HomeMy WebLinkAbout0046 SHEAFFER ROAD - Health 46 Sheaffer Road
Centerville F/R
172 034
i1PC 12543
No. 531OR
I
'i
YOU WISH TO OPEN A BUSINESS?
For Your, Information: Business certificates (cost$40.00 for 4 years). A business cerrificate ONLY REGISTERS'YOUR NAME in town (which you
must do by M.G.L,- it does not give you permission to operate.) You must first obtain they necessary signatures oil his form at 200 tilain St:., Hyannis.
Take. the completed form to the Town Clerk's Office, 1 si FI., 367 Main St., Hyannis, MA 02601 (Tovvn Hall) ant get the gUSHWSti Certificate that is
required by laws.
DATE:�� _ Fill in please:
�#r `? APPLICANT'S YOUR NAME/S: VC,�
BUSINESS YOUR HOME ADDRESS: ti
s ; TELEPHONE # Home Telephone Number
-
NAME OF CORPORATION: 2 5 5
NAME OF NEW BUSINESS i - QJC, - AUir-C TYPE OF BUSINESS��C C-
IS THIS A HOME OCCUPA I ? YES V_NO
ADDRESS OF BUSINESS C )� - LIS MAP/PARCEL NUMBER 1742- o3T (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH
This individual has been irS�f�r17ed pf per type o business.
,tt, permit requirements that pertain to this tf busi MUST\;OMPLY WITH ALL
(_ �I (ter HAZARDOUS MATERIALS REGULATIO�iS
Authorized Signature** _
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
.
6l:
Date:04/ > //J-
'` TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: � � I� t V` CC c
�
BUSINESS LOCATION: LC 1 . - INVENTORY
MAILING ADDRESS:q6 1 - CC t� C(Ilv - [�0,46-31OTAL AMOUNT-
TELEPHONE NUMBER: 6b )-q a-d- I b
CONTACT PERSON: -7
EMERGENCY CONTACT TELEPHONE NUMBER: b� ��-� �� MSDS ON SITE?
TYPE OF BUSINESS: CjC Q 0 ( ISO"
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives(creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous(please list):
Metal polishes
Laundry soil & stain removers
(including bleach) I � /c 1�����,� .AG, 0�,)-
Spot removers &cleaning fluids
(dry cleaners) new PW �.1D X
Other cleaning solvents j
Bug and tar removers
Windshield wash ��
LZ ,MOA
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature / �taff's Initials
i
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
Date
Owner �olnelc. cry-z- Tenant
Address S, 2� C2^tc��1/� Address
Compliance Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits 8, :3 0—1
13. Installation and Maintenance of Structural t 1,I, �w Wes„f 6,4
Elements I�"T�
14. Insects and Rodents 5`AIt Ws! a I f
15. Garbage and Rubbish Storage and Disposal /1AACA4 6 oy ^ ksftl Y"Alf.
e
t
16. Sewage Disposal j7 Zoc" ��d ,
.20o y- Ya4f-�'
17. Temporary Housing
PART II
{ G�
37. Placarding of Condemned Dwelling; C.V"Q C.K.`?'
Removal of Occupants; Demolition
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
u L W•Y y ter:. s.z....ri.{w-�' ,'r1. .^•`it•4 .,..r''.'�4t�er,,r ltri� rti:o* •r r •.T{�.F.'v.•. n�` •�.,�;jJ4,4,itM.�;. •1
TOWN OF BARNSTABLE
,d BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
Date
Owner St ,, tlol l^Pik l fVZ Tenant
Address y s � �1' �d CP^�Pn'� � t Address
complionce Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply
-5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use ,
12. Exits I�L3 jug
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents I i +/ )
15. Garbage and Rubbish Storage and Disposal n e G E ���<< ,r1� n�F` c y /� y�vc� ooM f
F„ rF
16. Sewage Disposal �(^ Zot
17. Temporary Housing /
PART 11 T- 12P
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Person(s) Interviewed _Inspector
If Public Building such as Store or Hotel/Motel specify here
rig
i �� /' `
4i ohs 4 s
pp L�
Logged In As:
Parcel Deta
A
II Tuesday, August 21 2007
u
Parcel Lookup
Parcel Info
_..,...__ __,,..,...._.__.,.,._,_ _._..._w�.....__...._..____..._.�.._...�.._.,,....._ Developer�._.._ ....�..,�.....�...__.__....�
Parcel ID 172-034 Lot°LOT 139
._. _.. ........ - ,., ...._.........
