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0153 SETH PARKER ROAD - Health
153 Sethi Parker Road Centerville P 147 092 fill UPC 12534 No.2 'bsr HASTINGS,MN - - r TOWN OF BARNSTABLE k :,LOCATION 1.3 ��'T-� PMZ4,�_10Z i� SEWAGE# VILLAGE -r1—"9 L.Le ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. �• O. �U� 7i-cj 3`�9 SEPTIC TANK CAPACITY 1252:6 LEACHING FACILITY:(type) iz (size) ���C f.L• 3 f�s NO.OF BEDROOMS �' , 4 A � `� J � OWNER ° OD1=q4aCW_ PERMIT DATE: i it—14, COMPLIANCE DATE: Z )- Separation Distance Between the: 4 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) 4- 140 Feet FURNISHED BY �/t C�fi��•�"r '35 �� 33 O. �N�ktf No. V" 00 06 _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye— G� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppYication for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair(V Upgrade( Abandrn( ) ❑Complete System ❑Individual Components Location Adaag�es or of No. �' O- Owner' N e,A ress and Tel.No �& 153Seth r�e�'lgv Cell �I �, d6 �,U t �1r�'stYn� WO �/ Assessor's Map/Parcel f 2 ^ S�- i'j �Q�(��'"/Q� c� ,-Iry i'llej / Q�3� Installer's Name Address,and Tel.No. Desi er's Name ddress,and Tel.No. �. 6X,1Q �7 1�9399 Ic � LDn . ear,nc LLG - i�j /_h �A ,A��2 l S&erat�Je�l �e�. G/ ram 114.0433 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of BuildineS f -��`Q�' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re tired) 330 gpd Design flow provided gpd Plan DateZc�l 5 Number of sheets Revision Date Title_ e,Pi3P0C30j<Syoew rim Size of Septic Tanrj 1,506 GAL• Type of S.A.S. Description of Soil 01:f- soIL W 0�S Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. S' .-, Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 0, --0" Date Issued .;.; No. m A E Fee / s k ' Entered in computer: a THE COMMO(51IVEALTH OF,M tiS.SACHUSETTS p ' PUBLIC HEALTH DIVISION TOWN OF B'AN'STABLE, MASSACHUSETTS - Yeij k 01pplitation for Misposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(V Upgrade(�` Atiandqn( ) ❑Complete System ❑Individual Components i Location Addres or Lot No. Owner' N e,Address anc�Tel No 4548 rLja I� �1 S r r&,r izd c��e��,ile,� .Liz, y Q / t r�'St�n� /0A Assessor's Map/Parcel f L) `� (5,�s�-- �j �Q��$Z� t C.ef'1��!/��f/�`/ .�/ i3oZ Installer's Name,Address and Tel.No. Desi ner's Name ddress and Tel.No. 1� Gu N-TV— "7'1 - 9399 t o i ' eri�' qq ) L LG yr 4 sT-�v s/ I at J d. CAdW am rl�.�i-2b33 Type of Building: Dwelling .,tNo.of Bedrooms 13 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building�e-S l� ,°r)- I(,Z,' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re uired) 330 gpd Design flow provided gpd Plan Date �C�23'15 Number of sheets Revision Date Title xU-��' � ah 3 0_1 L' .S`fpem e I Q Size of Septic Tanrl 1_506 GAL.. Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of (Compliance has been issued by this Board of Health. Sign Date Application Approved by - Date Application Disapproved by Date for the following reasons Permit No. ��/ (3 9� Date Issued --------------------------------------- --------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-siteSewage Disposal system Constructed( ) Repaired('L'-Upgraded( ) Abandoned( )by /" , !�-'�•0 W -at 153 S r t h �c !�C t l9d (U n �t✓,l/ %/ r has been constructed in accordance T with the''pr`ovisions of Title 5 and the for Disposal System Construction Permit No��--0't- dated / 1 i AI Installer � Designer s r G C-0 C1/✓")rC r,e-)a t C #bedrooms J � -3 4 d Approved design flow gp The issuance of t,is pe ffit shall not be construed as a guarantee"that the system will n'ctia �as des i nd. Date a 1 InspectorJr --------------------------------------------------------------------------------------------------------------------------------------- No.QC31 Fee �QC/ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal .6pstPnt Const urtion 'pefmit Permission is hereby granted to Construct(�) Repair(✓) Upgrade( ) Abandon( ) System located at j .� ,j t� 1l G �C( /<(4 C.,' ) fir V i l c /'-//7 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 m st be om leted within three years of the date of this p 4mit. Date Approved by FEB-05-2016 03:05 From: To:15087906304 Pa9e:1/1 02/04/2016 13:56 15009455458 CLARK ENGINEERING PAGE 02 i ` Town-Of Barnstable , ILK RegWsitory Services ii Rickard V.ScoX Interim mrectop s Public Health D;vlsion ThOMON McKeon,Director 200 Msin Street,.Hy&,Wb,MA 0260, 0;63ee• 508-8624644 508-790-6304 • I sraller�Deg' er rtiScatioq'Form 02/i6 Z016-008 Date: Sewage Fermit# Assessor's pYI'arce 14 /092 Designer: Clatneerirtg LLC nort tti COaB ruction Inatalle;: 156l Road ,Address: ,Address: 45 x stChaA 01633 Mara tins Mills, MA 02648 ------------- onQ1 11 /2016 Bortolotti Construction (d2ft) (i talier) was issued a PeCO I I to install a Septic 45-tem at 153 Seth Parker Road, eactorville (address) based on esign drawn b C14rk Eriginevring LLC dated 12123/15 certify that th septic system referenced above was anstallcd tially acco g ro e desk, wbu h may include Miuc r approved changes sach a4 anal rolocatio of the 'stribution bo and/or septic tank. Strap out (if required) wad Lspccted and d e soils ere found sati fwWry. i Certify that th septic system referenced above was installed I major chau (i_e. B eater than, ld ateral relocation of the SAS of any vertical re on of any co nent of the septic SYS 0m)but in accordance with Statc&Local Re as. Plan re ' on or a mfled as-buih by designer to follow. Strip out(ifrequited)w ected and soils ftm found sa ' ctory. 1 a system referenced above was constructed in po co with the terms the agpro letters(if applicable) 1 er,sto d�a asroM�� e xgaer's si=TBARNSTABLE ) (Affix s Here) IaLEASE TUR PURT.Ig HEAj,TR D _j]SI ER 'IFI C� LIANCE V AL NOT BE JSSjMn UNTIL—BOTH I= FORM B C_E D BY 'IHE B ST E LIC TH D ON. you. 9:45epticM)4sner CcMfiostron osm Rev 8-14-13.dw f Town of Barnstable P a Department of Regulatory Services MWIFFABIA: Public Health Division Date 200 Main Street,Hyannis MA 02601 Date Scheduled Time Fee Pd. Soil Suitability Assessment for Sewa Disposal Performed By: �I GYti i C Lllt l:. Witnessed By: d / _. LOCA_T_ION&FGENERAL INFORIVIAT ON. • . ° Location 163 Address Owner's Name h Parker Address J 3 04� t A Assessor's Map/Parcel: 141 I O 'I A `Q�engineer's Name W✓id ,[,�. NEW CONSTRUCTION REPAIR f! Telephone# t ww ++ �1 Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) f al7 1 Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLEM Method Used Depth Observed standing in obs.hole: 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 Adj.factor Adj.Groundwater Level— 'PERCOLATONTESYT Date e .