HomeMy WebLinkAbout0021 SHANNON WAY - Health 21 Shannon Way, Centerville _
A= 170-244-001
No. 42101/3 ORA
ESSEVrE
10%
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' TOWN OF BARNSTABLE
LOCATION.,)-( �WA-4xftf ��`'I SEWAGE# 16 t!- !
VILLAGE SSESSOR'S MAP&/'PARCEL f-70 Jk4�e4-�
INSTALLER'S NAME&PHONE
SEPTIC.TANK CAPACITY
LEACHING FACILITY:(type) i' {¢— (size) _�5.4
NO.OF BEDROOMS
OWNER _T'
PERMIT DATE: i�S� COMPLIANCE DATE: v s
f
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) eet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) rf 6E Feet
FURNISHED BY
Way 44
y JV•G
z I
No. dot '" Fee to
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4pliLation for )Disposal *patent Construction permit
Application for a Permit to Construct( ) Repair(✓�Upgrade( ) Abandon( ) ❑Complete System �dividual Components
Location Address or Lot No. ` �5h hllan Owner's Name,Address,,Tel.No. 6W• FPO6W
Assessor's Map/Parcel 10 v('� '-�
Installer's Name,Address,and Tel.No.g—ft-tft.$• 84)Of esigner's Name,Address,and Tel.No. �O�-36 a=
i`�5o�-Fv(a %Co►- (-rracl icxn Za-+c • s�Cfy 3�e i 9311r /+Main SW-
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size � sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 O gpd Design flow provided Sq re 3 gpd
Plan Date A-1q;,e 13, ecu,j Number of sheets . Revision Date
Title e�1 S _ Yl a� �?! SRLt.t1 w a U cn ie-rultle MKS
Size of Septic Tank exi4 M 163l9P I _ Type of S.A.S.
Description of Soils Q
Nature of Repairs or Alterations(Answer when applicable t Q0 0
_[�» �•- �^SAX f0.
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 Environmenta a and n to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
(J
Application Approved by Date
Application Disapproved by Date
for the following reasons
®�
Permit No. Date Issued
Fee le o
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
1 r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
}
21ppIication for Disposal .pstem Construction i3ermit
Application for a Permit to Construct( ) Repair(.o�Upgrade(`) Abandon(1 ) ❑Complete System EA4n'do ividual Components
Location Address or Lot No. 1Glh71On .L Owner's Name,Address,and Tel.No. .'� �al(j S V
Cie -Nke cu I(�'� MffW_S)C>'Cc�v�nw-i I c/a &-A erocecl�u
Assessor's Map/Parcel 17(� a(/y_ n A
Installer's Name,Address,and Tel.No.-,)W-q, S• 2S goZ(p esigner's Name,Address,and Tel.No. 3`p ES3G� -
Qor-wly C'o��st-rcx�crn;zrc • ,t r�4�se � iflee.ri 434 /Clair) SF'
RQ
Tpe of Building:
y� Dwelling No.of Bedrooms Lot Size Y` S/) sq.ft. Garbage Grinder( )
` Other Type of Building . i t ;,r- No.of Perso n Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ,3 3�, '� a gpd Design flow provided �s 3 gpd
Plan Date Rnn� apr 4, Number of sheets 1 Revision Date
Title ! i k Ankl, Z` -21 S�qnali/j 61,h C1 Rud1, AA19
Size of Septic Tank 2x1�I , Ty of S!k9. f
Description of Soils
Nature of Repairs or Alterations(Answer when applicable `%� �``
C417 go
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.G ee a�to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed ,/ Date
Application Approved by ( Date
Application Disapproved by Date
for the following reasons o
Permit No. - 1 Date Issued t 5
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by dn UZ,
has been constructed in accordance with the provisions ooffT.iittle 5 an 1 e for Disposal System Construction Permit No.4906- 1;1l G
�dated '5'O
Installer 127r'-�Fj /,{E �,�St(�G�-{nt,ll, J.�nL Designer y'AOD l�?rj to e. r) -,e l�i�hC A,f '
#bedrooms Approved design flow , gpd
The issuance of this permit shall not be construed as a guarantee that the system wil func' n as d s nedn
r I
Date Inspector ( �
---------------------------------------------------------------------------------------------------------------------------I-/-c---J------------
No. p�O I J Fee r V
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at �! s S�xc n mmn al u./ �P� /e rul/AF
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.'-�
Date Approved by
JUL-02-2015 03:24 From: To:15087906304 Paae:1/1
Town of BayugWlble
k� Regalatury Services,
ThOMM F.Oef er,DtMdox
MARL Pubife Health Dividm
200 Waft S teet,Namw&,MA 0260JL
Office: 508-962-4644 Fax 508-790-6304
iGalles Ce$titmnom>Eb
t-7l�j�u��!