Location 146 SHEAFFER ROAD Pri Frontage 100
.........
Sec Road Sec
Frontage'
�- _ _- ....
Village 10ENTERVILLE Fire District�C-O-MM
i .._... ,r_------------- _�_...-_..._� ... __ ......... _-_ ___ __ . _
Sewer Acct{ Road Index;1477
Interactive a ' i
Map !
Owner Info
owner!CRUZ, SINVALDINEIA Co-Owner;
Streets ;800 BEARSES WAY- UNIT 3WC Street2
City HYANNIS state;MA Zip 02601 Country USA
Land Info
_..... ., . _. ....
Acres 0.34 use jSingle.Fam MDL-01 zoning RC Nghbd 0105
Topography:Level Road:Paved
................................................. ........ _.._.. .........
utilities;Public Water,Gas,Septic Location
Construction Info
......... ........._1 ...... ...... ........ .. .................. ........ .................................. .. ....
Building 1 of 1
Year _ Roof i Ext
Built
1975 struct GableiHlp wall (Clapboard
Effect'1344� �- Roof,AS h/F GIs/Cm AC None
Area '.._ _ Cover# P __ P_ Type . q_
31�nn g 'rr
• Int Bed 3 3 a3�nrrs3��tttms���r!+
j 3N33pN1Y tr'Sra` / 9
Style Raised Ranch wall Drywall Rooms 3 Bedrooms
_._.. .__Residential....
Int Bath ;
Model : Rooms s2 Fully
Floor
..ar trot
Grade!Average Type,Hot Water Total
Rooms 6 Rooms
Stories 1 StoryFuel Heat(Gas Found-ation T :cal
yP
Per History_. _ _....__......._........ .
11L.L.-. 6.te I Purpose I Permit# I Amount I Insp Date I Comments
Visit History_._ _._._._._._.__ ._._..._..._ ___......_ _.. ,... ...._.'
Date Who Purpose
4/1/2005 12:00:00 AM Gary Brennan Meas/Est
11/1/2002 12:00:00 AM Paul Talbot Meas/Est
12/29/1999 12:00:00 AM Martin Flynn Meas/Listed
- Sales History
Line Sale Date Owner Book/Page Sale Price
1 10/1/2004 CRUZ, SINVALDINEIA 19096/048 $335,900
2 6/28/2002 KARLSEN,ARNOLD & KATHLEEN T 15318/271 $225,000
3 HUGHES, CHARLES F TR 7110/346 $0
4 HUGHES, CHARLES F 2307/324 $0
Assessment History
__. ...... ......... ......... ......... _... _.
Save# Year Building Value XF Value OB Value Land Value Total Parcel Value
1 2007 $132,800 $18,700 $0 $147,700 $299,200
2 2006 $119,200 $18,700 $0 $149,100 $287,000
3 2005 $112,700 $18,500 $0 $135,100 $266,300
4 2004 $91,500 $18,500 $0 $101,300 $211,300
5 2003 $87,900 $18,500 $0 $44,600 $151,000
6 2002 $87,900 $18,500 $0 $44,600 $151,000
7 2001 $87,900 $18,500 $0 $44,600 $151,000
8 2000 $60,300 $13,500 $0 $30,100 $103,900
9 1999 $60,300 $13,500 $0 $30,100 $103,900
10 1998 $60,300 $14,300 $0 $30,100 $104,700
11 1997 $82,800 $0 $0 $26,800 $109,600
12 1996 $82,800 $0 $0 $26,800 $109,600
13 1995 $82,800 $0 $0 $26,800 $109,600
14 1994 $78,300 $0 $0 $33,200 $111,500
15 1993 $78,300 $0 $0 $33,200 $111,500
16 1992 $89,300 $0 $0 $36,800 $126,100
17 1991 $97,100 $0 $0 $53,600 $150,700
18 1990 $97,100 $0 $0 $53,600 $150,700
19 1989 $97,100 $0 $0 $53,600 $150,700
20 1988 $65,300 $0 $0 $19,200 $84,500
21 1987 $65,300 $0 $0 $19,200 $84,500
22 1986 $65,300 $0 $0 $19,200 $84,500
Photos
a :
,. TOWN OF BARNSTABLE
1.,'CA-4kiN yLv -�'ti/-;4 fFL=2 �1� SEWAGE #
Y(LLAGE r,,Al i-c`_ ASSESSOR'S MAP & LOT-1 7,2
Q STALLER'S NAME&PHONE NO. j=' L L 19 "9 A 0 2,
SEPTIC TANK CAPACITY �� O
LEACHING FACILITY: (type) / 7`1'641-04S (size)
NO.OF BEDROOMS
BUILDER OR OWNER_
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
'( �
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A/'
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�7 I�" � Y�O
,�--' � ��,��" G�. Z ar
. . � . � � 3 .�, � 3
No. U N j� t r• Fee/t' /`
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:LZ
• Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
3pplitation for Migool *pgtem Construction 3permit
Application for a Permit to Construct( ) pair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. u 3 9' �I Owner's Name,Address and Tel.No. 1 j 3, 4,b
Assessor'sMap/Parcel �(P S ti �G�' /&4
C ,n i )
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel. o.
