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HomeMy WebLinkAbout0096 SHEAFFER ROAD - Health 96 SHEAFFER RD. , CENTERVILLE A=[72-029 UPC 12534 No.2 q� s HASTINGS,MN TOWN OF BARNSTABLE LOCATION SEWAGE# ;L0 - �6 Y>ILLAGE i'ay Fz 411L L r ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. K � �,/,g SEPTIC TANK CAPACITY /OW J2k i5! f 1& l LEACHING FACILITY: (type) (size) NO.OF BEDROOMS OWNER S TTt'U!i PERMIT DATE: G/f 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) MAFeet, FURNISHED BY L a No. �-�./ I Z Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpiitation for Misposai *pstem Construction permit Application for a Permit to Construct( ) Repair(4upgrade( ) Abandon( ) ❑Complete System ❑Individual Components LocatiQa.Address or Lot No. ��. S 64 FFFZ R 1) Owner's Name Address and Tel.No. Assessor's Map cel J �sj /�� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Buildiug: Dwelling No.of Bedrooms Lot Size «�� sq.ft. Garbage GrinderJ^� Other Type of Building No.of Persons Showers( f) Cafeteria(--4 Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date U(''- --���,6// Number of sheets � Revision Date I� Title v�P�a��lr_r /S�SA. 4 ,S 5 � /,�.,1/ Size of Septic Tank ype of A.S. Description of Soil AP G Nature of Repairs or Alterations(Answer when applicable) L a Cif 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 no o place the system in operation until a Certificate of Compliance has been issued by this Board of ea t Signed e4 Date O / Application Approved by Date Application Disapproved b Date for the following reasons Permit No. 20J. — 269 Date Issued 8/17/001 I --------------------------------------------------- --------------- �y .,-� .�. ..,-• y..r+eti.-+.�+�.•r....-......�+•r... «.s r' h.„r.w.•...•.,�,'.w,...-..,-.- w...y...�. --_.n._..-..:.... —,-.....,....v.- .---.-a�� .,..»-.. 6 No. s""`i l� _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppYication for Disposal 6pstent Construction i3erntit Application for a Permit to Construct( ) Repair(4upgrade( ) Abandon( ❑Complete System ❑Individual Components LocatignAdd ess or Lot No. 7/ c�0 FFRAC ZZ p Owner's e Addres a d el.No. Assessor's Map cel ) a q 9����FV, C PfUrf2U/Gl1` Ao(9' Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder.--} Other Type of Building s 100,VC No.of Persons L Showers( A Cafeteria(--� Other Fixtures _ -7 Design Flow(min.required) gpd Design flow provided � Gt gpd Plan Date o Number of sheets f Revis'on Date -—� Title 5—(ECuS /z Size of Septic Tank Type of�A.S. Description of Soil �� S ` Nature of Repairs or Alterations(Answer when apilicable) c w 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 n o place the system in operation until a Certificate of Compliance has been issued by this Board of ealt Signed Date Application Approved by - Date 9 I Application Disapproved by� Y Date for the following reasons Permit No._ Z01 Z(09 Date Issued 81,717,011 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance j' THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )byiy�`���' �+��, � �- ^--- at / r g'G'= �-- C} t1t has en constructed in accordance / 1 with the provisions of Title 5 and t 4e for lDisposal System Construction Permit No ��`� date• Installer"` ' 1 Designer #bedrooms Approved design flow �J gpd The issuance of this permit shall not be construed as a guarantee that the system will as designed.,/� —, Date r/' ff Inspector _ � No. -------Fee-------------------- 00, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstrut Construction i3ermit Permission is hereby granted to Construct( ) Repair( � Upgrade( ) Abandon( ) System located at (� S�6 A T—F C P, R ►J 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:Constr ction ust be completed within three years of the date of this permit. Date Z'O 1 Approved by t , TRANS. NO.: CITY/TOWN: �mrhom* e / Ce,4feryi lle APPLICANT: ADDRESS: qG 3keg p f er pcvq