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HomeMy WebLinkAbout0156 SHEAFFER ROAD - Health 156 Sheaffer Road. `Centerville F ' t A = 171 055 .+ UPC 12534 Z �� No.2-153LOR � � 14ASTINGSa. LIN /� TOWN OF BARNSTABLE LOCATION /��C�/ 51 eA FireR R,01 SEWAGE # VULLAGE ceAlreg11L e ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. J'l t Al A e 0*1 S'o A-' SEPTIC TANK CAPACITY A D D o z,- LEACHING FACILITY: (type) W e LL 5 (size) .�,�' /3 " %�• NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6 \ 53.4 T (WAN OF BARNSTABLE LOCATION �SCO Sl�ea �t� 2C, SEWAGE # )VILLAGE (A_rCCfv►1t4 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. A' SEPTIC TANK CAPACITY �� FA1LE® 1NSPECTION LEACHING FACILITY: (type) �'� G'� 6� (size) NO. OF BEDROOMS 3 Q BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Z_/1 Q2c "o* Fold - 1 A ( ALa B � o xe � Q a 57 J No.,, 0 255 Fee �D 6 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES'MASSACHUSETTS Rpprication for -Mi5pogal *pgtem (Con5truttion Permit Application for a Permit to Construct( )Repair(� )Upgrade( )Abandon( ) 0 Complete System 0 Individual Components Location Address or Lot No.15(o Jr .Owner's N e Address and Tel.No. Cry y'6 ®� w_� t.aC9.VI'i.� � Assessor's Map/Parcel i 7all f Installer's Name,Addr ss,and Tel.N . Designer's Name,Address and Tel.No. r plm s Type of Building: . Dwelling No. of Bedrooms\ 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow -33 d gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank - Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) O�II 1,9AC'�'1AAR IJ c 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 iss yat is Dardl 9f4jea h. Sig DateL+�� Application Approved b Date Application Disapproved for the following reasons Permit No. =Q�5 '— 3 3 5 Date Issued No.cJ�Q� 5 3 Fee /DC) 14-• _.� THE COMMONWEALTH OF MASSACHUSETTS jeered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BAR NSTi4BMASSACHUSETTS Rppr cation for Mi5poga1 *p5tem CCon!6truction Permit Application for a Permit to Construct( " )Repair(x )Upgrade( )Abandon( ) O Complete System ❑Individual.Components Location Address or Lot No. Owner's Name A dress and Tel.No. Assessor's Map/Parcel ? Installer's Name,Address,and Tel.Np. 33 Designer's sNName,Address and T 1.No. d�ex- Z 5o n D_ _ 9 t�V (sot) IQ-AI-� '8o'x t a5 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 33 © gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nat urg of Repairs or Alterations(Answer when applicable) 17l I f t l d 4 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 iss b his oard of- ea th. Sig i6d Date Application Approved Date Application Disapproved for the following reasons , Permit No. -100 — 3 3 Date Issued 5 ----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ' Certificate of (Compliance THIS IS TO CERTIFY, t t the On-site Sewage Disposal System Constructed( ) Repaired (A )Upgraded( ) Abandoned( )byW60mb "Id at A a l has been constructedin'taccordance with the provisions o Titk 5 and the for Disposal System Construction Permit No.rV-V--2-7 3 5 dated /��. Installer &bk1^ Thol LYl I Designer MoARr- The issuance of this permit a not$b cc°nstrued as a guarantee that the stem ill un tion as designed. Date 1_6 �/ . > Inspector No. 5 3,-3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS nigpont *p! tem Con$truction Permit Permission is hereby granted to Cons ruct( ))Repair(X)Upgrade( )Abandon( ) System located at 1,o JY �_p coif vvv i L . ai - 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 fhis� Date:__ 7 �i �S Approved by Town of Barnstable Regulatory Services Thomas F. Geiler,Director 9 • IARNSrABLE, i q 16 Public Health Division arp ;�s Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: V ZU OJ Designe Installer: Address: . �• (/ �O / Address: `� �62 Vfl On was issued a permit to install a (date) c (fiiiltallerT septic syste: in- 5-L Vim/ �'��� based on a design drawn by (address) ktaw Z Slated ZoaS- . (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 an comp neat of the septic system)but in accordance with State& Local Regulations. Pl ' rev' ion or certified as-built by designer to follow. "v OF M S E 0 EY R (Installer Signature) No. 1140 �FGISTS 2► l Isq Pa 1 NITAR� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTA.BLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form L 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOII,EVALUATION EXEMPTION FORM hereby certify that the engineered plan signed by me dated O /0 ,concerning the property located at meets . all of the. following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The.soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed • The bottom of the proposed leaching facility