X-0/
Type of Building: S`
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(71
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 13 o gallons per day. Calculated daily flow 6•6.6 gallons.
Plan Date a'3 (/ Number of sheets Revision Date
Title
Size of Septic Tank 3va & gk IL)"% Type of S.A.S. '�1 AbgEjk, e4441 1n140 21-d 'J
Description of Soil S{Y
Nature of Repairs or Alterations(Answer when applicable) S�f c5�h�✓Z "��>
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 lace the system in operation until a Certifi-
cate of Compliance has been issu by this Board of He
Signed ��� Date _
Application Approved by " Date
Application Disapproved for e following reasons
Permit No. yo l a 6 Date Issued 0 L,
No. D U O LI— + d V a�'" 'i ' Fee/L
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
"
. P�JBLI`C HEALTH DIVISION - TOWNOF BARN,. :TA-BES MASSACHUSETTS
ap Yication for �oigpogal 6pgtem Con!5truction Permit
Application for a Permit to Construct( )Repair(x )Upgrade( )Abandon( ) ElComplete System ElIndividual Components
Location Address or Lot No. 17 � O 3 Owner's Name,Address and Tel.No. H/ 31
Assessor'sMap/Parcel 1 jj_ /+ / G 15 h� /7,1 7 „
(. C Yl iry
Installer's Name,Address,and Tel.No. j Designer's Name,Address and Tel.No. f
I t 5 Gj`s P�.S �°h S/+ .S w�'''J.Fe /�� �f•er-�f"� ��.,,.,...... ,
Type of Building:
Dwelling No.of Bedrooms 3 Lot..Size— sq.ft. Garbage Grinder( y?)v
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33 o gallons per day. Calculated daily flow 6 c gallons.
Plan Date 7 12-3 l 6 L Number of sheets .Revision Date
Title
Size of Septic Tank l5,0 U ri4I10, Type of S.A.S. 1� 14 1 r C17r %</-4:,J
Description of Soil S-r-e S c, °v)
Nature of Repairs or Alterations(Answer when applicable) s f S
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 lace the system in operation until a Certifi-
cate of Compliance has been issu- by this Board of He a-
Signed (_J� �-'`- t Date C
Application Approved by AD VV-1 1 Date
Application Disapproved for a following reasonsl
Permit No. U V L a Date Issued Wf o t/
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(X)Repaired ( )Upgraded( )
Abandoned( )by 0,f I,S b 1c r S < SJ, f
at LA (o s h P g Ad C y i k,,il, i I k'n Gt has b en construct d $ncc rdance
with the provisions of Title 5 and the for Disposal System Construction Permit No. D(10 L(' 7.2b dated ��O
Installer t t t t 60C I)-.o Cc Designer f
w 1
The issuance 4o this �r u shall not be construed as a guarantee that the sy§te ill fu ction as dl ned.
Date I a � Inspector e
— - — -�----------------------------
No. Fee 10
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwigpogal *pgtem Congtruction Permit
Permission is hereby granted to Construc Repair( )Upgrade( )Abandon( )
System located at (� S h�° r n c r1� , j� !1 y/' !( � � n S ✓ �� s'r', S
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of thiis-Permi .