,Date; it, Assesso�r'sM2 tFaacel�
U9: C j b#��: YI
gDep: M t:
i
Oa �� �� '��.�Q� �(�11U/�raa issued a pe�itto in�sEeIl a
(data): s�stallec)
-1 MEW
at � �11 vU.�.i�+���danadasigpdrawalaY
s ( $)
dated_ llll�"
the ft septic9Y ifereued above w bataned sabstantalp Ucofft tO
sucks as lateral zelocatou of tha
the d=gn,•which mo iml-mde,mmoz approved cages
6ftlutim box andlor sep4.c tank.
I rarlifp that the sey6c system rsfczaaced above was filled with m*w changes (i.e.
gmatea than IQ,latezal rebacattan of the g.A,s or any vertical relacatlOA of auy ODW= t
of ILO.septic Ugem).hnt in acctudence with State&Local'p egulatj=, Plaa XWLgian.ax
cezdW as-bbAt ig(M to f0ltowv
IEEp
tomML
: •
� (Irsstaller'9 Si�di$e} �.�_.•�� •'.':��
E
(DesigQer's 3ignatuze (AiftDesxgna's temp Hem)
pLYAA TOBAYtN ^� C Y'1'� ��VIHICDPC. 'i"�'lCi4T� �l�
Op p'y wMLL OT T�F As- T CARD ARE
' ]g�, �Y TIC BAR1VSfA'�LE LIC I�ALTgD
O:�ealfhl9e�ti�JDesiRaiuCeitific�;naFars3 Zb-94� •
j
1 �
Town ®f Barnstable
°pTHE Tod Regulatory Services `
Richard V. Scah, Interim Director . "
CAB . ; Public Health Division
169. A`�� Thomas McKean Director
200 Main Street,Hyannis,NIA 02601
Office: 508-862-4644 Fax: 508-790-6304
Homeowner Certification Form for Alternative Systems
Property Address:
Assessor's Map\Parcel:
Property Owners lame:
In accordance with Massachusetts DEP alternative system approval letters, the following certification.
information is required by the Owner of record. ' The Owner of record must place an "x" in the
applicable box next to each line certifying.the information.
Yes N\A
❑ I have been provided a copy of the Title 5 I/A technology Approval letters.
(15 page Standard Conditions letter and the specific technology letter)
❑ I have been provided with the Owner's Manual
❑ I have been provided with the Operation and Maintenance Manual
❑ ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my
responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10),
and the Approval
Q ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to
provide written notification of the Approval to any new Owner, as required by
310 CMR 15.287(5)
❑' ❑' If the design does not provide for the use of garbage grinders, the restriction is understood I
a P g g
and accepted
El ❑ Whether.or mot.covered by a warranty, I understand the requirement to repair, replace,modify
or take any other action as required by the Department or,the LAA, if the Department or the
LAA determines the System to be failing to protect public health and safety and the
environment, as defined in 310 CMR 15.303
agree to comply with all terms and conditions above.
Pro erty...Owners„p ed ine
� f5
`11rope wners Si ature Date
Dote: This form must be submitted aloe with the septic system disposal works permit
application for all RA systems including new construction, repairs\upgrades, with and
without aggyregate (stone) and with conventional design criteria or credited design
criteria.
Q:\Septic\IP,homeowner certification.doc
r I
Town of Barnstable Barn
Regulatory Services Department
�
nnRxsrn � 1
Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office:.508-862-4644 Richard V.Scalli,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL 9 7014 1200 0001 0358 0574
March 25, 2015
James O'Connor
9 Sturbridge Way
Brewster, MA 02631
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 21 Shannon Way, Centerville,MA was last inspected on
October.31,2014 by Michael DiBuono, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• System is in complete hydraulic failure.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF/T E BOARD OF HEALTH
�a
Thomas McKean, R.S., CHO. U
Agent of the Board of Health
0
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\21 Shannon Way Cent Nove 24 2014.doc
S61Q Town of Barnstable Office: 508-862-4644
A Fax: 508-790-6304
Regulatory Services Department
Public Health Division
NAM Thomas A.McKean,CHO
200 Main Street, Hyannis, MA 02601
Payment Receipt
Septic (Disp.Constr. Permit) Payment received: $100.00 (Check) on 5/8/2015 Permit number: 2015-129 I
Check number: 10460 Check amount: $100.00 Name on check: bortolotti
,Owner: TAMES OCONNOR
Address: 21 SHANNON WAY, Centerville
I
JUL-02-2015 01:03 From: To:15087906304 Paee:1/1
i .
(j of 13amsttable
i E Reg tomY Services.