DESIGN FLOW: 3 V gpd REVIEWED BY: DATE: �%We- Z- 2P 1� N/A OK NO �,:r.. OUR Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot,tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u)] Locus Provided [310 CMR 15.2204(t)] ,/ Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for �, components) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required [310 CMR 15.412(4)] V/ Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15.220(4)(d)] a/ Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)( ] daily flow septic tank capacity(required andprovided) soil absorption system (required andprovided) ✓ whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] ✓ Existing and ro osed contours [310 CMR 15.220(4)(g)] t/ Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (i)] +� Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate? [310 CMR 15.2421 ✓ x Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] Vr Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Address q6 Sheg per poa Sheet 1 of 7 f N/A OK NO Location of every water supply,public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply V/ within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. 310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.21l(1)[11) Profile of system showing invert elevations of all system components and the bottom of the SAS 310 CMR 1 5.220(4)(o)] Stamp of designer [310 CMR 15.220 1 and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3) Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as / approved for an upgrade under LUA at 310 CMR 15.405(1) k ] Test hole adequate to demonstrate four feet of suitable material? / [310 CMR 15.103 4 ] v Test Holes adequate to confirm adequate groundwater separation? / [310 CMR 15.103(3)] r/ Benchmark within 50-75' of system 310 CMR 15.220(4)(g)] Materials specifications noted? [various sections of 310 CMR / 15.0001 V System components not> 36" deep (unless Local Upgrade / Approval or LUA requested) 310 CMR 15.405(1(b)] Address q& �6eG1�`1"C�r 1 "I Sheet 2 of 7 N/A OK NO Vic �a iki..&'' Size OK? [310 CMR 15.223(1)] Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR / 15.227(6)] V Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] r/ Note regarding installation on stable compacted base [310 CMR 15.228(l)] J Separation between inlet and outlet tees(no less than liquid depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9"must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 t/ CMR 15.232(3)( ] Three access covers (inlet and outlet must be 20" or greater) - / middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<1000gpd, two for systems>1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CNM 15.228(2)] > 10 ft from building foundation [310 CMR 15-211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] a/ H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] _ NOW . %her'_. ,.ate �r�r �+,• �_ � +� Required when other,than single-family dwelling or flow>1000 � d [310 CMR 15.223(1)(b First compartment 200%daily flow; Second compartment 100% daily flow [310 CMR 15.224(2) and(3)] "U" pipe through or over baffle, outlet of each compartment with / as baffle or approved filter [310 CMR 15.224(4)] V Address � � � ��� Sheet 3 of 7 N/A OK NO Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below water line (when water and sewer cross, see 310 CMR 15.211 1 1 ) Cleanouts required/provided ? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable ` [310 CMR 15.222(6)] 1/ Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) 310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphonproblem/(leachfield below pump chamber Endca s or vent manifoldspecified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 ✓ CMR 15.252(2)(h Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) J DTI�B ° Ell i Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a Riser if deeper than 9" 310 CMR 15.232(3)(f)] o/ Inside minimum dimension 12" 310 CMR 15.232(2)(b)] Minimum sum 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] Capacity(emergency storage above working--design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] �! Service components accessible(not too deep with piping, disconnects accessible) J Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and(8)] V Stable Compacted Base [310 CMR 15.221(2 Buoyancy calculations needed? Provided? [310 CMR 15.221(8)] Address �� �v ►`oq(4 Sheet 4 of 7 N/A OK NO 1 Calculations correct? ��� 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] ✓ Required separation to groundwater? [310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] C� Inspection ports specified and within 3"final grade? [310 CMR /' 15.240(13) V/ Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and V/ Guidance Document] Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] ✓ Each structure with one inspection manhole(if>2000 gpd must f be to grade) [310 CMR 15.253(2 V Aggregate 1'minimum- 4'maximum. [310 CMR 15.253(1)(b) 2' sidewall credit maximum 310 CMR 15.253(1)(a) In bed confi ration, inlet eve 40 s . ft. [310 CMR 15.253(6 MW ' �� ` CO,vT x� 1 . Width 2'minimum 3'maximum 310 CMR 15.251 1)(b)] 100 feet-maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) 310 CMR 251 1) d ] ✓ Situated along contours 310 CMR 15.251(2)] f Breakout OK? 310 CMR 15.211 1 4] and Guidance Document] BF! .4 minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] ✓ Aggregate depth below discharge pipes 6"minimum, 12" maximum. [310 CMR 15.252(2)O] ✓ Separation between beds 10'minimum. 310 CMR 15.252(2)(0] Bottom area used in calculations only 310 CMR 15.252(2)(1)] q6 Address 5��� ��� `"� Sheet 5 of 7 N/A OK NO o Pressure Dosed System ? Provided pump and piping / calculations as required 310 CMR 15.220(4)(r)] V Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A / Remedial Use Approvals] V If used in gravelless system -make sure jet is directed as not to / scour soil interface Guidance Document (s Inspections once per year(systems<2000 gpd) or quarterly (>2000 dgood to note on plan 310 CMR 15.254(2)(d)] Construction in fill -Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255(2)(a) Side slope not exceed 3:1 ? 310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and. Guidance Document At least 5 ft. from impervious barrier to edge of SAS (10 ft. / recommended [310 CMR 15.255 2 e V � Ml 61 ' Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface _ µ .w Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has licant submitted a co of a maintenance Mew e Are the variances listed on the plan ? [310 CMR 15.220 (4)( RLS Stamp necessary on plan if a component is within five /� feet of property line 310 CMR 15.412(4)] `./ New construction or increased flow proposed- [Refer to 310 CMR 15.414] Address q6 �hMTB e r 'w qd Sheet 6 of 7 N/A OK NO �1itrogeii��S'�►%sxt�e � . �.Fx ti � � �;��. � �� Is the system in a Designated Nitrogen Sensitive Area(Zone U for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such / existing systems] Is the system proposed on the same lot as served by private well ? / [310 CMR 15.214(2)] �/ Are the nitrogen loads proposed in compliance? [310 CMR 15.216(l)] w Pumping to septic tank? 310 CMR 15.229] Shared System [310 CMR 15.2901 Address �� � � (I l e� Sheet 7 of 7 Town of Barnstable Regulatory Services s Thomas F.Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer&Designer Certification Form Date: Sc-T� q, 2,00 n. CouGH�NOwtZ Designer. 1 Installer: �`r , � S�C�i/A�Dn, Address: 43 T I A-W 6 L C 6R Address: ti On C7 ho <e 0 fzlZ jfS ., iu was issued a permit to install a (date) (installer) septic system at q� 5hegffer Vog4 based on a design drawn by (address CDuGW�W W f, dated 401 / 72, 2,P11 . (designer) . I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &.Local Regulations. Plan revision or certified as-built by des' r to follow. 