Date:_. Q �t l l)L�_ Approved by ('V'✓ '�-fi��,
TOWN OF BARNSTABLE o
I
. LOCATION SEWAGE # (I�' "�
VILLAGE C �/ ��lit t 1 ASSESSOR'S MAP &LOT 7 _c
INSTALLER'S NAME&PHONE NO. r LL t 9- 1S A 5
SEPTIC TANK CAPACITY- IS-0 d
LEACHING FACILITY: (typz,41
��i/7`(C� TOE_(size)
NO. OF BEDROOMS
BUILDER OR OWNER
I .
PERMITDATE: v COMPLIANCE DATE:`
Separation Distance Between the:
Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200*feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
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V
1
A
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0 f33 C3
- ti i c•�7rri r-11U1 SWEETSER ENGINEERING
TO Ellis Brothers P.01
'own of Barnstable
Regulatory Services
Thomas F.GeBer,Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-W24644
Fax 508-790-6304
Installer&Designer Certltica a Form
Date: September 2004
Designer. canna Johansen Installer: Ellis 3r�th�re enern,CtlO3
Sweetser Engineering
Address: P.O. Box 713 Address: pja, gox 59
South_DenuiC MA 02660 Yarmouph Port, K& 02675
On _ 8J18/04 Eijis Bro ��T� ns
(date) (installer) was issued a permit to install a
septic system at 46 5heaffer Road Centerville(address) based on a design drawn by
T_ y JohsnsenfSw2etser End_ dated
_ July 23. 2004
(designer)
Y certif y that the Septic systern referenced above was installed substanya accor In to
the desiggnn, which may include minor approved char such
dlst dbutlon box and/or septic tank,
as h relocation of$the
l certify that the septic system referenced above was installed with major changes (i.e.
gmtat¢r than 10' lateral reinratinn of the SAS or any vertical relocation or any component
of the septic system) but in accordance with State&Local Regulations. Plan revision or
certified as-built by designer to follow.
(Installer's Signatju, CPU Oi
ure)
10
esigl Signature) K
(Affix Designer's Stamp Here)
PLEAS$ TO BARNSTABLE PUBLIC HEALTH DIVISION. CER I ATE
BUILT C ARb;R . EIVED BY THE BARNSTA�BLE PUBgMORM AND AS-
K YOU. N.
Q:HedLh&p&/L)eslgner Certification Form
r -
TOTAL P.01
TOWN OF BARNSTABLE
LOCATION
7 S/T SEWAGE #
VILLAGE �T ASSESSOR'S MAP & LOT i7 oZ- O 3'
A-1;-00£cl:,4J'
R'S NAME&PHONE NO. L141t1C D Sa 7 5-' v�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
,:PERMTF DATE: GdCE DATE: a
`rr
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching.Facility Feet
'PrivateWater 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 �`
,=
r _
_ 33
o
�o,4�
TOWN OF BARNSTABLE
L`JCk, ION 6 ��F/�£� SEWAGE #
VILLAGE C F".,T ASSESSOR'S MAP & LOT
/ -V 5Pf c 0ps
Rd§ ER'S NAME&PHONE NO. A 1, eg4, 1-,c"
SEPTIC TANK CAPACITY 7-_G !a A
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
,—BUILDER OROWNER ll U rll£S 1*7,el—1 1
- PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
.Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
t
55
r ,
� ORSMppNO
SESS
S
COMMONWEALTH OF MASSACHUSETTS
f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
V
c DEPARTMENT OF ENVIRONMENTAL PROTECTION
0
�qM N0y �`O
,� 350 MAIN STREET
WEST YARMOUTH,MA
r► 508-775-2800
TITLE 5 RECEIVE®
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE SMENTS
SUBSURFACE SEWAGE DDIrSPPOSAL SYSTEM FORM JUL 1 6 2004
CERTIFICATION TOWN
M-172 P-034 OF BARNSTABLE HEALTH DEPT.
Property Address: 46 SHEAFFER ROAD
CENTERVILLE,MA 02632
Owner's Name: ARNOLD&KATHLEEN KARLSEN
Owner's Address: 11 COLD HILL DRIVE
GRANBY,MA. 01033
Date of Inspection 06-22-04
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is tire,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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: ? " 7 C> y
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 tot lie buyer,if applicable,and the approving authority.