Tbooasea F.!Gene$,tph•ector
Public Health DMSiOIL
VAM
200 6'trMt,Rye,MA 021,111
FMC 5aa,'790-6304
Ofco: 509-662-4644
al➢e� ]lea eDr t✓e ��v�Fm
Date. ,•.! sewage Ferment# 6Q��-1�� �seaeour'® p11'srcel�
Des;
A3la -as,
t
fn
)' issued a permit to hataii a
tom.
(znsialler)
I. d on a deaip dawnbY
eG (mess)
✓�► I m'Ady'tbatft septic system xeftre�,ced above wm mA�d anbSW161aY$eC° to
ed es gw&89 lateral Mloration of t$e
ft dissign,Wbicb may'�Inde,minore�rgaoro •
dish ibUdau box audlor septic tank.
Y amp t tkie septic system iefeTmeed above was installed with major obauges
ell reloeatiion of BUY oomponez�t
�eatet tbsn 10'lateral zelocatiwa of tbo SAS or aT verb.
o£tbe septic syat=)but in acccn tO wlAL State Racal Regulatirras. Plan xevie7oa or
follow.
certified as b5 1 to s�vo
:NO::4BS01:...
(ma 's S�gnatue) '4Q:
TJi tJ . —7 j ti
(De��'$Signatuze (A��eaigoex's Stamp��)
MIZABLAN
U TO AWN AN ® '�UII,T
CO YOU
• I,�C TH D 9II
O:H�n1 /Seoti�si�a� c onEorm.3-26-04Aoe
Town of Barnstable
Barnstable
.� Regulatory Services Department j
i639. �� ' Public Health Division
I
lip 200 Main Street, Hyannis MA 02601 2007
Office:.508-862-4644 Richard V.Scalli,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7014 1200 0001 0358 0574
March 25, 2015
James O'Connor
9 Sturbridge Way
Brewster, MA 02631
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 21 Shannon Way, Centerville, MA was last inspected on
October.31, 2014 by Michael DiBuono, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• System is in complete hydraulic failure.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF BOARD OF HEALTH
Thomas McKean, R.S., CHO.
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\21 Shannon Way Cent Nove 24 2014.doc
E.
'(ME, ,� Town of Barnstable Bare
Regulatory Services Department AtAfffflf=C j
�STABM I
"'" Public Health Division
200.Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scalli;Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2851 3979
_� ±v\
December 4, 2014 �- _2
R
James ONConnor
9 Sturbridge Way
Brewster, MA 02631 "`
• ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 21 Shannon Way, Centerville,MA was last inspected on
October 31,2014 by Michael DiBuono, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system.showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• System is in complete hydraulic failure.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
1
Thomas cKean, R.S., CHO.
Agent of the Board of Health
•
QASEPTIC\L.etters Septic Inspection Failures or Future Evl\21 Shannon Way Cent Nove 24 2014.doc
i
Postal
(Domestic Mail Only;N?,Insuraifice Coverage Provided)
FICIAL USE
Ln
CD Postage $
ti
Certified Fee
Return Receipt Fee
Pos ar[i
p (Endorsement Required) ^ Here O
Restricted Delivery Fee
C3 (Endorsement Required)
r'q v
M Total Postage&Fees.
James O Connor
9 Sturbridge Way
Brewster, MA 02631
Certified Mail Provides:
■ A mailing receipt
■ A unique identifier for your mailpiece
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047,
ZHF r
Town of Barnstable Barnstable
> &
Regulatory Services Department j
Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scalh,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7012 11010 0000 28513979
December 4, 2014
James O'*Connor
9 Sturbridge Way
Brewster, MA 02631
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 21 Shannon Way, Centerville,MA was last inspected on
October 31, 2014 by Michael DiBuono, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• System is in complete hydraulic failure.
You ate ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas cKean, R.S., CHO.
Agent of the Board of Health
Q:GSEPT1C\Letters Septic Inspection Failures or Future Evl\21 Shannon Way Cent Nove 24 2014.doc
i
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Jjissgl2jintranetjpropdataJParcelDetail,aspx?ID=11465 Live Search w P
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Parcel Info
Parcel 170244001 Developer LOT1
ID Lot
Pri ar''
Location 121SHANNON WAY
Frontage
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. Sec I Sec
Road Frontage
Village ICENTERVILLE iI Fire. C 0 MINI
Distrct
jTown sewer exists at this
address Na Road Index 2149 I s
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ASbuilt Septic Scan: Interactive ' � _ IF
170244001_1 Map .. '
Owner Into I
Owner JOCONNOR,JAMES Co-Owner
I _
Streetl 19 STURBRIDGE WAY I Street2
City BREWSTER I State LMA] Zip=02631Country
Land Info 'L''
Acres=.00Use ISingle FainMDL-01 Zoning= Nghbd 0105
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Done 7!!IJII�IhJ�jIJ� Local Intranet ' 100°I°
Startl; j Q,15EPTIC1Letters Septi,,, W21 Surrey Lane,doc Mac,,, Parcel Detail Windows I.,, yf1 11,59 AM
Computer name : HEALTH899JF User name : flvnnl Operatinq Svstem : Windows NT (5.1)
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Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Shannon way
,M
Property Address -
Ken L Silva
Owner Owner's Name —
information is
required for every Centerville Ma 03632 10/31/14
page. Cityfrown 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 filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: C
key to move your
cursor-do not Michael DiBuono
key the return Name of Inspector --
Y
DiBuono Sewer and Drain a.