1N OF As �o DAVID cy� S Signature) � D. er COUGHANOWR i N . o. 1093 ���✓� t—S SgNItARkPN (Designer's Signature) (Affix Designers Stamp Here PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DMSION. CERTIFICATE OF Co LIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HE L H DIVI,SIGN THANK YOU. Town of B • �,►tE,� arnstable P# Departinent of Regulatory ' i��="�°�'�*�' vAmerABLAS Public'Health Division Date J"'�"e ,, ib3P h 200 Main Street,Hyannis MA 02601 Date Scheduled `BUG 21 ; Time 6 O Fee Pd. Ch Soil Suitability Assessment for Sewage Disposal Performed By: Q a V 1, 1°l b • CO WAAM0Wr `J0 h D PS tn-trq 1�Witnessed By: LOCATION&GENERAL INFORMATION Location Address qG <�14E B-1;-r1'Tz� 20 A Owner's Name C F N TP,RV I C.�' p Stephen # TPSS/c 1 Address 6(, Slhcq-F?Fer Rol Assessor's Map/Parcel: Ce lf-elr vi ll e/ h14 /2 7 Engineer's Name D(}v 1 A CByG ry��J 9W,� NEW CONSTRUCTION REPAIR V Telephone# Soli� '3 41-4 t' �4 Land Use �C S 12(��li"'1 to e Slopes(9b) ® Surface Stones d6��r Distances from: Open Water Body 100 + ft Possible Wet.Area 100 ft prinking Water Well I�0`F g Drainage Way So t ft Property Line 'V f ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands fn proximity to holes) • t.ovov f t LXT t-7� �1 15000 a © e 0 q 7� wP-2- TP-► Parent material(geologic) rd Cd cl Ou t-W454 Depth to Bedrock V l d P)e Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face 10 P1 e + Estimated Seasonal High Groundwater lwo r e +-k ci h L '( DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: ln, Depth to soil mottles: A 0Ke at l�Z In. Depth to weeping from side of obs.hole: In, Groundwater AdJustment fr. Index Well# Reading Date: Index Well level Adj,fketor,�, - Adj.Groundwater Level,,,o, PERCOLATION TEST bate,&(2 1 t ,I,�e t o(1 N1 Observation � r Hole# Time at 4" l Depth of Pero 21 m 00 Time at 6" Start Pre-soak Time @ 0-d0 1 lime V141) IVIi t1 End Pre-soak `•�_�0 Rate Min./Inch P; Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N) `y Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFORM.DOC L DEEP.OBSERVATIONHnLE LOG Hole# Depth from Soil Horizon Soil Texture Surface(in.) Sdil Color Soil. Other (USDA) (Munsell) Mottling (Structure,Stones;Boulders. isistencv 96 t3rav 11 L S -16 a [our► 16 P-ZII �\)vh.P i 4S _13 C E ELsc l�►d DEEP OBSERVATION HOLE LOG Hole#_7 Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) Other (Munsell) Mottling (Structure,Stones,Botlders. 0—(S 'Congistency,%OWLeD 104 (�r► �� R /� tt , DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) (Munsell) MottlingOther (Structure,Stones,Boulders. Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from .Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. ons' ten s Flood Insurance Rate Man Above 506 year flood boundary No_ Yes Within 500=year boundary' No V Yes Within 100 year flood boundary No Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perv'ous material exist in all areas observed throughout the area proposed for the soil absorption system? L If not,what is the depth of naturally occurring pervious matorlall Certification I certify that on i). �� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consiste SN OF the required-training,expertise and experience described in 10 CMR 15.017. a`� DAVID•, Signature �'� �y ---- Date � ''� I'l cOUGFfAN�IR ` sp LrNS Q• • �<.�VALtIP�O Q.WEPTICVERCFORM.DOC P�oF�He Town of Barnstable Barnstable ro�� A1NMerica City y� Regulatory Services Department B RNFrABLE, - Public Health Division 9 MASS. 04 �°ArFbMACOhl 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 5613 July 19, 2011 Ms. Jessica Stamaris 96 Sheaffer Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at, 96 Sheaffer Road, Centerville, MA. was last inspected on 6/23/2011 by Sean M. Jones, certified septic inspector for the State of Massachusetts. According to the private septic system inspector, the system"Fails" due to the following: • Back up of sewage into facility or system component due to overloaded or clogged SAS. • System is in 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 may result in future enforcement action -PUR ORDER OF THE BOARD OF HEALTH 6:;�homas McKean, R.S., CHO Agent of the Board of Health R ! t Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc __ �, �y��„I� i �� i � U� '.� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information I forms on the computer, use 1. Inspector: only the tab key to move your Sean M. Jones cursor-do not . Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code 8)477-8877 S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CM 1.5.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails . -) t� ❑ Needs Further Evaluation by the Local Approving Authorityk s 6/23/2011 Inspector's Signature . Date The system inspector shall submit a copy of this inspection report to the Approv i g Authoh$i (Boarsd of Health or DEP) within 30 days of completing this inspection. If the system is a)shared s rem on 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•09/08 Title 5 Official Inspection Form:Subsurface Sewag Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/Town 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: 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): I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M ,•'' 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M ,•'' 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/Town 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 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: 1 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 1/z day flow t5ins•09/08 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/Town 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 or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•09/08 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 °�M •' 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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? . ® El information 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): 330 gpd t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I _ Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: At time inspection the septic tank was found o be overfull to the cover, tank was pumped with large amount of water backflowing from the s.a.s.. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 [ e� Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/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: partial pump, 1500 gallons gallons How was quantity pumped determined? Reason for pumping: Tank was overfull, pumped to allow for usage 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M ,•y' 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system repaired 1998 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every 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 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was overfull to the cover, tank was pumped out to allow for usage. While pumping, water was observed backflowing from the leaching facility indicating that it is hydraulically overloaded. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/09 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/Town 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 ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was not located 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2x500 gallonchambers ❑ 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.): The septic tank was overfull to the cover, tank was pumped out to allow for usage. While pumping, water was observed backflowing from the leaching facility indicating that it is hydraulically overloaded. 