Notes and Comments
FAILED
****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 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 46 SHEAFFER ROAD
CENTERVILLE,MA. 02632
Owner: ARNOLD&KATHLEEN KARLSEN
Date of Inspection: 06-22-04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: N/A
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 31.0 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is iimninent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system mill
pass inspection if(with approval of the Board of Health)''
broken pipe(s)are replaced
obstruction is removed
ND explain: -
Title 5 Inspection Form 6/15/2000 2
t y
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 46 SHEAFFER ROAD
CENTERVILLE,MA. 02632
Owner: ARNOLD&KATHLEEN KARLSEN
Date of Inspection: 06-22-04.
C. Further Evaluation is Required by the Board of Health:N/A
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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,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 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 1.00 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"" This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
I
Title 5 Inspection Form 6/15/2000 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: 46 SIIEAFFER ROAD
CENTERVILLE,MA. 02632
Owner: ARNOLD&KATHLEEN KARLSEN
Date of Inspection: 06-22-04
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
—7 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in pit is less than 6"below invert or available volume is less than''/�day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from.that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes 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 11 of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant
threat wider Section E or failed wider 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 46 SHEAFFER ROAD
CENTERVILLE,MA. 02632
Owner: ARNOLD&KATHLEEN KARLSEN
Date of Inspection: 06-22-04
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volurnes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered;opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
✓ Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)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)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 46 SHEAFFER ROAD
CENTERVILLE,MA. 02632
Owner: ARNOLD&KATHLEEN KARLSEN
Date of Inspection: 06-22-04
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 2003-23,000 GAL./2604—52,000 GAL.
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of infon-nation: N/A
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
•� Septic tank,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
humvative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
8/87 PERMIT#138
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 SHEAFFER ROAD
CENTERVILLE,MA. 02632
Owner: ARNOLD&KATHLEEN KARLSEN
Date of Inspection: 06-22-04
BUILDING SEWER(locate on site plan): ✓
Depth below grade: ✓
Materials of constriction: Cast iron ✓ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Conunents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 2'
Material of constriction: 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)
Dimensions: 1000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions determined: AS BUILT&PLAN
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL,OUT LET BAFFLE.
NOTE:TANK TO BE PUMPED AFTER INSPECTION.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: _ concrete metal e fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 hnspection Form 6/15/2000 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: 46 SHEAFFER ROAD
CENTERVII_,LE,MA. 02632
Owner: ARNOLD&KATHLEEN KARLSEN
Date of Inspection: 06-22-04
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Continents(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: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
I
Page 9 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 SHEAFFER ROAD
CENTERVILLE,MA. 02632
Owner: ARNOLD&KATHLEEN KARLSEN
Date of Inspection: 06-22-04
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits, number: 1
leaching chambers,number:
leaching galleries, number
leaching trenches,number,length
leaching fields,number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE 1000 GALLON PRE CAST PIT,PIT AND COVER 3'BELOW GRADE,PIT IS FULL,
NOT LEACHING,NEED TO REPLACE.LEACHING.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate 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 or no):
Connnents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Commuents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15/2000 9
I
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properri Address: 46 SFiEAFFER ROAD
CENTERVILLE,[vL4. 02632
Owner: ARNOLD&KATHLEEN KARLSEN
Date of Inspection: 06-2204
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 die building,
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Title 5 Inspection Form 6, 151200i0
I o
Page I I of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 SHEAFFER ROAD
CENTERVILLE.MA. 02632
Owner*. ARNOLD 8c KATHLEEN KARLSEN
Date of Inspection: 06-22-04
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estinnated depth to groundwater 48 feet
Please indicate(check)all methods used to detentnine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abuttim1 property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
—T Accessed[jSGS database-explain:
You must describe how you established the high ;;round water elevation:
USGS WELL DATA
WEL SDW 252 48' --
70NE D 5.2
ADJ 42.8 — --
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Title 5 Inspection Form 6/15/2000 1 1
SWEETSER ENGINEERING
P.O. BOX 713 — SOUTH DENNIS —MASSACHUSETTS 02660
TEL (508) 398-3922 FAX (508) 398-3063
LAND SURVEYING — ENGINEERING—TITLE 5 SEPTIC SYSTEMS
SEPTIC DESIGN PROPOSAL PAGE 2
PROPERTY SURVEY AND FLOOR PLAN SKETCH
Please fill out this form,including the floor plan sketch, and return to us with the signed proposal and retainer.