-.:;�.�-r �..,..,..,-_..,:..... � Time Observation j - - - - - Hole# / Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak / I G il. '- Rate Min./Inch 4—Z.m h i n C, Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC • �o �s l� DEEP OBSERVATION HOLE LOG_ Hole# Depth from Soil Horizon Sod Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) 0-10 .A )014 5 - M Ffl thlt I(7 110 02 [Q'-[A 4141 Nr) frl61l2u Ao, 0-0 C, [OU 6,J& r 2 DEEP OBSERVATION HOLE LOG„`$ Hole# gt Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# - Depth from— Soil Horizon Soil Texture Soil Color ....µSoil Other Surface(in.) (USDA) (Munsell) 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. Consistency-%Gravel) Flood Insurance Rate Mao: yy Above 500 year flood boundary No Yes Within 500 year boundary No 3 Yes Within 100 year flood boundary No X Yes_ Denth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perviou material exist in all areas observed throughout the area proposed for the soil absorption system? C4 If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of En*. ctectional Pr d that the above analysis was performed by me consistent with the required training,expertise and expen e'�scribed in 310 CMR 15.017. Signature a° ® Date Q:VSEPTICPERCFORM.DOC OOMMOINI TI EALTH OF l ;/71 DEPART-1 OFFICE OF EtiZIRO\�'rEN 1 T =i EPARME ;T OF Ei�ti7IO'� EIv^�Z PRCTFCyI 1J O !y 0 9� Z TI i L.E 5 OFFICIAL INSPECTION FORM—-NOT FOR VOLUNTARY ASSESS'MENTS SUBSURFACE SESYAGE DISPOSAL SYSTEM FORM PART A ? /CERTIFICATION Prcpern Address: SJ �e f�1 � � /1�/ Ge H ►��, e -off 6�� `� Owner's-acne: CG►t^�S7�r✓1 cH c✓g/� Owner's_address: .Se f� ✓J�?r RLI Date of Inspection: �/O /? 6 \'ame of Inspector: (please print) 7 A,-� Company Name: CIO,y10 — / ,dF-C ff Mailing Address: z Telephone Numbe CERTIFICATION STATVVIENT I certify that I have personally inspected the sewage disposal system ar thds address and th he below is true, accurate and complete as of the time of the inspection. The inspection:,as _erf=-2-5 training and experience in the proper function and maintenance of on site sew-aze d_s a 'posa -e.�, I am a Tgp approved system inspector pursuant to Section 15.340 of Title 5(310 01R 15.000). 1 he s 7 _ Conditionally Passes ' Needs Further Evaluation by the local Anpro o--r . Fails Inspector's Signature: Date: to O,b' The system inspector shall submit a cone of this inspector.report to the Appro�-nff utho - DEP)within 30 days of completing this inspection.If the system is a shared system or has Les-p gpd or greater, the inspector and the system owner shall submit the repot to i±e a-,prona �_:c c - DEP. The original should be sent to the system owner and copies sent to the buyer if annf a autho tv. Notes and Comments "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 rill perform in the future under conditions of use. the same or different Title Inspection Form 611512000 Pa°e 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS SE S S gIE NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM CCERTIFIICATIO'!(continued) . Property Address: 7 JG! �t /���✓ RrJ v�Te v ,3, Owner: e Date of Inspection: O / /d Inspection Summary: Check A,B,C.D or E i ALIT AYS complete all of Section D A. Svste I ses: C I have not found any information which indicates that any of the failure cetera desk=bed_n_ CN R 1 or in 10 CNIR 15.304 exist.Any failure criteria riot evaluated are indicated beio-. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"sec on reed to be replaced or repaired. The system upon completion of the replacement or repair, as approved by the Board of Health. %y=:'_-pass: Answer yes.,no or not determined(Y,N:ND)in t'ne for the following statements. if"not deie=inedI u ea_: explain.- The septic tank is metal and over 20 years oldY or the septic tank(whether metal or 7,01) unsound. exhibits substantial infiltration or-xfiltration or tank failure is intirninent. SvsteTM �'_na__ existing tank is replaced with a complying septic tank as approved by uhe Board of Health. "A metal septic tank will pass inspection if it is srn:cturalh sound,not leaking and if a Ce::ti":ate indicating that the tank is less than 20 years old is available. \�D explain: Observation of se,\page backup or break out or high static water level in!heto_roker,e- obstructed pipe(s) or due to a broken,settled or uneven distribution box. System rr11 pass approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced \�D explain: The system required pumping more than 4 titnes a year due to broken or obs:_ �ctee pass inspection if(v ith approval of the Board of Health): broken pipes)are replaced obstruction is removed explain: Pave of I I OFFICIAL I\SPECTION FORA-NOT FOR VOLUNTARY ASSESS'xa TS SUBSURFACE SEWAGE DISPOSAL SVSTE'NZ INSPECTION FORA1 P A-RT 4 //CERTIFICATION(continued) Property Address: Owner: aze/ Date of Inspection: C. Fur her Evaluation is Required by the Board of Health: Conditions exist which require further evaluaron by the Board of Hea_st? in order to dete—i-e ------ is failing to protect public health, safety or the environment. 1. System«ill pass unless Board of Health determines in accordance with 310 CAIR 1-4.303(1)(b)that the s-.-stem is not functioning in a manner which will protect public health.safety and the en-,zronment: Cesspool or pri-,y is within 0 feet of a surface eater _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a sale marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any-) determines that the system is functioning in a manner that protects the public health,safety and en-vironment: _ The systern has a septic tank-and soil absorp-tion system(SAS)and the SAS is y.i:h t 1�'r fa-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 p blic vv aer su n'_ _ The system has a septic tank and SAS and fie SAS is v7thin 50 f et of a nriz.ate rater The system has a septic tank and SAS and the SAS is less than 100 feet but=0 Peer or mo om a private ,vyater supply well**.Method used to determine distance *This system passes if the well water analysis,performed at a DEP certified 1aborato_ =o_colifo--- bacteria and volatile organic compounds indicates that the yell is free fro?il pollu`on-e m.hat ;- :°a~ the presence of ammonia nitrogen and nitrate nitrogen is eouai to or less t-nf n-n ire-i ed .