reb Company Name ----- -
8 Johns path .
Company Address —
�"°^ S Yarmouth MA 02664""
Ity own State Zip Code,--
508-364-9587 S113522
Telephone Number License Number
B. Certification _
_Z,,y_ tea
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/31/14
lill"llpector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13
Title 5 Official Inspect"Surlfneewage Disposal System-Pagel of 17
t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Shannon way
Property Address —
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. Citylfown State Zip Code -date—of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in complete hydualic failure and has been for some time. Tank is a 1500 gallons Dbok is in
need of replacement and leaching trench is saturated
B) System Conditionally Passes:
❑ One or more system components as described. in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Shannon way
M
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or.obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of.Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed . ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require-further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
°M 21 Shannon way
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. Cltyrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form :Not for Voluntary Assessments
21 Shannon way
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. CltylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner o_ r operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Shannon way
M
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. Cltyrrown 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?
Z ❑ 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?
10 ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 333
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments
21 Shannon way
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. Cltylrown State Zip Code Date of Inspection
D. System Information
Description:
System is in complete hydualic failure and has been for some time. Tank is a 1500 gallons Dbox is in
need of replacement and leaching trench is saturated
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 2012 58,000
Detail
2013 60,000
163 Gallons per day.
Sump pump?
❑ Yes ® No
Last date of occupancy: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 21 Shannon way
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. Cltyr town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Shannon way
Property Address
Ken L Silva
Owner Owner's Name
information is Centerville
required for every Ma 03632 10/31/14
page. Cltylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
19
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 30"s
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.):
Septic Tank (locate on site plan):
Depth below grade: 1 ft
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene
El 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 Gallon
Sludge depth:
3"s
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
I
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Shannon way
Property Address
Ken L,Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
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 24"s
Scum thickness
3"s
Distance from top of scum to top of outlet tee or baffle 42"s
Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick
How were dimensions determined? Tape Measure
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: NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-3113
Title 5 Official Inspection Form:Subsurface Sewage,Disposal system-Page 10 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 21 Shannon way
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
El other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Shannon way
M
Property Address — ----- --
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
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 Needs to be replaced at time of new system
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.):
Needs to be replaced at time of new system
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:
,Sins 3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�w 21 Shannon way
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1 30'x 15'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Pipe in stone
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 21 Shannon way
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
System is in complete hydualic failure and has been for some time. Tank is a 1500 gallons Dbox is in
need of replacement and leaching trench is saturated
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Shannon way
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
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 all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
drawing attached separately
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
AsBuilt Page 1 of 1
'!r TOWN OF BARNST.1 BLE V 7' (0/�0/70
LOCATION Z �`�?0�1Ho� G✓aS/ SEWAGE#7 SM I.9-✓.
VILLAGE ee11.7` 1--1�le _.- AoSESSOR'S MAP&LOT2 W.do,
INSTALLER'S NAME&PHONE NO. og0l}�LvfI-J
SEPTIC TANK CAPACITY 45217Z�
LEACHING FACILITY: (type) 13'X 30Y6 s (size)
NO.OF BEDROOMS 3
BUILDE �OW
PERMUDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feel
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.