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•09/08 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 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every 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.): 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. CitylTown 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 � B O i TAN i� O zq6', Q z I p,8b= 0 3 13-Z= ZSr o SAS A.3• 55 r r f3.3. 3 MIA5ur4%(Ah are aSSvMeO t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments w 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/Town 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: 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Groundwater elevation was not established Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Sheaffer Rd. Property Address Jessica Stamaris Owner Owner's Name information is required for Centerville Ma 02632 6/23/2011 every page. City/rown 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 i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION v � C lam/ SEWAGE # I 0 -�5 7 J VILLAGE ram/~• ASSESSOR'S MAP & LOT 'D INSTALLER'S NAME&PHONE NO. 6 SEPTIC TANK CAPACITY 16 6­0 LEACHING FACILITY:y(type),;- " 9^i (size) i :Z NO. OF BEDROOMS J BUILDER OR OWNER PERMIT DATE:, . 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) t. Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t F?e-owr- t No. Fee $5 0 .0 0 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS O,ppYtcation for Migpogal *pgtem Congtructton Vermit Application for a Permit to Construct( )Repair Ocx)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 96 Sheaffer Rd Owner's Name,Address and Tel.No. 4 2 0—5 8 4 8 Assessor'sMap/Parcel Centerville Jessica Stamaris 96 Sheaffer Rd C 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 Sry PO Box 1089 Centerville 02632 Type of Building: Dwelling No.of Bedrooms 3 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 Leaching co s i s t i ng fo f Dbox, two 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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t is B and of Health Signed r�, >L-b Date _01 Application Approved by �' .,�_� Date Application Disapproved for thYfolloYing reasons Permit No. Date Issued rj_ 0 ;L, ^' No. Fee $5 0.0 0 - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -'TOWN OF BARNSTABLE, MASSACHUSETTS Olpprication for ;Di5poga[ *pgtem Construction Permit Application for a Permit to Construct( )Repair kX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 96 Sheaffer Rd Owner's Name,Address and Tel.No. 4 2 0—5 8 4 8 Assessor's Map/Parcel Centerville Jessica Stamaris 96 Sheaffer Rd Centerville 02652 Installer's Name,Address,and Tel.No. 7 7 5_g 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic SHs PO Box 1089 Centerville 02632 Type of Building: Dwelling No.of Bedrooms 3 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 a Nature.of Repairs or Alterations(Answer,when applicable) Title 5 Leaching cosisting Of DI)929xtw6 leaching chambers Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposalsystem 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 by tl.�s B99d of Health. Signed !%tom Date Application Approved by Date Application Disapproved for th follo ing reasons v 0. Permit No._ — .,�7* 7/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS Stamaris BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(x ) Upgraded( ) Abandoned( )by at 96 Sheaffer Road, Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 21 dated Installer W E Robinson Septic Srvice Designer The issuance of this permit shalVnot b cos ued as a guarantee that the s ste .ill function a�signe . tt Date t� Inspector ` No. Fee $50.00 u THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Stamatts Jigpoar *pgtem Con5trudion Permit Permission is hereby granted to Construct( )Repair( x)Upgrade( )Abandon( ) System located at 96 Sheaffer Road C.enterviller Tri i'al 1 r • W E RObi nann Septic Seraice 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: A _ —q Approved by N-_ U NOTICE: This Farm is To-Be Used For the Repair Of Faded- - Septic-S-ystems-onfy. CERTIFICATION-OF.SKETCH=ANWAPPLICA` I[ON-FOR-1A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED?PUANSY- I;- Wiliam-E..Robinson, Sr: ,hereby-certify-that-the-application-for-disposal,works construction permit signed by me dated concerning the property.