HomeMy WebLinkAbout0785 SHOOTFLYING HILL RD - Health � 5 Shoot Fly ng Hill load
Centerville
A= 142 -01. 4
OCYC(FD
UPC 12534
No.2� 15® 366R
MA8TIM08.Nll
" #
r �
No. I a Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppYication for Nsposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1,63'Shoo_QT/ht t4 j I! U Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel —Q Ge 1' "(,- V 6 5 ?C0 a,
Installer's Nam Address Tel.No.-'��, ,5zk Designer's Name,Address,and Tel.No.
�W-,U(r-s
Type of Building: IkC{V
Dwelling No.of Bedrooms 3 Lot Size a63 sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 331. S gpd
Plan Date L k2l 113 Number of sheets Revision Date
Title
r
Size of Septic Tank Type of S.A.S. g Z.Y
Description of Soil b e 4
Nature of Repairs or Alterations(Answer when applicable) &OARC&_�A e_4Yj0,W4r
& 2
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 Certificate of
Compliance has been issued by oard of Healt
Signed Date Z
Application Approved by Date
Application Disapproved by Date
for the following reasons
orn
Permit No. / l Date Issued ��''7
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4plication for MisposaY *pstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 6 S S�100 {�f� lam( �I I'r � Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel C( a
Installer's Na e, ddres Tel.No. 5Uv► A .�67U Designer's Name,Address,and Tel.No.
o? � <Gi/I I� IV�aS(1.Orc �tC - , CojllieeR,G
Type of Building: ``s,, R e V
Dwelling No.of Bedrooms e t Lot Size d c6 3 sq.ft. Garbage Grinder( )
Other Type of Building ( No.of Persons Showers( ) Cafeteria( )
Other Fixtures ?� j
Design Flow(min.required) r/ gpd Design flow provided 3 3 S gpd 1
Plan Date '/07-7 l� 3 Number of sheets Z--- Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil C E /6rij
Nature of Repairs or Alterations(Answer when applicable) /41$4 (2 Fs
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
a
__accordance with the provisions of Title 5 of the Environmental Code and not;to place the system in operation until a Certificate of f f
Compliance has been issued by This,Board of Healt .
_ Date Si ne` /
, g � _
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
----------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by 7a�k A Z�,
at:- (`"j d V—Q�16 a �� �� �� has been constructed in accordance
2
with the provisions of Title 5 and the for Dis osal S stem Construction Permit No.o�O (� / dated _
P P Y
Installer Designer
#bedrooms v Approved design flow 3 3 gpd
The issuance of this permit shall of be cons�ed as a guarantee that the syst m will fit n esi�d
Date z � s�// ,3 Inspector or
�
----------------------------------------------------------------------------------------------------------------------------------------
No.a� t��l �I Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal &pstem Construction J)ermit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at —] S h j&4k, 4 1,
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this pert�it--
Date 1 Approved by
1
12/30/2013 09:59 508477533 ENGINEERING WORKS PAGE 01
Town of Barnstable
Regulatory Services
Richard V. Scali, Interim Director
MAM
Public Health Division
Thomas McKean,,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862A644 Fax: 548-790-6304
Installer & DesiZner Certification Form
Date: L24 !D Seywage Permit-4 4/3 �� Assessor's Map\Jarcel
M1 e rI�
Designer , �.,a �••„n ew ss ,s Ln Installer- 4 h 9,f-e a.va
Address: 12 W 4114S'Ale)d ;(Ke _ Address:
on l — 13 AMA"-brCr, ''L �k C-c"fa- ' was issued a pezmit to install a
(date)
(installer)
Septic system aT t-?KS���ertX�wt' rM based on a design drawn by
s)
dated Z-7
(designer)
I certify that .he septic system referenced above was installed substantially according to
the design, which may include manor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (Le.