This information is necessary to properly prepare Your Septic System Design.
IF YOU ARE PLANNING AN ADDITION PLEASE INCLUDE THAT INFORMATION ALONG WITH THE
FOUNDATION DIMENSIONS AND LOCATION FOR THE NEW ADDITION.
Y r Round Home Seasonal Home Owner Occupied Rental
Total#of Rooms /Living
r ms V F nil Room/Den Room l' ll Zing Room #Bathrooms
Bed oo � Y �
Washer/Dryer Dishwasher Garbage Disposal Gas Service (� Town Water
In ground Electric Wires* In-Ground Oil Tank* In-ground Sprinkler In-ground Gas Pipes*
* Please note on sketch where located. Sweetser Engineering assumes no responsibility if in-ground components are
damaged du 'Soil Testings, Inspections, Locations of and/or Installation of New Septic System.
Cellar: Full Partial (Crawl; Slab
Wells: t Main Use Irrigation Only (please provide location of all ivells)
PLEASE USE THE SPACE BELOW AND THE BACK OF THIS SHEET TO PROVIDE US WITH A ROUGH SKETCH OF
THE EXISTING FLOOR PLAN (ALL FLOORS). Also include any items that should be avoided,IF FEASIBLE,i.e.shrubs,
trees, patios,electric lines,tanks,etc.
IF YOU ARE PLANNING AN ADDITION, PLEASE PROVIDE THE LOCATIONAND FOUNDATION DIMENSIONS
1.tw R rr� Beep 8e4 Bea
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.DATE PERNA T ISSUED
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THE COMMONWEALTH OF MASSACHUSETT
BOARD O HEA
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Applirtatinaa -fair Uis uiitt1 Morkii Cnowitrurtioaa Punift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
......._..Cfar.........�1� 1da_.vr<:z.------------------------1'-a--7-------��--2-------------------------------------
Location-Address or Lot No.
affo-&-at........1r------ ---------
Owner Address
�Dr9lt 47- 4Y 201&��-o-oeA'• -------AlAri- ._-_
Installer Address
Type of Building 0*0 X A1041**-> Size Lot_._. 4;dZ -Sq. feet
Dwelling—No. of Bedrooms----------3..............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d 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_.._. .._____.______ Tota eacliinn :trea------
___...._•_sq. it.
z Other Distribution box ( ) Dosing tank ( ) �✓J �a aolR ✓r
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------
a Test Pit No. 1-----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...---._.---.--._-.-----
(X, Test Pit No. 2________________minutes per inch Depth of Test Pit.-__--_____-_____- Depth to ground water--.-__--_____-.-_---._.
a --------►-4 `1 --- - --------- ------- -- -
p / e /
x Description of So i �a . •. - ----- ----
...............----------_--------.......... •---•-- -••r-•-•------------•--------------------............ -••---••-•----------------•-•--------•----------------
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 Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by three board of health.
Signed-- ---..... =
��/,, ��Date
Application Approved BY ----C �-lam- 1
Date
Application Disapproved for the following reasons:...
--------------------------------------------------------------------------------------------------------------------- ...................----------------------------------------.....................
Date
PermitNo......................................................... 71
Date
---- ----- ----__-_----------------------------------- -
No.... .`----- Fimic ...................
THE COMMONWEALTH OF MASSACHUSETT
BOARD O HEAL
.......... ..... ......OF............... ..... .... ... , - .... ......... ..............
AVV irtttiun -for Ditipmal orkii C otuitrnrtinn Vrrnfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
�rFQ .........f3F._n� _ . - ------------ ----/.'/ ------
W Owner Address
Installer Address
U Type of Building 0 AIK <' •41 <- Size Lot.... feet
.-I Dwelling—No. of Bedrooms..._...---J--._--_---_----------------Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ---------------------------- No. of persons..---_-_.--------------.---- Showers ( ) — Cafeteria ( )
P4Other fixtures ------------------------------------------------------------------------------------
Q
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.................... Tota,leaching area........------.---sq. ft.
z Other Distribution box ( ) Dosing tank ( ) 0,6
W
Percolation Test Results Performed by---- -- ---------•-------------•••-•-••---•--•---•----•-....-•----------. Date------------------------------------....