-located at-, - 96 Slteaffer Road,-Centerville-. - -meets all Qf the following criteria: * T-here=are-mo wetlands within-100-feet-of the:proposed-leaching facility. I * There are no private wells within 150 feet of the proposed septic system. * There-is.no_increase-inflow-andior-change:.ufuseproposed. i * 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-tabie-elevation. , Please complete the following: A).Top-of.Ground-Elevation(according-to the-Engineering-Division.G_I.S..map) B)Observed Groundwater Table Evaluation(according to Health Division well map) �j QED.vCJ `' —DATE/ _1-111— LICENSED SEPTIC-.SYSTEM INSTALLER IMTHE TOWN OF BARNSTABLE NUMBER 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, thi,plan_shouldbe submitted)... ... ,� U TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE_ ,%`- r ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.1a SEPTIC TANK CAPACITY 16 e�� LEACHING FACILITY: (type) i 4- C (size) NO. OF BEDROOMS - BUILDER OR OWNER PERMITDATE:_ 0—,-x S� 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 i ' r �P i NOTES O 0/1ST it SC C'E ALE ROAD EXISTING LEACHING GALLERY IS TO BE PUMPED AND REMOVED. AEr EXCAVATE ALL ASSOCIATED. CONTAMINATED SOILS IN VICINITY a o �ivf� Jo OF PROPOSED LEACHING GALLERY AND REPLACE WITH CLEAN MEDIUM SAND PER TITLE 5. 2 EXISTING 500 GALLON LEACHING CHAMBERS FROM C F r 0 FAILED SYSTEM MAY BE REUSED ONLY IF THEY ARE 62 LOCUS Z W m z w FOUND TO BE IN SOUND STRUCTURAL CONDI T ION. 54 0 g In 55 �� w Q A I � 1 O CENTERVILLE. MA LOCUS MAP �� ..., ® __� '� I � I MINIMAL g �; LOT 134 �� I CONTOURS Ro US o ® ®�v m L� 40 0 a�a o m <� ARCEA e 15000 o� �e I EXISTING �-4o m O IL ®�\ 1 �j �1 \ I THIS PLAN IS INTENDED SOLELY FOR INSTALLATION �`% ®O I OF THE SEPTIC Lu SYSTEM DEPICTED ON IT.FOR ANY �zl''''J OTHER CHANGES TO THE PROPERTY INCLUDING A T N H FENCES R /� (� PLACEMENT OF DDI 10 S.SHEDS. E CES O n p erg® � J � � � � U u U � J()�� V/� O /., Ix ®z / d SWIMMING POOLS,OWNER SHOULD CONSULT WITH (� r ` yp� A MASSACHUSETTS REGISTERED LAND SURVEYOR. � � wv U3 � O� to ® a I � a1 �� !!J� � � a ® � I `' I I z <(A �� �I ® ® z2 DRIVEWAY Qi�p / LEIIFND CZ ,i O W I PAVEv Div ddb 12 p W LNJ �% ® I I 1 EXISTING � g� 9000 GALLON to O OUA ui —I iYl / SEPTIC TA NIX n � � o w< QO��cB 1 UTILITY POLE20 ft $ �tu LL OJ ® (/`J �® �g `4 ff' `� / TEST PIT® D-SOXO ui TP_2 0 � O t. sN i0� (f' Ix I:� 27 ft x 99 Pt x 2 ft O -'Z o Op I HYDRANT � DRAIN Eg o I g ° LEACHING GALLERY I ® �, ® � I dab 12-D 1 U U -O n I \ I DECIDUOUS CONIFEROUS �- z EXISTINQ . 16� z W LEACHING ;o-c ,•• 1 TREE qQp TREE/%�pa �ZW GALLERY ; r• •©; \ i Qab92-xA 12-P tl) NUMBER REFERS TO V ®� •1 \ IAMETER INCHES. LETTER DENOT ES TYPE. .....••.. d: (/v I O-OAK BNGB-BURNING BUSH C-CEDAR to ~c I 1 LINE � z_ F O ® , .. WATER O g O 52 a� !AI� � L�f! � W TER � �� qN Mq WJ 0 z— 0 O GA E 1 �— 54 ss'QC y�`�jH()F MgSs9C O� ti o �I GAS LINE / __� 55 0'� DAVID tiG ? ti j ® ag �� D N� a DAVID �� p w ��� GARBAGE GRINDER � COUGHANOWR D. N 65 COUGHANOWR W w i IS NOT ALLOWED No. 1093ea 0 WITH THIS DESIGN. LISTER O� CENSE �0 � u C=j w z J Z BENCH fMIAG�31� ���¢ ® 0 o �� < TOP OF WATER ��_ TIC SEWAGE DISPOSAL SYSTEM PLAN (� p ® � I g e ELEVATION =65.61 t;, � -TO SERVE EXISTING DWELLING e I w � pa SARNSTASLE GIS DATUM EST. STEPHEN � ESSICA STAMARIS m PLOWNER(S) OF RECORD (l 11 V 0 o 3: v 96 SHEAFFER ROAD 4. K SCALE. 9 /n = 2® ft '�G 1995 ,fit- CENTERVILLE. MA ® UL ° �/Q PROPERTY ADDRESS � O M zz F I 20 O 20 40 ?ON J o- ai ASSESSORS MAP 17 2 PARCEL 2 9 O u W W O 10 20 43 TRIANGLE CIRCLE e- w SANDWICH MA 02563 PLAN BOOK 247 PAGE 64 506 364-6694 f DATE: AUGUST2. 