i d VN / !,
z�z
Q �I°
O r
7
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=170244001&seq=1 11/10/2014
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Shannon way
Property Address
Ken L Silva
Owner Owner's Name
information is required for every Centerville Ma 03632 10/31/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12 + ft
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: Test hole log data 12/23/86
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
plan on file
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high groundwater elevation:
Test hole log data 12/23/86 on site plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
T
- Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Shannon way
H
Property Address
Ken L Silva
Owner Owner's Name
information is
required for every Centerville Ma 03632 10/31/14
page. Cltylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information— Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
' t
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Town of Barnstable # C
' yY Departionent of Regulatory.Services �� 1
14 uZIN3 , Public Health Division � I..� li slion Da e
" r�li h� 200 Main Street,Hyannis MA 02601
Date Scheduled Time &ee I'd, `
r '
'XI
,Soil Suitability .Assessment for Sewage is o al
Performed-B ry: l 60,7Sa(,_/e S Witnessed By: U". �S
I.,O CATION& GENERAL,AVFO:ltMA T I
Location Address oil
l �_�,��,_non Owner's Name�
' � �)1 ' u� Address
th
Assessor's Map/Parcel: (70/2 / �001 Engineer's Name
NEW CONSTRUCTION REPAIR Telephone#
Land Use: L awl Slo es 96 0 S /UOn to
P ( ) . Surface Stones /
Distance's from: Open Water Body �(OG ft Possible Wet Area >��� ft Drinking Water Wc11 ft
Drainage Way >GG1 ft Property Line > '") ft Other
ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pare tests,locate wetlands•in proximity to bolts)
2 q0,20
t^. IfL4riC Ee�S2Yn?h'1`
o
�
Parent material(geologic)(460 0 Q uWt5h Depth to Badrgck
Depth to Groundwater. Standing Water in Hole: /V14 Weeping from Pit Fite 4�1/A-
1?sdmated Seasonal Higlt Groundwater NIA NGT4,1, ', �Tc�TION FOR SEASONAL HIGH
Method Used: fit/ �6'�A.'I"ER TABLETABLE
Depth Observed standing in obs.hole: In. Depth to sQII motthns: ln,
Depth to wccping from side of obs.hole: In, Groundwater Adjuament 1r.
Index Well# Reading Date: Index Well Adf,factor,..,..,_,_.. Adj.Groundwater Leval_,,
PERCOJLATI.ON TES` ' Date., '1'1m�a__-_ _
Observation ' .
Hole# Tlma at 9"
t� .. �.'
Depth of Percy — + r_ — (� - - Time At G"
Start Pre-soak Time @ `Pima(9,14')
End Pro-soak l /�
RateMin./lach L�nt,�l/l�C•
Site Suitability Assessment; Slte Passed Sftg Filled: 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 1.00' of wetland,you must First notify the
Barnstable Conservation Division at least one(1) week prior to begiiw1ug,
Q:1S EPTICIPERCFORM.D O C
DEEP.OBSER'VATION HOLL SLOG Hole# I
Depth from Soil Horizon Soil Texture Sdil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders,
i t o f tcn Y -%%raved
Y
I�t-3g
7/3
DEEP OBSERVATION HOLE LOG Hole#
from Sdi'gonzon Soil Texture So11;Color' i'-" Soil Other
Dcpth
Surface(in.)' (USDA) (Munson)
Mottling (structure,Stones,Boulders.
onsis en CYb Gravel)
3&_ 3Z ' C ..""q s 2,fy
DEEP OBSER'V'ATION HOLE]LOG Hole It
Depth from Soil Horizon Soil Texture Soil Color Soil Other'
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistpricy,.YG c
VEEP OBSERVATION HOLE LOG Hole 9
Depth from Soil Horizon Soil Texture Soil Color Soil tither
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Co si ten
• v
Flood Insurance Rate MU, /
Above 500 year;flood boundary No Yes
Within 500 yearboundary No 7 Yes '
Within 100 year flood boundary No. Yes
.Depth.of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout th6
area proposed for the soil absorption system? Y-P `7
If not,what is the depth of naturally occurring pervious matdriall
Certii�cation �/r/(Z •
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the requited training,expertise and experience described in�10 CMR 15..017..
Signature Datbq
Q:\sEPTlaPE11CPQRM.D0C
11L11J V1.)�J11L'.V:lll .•.-
ATION Loy W NEZ-2 d rS( _ ,�A• 1.1c�....�.�p���
LAGS UA'1'1 J2.1,01634
LICANT
RESS ,1Z I,)4r,Mo/l .iG I&A i' L' yl1-L
' TELEPHONE NO. ' �('c (Noes-r.eti�sidable
INEER d. 10 ,� 1L)tL E f /A) ' TELEPHONE NO. ' •.Z
E SCHEDULED (�� ��;D 77 At� � ----
(APP'k cant' s sigssat it
. . . . .�j�. . . . . ... .�. ou fir. l'�1rZcLZ z4'i CrLCF•rvr� siibd�vis io+�'�-slldw ;��. . .
