HomeMy WebLinkAbout0086 SHEAFFER ROAD - Health 86 SHEAFFER RD., CENTERVILLE
A=172-030
�i
i
sln A
IN ® y
UPC 17534
No.2153COR
11ASTINOS.UN
TOWN OF BARNSTABLE
LOCATION 14`m P'rIC-1n' SEWAGE #
VILLAGE L= - ) ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. _ d 2 .A, 3 .7 "7
SEPTIC TANK CAPACITY e
LEACHING FACILITY: (type) (size),�;9%6 t'NO.OF BEDROOMS
BUILDER OR OWNER ;FO 1
PERMIT DATE: r COMPLIANCE DATE: >
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Faci ' Feet
Private Water Supply Well and Leaching Facility (If any wells e t
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands ezi
within 300 feet of leaching facility) Feet
Furnished by
p,���
�.
�, � �� �
l� �� �1 .. � .`"
;� � �� �
1
0 9
COMMONWEALTH OF MASSACHUSETTS
01 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 86 Sheaffer Road
Centerville
Owner's Name: John Pecoraro
Owner's Address: 86 ShPaffPr Road
CentPrg; i P
Date of Inspection:
Name of Inspector:(please print)_ Sean Jones , t
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1 089
Centerville, MA
Telephone Number: (.5081 775-8776
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.1 am a DEP
approved system inspector pursuanl to S ction 15340 orTitle 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Nee valuation by the Local Approving Authority
ail
Inspector's Signature: Date:
The system inspector shall submit a copy o"i4ion report to the Approving Authority(Board of NealthDr
DEP)within 30 days of completing this inspection.If the system is a shared system.or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be seat to the system owner and copies sent to the buyer,.itapplicable,and the approving
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
u'
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 86 Sheaf f er Road
Centerville
Owner: J4hn F,ecoraro
Date of Inspection:
. Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: � �-
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"pleaseexplain.
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 exiiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
•A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box flue 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 obsutxted pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are.replaced
obstruction is rtmloved
ND explain:
f
Page 3 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 86 Sheaf fer Road
Centerville
Owner.. John Pecoraro
Date of Inspection: . D �Q
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
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 i 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 frond 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION(continued)
Property Address: 86 Sheaffer Road
en ervi e
Owner: John Pecoraro
Date of Inspection: lb oaf
D. System Failure Criteria applicable to all systems:
You must indicate')+es".or"no"to each of the following for all inspections:
Yes Np
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool„
Discharge or ponding of eflluentto the surface of the ground or surface waters due to an overloaded or
�L clogged' AS or cesspool
Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
/ cesspool
J Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within I00,feet of a surface water supply or tributary to a surface
/ water supply.
_ � Any portion of.a cesspool or privy is within a Zone l of a.public well.
f.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 Katcr
supply well with no acceptable water quality analysis.(This system passes if the well wafer 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
�g are triggered.A copy of the analysis must be attached to this form.]
"D (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. ^^j
�
To be considered a large system the system,must serve airkility with'a destgu-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 dr'utking water supply
the system is within 200 feet of a tributary.to a stuface 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 has failed.The o%mcr or operator of wry 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 appropri.ate.regional office of the Department.
4
Page 5 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 86 Sheaf f er Road
Centerville—
Owner: John Pecoraro
Dale of inspection:__ /,)j3 aoufo
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(lows in the previous two week period?
.._ -Z Have large volumes of water been introduced to the system recently or as part of this inspection?
v _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
V _ Were all system components,excluding the SAS,located on site?
v _ Were the septic tank-manholes uncovered,opened,and the interior of the tank inspected for the condition
of thh 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? p Per
The size and location or the Soil Absorption System(SAS)on the site has been determined based on:
Ye� 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 Cis at issue approximation of distance
is unacceptable)13 10 CMR 15.302(3)(b)) PP
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION
Property Address: 86 Sheaf f er Road
en ervi e
Owner: John Pecoraro
Date of Inspection: o 6
PLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 C 15.203(for example: 110 gpd x N of bedrooms): `'1`/3 GA6
Number of current residents: _
Does residence have a garbage grinder(yes or no):/VCR
Is laundry on a separate sewage system(yes or no):-�Lz [if yes separate inspection required]
Laundry system inspected(yes or no): d JA
Seasonal use:(yes or no):_,�LD
Water meter readings,if available(last 2 years usage(gpd)): 2005 14, 000
Sump pump(yes or no): NZ) 2004 — 30,000
Last date of occupancy: Currt�f
COMMERCIAL/INDUSTRIAL Ar/j4
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,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 information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:_gallons_How` w was asquatf ity pumped determined? —
Reason for pumping:
TYPE OF SYSTEM `
./Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
avow '5as rCiy$
Were sewage odors detected when arriving at the site(yes or no):/V-D
6
I'a6c 7 u( 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSLSSIIIEN7'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0101
PART C
SYS UI INFOR111AT10N (continued)
Property Address: 86 Sheaffer Road
Centervi e
Owncr: John Pecoraro
Dolt of Imptcllon: [pW c�6
UUILI)MG SLNvLlt(locate oil site lrlan)
Depdt below grade: J b"
blatctials of construction:_cast iron _✓0 I'VC_other(cxplaiir).