__ o=:^e- failure criteria are triggered.A copy of the analysis must be arached to this 3. Other: Titlo Pace 4 of i 1 OFFICIAL INSPECTION FORM—NOT FOR V-OLUNT-RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTElI INSPECTTON FORM PARX A CERTIFICATION(continued) Property Address: 1Jr7 SG Gah%44 Owner• Date of Inspection3 0 D. Svstem Failure Criteria applicable to all systems: I'ou must indicate "yes,"or"no"to each of the following for all inspections: Yes '_\7o � ,/_ Backup of se;�,aQe into facility or system co=onent due to overloaded or ciog gec `.S or cess 7 oo> Discharge or pondina of effluent to the surface of the ground or Surface , aters ,sue to _n ove ozoee c- l _ 1---ro22ed SAS or cesspool Static liquid level in the distribution box above outlet imert due to.an overloaded cr loc_ed sspool _ Li id depth in cesspool is less than 6"below invert or a,:ailable volume is less t-an _ c/Kequired pumping more than.?times in the last year N OT due to clog,ed or obstruc-ed tirnes pumped V _ A y portion of the SAS; cesspool or pricy is belo--, high grog d�;ate:eie�°a non. Any portion of cess-pool or privy is-within 100 feet of a surface water suppl, or-.bi tar y to a surface ater supply. ; portion.of a cesspool or privyis within a Zone 1 of a public wve11. _ v portion of a cesspool or privy is within ;P p ,h� 0 feet of a private water sup Any portion of a cesspool or privy is less than 100 feet but-greater than 50 feet:---cm a n ;ate wtiter, supply well with no acceptable water quality analysis. [This system passes if the well water analssis. 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 c ppm,provided that no other failure criteria �/ are triggered.A copy of the analysis must be attached to this form.] /" "�(Yesno) The system fails.l have determined teat one or more of the above failure cr=tera ems-a; described in 310 C\1R 1 5. 03,therefore the system fails. !he system owner s could contact r B,--arc Health to determine what will be necessary to correct the failure. E. Large Svstems: To be considered a large system the system must serve a facility with a design Hots" of 10.000 gpd to 1�.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; the system is within 400 feet of a surface drinking;rater supply the a nit -, system is ,vithm 200 feet of a tributary"to a surface cL-ink'na water s nn_v — the system is located initrogen sensitive area(Interim Wellhead Pretec :on.fir=a— Zone II of a public water supply well if you have answered"yes'.'to any question in Section E.the system is considered a si?n c-r_t yes"In Section D above the large system has failed. Theo or ope-ator of ant tare significant threat under Section E or failed under Section D shah upgrade the system r tic i 004. The sysrem ow-ner should contact the a re r ppro regional office of the De:a.-imnen . • n Page_ of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNT_4RY ASSESS-IENTS SUBSURFACE SE)NAGE DISPOSAL SYSTEM INSPECTION FORM P_4.Y21 t3 CITIECIalST Property Address: / J e)4 4e i"I r, 6o162-2— Owner C,-, ttip Date of Inspection: ?— Check if the following have been done.You must indicate"yes"or"no"as to each of the-foLlo%ving: es�o Pumping information was provided by the oit-n- ,occupant. or Board of Healt'r: v Were any of the system components pumped out in the previous vo wee'v Has the system received normal t7bws in the previous two week period? Have large volumes of Rater been introduced to the system recently-or as r+art of�:is ec-on ---- Were as built plans of the system obtained and examined'(If they were not avaihole rote as ✓/ Was the facility or dwelling inspected for signs of sewage back up v — 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 lark in;pectea for of the baffles or tees,material of construction, dimensions,depth of liquid. depth of sledge and -:en--h of scuts Was the facility owner(and occupants if diferert from ow-ner)pro-,,ided n th__=orm -=or_Oil.:-_I -ooe_ maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site Las been dote_----_ec bag,d on: Yfll�o Existing information. For exa rple,a plan at the Board of Health, v — Determined in the field(if any of the failure criteria related to Part Cis at issue a -o<�~;�=or is unacceptable) [310 C112R 1�.302(3)(b)1 " - I:,- , 4ii nnn Page 6 of 11 OFFICIAL INSPECTION FOR`rI—\OT FOR VOLUNTARY ASSESS-A EN T S SUBSURFACE SE«VAGE DISPOSAL SYSTEIM EN-SPECTTON FOR AT PART C SYSTEM INFOR-MATION Property Address: / �� rG✓ �� Owner: Date of Inspection: OW CONDITION'S RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x_of bed corns): \umber of current residents: Does residence have a garbage grinder(yes or no): X Is laundry on a separate sewae system(yes oro):/� ive searatp -rr ed? Laundry system inspected(yes or no):/610 Seasonal use: (yes or no):A�V 'Water meter readings, if available(last 2 years usage(gad)): Sump pump (yes or no): ast date of occupancy:. yr AIt COADIERCIAL/INDUSTRIAL Type of establishment: Des--on flow(based on 310 C-1R 15.20:): gpd Basis of design flow(seatsipersons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ \or.