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 designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in compli aw'th the terms of
eesiS'neis's
val letters (if applicable) Ili op
�►
PHER
!'AC NTEE
n ) No,soils q '
At
gnature) ix Z7esignex's
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMMANCE WILL NIT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BVMT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION,
TIiA11i�YOU. '
Q;1SepticTesigner Certification FOM Rev 8-14-13,doo
r
TOWN OF BARNSTABLE "
LOCATION _ }� SEWAGE# aOl3
VILLAGE �h-F.Q���, �t.P ASSESSORS MAP&PARCEL
INSTALLER'S NAME&PHONE NO. i ^St*l A_S ar ^, 7114—
SEPTIC TANK CAPACITY
LEACHING FACILITY-(type) , (size) atUJY,X 14 A bL I L-
NO.OF BEDROOMS
.OWNER.T:iF,h /UG-A;r M trP-!q^,Q 2.
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private Water Supply Well and Leaching Facility(if any wells exist
on site or within 200 feet of leaching facility) feet
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet of leaching facility). feet
FURNISHED BY
3 C- lO w
F331+'-So
�53��
l�1
- Town of R, -a a�hle P#
' Departtnent:of RegulatoryServices
Public H6W,ith D><v s on. Hate
16.1 200.Mam Street,Hyannis MA 02601
Date:.Scitedaled Time Fee Pd
Soil-Suit ability Assessment for Sew VD
o '
Performed By �� -�'��-et Witnessed By:
LOCATION z GENERAL.INFORMATION-
Locatrop Address Owner's Ntime �q n n v�lq ��1���4
nJo /"M y f4 sr C.
CdL�(i Address
l vBO TccCt�ofQy Y �✓
Assessor'sm, /Parcel: `g Z — y q " �/ Engineer's Name
��-AL Otir-t
NEW CONSTR�UjC7 O REPAIR Telephone# �a - ?3?- `/7 6
Land Use. 1�-'�S� AdI Slopes('Yo) ]-!!7 Surface Stones ✓L-J C3 -�
Distances from: Open Water Body Uo ft `'Possible Wet Area A ft Drinking Water Well 7 �ft .
Drainage Way—A—ft Property Line 4-/ ft Other
SKETCH:(Street name,dimensions of lot,exact locations of test+holes&perc tests,locate wetlands ir proximity to'holes) '
Z�
--4
o
ja
&J, 1 :
Parent material(geologic) Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face ::62!W;- ,
Estimated Seasonal.High Groundwater l
DETERMINATION FOR.SEASONAL HIGH WATER TABLE
Method Used:
U�pdr Obsf.;Feu stunuirg in obs.hole: in.-'Depth td S41t titottie5, ln;-
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index.Well.# Reading Date: Index Well level. Adj.thctor. ..m Ac({`f7roufldwaterLeva1,.,,�
PERCOLATION TEST bate . Thu
Observation
Hole# Time at 9"
Depth of Pere. Time at 6"
Start Pre-soak Time® 64 S Time(9".;6")
End Pre-soak i F
Rate MinJinch Z
Site Suitability Assessment Site Passed�Site Failed: Additional Testing Needed(Y/N
'U
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
DEEP:OBSERVATON HOLE LOG Hole#
Depth from Soil Horizon Soil Texture SdIFColor.' Soil Other
Surface{in.) (USDA) (Munseli) Mottling (Structure,Stones;Boulders:
DEED'OBSERVATION`HOLLYOG " = Hole#- 2i ;;
Depth from. Soil Horizon Soil Texture ' Soil'Color• Soil Other.
Surface(ln.),, (USDA) (Munsell) 'Mottling,. (Structure,Stones;Boulders: .
� .
T60. 0 icy Y
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil.Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
vill-
DEEP OBSERVATION HOLE LOG
Hole#
Depthfrom SoitHorizon. Soil Texture Soil:Color Soil Other
Surface(in;) . (USDA) (Munse11) Mottling (Structure.Stones';Boulders.