Distance (rum private %valor supply well or suction line:_
Cwlnnunls(tin condition of juutls,venting,evidence of lcakagc,cic.):
SEPTIC TANK: ✓ (locate on site plan)
Dcplh below grade: /off "
Material of construction: vncrcic metal fiberglass_polyethylene
_utlicr(cxplain) _If tank is c)metal list
ccrtificat age:_ Is agc cunfrrnted•by a Cerlificate or Compliance(yes or nu):_(altach a copy of
Dintctisions: /ODD
Sludge dcpih:
DlStarlEC from lull of sludge Iv bottom of outlet Ice or bafllc: 3c)
Sewn thickness: p
Distance from top of scum to top v(vutiet ice or bafllc:
Distance Gum butium of scum to boitour of vutla)cc or bafllc: —
low�scrc dimensions determined: D�Qllcvt Cd,zr-s
MC�svfe N^c .I-%
Comments(on pumping rccouuncndetiuns,inlet and outicl Ice ur bafllc condition, slructwal inlc6rity,liquid Icvcl_
&s lcclatcd Io outicl utvcrt,cvidcncc of lcakagc,cic.):
IGnK floes Ac> ^^n, e to bcLL�Cte-,-.j
be'}IZrv» aF oJ-rtef- in,vcrr'
G1lEASE TMI': 141 (Io.catc on site plan)
DcpUi below grade:_
Malciial of construdiun:_cuncicic Inctal libciglass_polycth)•Icnc _ofltcr
(cxplain): _ —"
Dimensions:
Scum Iltick►uss:
Distance [Ion,lop of scum to full of uullct ice or bafllc:Distance Gom bottom of scum Iv bullum of uullct tcc or ba_the:
Date of last pumping:
Continents(on pumping Iccunuucndaliuns,inlet and uullct tcc ur bafllc cunditiu:t, stiucluial integrity,liquid Icy-CIS
as related to outlet im•cil,ctidcn(c of Icakarc,cic.):
7
)'age 8 of I I
OFFICIAL INSPEC-1'I0N FORM NOT FOR VOLUNTARY ASSLSS111<; YS
SUUSUIU-'ACE WYAU DISPOSAL SYS7'LN1 INSPEIC'1•I0N FORM
PART C
SYS'1161 INFORMATION(conlinucd)
Property Address: 86 Sheaffer Road
Cen ervi e
Owner: _ John Pecoraro
DAIe of Inspection: /ro b
TIGHT or HOLDING TANK: PJ (tank must be pumped at lime of inspection locate oil
t site plan)
depth below glade:
Material of construction: concrete_tue(aI_fiberglass hulyelliylene_other(explain):
Dimensions:
Capacity;_ ralluns
Ucsign flow; gallons/day
Alarm present(yes ui no):
Alarm level; Alann in wutkin utdcr
Date of last pumping; 6 [J'cs ur nu):
Continents(condition of alarm and fluat s%t itches,etc.):
DISTIUBUTION BOX: v I
.,,_(if ucscnl nwst be opcncd)(locate on site plan)
Depth of liquid level above outlet invert: D `
Conuueuts(note if bux is level and distribution tv outlets equal,any evidence of solids carryover,any evidence o
leakage i f
ntu or out of bux,ctc.):
e0vcr cJoz.—
('UAIP CIIAMBCIt:�I1lucate on site plan)
I'untpS in wurking order(ycs or no):_
Alanns in Working order(ycs or no):—
Cununenls(note condition of puny ha
t cmber,cundiliun of pumps and appurtenant es,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 86 Sheaffer Road
Centerville
Owner: John Pecoraro
Date of Inspection: I b pb /
SOIL ABSORPTION SYSTEM(SAS): V (locate on site plan,ezcavation'not`required)
If SAS not located explain why:
Type _. .
leaching pits,number.
leaching chambers,number: 3
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number: -
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
5ojI w-s r�rd /� ���Q (-�.�Ez.�.•• c1.._cPeChdl C.11
9 ��t QL S-k .�� a wafC-� Co yt/' C>-1w .