-sanitary waste discharged to the Title 5 system(�-es or no):_ 'Water meter readings_ if available: Last date of occupancy`use: OTHER(describe): GENERAL INFORMATIO\ Pumping Records / Source of information: Was system pumped as part of the inspection(yes or no):�1c� If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE SYSTEM ptrc tank, distribution box. soil absorption,systemn _Single cesspool_ _Overflow cesspool _Shared system(yes or no) (If yes. attach pre—lour inspection records.if anv) lnnovativP%Alternative technology.Attach a copy of tie current operation and obtained from system owner, _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components; date installed(ii�q wnend sourc oof fo=tijon. V ere sewage odors detected when arriving at the site(yes or no): T;tlo G T cn�r4:n t _ c n c Page 7 of 11 OFFICIAL. INSPECTION FORtz—NOT FOR VOLU a _-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1I P-RT C SYSTEM I T'OR_MATION(continued) Property Address: X T� �r y- PC-i Owner: CGt-- 1-,: G Date of Inspection: BL•ILDI\:G SEWER(locate on site plan) Death below �-rade: a6 '' Materials of construction:_cast iron _. VC_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints,:venting, evidence of leakage,etc.): SEPTIC TANK:-'-- Le on site plan) Depth below Grade: /51 -Material of construction:_✓concrete—metal_fiberaiass oo_vethvtene other(explain) J if tank is metal list ace: _ Is ace confuned by a Certificate of Compliance(yes Or no): _�'a ach a o certificate) X Dimensions: —7 Sludge depth: OZ i Distance>icm ton f sludge to bottom of outlet tee or baffle: Scum thickness:,-PSS� / // 6 �� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom o outlet tee or baffle: l Hov,-were dimensions determined: o/e iQ. --we-viee- Cotrments.(on pumping recommendations,inlet and outler tee or baffle condition. st-ucrura' Y as related to outlet invert, evidence of ieaka2e.etc.): moo GREASE TRaP:�Iocate on site plan) Depth below trade: _ Material of consTsction:_concrete_metal_fiberglasseivetLvle e ote- (explain): — Dimensions: Scam 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: Comments (on pumping recommendations.inlet and outlet tee or baffle condition,s—u,:--al as related to outlet invert, evidence of leakage; etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR`'OLU TA-RY ASSESSMENTS SUBSURFACE SE`YAGE DISPOSAL SYSTEM INSPECTION FORM PA-IRW C C SYSTEM ENTORMATION(con`s ued) Property Address: /✓� S�r'7 G✓�eY Owner Date of Inspection: 0 3 r TIGHT or HOLDING TA1'Ii: /' (tank must be pumped at time of inspecri on)(iocate on. s_ a=, Depth belo-,v grade: Material of construction: concrete metal f7iberglass r'olyethylene o7her;::e7,nla.-:`: Dimensions: Capacity: gallons Design Flow: gallonslday Alarm present(yes or no): Alarm level: Alarm in working order(yes or not: Date of last pumping: Comments (condition of alarm and float switches,etc.) DISTRIBUTION BOX: �(if sent must be opened)(locate on site plan) Depth of liquid level above outlet invert: l�Dl'i"1G Comments(note ifbox is level and distribution to outlets equal,any evidence of solids caT—,-o--er, a e of leakage into out of box. et � PUMP CHATNIBERa�C) (Iocate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (nore condition of pump chamber. condition of pumps and appurtenances_ etc. Titl. 4, lncna�ttnr �nrrn (%1 G!7(lfl(1 r Page 9 of 11 OFFICIAL I\ISPECTION FORM—NOT FORVOLLITARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO- FORM P-N-Ra C SYSTE_l'I INFORMATION(continued) Property-Address: 6 A 9,4-e, Owrer: v G '^ �✓G Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type Q/2 — �c,� - C leaching pits,number: C leaching chambers.number: Sao leaching galleries:number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: innovatne.'alternative system T�,peitiame of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, dame soil. conditicn of .ge_a=oa. etc.): / CESSPOOLS:A (cesspool must be pumped as part of inspection)(locate on site plan, \umber and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum laver: Dimensions ofcesspool: 'Materials of cons?uction: indication of groundwater inflow(yes or no): Comments (note condition_of soil, signs of hydraulic failure, level of ponding. condition e' c-ti 0�. PRIVY: i!�-(locate on site plan) Materials of construction: Dimensions: Depth of solids: CGI merits (note condition of soil, signs ofhvdraulic failure,leve11 Of po d no: Page 10 of 1 i OFFICIAL INSPECTIO\ FORr1-NOT FOR VOLL`\T- I,Rl- ASSESSMENTS SUBSURFACE SEWAGE DIS.POSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORNL4,TION(con-hued ProFertv Address: /j- �4 Owner: �e Date of Inspection: /O SKETCH OF SEN AGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least t,%vo pern_an:nt or ' enchmarks. Locate all «-ells %within 100 fee-.. Local:where public eater supplh ent rs tr_e bail: n l �i4oiti7- � • .l a 3S o T,+lo Tncnontinn nrr (il /1(1nn n A Page 11 or 1 1 OFFICIAL INSPECTION FORM-?SOT FORtiOLL___NT_-�_R_ ASSESS7�IEN T S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR:-T Y!vRT C SYSTEM INFORMATION(conned) Property Address: /.53 S_/4 `lJ.vner: Cat ✓L4"-e Date of Inspection: O 3 O,C SITE EXAM Slope Surface water n �L Check cellar Shallo%v-,veils Estmated depth to --round water X'9 feet rb " Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked, date of design plan rep ie_.:d: Observed site(abutting property/observation hole«athin 150 feet of SAS) Checked with local Board of Health-explain: Checked«-ith local excavators; installers-(attach documentation) Accessed USGS database-explain: You must escri'pev o'ti" -ou establis lffi:l}igh ground wxa er elevation: S /ems e C, Ccer (I n T .. Trt1.c � Tnrncrr�rn 1-'nrm (� 1 c��nnn 1 i r i , I U5E I oaD C clo►a S6gnc.14,►sK j L Aick 4-2 Ckpctr(*iSosF C 2.6: 3T5 C�4'i _ ia,r Air& � Sa�F � >��K i ••til, 1 `T z>IrA. - 'TD ES t eckA FLo v./= 425 Ex F-P �%ct Lx �w•,ct 33 O Ez?D ✓ ' ( ~.^ '\_— '_- �t OF iy PETER.. St LLIVAN I r iU; NQ. 29733 TT-r sr. oL:r_ �� •I sjsrAu:4515-�L -rc., e OF 2.0 o qu'P,lG ,vr. ScN� �� IOUo tODZ] ox `�,� _ _. _phi. 4�•5f�ly fNYQ�,g °•b LEAcH tug/4sa S ,c PIT MN45,1 )sV 4 A- T,t uK ° �4�otiCv�sx C E:RTl.FI E-0 PLaT 1 .At-1 EL .o l--o c-AT)a N ��r�-�'�=5 l_4 17. H2O 3y,v LC)T G _ •. is .,: _ -P op-t)s � R E�•l s tit� t_AR-Q t c.E'�T1FY "Cl-l�'•'r""�'E �•-1o�s� �,vt L. Cz7?yCf�G-�S W rN 714 5I=F- -1YAF A1�'R 5�`T'��K -Fib-�11t?E tY4>✓N 5 aF 7 E -r-o vc/Q z:;,F ,R1�1�"`j1 UI� 15 bT - �D�-CEO V/lTt411J --HE. TH15 R/��j 15 11ZIT A5E DNAN Ih5TRuM N SuRYEY AND Ti HE OFFSETS •SHOWN 5NZ)4L-D 13E L)sEq �'a ESr�{gLISN LaT L1NE5. c-._ _.Ja3auaIt. v COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ; DEPARTMENT OF ENVIRONMENTAL PROJEGIi OW . JUL z 7 2004 1/ TOWN OF BARNSTABLE HEALTH DE=PT, . TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION PAP Property Address: 153 Seth Parker Road PARCEL Centerville L0� (� Owner's Name: Sally Sacco Owner's Address: Date of Inspection: r, ' ! O Name of Inspector.(please print) W i 11 i am E_ .Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville, MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 15340 of Title 5(310 CN'IR 15.000). The system: ✓P/asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: az-- Date: — '-0 v2 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healthw 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 seat to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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 I Page 2 of 11 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 153 Seth Parker Road Centervile Owner: Sally Sacco Date of Inspection: G r Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em 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. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaire .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,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*or the septic tank(whether metal or not)is structurally unsound,a ibits substantial infiltration or exftltration or tank failure is imminent System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. 'A metal s tic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating at the tank is less than 20 years old is available. ND explain: Obsi rvation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed ipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of oard of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expla' e system required pumping more than 4 times a year duc to broken or obswmicd pipc(s).The system will pass ins ction if(with approval of the Board of Health): broken pipe(s)are replaced _ obstruction is rcmovcd ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_153 Seth Parker Road Centerville Owner: Sall Saccn Date of Inspection:. C—19-0 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 fail g to protect public health,safety or the environment. 1. ystem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s stem 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 2. Syst m will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is runctioning in a manner that protects the public health,safety and environment'. _ J be system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surfa a water supply or tributary to a surface water supply. e system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. he 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 frond a pri ate water supply well•• Method used to determine distance • This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform cteria and volatile organic compounds indicates that the well is Gee from pollution from that facility and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fail a criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 153 Seth Parker Road Centerville Owner: Sally Sacco Date of Inspection: •��3 D. System Failure Criteria applicable to all systems: You must ndicate"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{low 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 Net 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 (fiat facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (Yes1No)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: T be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 9p Yo must indicate either"yes"or"no"to each of the following: (Th following criteria apply to large systems in addition to the criteria above) 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—1WPA)or a mapped Zone 11 of a public water supply well If you ave answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"i Section D above the large system has fined.The vwnu or operator of any large system considered a signific nt hreat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. -stem owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 153—Seth Parker Road Centerville Owner: Sal1jr Ar-rn 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 t/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?. V _ 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? t/ Were all system components,excluding the SAS,located on site? (/ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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)J 5 Page 6 of 11 , OFFICIAL INSPECTION FO RM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 153 Seth Parker Road Centerville Owner. Sall S Date of inspection: —o `' FLOW CONDITIONS RESIDENTIAI. Number of bedrooms(design):. Number of bedrooms(actual): 3 DESIGN flow based on 310 CM R 15.203(for example: 110 gpd x fl of bedrooms): .3 C a Number of current residents: .b Does residence have a garbage der(yes or no):Zd . Is laundry on a separate sewage system(yes or no):, o [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no): /0 s Water meter readings,if available(last 2 years usage(gpd)): 2003 — 9, 0 0 0 Sump pump(yes or no):A U 2002 —. 21 ,0 0 0 Last date of occupancy: COMMERCIAL/I UST/RIAL Type of establishme t: Design flow(based n 310 CMR 15.203): gpd Basis of design flo (seats/persons/sgft,etc.): Grease trap prese t(yes or no):_ Industrial waste olding tank present(yes or no):_ Non-sanitary w ste discharged to the Title 5 system(yes or no):_ Water meter r adings,if available: Last date of rcupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as • of the inspection(yes or no):! If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE F SYSTEM eptic 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)anncjsource of information: i Q Were sewage odors detected when arriving at the site(yes or no): 0 6 Page 7 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 5 3 Seth Parker Road en t ervi e Owner: Sally Sacco Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of constru n:_cast iron _40 PVC_other(explain): Distance from pri water supply well or suction line: Comments(on if of jout ,venting,evidence oC leakage,etc.): SEPTIC TANK:_ locate on site plan) Depth below grade: 1, Material of construction:_✓concrete metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance(yes or no):_(attach a copy of certificate) A , r Dimensions: G Qr 4 IN 79 C, Sludge depth: ,w- Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:-/'2= I � Distance from top of scum to top of outlet Ice or baffle: 8' Distance from bottom of scum to bottom of outlet tee or baffle: 1 , , How were dimensions