Test Pit No. 1---------- ----minutes per inch Depth of Test Pit_.._---___---.._-- Depth to ground water....-..--.--.----. -..-.
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.--.............---. Depth to ground water--.-----------..--------
O Description of Soil--------------
•••-• hx
W ------------ �s �1 ...............................
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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Si d- y - �
Application Approved By..L ... ..... . . . .... ........ .....
i Date
--------•-•--- ........................
--•................Date--•--•-•--....
Application Disapproved for the following reasons------------------------------------!/�
---------------------------------------------------------•----
......------•---•-•-••----------••----------•-------•---••••--------••--•••-••-----------•-•-•-•---------..•••-••--••------•-----•-••••••••••...•••-•--------•-•••----•---------••------••---------.
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALT
...............OF......... ....
Trrtifirtttle of Tlimptittnrr
TH S I ERTI Tl Individual Sewage Disposal System constructed ( ) or Repaired
at--_---l-LL- -------- -- -- --- — ---- ------ — In _. __ '_---- -�--------------
has been installed in accorcYa ce with the provisions of .ti e XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N ------------- ----- dated_.- .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
/ ..........OF... ............. . ..........................................
No.(........�--------- .. FEE--/ ----••----•--•
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Permtssi0 ereby granted- 1�` 'Z------ -----�- ------------- ---------0...........................................................
to Const� t r /� Oor�Repair }ual Sewa Di oral em
at ---- __ -
eet
as shown on the application for Disposal Works Construction er it N Dated......_..-J------- ----------------
•-- ----- - ....t_.�y
and of Heal
DATE............... ------•---...------.....-------------•-•••------------•--•------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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ELEV.
_ 100 00 10 FT. MINIMUM 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE DATE OF SOIL TEST A1�Y�3, Q�4___
— —___--
I (ASSUMED) CLEAN SAND _M--- i
SOIL TEST DONE BY fj,_)kljLQX
I COVERSTE I INSPECTION POR? WITNESSED BY ------------------
4" SCHEDULE 40 PVC PIPE I , 7LOAM A?,-;D SEED ORMIRVATM HOU 1 ELEV.-_9!•60
MIN. PITCH 1/8" PER FT I INCHES
PERCOLATION RATE _ �_ MIN. INCH AT 60 ..��
2" LAYER OF / -�_-�..-=-
1/8" TO 1/2" DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
4.Sf 4" CAST IRON PIPE M X WASHED STONE
(OR EQUAL) MINIMUM f !94.70 1AAX.
0-7 0/E MEDIUM SAND
SLAB ELEV. _9 91'6_•50 PITCH 1/4" PER FT. �• NOT VENREQUIREDL ( taYR7j1 NO
--' SLEEVE I ` I 7-24 B LOAMY SAND fI10YR6/6 20% COBBLES
FLOW LINE I91.70I 'o, 24-42 Cl COARSE SAND 2.5Y7/4 20% COBBLES
ELEV. = 85.5t_ 10"
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1 ELEV. �1VOC °°o °10• ° 42-156 C2 COARSE/ 2.5Y7/4
ELEV. _ _�4;�Q_ GAS _ 6" SUMP L -g - ° ELEV. _ �• _ ��, n I'MEDIUM SAND
BAFFLE ELEV. _ 92.80 ELEV. _
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LIQUID OUTLET DISTRIBUTION ELEV.
DEPTH TEE BOX __n2Q-
(TO BE PLACED ON FIRM BASE) /4) 06;Gl CAPAC/T.►'INRLIRATCPS WW 5T6WE z
4 FEET 14 INCHES TO BE WATER TESTED � ,77
5 FEET 24 INCHES 1500 GALLON IF MORE THAN ONE OUTLET IN AN 11'X 36' 10 " TRENCH F6Yc'�lAPON
87 FEET 29 INCHES FEET 34 INCHES SEPTIC TANK (TO BE PLACED ON FIRM BASE} SOIL ABSORPTIOA? I WELL N/A NO WATER ENCOUNTERED AT 156'_ ELEV.
3/4" TO 1 1/2" CLEAN -� SYSTEM (SAS) j ZONE
INDEX
DOUBLE WASHED STONE ADJUST
FREE OF FINES & SILT DESIGN CALCULATIONS
USGS PROBABLE WATER TABLE ELEV. = _ NUMBER OF BEDROOMS 3__.
SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATEF TABLE ( / j ) ELEV. = GARBAGE DISPOSAL UNIT _ �_
NOT TO SCALE BOTTOM OF TEST HOLE ELEV. = 5Q_ TOTAL ESTIMATED FLOW
( 110 GAL/8R./W X _ 3 BR.) _,' Q_ GAL./DAY
REQUIRED SEPTIC TANK CAPACITY _�Q_ GAL.
ACTUAL SIZE OF SEPTIC TANK _15W GAL.
SOIL CLASSIFICATION _ 1
DESIGN PERCOLATION RATE < 5__ MIN./IN.
EFFLUENT LOADING RATE Q,Ii GAL./DAY/S.F.
LEACHING AREA 474_. SO. FT.
(11X36)+(47X2X10/12)
LEACHING CAPACITY (AREA X RATE) _3*tQQ GAL-/DAY
474.33 X 0.74
RESERVE LEACHING CAPACITY 351 QQ GAL./DAY
• 95.7
/ NOTES: I
/ 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P.
TITLE 5 AND THE TOWN'S RULES AND REGULATIONS FOR THE
SUBSURFACE DISPOSAL OF SEWAGE.
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
WITHIN 6" OF FINISHED GRADE.
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
/9 / WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN
�O 5 8 1, 99 0 , l ��7L� ^ r ( I Cl t.�/f' ,/ 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. I
4 P V J 4. ANY MASONRY UNIT T t
� '� �� MORTARED IN PLACE, USED 0 BRING COVERS TO GRADE SHALL 8E I
y5 ^�
\` ✓ NO DF'1EQM!NAT!a4' HAS BEEN MADE AS TO Co PLIANCE WITH
v _
DEEDED OR ZONING REGULATIONS. OWNER % APPOGANI IS ,
`• / \ 90 ` OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION
CONTRACTOR IS TO CALL. "DIG-SAFE" AT 1-888-344-7233
AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE.
980 9 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL
99.
g 7 `so AS SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE.
o
ANY VARIATION IS TO BE BROUGHT TO THE ATTENTION OF
OF SEPTIC THE DESIGN ENGINEER IMMEDIATELY.
g 8. PARCEL IS IN FLOOD ZONE
99 1 BY OTN A5 96 6 9. LOT IS SHOWN ON ASSESSORS MAP _172 AS PARCEL
1500 GALLON r > ��� 3 I ! 10. EXISTING SEPTIC TANK. D. BOX, AND LEACH PIT ARE TO BE PUMPED
AND REMOVED.
4� / SEPTIC TANK `` ` 11, WASTE LINE IS TO BE SLEEVED INSIDE 150 PSI PRESSURE PIPE AS
c" 0 // / ) Qo S� �'��HC}► �4v,`��* IS SHOWN.
-1 0 2 ���� 99.7 TANYA
LOT 139 �-�� NAGOEAU T Jftl
15,OOOf S.
z, NO. 1095 a
APPROVED: BOARD OF HEALTH
99.8
"(✓'
L 6.8
9 /
99.4
9.5
DATE AGENT
PROPOSED SEPTIC DESIGN
94,8 KATHUEN KARLSON
`(94) ��� srq�F I LOC. 46 SHEAFFER RD.
BARNS TABLE m
SOI
ASS.
TEST 91.2 LOCUS' � S' 235 GREAT RN ROAD AWDWCLWG l
t �Q 508— SOUTH OD BOX 713ASS.
LEGEND: ® �� Ca 398-3922 02660
EXISTING SPOT ELEVATION x0.0
Zy EXISTING CONTOUR ----00----
FINAL SPOT ELEVATION (� Q) DATE �ULY 23, 2004 f SCALE 1 " = 20'
/ FINAL CONTOUR 0 Q f
SOIL TEST LOCATION TIP
UTILITY POLE `Q Q� REVISED -i_1 JOB N0.
TOWN WATER =W=•��-W
(^__ 6022-00
89 6 CATCH BASIN �[]�
GAS LINE c REVISED
G -
CESSPOOL LOCATION MAP i� SHEET 1 OF 1
CLEANOUT --ems C.O,
I
C �SB�PROJ�-OOSdwq�-OO.DWG 02004 SWEETSER ENGINEERING