CESSPOOLS: n Ihcesspool 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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: N I (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.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 86 Sheaf f er Road
Centerville
Owner: John Pecoraro
Date of Inspection: O 3 ,doh
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
v i
o a
A-( ' lam`
13-i
O
R-d i 6'
s ass
A-3
10
Pate I l of 1 I
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 86 Sheaf f er Road
Centerville
Owner. John Pecoraro
'Date:of Inspection:
SITE EXAM
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to ground water S feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
/�X17uI�cQ 1-a-4r,- le.a—ho.ti �,.,�.5 .es t,)',Sh,c.� t�y accrss r�q `To„. Or Isorns-f -bic.
11
.._,
No. Fee $5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES Y
MASSACHUSETTS �v/
01ppYfcation for Migoal *pgtem Construction Permit
Application for a Permit to Construct( )Repair(xx)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 86 S he a f f e r Rd Owner's Name,Address and Tel.No. 4 2 8—1 91 9
Assessor'sMap/Parcel Centerville Robert Portz 86 Sheaffer Rd
Centerville MA 0263
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Service
P O Box 1089 Cneterville MA 02632
Type of Building:
Dwelling No.of Bedrooms 3/4 Lot Size sq. ft. Garbage Grinder(no)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic Leaching system
consisting of D-Box and three leaching chambers
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance
g g 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 by th' SA of Heal
Signed Date
Application Approved by Date -
Application Disapproved for the follo mg reasons
Permit No. .5�4 Date Issued
7 ..,.. .. _ .....�, ....,,_ i.;,.. �� . ..��.. .. -. ... .....- v.,..-.•- ,.,fi,..�„�,�. ,rnw,+vuw....w.n.- ._ ., r�°• „ .. r•. 3..+�:. .w�.:��:..,,,�.�--ti.�:7k1.
No. - S� Fee $5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
t
ZI.p.plication for Otopool *pgtem Construction 0ermit
,Application for a Permit to Construct O Repair(XX,I Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 86 Shea f f er Rd Owner's Name,Address and Tel.No. 4 2 8-1 91 9
Centerville Robert Pvrtz 86 $' heaffer Rd
Assessor's Map/ParcelCenterville MA 0 Z6 3 2
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Sert*ce
P 0 Box 1089 Cneterville MA 02532
Type of Building:
Dwelling No.of Bedrooms 3 4 Lot Size sq.ft. Garbage Grinder(no)
Other Type of Building No. of Persons Showers( ) Cafeteria( )
;' Other Fixtures `' ;
Design Flow gallons per day. Calculated daily flow
P Y Y " gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
F r _
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic LeVching system
consisting of D-Box and three leaching chambers.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the nvironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issuSo by th oA of Healltl,
Signed v� •"`" ---Date
Application Approved by Date
Application Disapproved for the follo mg reasons
Permit No. - .5� Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Pottz Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded( )
Abandoned( )by
at ` 86 Sheaffer Rd, Centerville has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. AF dated
Installer W E Robinson Septic Sre Designer
The issuance of this permit shall not be construed as a guarantee that the system will fun�ction
. as designed.
Date 1 / `% Inspector_ — �
No. .5� Fee$cJ 0.0 0 Q
THE COMMONWEALTH OF MASSACHUSETTS
i .
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Portz Mi5pozaf *Pztem Construction Vermit
Permission is hereby granted to Construct( )Repair(XX)Upgrade( )Abandon( )
System located at 86 Sheaf f er Rd
Centerville
Installer: W E Robinson Septic Sry
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 this permit.
Date: %�.S(i - 'rb,� Approved by
a' y
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
-E�GINYE-R-ED--PLANS)
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated e concerning the
property located at 86 Sheaffer Road, Centerville meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) 2J,
B)Observed Groundwater Table Evaluation(according to Health Division well map)
�q
SIGNED: DATE /
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
F6do-
6�
TOWN OF BARNSTABLE
LOCATION J/Y c=� /��'L� � SEWAGE # 2
VILLAGE.