determined:_ e5 Go A 5 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum.to top of outlet(cc or bate: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping reconunendations,inlet and outlet ice or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 153 Seth Parker Road Centerville 1 e Owner: Date of Inspection: TIGHT or HOLDING TANK: must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: c crete metal fiberglass_polyethylene other(explain). Dimensions: Capacity: gallons Design Flow: allons/day Alarm present(yes or o): Alarm level: Alarm in working order(yes or no): Date of last pump' g: Comments(condi ion of alarm and(loaf switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: p Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: locate on site plan) Pumps in working order(yes or no): Alarms in working or r(yes or no): Comments(note con ttion of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 153 Seth Parker Road Centerville Owner: Sally Sacco Date of inspection: C, — �e Ll SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required) If SAS not located explain why: e Typ!/l y eaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): L V-�-26.r ya/ CESSPOOLS: (cesspool m t be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet' Vert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool- Materials of constructi n: Indication of ground ater inflow(yes or no): Comments(note co dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on sit plan) Materials of constructio Dimensions: Depth of solids: Comments(note con-Clition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 153 Seth Parker Road Centerville Owner: Sally Sacco Date of Inspection: G_ 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. 333 r _ 10 � Page I 1 of 11 r- OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 153 Seth Parker Road Centerville Owner. Sally Sacco Date:of Inspection:_, - SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: C*cked with local excavators,installers-(attach documentation) 4 Accessed USGS database-explain: You must describe how you established the high ground water elevation: j IS '*449 oc;2 11 No`��------<��� �� - Fps..••:"'"U.......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH OF......................... --------..............--- Applira#ion for Disposal Works Tonstrurtiott Frrinit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: • ....... ....!..... ........... ......�lQ:�.... . -•--------------...--------• ----- ------ .. --•-------• ---• .. ion ddress Lot No •• ....»_..... ...' .... . .............. .................._ . . ....... ......_._.. wner� Address .................• ......•- PQ Installer Address @ Type of Building Size Lot ..__...•.. ..!��Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (/�/D Garbage Grinder (^,oO aOther—Type of Building --__-_______••_--•-•----._.. No. of persons............................ Showers ( ) — Cafeteria ( ) @ Other fixtures -------------------------------•---------------------.••-----•••------•-----•-----•--•----•---------------••-•-- W Design Flow.........! ..............gallons per person per day. Total daily flow-----------77;K 5 ............_gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ �4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---_----__--_-_--_--_--. Lr, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ----------------------------------------- •----------------- ------------------------------------------ --------------•-•------------•--------------------------- O Description of Soil......................................................................................---------------------------------------------------------------------------•----- x U ...........--•--•-•--•••---------•••-•-••----•-•-••••-•-•------....•-••-•---------------------------------•----...-•-•-----------••-••-•-•--•-•••------•••-••------•---•----••••-•--.............-------- w x ••••---•---•--------------------------••---------•••---------•-•--------•-••.......-••••-•--•-••••-•-•----•----•-••-•--------------••-•-----•-•------............•----•--- ............................ V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•---------------------------•--•------------------------...----------...----••--------------------------•-------------------....---------------------------••-_..-------•-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ITT I:cW. p 5 of the State Sanitary Code— The undersigned - t her agrees not to place the system in operation until erti'•cate of Com liance has been i by the of alth. G Signed --•------------•-------------z Dt Application Approved BY .. L' .... D Application Disapproved for the following reasons-----------------------------•--------------------------•------------------------------ ---- --••-••---......••-•-•-•-•-•••••--•--••-•••--•-----•-••--•---•••-•-•••---....-••-----••••-----••••••---•---••-•--------•--••-••-•••--••-•-•-----•-•••-------------------•------•-----------•-------•--•- Date PermitNo. ......... Issued....................................................... Date N .__.. �—mot F�$."� ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD F LTH - P App iratinn fear Utipnllal Works Tonstrnrtinn rumit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at./ .................. ...................... .................................................................................................. I3Ve�tion Addressjw#^or Lot Aar.9" `•' .....1 . ... ..of W �Owrer y Address Installer Address PQ 4 " Q Type of Building - Size Lot..- ^ _�!_................Sq. feet V Dwelling No. of Bedrooms............................. .....Ex ansion Attic �., g— p (, r7 Garbage Grinder (yl) Pk Other—Type of Building ............................ No. of persons............_............... Showers ( ) — Cafeteria ( ) Other fixtures ................................. .� ------ W Design Flow............................................gallons per person per day. Total daily flow........................-_--_ -.._..._gallons. WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--._..--_--__-______sq. ft. Seepage Pit No-_------------------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--..--.--_--_-_-__-_-_-. Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•-•-•--•-•-•------•-•••---•------••-•-•--...••••---•-•.................•--..._..•---...--•••-•-•--•......................................................... Descriptionof Soil........................................................................................................................................................................ W --------------------------------------------------------------------------------------------------------•----•---•-........-•----•---••---•-----...--•---------•--•-------•-----•--•-•--------•-------- U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. ................................................................•-••-----------------------------------------......•-•---•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T..T }of the State Sanitary Code— The undersigned✓furti:er agrees not to place the system in operation until Cert'"-care of Compliance has been e;d by theMbottrd of liealth. oe _ ............................................' jam Signed..-:'_':..... C-----�---•-••.» c- Application Approved By---- �` ~% '"' ,_..:!�.�!-��� Date Da Application Disapproved for the following reasons:.............................................................................................. ................ ......................................................................................................................................................................................................... Datc Permit No.--+::;�. =-•- ��_--- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4Jra "�i`J...... OF................ ........................................................ Trrtifiratr of Tlantphana THIS S TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Installerf'�`,,,�,�� , has been installed in accordance with the provisions of T I T IE j of The State Sanitary Code--as descr ige,,in the application for Disposal Works Construction Permit \o----- �...._ _ 9 dated....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL TUNCTION SATISFACTORY. DATE................................................................................ ' Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Ni� <'i� .............I..... .!Ll..........OF.................. -^ -�........................... rEG1�� in�r�an ,1 nrk �nnrnnr##in_n rrnti� Permission is hereby granted............ x - to Construct F or Repair ( ). tmL Indio' al� Sewage.-..D...•.i.tes..r oCs a�lSystem r ............... ....�%'�' ____-------__at No........... I-�_...__._. Street �r^^ , as shown on the application for Disposal Works Construction Permit No& '-`?_`......gDated___ ._'--_ . _._ - •• � c�- . Board of Health DATE----mil _.--' FORM 1255 HOBBS /W.RR.N. INC., PUBLISHERS • j i • I �F-5 let KI kTA \ t�jcj•<�Ci S�P'nLTiw�C.: 33D x�saX= �Q956�P'� ,`*� I S�Lit�•i`:� ! � � =:; 7,6'?05AL'Prr— USM loC)e>-CTAl.%.ou�cr W r rr4 1 .C ZQ 61}tr'p '6To Ar VTO sr- 1-2 Ch4ccK.�soaF.C2.5= 3z5G� < _ C�l9�-Cf'I`(•Wst=��a•0 � �:'i a t--`coo-�. � •��'i. �C'aT4 "p fi4 t tX ii Fi..o u/t 425 Ex OF .s�aY t� zM�►.I.A¢L�55 "r' t r��•oo �'',-._ �P�: Mgss9 I Sys l-{ ���C--k' = -PETER:. SULLIVgN.. i , N Nq..2.9733 Tm—ST'NoL INCa 60\/15=k_ k IT J41 Q -F647.g o V� �yo II I✓ ti::a -Toy OF FU7 U f g7• u I .W)1� ��� SU���DIL Q%:`7 CT LEA-c.H co pTI' IAlJ'}�,I ItJ�l4�•4 T,�autG MOW — :wnu 3.�,01� sx C E:RTI,Fl E.D ?I--O-T P1-AT-1 N.p .t� . �. t. EL 3y•n I_c3cAT1aN )2.0 - 315 ,0. . . .. . :.•, _. . • :. : . .. tom- Ax�'� �- �1`(e, 1�C I c.Et;'c'1FY "l'FIPc""r.'Tik E p�R•1 o s�� •5 Hr7wt�l R E6•l SiEF�tu M�ty"R SU��I�z�-RS A14-17 5E1'�aAGK "REQtlI�EMi✓NT'S VF -ra•,��z�F•�,����i..�.�uL� t S :��..���- �T�..1 Ca t�T: ,�l� 1�.� ,!�M,.'.,.l.��,... 1,..acA`�� �tTt->1t1..1 't'"1-��. 'Fl..a��Lhl�, T+��s R-A�1 i5 NtSf'1,n5tp aNHN INSTRUMENT 5UK\- EY ANO I HE OFF5ET5 6HWAIN 5HZ)4LU 1gDT r3 E uSE-Q -T'a ES- &'51-15H Lam-(• L)NE S. [4NSTALLER'S TOWN OF BARNSTABLE CATIONZ ov6 6; atW &,xZR - SEWAGE #geLLAGE ��ly6L��Ili ASSESSOR'S MAP & LOT NAME & PHONE NO.��W �� TANK CAPACITY ,/0T"V ,6 Q to EACHING FACILITY:(type) ` (size) NO. OF BEDROOMS _3 _PRIVATE WELL OR PUBLIC_ WA BUILDER OR OWNER W,4 f/ DATE PERMIT ISSUED: -off ' 62-4 DATE COMPLIANCE ISSUED: - - � VARIANCE GRANTED: Yes No ��' r , C)tj `7 o DEEP OBSER VA TION HOLE LOG LEGEND Cen terville. Existing Contour ` T.H.#1 T.H.#2 �� Proposed Contour o i Date of Test 12-22-15 Date of Test x 37.5 Existing Spot Grade ROOd o s Moss. Existing Grade Existing Grade 43.1 Proposed Spot Grade \\ \f 0�� er °°a �o9o'i'o Depth 0 38.8 De th 0 w Water Service ` g�OGv- �¢ oa P P ohu- Overhead Utility Lines) 9 �0 r \� A u Underground Utility Line(s) \ CL Loamy ot� 9 Gas Line o Z y} c Sand t © TH Test Hole and/or Boring Location U 10YR 3/4 Q Percolation Test Location \ m ker Rd• Friable Concrete Bound (CB) CB Fnd.\� ` Oy, O p � Seth Ppf ST. Septic Tank ` \ VV (f I 10" 38.0 ���� D.B. Distribution Box \ � 00,00 LOCUS A. B SS. Soil Absorption System `\ o Loamy RA Reserved for Future S.A.S. of \ � Sand CU-) Utility Pole \� Setr P�Otef \` \` LOCUS PLAN 10YR 4/6 ® Catch Basin 5$ O�n \ 38,6 � Friable Fire Hydrant ) Tree or Hedge Line \� 'ide \� ` Ft' 39.0 ` 16" 37.5 [15.000] Reference to 310 CUR Title 5 f`50 38J Assessors' Map 147, Parcel 092 ' \ \ 38 BENCHMARK. ` OWNER OF RECORD: 9,1� 3 Center Catch Basin 38,4 / Paul P. Boorack "A E/ev.=38.7 NAVD88 �\ Christine E. Cantwell 1 i Deed Book 21880, Page 184 38,0 � 8 4 Plan Book 386, Page 94, Lot 663 � / \ 38 38,1 .5 \\ Rd Approximate Location 54" 34.3 POrker -� /g 38,5 \38.8 \ of Gas Service Setr�Je \ \ Prop. Corner �g ,% 39,0 �. 100' from / '0' � 9 d GENERAL NO TES 9 0 � ` R / 105• �'\ \ Z' s- 0" e� \ A.} Neither driveway nor parking areas are allowed over septic o af1� ` C 36,6 /g �� O � 38,9 \,g O th P�Otet ` system unless H-20 components are used and system is vented. Coarse Sand 5 Ft• Overdig x"36,9 .' ` �� �� � Al S O'A \ B.) The designer will not be responsible for the system as de- SEE NOTE 12 � �' \ o• p \ ' 1 � � signed unless constructed as shown. Any changes must be 10YR 8/6 i TH-1 �\ 39.4 o m approved in writing by the designer. Loose 36.7 8.0 a� 39,6 . .