SB3S01[Z 9 b�AY' 6s LO'r TVOs ti P 17 1} 1 SOIL LOG Pt., AK.4G.3 qj
-DIVISION NAME - DATE � o TIME 371
ANSION AREA: La(i11 . •. '. ENGINEER::N
N WATER ' . PRIVATE WELL T. c 1. ('xl BOARD OF HEALTH
EXCAVATOR
TCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES: ,
L 67- 1
r
COLATION RATE: ,_
< Z MINI INC14 ��•�
T HOLE NO: � ELEVATION: TEST HOLE NO: ELEVATION:
1F LOAM SUt35oll. 1
2 2
ter, 1
3 ' 3 J
4 4
5 5
McoI�N1 �e
8 .;
91 �p 9
" 10 10
12 12
13
13 14
+ 14 ;;a
s 15 15
16 16
:TABLE FOR SUB-SURFACE SEWAGE: LEACHING XIELD'k LEACHING PITS D<
. LEACHING TRENCHES- v
►UITABLE FOR SUB-SURFACE -SEWAGE. REASONS: .- --
.'E: ENGINEE!RING PLANS MUST SHOW NUMBER ASSIGNED .ON PERC TEST Al""
:GINAL: COMPLETED �N �NT1(2F�'Y @Y P_ F,. A�,�',('�)RHEJD "0 130AM)
ly: RETAINED By APP1,tCANT .
TOWN OF BARNST,.kBLE 01P611
LOCATION Z, afmgw lNa�l 3 SEWAGE # P+r"If 1� I
VILLAGE ��� ! � ____- A, SESSOR'S MAP & LOTZzu�sa/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILrrY: (type) �✓~-l�3®l'� `� S� ' �size)
NO.OF BEDROOMS
BUILDE OR OWaNER
PERMUDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
-1
ASSESSORS MAP
No. 1 ���` PARCELK 'f� �A°_- "0�! Fee d
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01papiication for Mizpogal *potem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
yG�,Ps Cd�� � gg
Cry ��y%/e ~sL.Is
CsU15J 776 -,S 306
Installer's Name,Address,and Tel.No. ®P2�0 Al Designer's Name,Address and Tel.No. ti
j'1?9 q 97,,
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder(ll1c�
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow //G ni;t gallons.
Plan Date ! i 4.5 Number of sheets Revision Date
Title
Description of Soil L.or,,iyl C�__ .51,14 ;Fri"/ .7 ael'"`i 6 /4_*1
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 issue /�A�;
Signed Date l
Application Approved by
Application Disapproved for the following reasons
Permit No. /"fip �F,y Date Issued
No. Fee
THE COMMONWEALTH OF.MASSACHUSETTS - t`
W
PUBLIC HEALTH D_IMISION TOWN OF BARNSTABLES.ItI�ASSAC:HUSETTS
ZIppricatio-- r Zfii po�mt bp!5tem Cowaruction Permit
Application is herebytmade for Permit to Construct( )or Repair( )an On-site Sewage Disposal System at
t - -
Location Address or Lot No: �/ Owner's Name,Address and Tel No.
�/ �jci/1/la� (tea f�41{sr _ 'G'011,4
1,7
276--S-306 , Q� �
Installer's Name,Address,and Tel.No. ®r�� � Designer s'Name,Address and Tel.No. 9
9 /
Type of Building: 1
} Dwelling No.of Bedrooms Garbage Grinder(N®)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow • 34 gallons per day. Calculated daily flow gallons.
Plan Date S 14 Number of sheets Revision Date
- Title
Description of Soil L.0r4111F7 d- S'GA ;G,
+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
+w 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" �toar He 1 p
Signed Date
+ Application Approved by
Application Disapproved for the following reasons
k Permit No. '91. e Ile Date Issued
f
THE COMMONWEALTH OF MASSACHUSETTS
M PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS
Certif irate of Compliance
THIS IS TO CERTIFY,that the n-site Sew a Disposal System installed( )or repaired/replaced( )on
by I C9% �47 � for��� S 0—Connbr
as has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit N ated l'-�0Use of this system is conditioned on compliance with the provisions se h below:
----- No. , `�,�- — r�————————_-_---�————_ .�.,.,m�,.�.——— Fee �!/' �.— •4
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
i
Migoal bp!5tem Con.5tructiou. Permit
Permission is hereby granted to >3
to construct( repair( )an On-site Sewage System located at 1
I ry
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to a:J
comply with Title 5 and the following local provisions or special conditions.
All constructidn must be completed within two years of the date below. oo ;
Date: � -' f O kJ` Approved
t ;
NOTES
SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE 1. DATUM IS NAVD 88
MARKED WITH MAGNETIC TAPE OR o
(NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 2. MUNICIPAL WATER IS EXISTING v O°
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE Gr o a
3, MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
\ TOP FOUND. EL 53.5' PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE
4. DESIGN LOADING FOR ALL PROPOSED PRECAST
MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTE 52 0 UNITS TO BE AASHO H-LQ �r e (ce( Locu
o
PRECAST H-10 NOTE: MIN. WALL THICKNESS 2" e e
' RISERS (TYP.) 5. PIPE JOINTS TO BE MADE WATERTIGHT.