fL n )
_ ASSESSOR'S MAP & LOT / _ d 3p
INSTALLER'S NAME&PHONE NO. K d A
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) — C �, c (size) /-�R,n
NO. OF BEDROOMS_7��
BUILDER OR OWNER �b / —
PERMTTDATE: "-ate COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Faci Feet
Private Water Supply Well and Leaching Facility (If any wells e t
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands ezi
within 300 feet of leaching facility) Feet
Furnished by
s
e'—
i
i
I
._ I
AsBuilt Page 1 of 1
TOWN OF BARN.STp /ABLE
LOCATION IC SEWAGE #
VILLAGE C' L'—�- I ASSESSOR'S MAP&1LOT 72 - 0,50
INSTALLER'S NAME&PHONE NO. I i �, ti 3 + t- -7 '7
SEPTIC TANK CAPACITY le R=
LEACHING FACIL=: (type) 4 C.. (size)e9-6
NO.OF BEDROOMS
BUILDER OR OWNER PO 'Z I Z--
PERMITDATE: 9'—cP- T� 7' COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Faci ' � Feet
Private Water Supply Well and Leaching Facility (If any wells e ' t
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands ezi
within 300 feet of leaching facility) Feet
Furnished by
r'
� 1
3�
i
i
http://tssgl2/mtranet/propdata/prebutlt.aspx.mappar—172030&seq=1 4/3/2013
L 0`C A'T ION e f SEWAGE PERMIT NO.
s ,,,SEWAGE
1 l 6
VILLAGE f
INSTALLER'S AME i ADDRESS
r'C
e U 11.D E R OR OWN ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
}1
W �6
6
f
F�
r
- per • - .. ` . ".-
FsS....r.�.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------...��-ti......._O F.......... ............ ... .......................................................
Appliration fear Diii-Vniitt1 Workii Tnwtrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.. ............ .... .............. ............. .....`...t 3 ----•-----•-------.........--•--•-••••----
ocation dress or Lo
---------------••---- ...... . ...........
...............
a wner . _ Address
............... . � }------- . ... ..ZM.............. ..........••••--------...---....................------•----.......
Installer Address .�
Type of Building Size Lot...... v......... feet
Dwelling— No. of Bedrooms_..__ Expansion Attic (vb) Garbage Grinder (y%_o)
ok Other—Type of Building No. of persons............................ Showers
G.� YP g -.._...-•-•---•---•---••--•- P ( ) — Cafeteria ( )
w Other fixtures -------------------------------------------------- - -
W Design Flow.._AL:u...............................gallons per person per day. 'Total daily flow.......................33 v.........._gallons.
W Septic Tank—Liquid capacity
VQ...gallons Length................ Width................ Diameter_--__-__ ---_- Depth................
x Disposal Trench—.No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---_---------------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by........ o .. ._�...... .._ Date.... 13..............
aTest Pit No. 1................minutes per inch Depth of Test Pi --------..--- Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of 'Test Pit.................... Depth to ground water.._................____.
a ....................................
-••----••-•......-•••------•-•-•.. ..........................................................................................................
Descriptionof Soil -------------------------------•----------------------•--------------...._.....--------------••-
x
v .......................................-................................................................................................................................................................
W ----------------------------------------=------•------•----------------------------------------------------------------------------------•--------------------------------•------------
VNature 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'I'I U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beN issued by the Lrdof.Health.Signed � ................ .........................l ......_
Date
Application Approved By....... /Z "L. ".,
::_ !
Date
Application Disapproved for the following reasons_____________
..............••-•-------••---•-•----...-.----•------...---------•--•-•--•-----•-•--•------.....----••---...------•------•--..•...............................•..... ......--.. . ......---------
Date
PermitNo......................................................... Issued-.......................................................
Date
r
No....f.5.2.--l/60 FRs... ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_.----...... cac ..........OF....... , Q�Qo..............................................
Application for Di,ijioott1 Vorkg Tonitrnrtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
..................... ..................---.�.....� .... -.-...-•---------- -------------t.........-.........3 "...----......---------.....------..............----
Loc3tion- dress or Lo I
......................�.... L1.t?sf�r.. ............._..... ` t5X.. .... :? ...............
Address
,It/,�, t caner ...............................
Installer Address
Type of Building Size Lot____A Zjpv........Sq. feet
Dwelling—No. of Bedrooms......3..................................Expansion Attic OAq) Garbage Grinder (via)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ................................. .
W Design Flow.... ...............................gallons per person per day. Total daily flow.......................33..q...........gallons.
WSeptic Tank—Liquid capacity4!?00...gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________--- .--- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........ ..... .. ........ ... .. Date....t .� /u
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to groundwater.........................