•.. Tom, C.) Contractor shall be responsible for verifying the location of Approximate Location of t. fi:.. a I ` all underground and overhead utilities prior to the commencement PP 39,6 39,2 cr N � 9 Underground Utilities `�! ���39,4 a3 ` I \\ of work. 700• \\ 138.5 �38 ,(. fro \ / \ ��each�n9 qm .7 � \ /' CONSTRUCTION NOTES \ reo /' / 6.9 i\�` \\ t��g / 1.) All construction shall conform to the State Environmental Approximate Location of i \W ��\\\ EX�S {00� Code, Title 5 and the requirements of the local Board of Health Existing Septic Components �� \\ 3 �e e�l��g 4.0.6 ■ loop*100006 /'' 2.) Topsoil, subsoil, peat, or other unsuitable or impervious per As Card on file with i38,0 � E` 39 8 +�r+�"� // material [15.255 (1)] shall be removed five (5) feet laterally Barnstable Board of Health ' F�' 1•' ■ in all directions beyond the outer perimeter of the soil absorp- 15t eG� •.� / tion system to the depth of the naturally occurring pervious p 37,9 / materials) and replaced with fill material meeting the spec- soon to be Pumped & Removed � � 0' Q+�"'' + 100 Ft. from ifications of 310 CUR 15.255 3 ■+� \ Top of Bank /' 3.) Septic tank(s), grease trop(s), dosing chambers) and dist- ribution box(es) shall be set on a level stable base which has \ 12°" 28.8 ■ been mechanically compacted. If component is placed in fill,/ proper compaction is required to ensure stability and to prevent ■ ` / settling; native ground with a 6 inch stone base is otherwise adequate [15.221(2)]. 4.) Base aggregate shall consist of 3/4" to 1-1/2" double Representative of Approving Authority: \ / �+ / /' washed stone free of iron, fines and dust and shall be installed David Stanton R.S., Barnstable Board of Health Lot 663 from below the crown of the distribution line to the bottom of Soil Evaluator. David A. Clark, P.E. - Clark Engineering `� / Record Area=15,262 S.F.f \. \ / the soil absorption system [15.247(1)] Base aggregate shall be ,�.� or=0.35 Ac.f y �' free of iron, fines and dust [15.247 (2)].covered with a 2" layer of 1/8 to 1/2" double washed stone Percolation Rate: f 0000' ,-._.. ) ram the- date of-instollator, c d '' . oil_:absorption.:ays ..m M "m #1 - < 2 min. per inch in coarse sand; Substratum C � R #2 - min. per inch in ` P OAK f / until receipt of a Certificate of Compliance, the perimeter of the No Water Encountered \` soil absorption system shall be staked and flagged to prevent Appropriate Index Well: SD 252 16 3 S ��eth �Ot the use of such area for all activities which might damage the \ '(0 / system [15.246(2)]. Water Level Range Zone: V D �. 6.) The Board of Health shall require inspection of al/ construction Water Level for Index Well., 47.3 `\ _ ,� by an agent of the Board of Health and the designer and shall require such persons to certify in writing that all` work has been for Month - Year. 12-1* completed in accordance with the terms of the permit and Adjustment: 3.5 , Observed Ground Water Elev.: 22.0 \� 0� approved ions.accordance hours advance t' 5. PP P notice is requested. Adjusted Ground Water Elev.: 25.5 � e 1� * Observed Wafer Elevation in Adjacent Bog Goto9 \ 5 �Oy Z) All system components shall be marked with magnetic marking Pme tape or a comparable means in order to locate them once buried. 430 �e11 \ 24,2 SYSTEM DESIGN CALCULATIONS v� oet, Top 0f Bank24,0 1.) Basis of Design ae 1 ` _ .223. 1� / Number of Bedrooms: 3 �ed�R` old 9 \ /'/ 23.6 x 22,0 1 " Other. N p�.in �` /• x' 2.) Design Doily Flow Sewage Flow: 330 GPD G1 Qatr \ /'' Cranberry Bog 3.) Septic Tank Capacity { �c Required: Provided. 1500 Gal. Bedf� got `` ,'/ Observed Water K';' , 4.) Soil Absorption System Capacity FLOOR PLAN \ / Elev.=22.0 �' ' DAVDA Required: 330 GPD / �' ` o � C ARK�"�' Provided: 349* GPD \ / 9" C'Vli , 5.) A garbage disposal is NOT permitted with this design „ No.41172.6 �lb7L /.•ra* 25 L.F. x (2 + 12.83 + 2) x 0.74 gal/SF �8 0 20 40 60 3 4 4� + 2 ends x (2x 12.83x0.74go1/SF) \ � „ B. PROFILE OF SYSTEM SECTION A-A CHRISTINE BOORAI"V Not To Scale Not To Scale PA UL BO ORA Top of Foundation 39.8 CL Finish Grade 38.5 Finish Grade 38.5 38.0 2% Slope minimum 38.5 8'inin. Finish Grade Raise covers of the D-Box with pre-cast Raise covers of the septic tank with pre-cast concrete concrete water tight risers over inlet and Elev. = 6" water tight risers over in/et and out/et tees to within 6" outlet tees to within 6" of finish grade. Raise manhole cover p within o inches CLARK ENGINEERING LLC 37 0 of finish grade [15.228(2)]. 36" of finish grade using precast concrete riser, " ( ') concrete blocks, or brick masonry. 1.5' 36 max 1'4 max Elev. = 1.9 ( ) 9 min E/ev. Raise manhole cover to within 6 inches Elev. = 2.4' 156 Crowell Road Suite B, Chatham, MA. 02633 37 1 36.1 of finish grade using precast concrete riser, 36.1 _ concrete blocks, or brick masonry. Tel.: (508) 945-5454; Fax.: (508) 945-5458 SEWAGE DISPOSAL SYSTEM PLAN 29 minimum slope--- _ -�-2" layer of 1/8"-1/2" 6" min. 6 min. 1X minimum slope 1X minimum slope - - - , - • washed stone _ . • _ Q a Flow Line - . . - . . - . _ . . - . . . - . . - . . - 4" schedule 40 PVC pipe C " _ . . - . . _ _ - _ - _ - _ - _ - 10" min. 14" I" schedule 46) PVC pipe 6 min. Out/et pipes from D-box shall - _ - � � - - 3ashed 1/2" - - - - - _ _ _ washed stone 0 a 153 Seth Parker Road, Centerville, MA remain level for at least 2 feet I Effective _ _ _ - EXISTING 1 before pitching to soil absorption _ E/ev. = 2, Depth a 0 - - - - - Elev. _ - - EDepthcie Elev. = Effective Elev. _ - _ - _ - Rev. # Description of Revision Dote Schedule 40 PVC Tee Baffle system [15.232(3)(c)]. 35.30 0 - ' ' - ' ' - - 2 35.30 Depth 2' 35.30 ❑ ED El El 0 Elev. = E/ev. = 48" min. Tuf-Tite E/ev. _ Elev. = E/ev. _ - - _ - _ - _ - _ - _ - _ - _ - 33.30 � � EJaa � a � � � 37.6 35.90 (GB-1) 35.65 35.63 35.46 - - - - Bottom of Leaching Facility - - - 1-4' �-41 � • I-•- 4' -F 8.5' I 8.5' I--- 4'----I Distribution Box l ....•. ......•. •.... DB-9 Effective Width 12.83' 1 Adjusted Water E1.=25.5 Se tic tanks shall be installed an"a''/eve/ stable base Effective Length 25' p O (J'0 X 30 > Bottom of Test Hole 28.8 9 Pipe Run that has been mechanically compacted and onto which 6 Leaching Galley (10' min.) inches of crushed stone has been placed [15.228(1)]. Date: 12-23-2015 Drawing No.: 10, 1500 gallon Sep tic Tank � 2' s' to 12' H-10) Scale: 1" = 20' Sheet No.: 1296010A (H 10) 1 of 1