RIS
IS 50 9� 4"OSCH40 PVC e
cm PIPES LEVEL 1ST 2' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE o
2" DOUBFF� WASHED PEASTONE Q
OR GEOT TILE FABRIC 49 0' WITH 310 CMR 15.000 (TITLE 5.) z Choppo u/
10" EXISTING 14"
TEE SEPTIC TANK TEE *49 5'f 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND o ° n
000000000000 NOT TO BE USED FOR LOT LINE STAKING OR ANY Q_
GAS BAFFLE;: °o,°o�g "48.5' o OTHER PURPOSE. v�
48.68' 48.51' 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.6" MIN. SUMP og 46.5 Q
12" MIN. INT. DIM. H-20 3050 INFILTRATORS 9. COMPONENTS NOT TO BE BACKFILLED OR Rote Z
CONCEALED WITHOUT INSPECTION BY BOARD OF
6" CRUSHED STONE OR MECHANICAL 3/4" TO 1 1/2" DOUBLE WASHED STONE HEALTH AND PERMISSION OBTAINED FROM BOARD Route 28
COMPACTION. (15.221 [21) OF HEALTH.
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1.4% SLOPE) ( � SLOPE) OVERALL DIMENSIONS TO OUTSIDE OF STONE: 30.4' X 10.25' 10. CONTRACTOR SHALL BE RESPONSIBLE FOR
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM ( 1 5.7
CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP
LEACHING VERIFYING THE LOCATION OF ALL UNDERGROUND &
FOUNDATION- EXIST. SEPTIC TANK 57' D' BOX 3' OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NOT TO SCALE
FACILITY WORK.
**INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT
1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 170 PARCEL 244-1
WITH 1500 GALLON H-10 SEPTIC TANK IF NOT SUITABLE (OR H-20 BOTTOM TH-1 40.8' SHALL BE REMOVED 5' BENEATH AND AROUND THE
NO GROUNDWATER FOUND
SEPTIC TANK IF IT WILL BE SUBJECT TO VEHICLE LOADING). PROPOSED LEACHING FACILITY.
12. EXISTING LEACHING FACILITY SHALL BE PUMPED
AND REMOVED OR PUMPED AND FILLED WITH CLEAN
LEGENDSAND.
99- EXISTING CONTOUR /
X 99•I EXIST. SPOT ELEV.
99 PROPOSED CONTOUR
y2 LOT 1 N /
[98i4] PROPOSED SPOT EL. e 43,572t Sq Ft /
L
TH 1 \� /
TEST HOLE �
YY / SYSTEM DESIGN:
2�-_ SLOPE OF GROUND /
ELECTRIC EASEMENT
UTILITY POLE GARBAGE DISPOSER IS NOT ALLOWED
� 53
5'
FIRE HYDRANT 57 38 / �` DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD
S
NOTE NOT ALL SYMBOLS MAY APPEAR IN DRAWING 0 -J USE A 330 GPD DESIGN FLOW
TEST HOLE LOGS 5C;
S'� SEPTIC TANK: 330 GPD (2) = 660
/ `ENGINEER: DANIEL E. GONSALVES, SE #13587
KS { TH' EXIST. RE-USE EXISTING SEPTIC TANK**
THz `, SAS LEACHING:
DARREN MEYER,
WITNESS: RS
�qF 9� is r.
\ o� � � x SIDES: 2(30.4 +10.25) 1.85 (.74) = 111.3 GPD
DATE: 4/13/15 % / `� N BOTTOM 30.4 x 10.25 (.74) = 230 GPD
PERC. RATE _ < 2 MIN/INCH �'Fti�F / o-� s . �n 52. 8 I s TOTAL: 461 S.F. 341.3 GPD 2�
CLASS I SOILS P# 13729 �o \ �o ,`���a 6 USE (4) H-20 3050 INFILTRATORS,
�� ��
ELEV. ELEV. / �x 52. ,c �; s2.37 \\ , o WITH 1' STONE AT ENDS AND 3' AT SIDES
2 z z 8 MAP 170
p 51 .8 p„ 51.8 0 �,z ---2 ss
�\ W /w 5,'g 6 \\ PARCEL 181
A 6� x �` �\ 1 `. 52.97 �gLLfN
A `" w
LS LS �22L `. r7 ��\ (#14 SHANNON WAY) MA
/ G tt`!\\�j 1, 2. 8 APPROVED DATE BOARD OF HEALTH
1 411 10YR 2/1 12 , 10YR 2/1 ��o / ,\ MTR.