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+ •-•--•••••••------------------•------------•---------•••--•---•....•---------•------••-•----------•----•----•-•--•------•-•-•----..........__.....•-••....--
0 Description of Soil............................................................................................................................................................-...........
U --------------------------------------•---------------------------------------------.....----------......----------------------.....---•-------•---...................................................
W
-----------------------------------•--••---------•-----------------••-•-•---•-------------•-•......•----•••••----•-------------•--------••••••---------••--•--•---•--•-•---------•--•••.............•...
U Nature of Repairs,or Alterations—Answer when applicable................................................................................................
------------•------------- ............................-................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
the provisions of TAITILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beR issued by-the bmrd of health.
S' I••_... ...... . ......... . ....... 6 �0 /t 3
•. .--••••-------•-•- -•----•--•.....•-•--•..• --
ApplicationApproved By._....... ........... ------------------------------------------------
Date •
Application Disapproved for the following reasons-------------------------•--...._.....---.._..---...-•--•------.----•----•-------..._....._........._.....__.._..
.................................•----------•------------.....--•------------.....-----------.......-•---•----••...__..........••--•----...-•-•-•----••--•--•--•-••--------•-------------•--•--•-------.
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH``'~
.........................tF.... ......OF....... .......................................
Trrtif irtttr iaf Tant;iHaurr
THI IS 0 CUR ', IT t the Individual Sewage Disposal System constructed ( or Repaired ( )
by-•-•---••-. h: ......................................... .t c ... .._-----•.................. ----- ------ ..........------...........--•--•-••---------......................-•-------
......----Insta--- ..._.... n
has been installed in accordance with the provisions of TITLE The S e Sanitary Code as described in the
4011Y �e
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BXCOZNSTRU S A GUARANTEE THAT THE
SYSTEM 1AlfLL/F�'INCTION SATISFACTORY.
DATE. (...r!/ 11 ----------••- Inspect ..------------.....-•-•-•-•-••-••-••-•....•----.------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........0F... ........... S
r
No......................... FEE........................
�i��o�ttl , orko Cho otr ion ��erntit � �
Permission is .ereby granted...................�-��...... !1.0 �`r' '•..................................•----......---...................-----
to Construct *'") or Repair ( ) an In ividual S wa s Dispog System
atNo.--•-•• � 3------ -----••----•••. ------------•--------------....................................................
Street
as shown on the application for Disposal Works Construction Pe.remit ..................... Dated..........................................
...............•-•-•----•---............. ...--•------•••---•...----.-•---•-----.......--•---•....--•••-
Q Board of Health
DATE. •..-5-�11_...-----•--•-----
FORM 1255 A. M. SULKIN, INC., BOSTON
V� Sf0NJ vJ—* t
51►..t G ts. F A M t t_Y - ';S B c p R o o M �y�",�FF��� . __ '��'— ,
wo GACL�AGE �jt2aNDE2.q_
'pAt �ovV x 1►ox 3 = 33C'G.P. o VS.3- - - - - - - y
>5EPT►G TANK = 33ox15o'/• �47�G.P. O -� - �ao.c
r FX%
t o 0 o GAt-. i //Z�s-ro*i�=.
o%5Po5n1= Pi•T u5E`
GO7-T0.y .tl L:72,54 = 7B �: f= •f; 20
71
F�QQL G i,t rya ,C Cl) 717
`. Cw. a O AkAN ul
�\
ko. 19334 U MES
1 ci/3T��
"fig 9$b cu�c '� G;
T E�'t' T o P F N D 4 S T
17
DUST. INS: SEvriC `
BvX �3 9 •Z-p,rtK
_ .
PIT
6'Tv N 6.
r
Cf-f- 9-Ttr-IG0
i � C�� Y/GL
/33 1. otAT totil
Llo 5CA►_1 SGALa
P A rT.1 REF E2EM GE.
' ,H
NE;R6at� GolKP�-`(�.1nlITF�-tH� S1DE."t:1tJ� -- „_..
Awto S�Tp4GK fz6Q�tQ:,>=M'i=NTH of �f N� �
'To W?%A or_ Z3�2N5.1•b.C�.� AND tS t�crr 6� 2 �/� �G. t3�
LOGp.T D WITN �7rm=[> P�.o tN
: DATE 1 IG gAxTE V- t. s- INC.
R.EGi`5-Trc26•U �A►1DS�t2YEYoeS
T►-tiS Qt_n.N is Nort" E3n5�-D ova a vs�r-E2vt�t...� a MASS•
-40 Lo+ 1Ppi :le- e�-