will-be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Fnmptor method when applicable] Please complete the following: . A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +adjustment for high G.W. D CE B A and B SIGNED: ATE: NOTI Based upon the above information;a repair permit will be issued for bedrooms maximum No additional bedrooms are authorized in the future without engineered septic system plans. gaSeptic\percexernp.doc COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS � ' � 'SABLE DEPARTMENT OF ENVIRONMENTAL PROTECTI,O PR, 2 . Aid 9: 02 FXLED INSPECTION _._ . .DIV; ION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 156 Shea ffer Road Owner's Name: Centerville, MA 02632 Bob Peterson 1 v Owner's Address: Date of Inspection: April 6, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Y* a Inspector's Signature: Date: Al2ri19. 2005 The system inspector shaof this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. 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 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 156 Sheaffer Road Centerville, MA Owner: Bob Peterson Date of Inspection: April 6, 2005 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is 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 due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 156 Sheaffer Road Centerville, MA Owner: Bob Peterson Date of Inspection: April 6, 2005 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 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 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: 156 Sheaffer Road Centerville, MA Owner: Bob Peterson Date of Inspection: April 6, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No i Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than day 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 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 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.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 156 Shea ffer Road Centerville, MA Owner: Bob Peterson Date of Inspection: April 6, 2005 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? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: I Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION. Property Address: 156 Sheaffer Road Centerville, MA Owner: Bob Peterson Date of Inspection: April 6, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL 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: Pumped in 2000-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in approximately 1973-per owner Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 156 Sheaffer Road Centerville. MA Owner: Bob Peterson Date of Inspection: April 6, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 15" Material of construction: ✓ concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement baffles were present. The liquid level was even with the outlet invert There did not appear to be any si ns of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 156 Sheaffer Road Centerville, MA Owner: Bob Peterson Date of Inspection: April 6, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 156 Sheaffer Road Centerville, MA Owner: Bob Peterson Date of Inspection: April 6, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The leach pit had 5'6"ofliauid on the bottom The scum line was up to the inlet pine The pit had signs of failure The bottom to grade was 8. The cover was 12"below Qrade CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 156 Sheaffer Road Centerville MA Owner: Bob Peterson Date of Inspection: April 6, 2005 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. A RAL� r o A 13 aS 3G all S7 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 156 Sheaffer Road Centerville, MA Owner: Bob Peterson Date of Inspection: April 6, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- 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: topojzraphic and water contours snaps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours map, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied, relating to the system, the inspection and/or this report. 11 4 No.....5.��.. F$$...2.................._ . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...: ....!&2.G tv.............. OF.......64-0—tD-5 il!;.n.............................. Appliration for i-spaas al Works (foustrur#iaan rjernfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System it: M ... .--••-•-- •. ation-Address t o. �.,r ..- --J��.le- .. �.. ................................................ N .......................... ..... . W Owner � � ��••• �ddre� L.<tl.fj �? �Y.�!...._.`.!�3 1u.................®aEa(.... ................... Installer Address UType of Building Size Lot......IS,' a......Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—Type of Building p ( ) ( ) g .1.i�"O_cr..d�rt�.�•I\To. of persons ............. Showers — Cafeteria dOther fixtures ......................•--•--•--------...------••-------••••-••-•-•-------•--.............•••.....-•••-•••--••--••---•••..........._................. WDesign Flow............................................gallons per person per day. Total daily flow........_....... .. .................gallons. WSeptic Tank—Liquid capacity/M...gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width...._.............. Total Length.................... Total leaching area....................sq. ft. 6ka'J tic Seepage Pit No--------------------- Diameter.......... � 2 Depth below inlet.._................. Total leaching area..T .sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..._.................... r.M4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................. C4 • ••.... O Description of Soil-------- .............................................. W UNature of Repairs or Alterations—Answer when applicable..._._.......................................................................................... ...............----..................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescr'bed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Co The unde signed further agrees not to place the system in operation until a Certificate of Compliance has bee ed by th r o. ea*. S' •••--••• .... ••--•••---• •-•----••-.......... I..�'.4 Dat/-7..2,, Application Approved BY ''1 ..................... .... ---•T��.D. ate Application Disapproved for the following reasons------------------------------------------- ---------•-------------...-----------...-----------•------------•---- •---•••........•------•-••-•-----------•--•-•----•••------••-••••.-•---••-••••------.....-•••....---•-•----••-•-••-•...-----••-•-•-•-•••-------•---•••-•-••-•••••-•----••......---•-••-••-••--•••--•••- Date PermitNo......................................................... Issued............................................I No...... _j............. ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... F...... 4.7 A? ;VJ ..............�O 'i", --_-----_--.......................... 4phrativit for 13isposal Works Tanstrudion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: V 46............................................................................. . . ................ L 'r-_ 'V Vq ire.' or Lot No. ;.'ali ion .............. ............................................... ............ W Owner Address, .................................... 7) ie-------6-61 ......ixt�-......... ---------------------------------------- �7tnsalter Address U Type of Building Size Lot------ISk�!:Y......Sq. feet Dwelling—No. of Bedrooms............2............................Expansion Attic Garbage Grinder Other—Type of Building (..mi-d.l.-No. of persons............/5�............. Showers Cafeteria Otherfixtures ....................................................................................... Design Flow............................................gallons per person per day. Total daily flow................3.4........................gallons. P4 Septic Tank—Liquid capacity/dO...gallons Length................ Width___.._.......___ Diameter................ Depth......_......... Disposal Trench—No...................... Width.................... Total Length._.___......._...... Total leaching area....................sq. ft. 6 Seepage Pit No_____________________ Diameter__-_7 Depth below inlet........._.......... Total leaching area_-?6.'1..sq. ft. Z Other Distribution box Dosing tank aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-------_------_------- rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit....._.............. Depth to ground water......._.___........._.. Ix ...................... 0 Description of Soil.......... U ........................................................................................................................................................................................................ W Z ............................................................................................................ ........................................................................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedefribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary 9.df-The uii'dersigwd further agrees not to place the system in operation until a Certificate of Compliance has sued by tW boo 61 health. 7 ned.....................................J_ ------------ p ---------•-------�- ------- _Date ,,, ApplicationApproved By.........................................................................................r...... Dite Application Disapproved for the following reasons:........................................