e e 2.8 TITLE 5 SITE PLAN
LS LS \ U) o OF
`c'h52.92� �
4/6 10YR 10YR 4/6 �6
38" 48.6 36" 48.8' 10 BENCHMARK. USE \ o 21 S H A N N O N W A Y
UTIL POLE / G� STEP AT EL. 52.8'
`'�' \ CENTERVILLE, MA
•ss�o5
PREPARED FOR
PERc
MS MS BORTOLOTTI CONSTRUCTION
MAP 170
y PARCEL 182 c-
LUMy ' - -�3_i> DATE: APRIL 13, 20195
2.5Y 7/3 2.5Y 7/3 &II SHANNON WAY)
x OF MgSS '�t�oFna � �tHOFMAsse off 508-362-4541
fax 508-362-9880
DANl1=LA. ANiEL. c ANIEL ��> I
s OJALA ��+ o OJALA A. A. downcape.com
o CIVIL ' CIVIL OJALA OJALA o down cop e engineering inc.
' No.46502 �, No.40980 No.40980 v 1
132" 40.8' 132" 40.8'- \� t'. o o
"F �� � \ P'o
GIST ,� FSS� � 5�� civil engineers
Sccle: 1"= 30' �SS/ E �� .,; ssfoNA� EEO Np ° r` °
�,, �. �� land surveyors
NO GROUNDWATER ENCOUNTERED R " 939 Main Street ( Rte 6A)
0 15 30 45 60 75 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675
15-055 BORT - BROADHURST.DWG
a
SEPTIC PROFILE TEST HOLE LOGS i
T.O.F D EL DOT TO
RAC,- LA/'
ACCESS COVER TO W NN I' OF FIN. GRADE
ACCESS COVER (WATERTW4M TO ENGINEER:
F
MINIMUM .73' OF COVER OVER PRECAST /� "THN Ir OF FIN. GRADE ,�--
2X SLOPE REQUIRED OVER SYSTEM z.. / %vt�. ,K'L•i,�,,; v � �
WITNESS: _ o
• RUN PIPE LEVEL
(Del_) FOR FIRST 2' DATE:
PROPOSED /S� tiro _
PERC. RATE
GALLON SEPTIC
s TAW (HLe-) �---- - s = T----�---,----ram--- - , , s d -�- P
S2 Z _ CLASS ____ SOILS
zX SLOPE) 6" CRUSHED STORE OR MECHANIf L I , oo S 1, S k'f 3� _ / •6���
DEPTH OF FLOW - COMPACTION. (15.221 [21) V ef�
TEE SIZES: (Z>< SLOPE) (:X SLOPE) 3/ TQ /% ✓� +.vQS� , -�
INLET DEPTH - /U S"T O.v 7 - ----
OUTLET DEPTH LOCATION MAP
14 cz -- --1
_
ASSESSORS MAP ���`� PARCEL
FOUNDATION— l SEPTIC TANK 3 D' BOX LEACHING
FACILITY �
.),4 f: FLOOD ZONE
BUILDING ZONE: `-
,f.
G- SETBACKS: FRONT
Fl7 I SIDE
REAR - ��4 _
' ) PLAN REFERENCE:
---Q _N
1 . DATUM IS
Ap-% 44 ocy � 2. MUNICIPAL WATER IS
SEPTIC DESIGN: (cARa,�cE DISPOSER Is / 4 )
1 t3N _ �`� 3. MINIMUM PIPE PITCH TO BE 1/8 PER FOOT.
f DESIGN FLOW. __ BEDROOMS ( GPO) - _ GPD 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE. AASHO-H /�-
1� _N USE A = GPD DESIGN FLOW 5. PIPE JOINTS TO BE MADE WATERTIGHT.
k SEPTIC TANK: GPD (_L) _ �6Q GALLONS 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
a = t USE A GALLON SEPTIC TANK ENVIRONMENTAL CODE TITLE V.
' 9 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE USED FOR LOT LINE STAKING,.
SIDES __ ( -_ GPD 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
-BOTTOM GPD_ a " ( '� ) 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
TOTAL: ) S.F. -33 GPD INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
FROM BOARD OF HEALTH.
10.
qy
0 .� �¢ SITE AND SEWAGE PLAN OF ----
IN THE TOWN OF: -- - --
BOARD OF HEALTH
PREPARED FOR:
LPPROVED DATE MA
0 yd Feat
f
-- -- ----------
�CG A---6A lCNA-J.Q,< SCALE: =3 DATE: _ a_----
T"
Y down cape engineering, ine
CIVIL ENGINEERS 0.,ALA � l
P` LAND SURVEYORS CIVIL
/ PHONE 508-362-4541 NO.
/ FAX F -36 -9880
_ 508 2
r / - main s AR P.B., P.L.S. 1'_ TE
JOB
.� b138 yarmouth ma