2011 I E T E-3 4 9 8 PAGE l O F oN 2 vERsr � � I, woe II DATE OF TEST: AUGUST 2. SOIL TEST L O G SOIL EVALUATOR: DAV D D. COUOGHANOWR, R.S. - DD EM G U V C A L C U L T U OO N S WITNESSED BY: DONALD DESMARAIS[. HEALTH DEPT. PERC NUMBER: 13340 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLOWS NO GROTUNDDWAT R ENCOUNTERED OUTWASH USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL TEST PIT 1 CONDITION. IF NOT, INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) PERC AT 74 in - 2 MIN/INCH IN C SOILS DISTRIBUTION SOX: USE 3 OUTLET D-BOX. ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOIL ASSOROTIOIN SYSTEM: A 27 It x 11 It x 2 It LEACHING GALLERY CAN LEACH 66.40 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING Abot = ( 27 x 11 ) = 297.0 of 0-15 FILL Asdw = ( 27 + 27 ¢ 11 ¢ 11 ) x 2 = 152 s9 Atot = 449 s4 15-18 Ap LOAM 10 YR 2/1 NONE FRIABLE Vt 0.74 x 449 = 332.3 GPD 62.85 1B-45 B SANDY LOAM 10 YR 4/6 NONE FRIABLE USE A 27 1t x 11 It x 2 It GALLERY. Vt 332.3 GPO > 330 GPD REQUIRED 45-132 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 55.40 1000 GALLON SEPTIC TANK DIMENSIONS AND DETAIL NOT TO LEA CHI NG GA L L ER Y USE EXISTING H-10 UNIT SCALE TEST PIT 2 PO ENOTUNDWATER MAATERIAL ENCOUNTERED OUTWASH SEPTIC TANTANKIS L BE PUMPED DRY LEACHING ORYWELL(H-000 GALLON NOT LOADING] SCALED TIME OF INSTALLATIONAINSTALLATIONAND IS TO BE EXAMINED FOR STRUCTURAL CONSTRUCTION DETAIL ELEVATION INTEGRITY. INSTALL NEWPVC OUTLET DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER TEE EQUIPPED WITH A GAS BAFFLE. DRYWELL UNOT 5545 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 16la Q ST0 7 0-15 FILL �TApER 27.0 1t 15-IB Ap LOAM 10 YR 2/1 NONE FRIABLE 18-45 B SANDY LOAM 10 YR 4/6 NONE FRIABLE " a g 52�® 45-132 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 0 0 55.45 0 P NOTES 3.08 4@ 5.5 fl@ 4 4t 5.5 fl4 3.08 @t q� 27.0 1t 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. ffgo� o� 9 500 GALLON ®RYWELL 2) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED ®acENSa®�� AND DETAIL FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. INLET OUTLET 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS COVER COVER USE H-10 UNIT INSTALL ONE INSPECTION OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). RISER TO WITHIN THREE 4) .INSTALLER TO VERIFY, LOCATIONS OF ALL UNDERGROUND UTILITIES —► A, /N ®RO VFLOW LINE INCHED of FINAL GRAD NO INDICATE LOCATION .° BEFORE EXCAVATING FOR SYSTEM. _ —► O ft� a FROM 10 in 94 TO ON AS-BUILT PLAN 5) "AL.L- STONE• TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE. BUILDING ROM D_S®X 6) ECO-TECH.'ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES LD in LIQUIDAND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. CA� LEVEL BAFFLE 0 33 s 0 Z) SYSTEM IS NOT" DESIGNED' TO WITHSTAND VEHICULAR LOADING. DO NOT Joao 000 In 0 a 0 0 0 a 0 0 0o a 0 _ 0 o PARK OR D I EV ICLES OVER SEPTIC SYSTEM. a 0 0 0 0 B1-SEPT.IC 'TANKS SHALL;-BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL SEPARATION OF INLET AND OUTLET TEES STABLE BASE "THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SHALL BE NO LESS THAN LIQUID DEPTH SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. 102 in CROSS SECTION VIEW CROSS SECTION VIEW DISTRIBUTION BOX 2 in PEASTO E 2 in PEASTO E DIMENSIONS AND DETAIL USE SHOREY OS-3 H-10 28 3/4 a+ TO ELECTIVE 314 t+ TO 26 SEWAGE DISPOSAL SYSTEM PLAN NOT In �-►tea�,GRAVELoEPrrl I-I�2 r� ,n MOT TO PAGE 2 OF 2 DOLE --► 37 In 56 In. 37 O in In FOM TANK St TO ESSICA STAMARIS 132 � SAS O 9G SHEAFFER ROAD INSTALLER MAY SUBSTITUTE AN APPROVED OEorExraE .::..:.:...:::..:..:.......... CENTERVILLE. MA �� u�Yl■ FABRIC IN PLACE OF THE 2 in. PEASTONE LAYER SPECIFIED. B In STONE SASE AUGUST 2. 2011 ETE-3498 D b 5 doy �� CROSS SECTION VIEW