*.i....................................................................... ...................................................................................................................................................................................................... Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ................OF......... .,6.lr..................................... AT werfifiratr of Bunt rttttnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by........... Kj:��A........ ....................................................................................*-------------------------------- 1* FA Anitaller Et ......... ___ at�A:......L.-t.2;..... ...c....C. iy,,-- ------ ......... C_,�uil �.;V,e has been installed in accordance with the provision-, of Article XI of Thy State Sanitary Code,as described in the ,j , ta application for Disposal Works Construction Permit No..................... -,>...... da t ed o:n.Z 2.__�............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector........ ---------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, j. .................................. ........ OF....... k No..-. .................. FEE :.................. %pogal Works 6ittstrurtion ramit Permission is hereby granted.__. 22 M., g........ ............................................................................... to Construct ) or Repair ( )'an Individual Sewage Disposal System atNoi ... ....... ........A xAd..................................................... �........................................................ Street ...... Date as shown on the application for Disposal Works Constructi ............................. o7 ------------------------------------ ...................................... - . B.- of Health DATE................................................................................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS F F Qp oo' ASSESSORS MAP : I1 ( NOTES: PARCEL : JcS S HOLE LOGS Fq o qy Q pp 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH Q q Q FLOOD ZONE : NON P�� SOIL EVALUATOR :.-1� W? F� C THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF ' R Q WITNESS •-_NQtl �U1 ' -o � � BOARD OF HEALTH REGULATIONS.cc,�� �4 REFERENCE : �� Ib2 Dg DATE: 86 j4 2--60S- 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, �( SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO PERCOLQT I ON RATE : t 2MfaJl INSTALLATION. Ctr�i A-Ss Z S®1-LS LTfrR=o.-t y d v 9 z -0� TH- I �L, (03 �o TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE h v /4 5�� (OVP.3�y DETERMINATION. pR � — `� �2-� 1 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS LoR-Nt SPECIFIED OTHERWISE) r T-S �� " 5)t- T �� THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A L O C A T I O MAP (I� 32 —6U.�3 GARBAGE DISPOSAL. 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) t MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON /�• ti°j "' �3 A BASE OF 6"OF CRUSHED STONE. Gee USHfP -- 52 '° Ftq�&o PER- SEPT I C SYSTEM DESIGN 7 _1S __rte.- INSTML. 1 / r �' ��KNOWN_P_klyh�_W�1,.t1�1__l���l lSL)_OF �ROp, l.�kG�fi�IJ�- FLOW ES'i I MATE I fl �VFi'iLf}AM�_W�►_ 'a-F_Pk0 P. -jk -i nl y i�.E Y c�- `tawrV a� BA�us �J BEDOOMS AT Il� GAL/DAY/BEDROOM - JD GAL/DAYra-o 63 150.00 ft SEPTIC TANK 12 4b !6 v4 0 N 3 GA'_/DAY x 2 DAYS - 60 GAL t USE 1060 GALLON SEPT I C TANK —eg#5- i P,1K-r-- W/I,�UU /41) Q� 1 PAVED r DRIVEWAY � 1 S1cP nc� 1 iv1L I F ]�itr L / JA&10%E D SOIL AESORPT I ON SYSTEM B�°.. UN>7ES f ZED o t�E(2) 7. S DE AREA:L 25 t- 7 - = S 0 � U �Z tt3�21x2 x O� I 2 � 1 ' BJT70M AREA: 2S 13 A O 7-f 3 Z40 S0 ® + E1IS77A)l f �, CO ® Z Z oo�Gate,' 0 3 S .v G P-t> LUw t J �(0 � � If�ll ` ' ;>330 GPD ray w W ° , it s 1 SEPTIC SYSTEM SECTION o X � a 63 Lj �W y ' 6�= EL Cod �T ° � T O LL WATER ! 20 fr TE 1 12 fr W GA 2 E 0 I�WA-TER LINE. (p 6•�-���S w ' E�iST1�r ,. _-� LFAcI13.0 IoIT \ HEM f I r=X15T1N �a - a h rad� I 1 S . .. =1 Irj 4 1? Iwc _ o ins{�t1 I 2 twGl�T / V. T 128 ' pZ '- bk asGAS LINE! ---- L0 (ai Bade ADO6REA - hm 15400 s + N� �I. ''stet, �, b ( (� A -eox 60.E n � co » E GAL , 63 150.00 ft 63 � JP�Ve jle!s5 3�41:III Do Me I SEPTIC TANK DP'3 Waske.� Stye �,�5 a ARK M —ZS x ► k BENCH K NAIL IN ROAD g7B2TTOM 0�- S j t}r✓� Err ; S2• i° I P NATION p € v G pATVM ASSUME � SITE AND- SEWAGE PLAN LOCATION 15(o &fE li l-r-ER �Di9'p \�,A oF,�s 645NTEk-V I LLC A14-- ARE N PREPARED FOR R6BER-T- Pej/�=- Sen( _ No. 1140 N �s cISTE�a �N1rARX� SCALE : 1 "_ 20 w DARREN M. MEYER, R.S. z P.O. BOX 981 DATE : lI'la►�B 2_ooS 5 EAST SANDWICH, MA 02537 W DATE HEALTH AGENT Ph: (508) 362-2922 3 w Z . I 1 .