =13.0 % ,, ,, ,, . \ `\\`\\\\ °\ \\ \�\ i'.i ./ y''r' SCALE: AS NOTED DATE: JUNE 8, 1999 1500 GAL. LEVEL ,, /�,i ELEV. = 14.9 E2„ INV. 4" DIAMETER 12.8 INV. 12.6 olsT. 2 �scHeo E1�• _: A' SANDY LOAM 10 YR. 3/2 REV. JUNE 24, 1999 SEPTIC TANK INV. =124 Ulf 40 _6„ Box p,v A' SANDY LOAM 10 YR. 3/2 INV. =12.2 Plps _ _ -_ _4„ B' SANDY LOAM 10 YR. 5/6 1 o.Oo' --- 1. B T.ER & NC INVMIN. 6 CRUSHED t. r'� AX NYE- • • . ..• � SANDY LOAM 10 YR. /6 20 IS R ` B' S N TER AND SURVEY STONE BASE REGISTERED L ❑ S ✓ _ -20" , ,' ���' CIVIL ENGINEERS , BOTTOM ELEV.11.0 C MEDIUM SAND 10 YR. 5/6 As9c ERVILLE, MASS, ❑ST I CERTIFY THAT THE PROPOSED FOUNDATION C' MEDIUM SAND 10 YR. 7/4 STELHEN tim SHOWN HERON COMPLYS WITH THE SIDELINE AND SETBACK REQUIREMENTS OF THE TOWN OF -48" -' BARNSTABLE, AND IS LOCATED WITHIN FLOOD `n -54 PERC TEST o 9 v%is � Of %s ZONE B. �o, FGI P� � .... I _>_' C' MEDIUM SAND 10 YR. 7 6 �Fss STE G\ate .10HN DATE. _ R.LS. -9.25 NO WATER ELEV. 7.25 a. zse74 J. __. -9.25' NO WATER ELEV. = 5.65 PROFILE o NAL PLAN REFERENCE: BOOK 305 PAGE 46. DEED REFERENCE: BOOK 4759 PAGE 127. NO SCALE #99025