Fl�nd T*na+tdnttce-Rate Man:
Above 500 year flood'loundary No Yes' ,
Witlttn S00 year boundary No Yes;
Within f00 year flood boundary No Yes
De�ith ofhFaturallv'Occurrine Pervious Material
Doesa>;least=four feot of naturally occurring pervt us trtaterlal.exist in all areas Observed throughout,fthe; ,-
area proposed for the soil absorption system?
If not;-what`is"tlie depth of'naturahy occurring pe ious material
Cei=tifieation
I certify that on Cl� (date)L have passed the sotl evaluator examination approved by_sthe
Department of Environmental Protection and that the above analysis was performed by rite consi"scent
, .
file reyutred train' ' ;" xperhse and experience descnbetl'in 1U'C1vIR 15017: "
Date)
Signature '
�SPTICIEERCFORM.DOC
Town oftarnstable Barnstable
Regulatory Services Department j
• IARNSrABL,E, ' �m
MAS&
FD� Public Health Division
a`��
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F. Geiler,Director
FAX: 508-790-6304 SECOND NOTICE Thomas A.McKean,CHO
CERTIFIED MAIL # 7012 1010 0000 2851 0855
October 15, 2013.
AF�/K/A Fed Nat'l Mt'g Assoc
% Citimortgage, Inc
1000 Technology Drive
O'Fallon MO 63368
RE: 785 Shootflying Hill Road, Centerville MA
CORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 785 Shootflying Hill Road, Centerville, MA was last
inspected on 12/13/2012, by Shawn Mcelroy, a certified septic inspector for the Sate of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following: i
Y 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 with the deadline period will result in future
enforcement action.
PER ORDER OF TH BOARD OF HEALTH
Thomas McKean, R.S., CHO.
• Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\785 Shootflying Hill Rd.Cent Jan 2013.doc
i
s
�t�r
Town,of Barnstable Barnstable
Regulatory Services Department AlAmeficaCity
i 'A s Public Health Division
STAB
Ev µ. 0. 2007
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 701.2 1010 2834 5178 9316
June 12, 2013
Fannie Mae F/K/A Fed Nat'l Mt'g Assoc
% Citimortgage, Inc
1000 Technology.Drive
O'Fallon MO .63368
RE: 785 Shootflying Hill Road, Centerville MA
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 785 Shootflying Hill Road, Centerville, MA was last
inspected on 12/13/2012, by Shawn Mcelroy, a certified septic inspector for the Sate of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
0 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 with the deadline period will result in future
enforcement action.
PER ORDER OF THE B ARD OF HEALTH
Thomas McKean, R.S., CHO.
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\785 Shootflying Hill Rd.Cent Jan 2013.doc
f
Town of Barnstable Barnstable
Regulatory Services Department j j
* Ism
* BARN3rABLE, '
MASS.6Public Health Division
�A��
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 # 7012 1010 2834 5178 9316
June 12, 2013
Fannie Mae F/K/A Fed Nat'l Mt'g Assoc
% Citimortgage, Inc
1000 Technology Drive
O'Fallon MO 63368
RE: 785 Shootflying Hill Road, Centerville MA
• ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 785 Shootflying Hill Road, Centerville, MA was last
inspected on 12/13/2012, by Shawn Mcelroy, a certified septic inspector for the Sate of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• 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 with the deadline period will result in future
enforcement action.
PER ORDER OF THE B ARD OF HEALTH
r
Thomas McKean, R.S., CHO.
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\785 Shootflying Hill Rd.Cent Jan 2013.doc
Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=13564
_
�''�`' `° a
Logged In As: Parcel Detail Monday, May 20 2013
Parcel Lookup
Parcel Info
Parcel ID 192-014 Lot
Developer'LOT 26
I
Location 1785 SHOOTFLYING HILL RD ( Pri Frontage150 I
Sec Road I Sec
Frontage 17
Village CENTERVILLE Fire District C-O-MM
Town sewer exists at this address 0 Road Index 11484 I
Asbuilt Septic Scan: Interactive ',
192014 1 Map 1 }' P �'
t
Owner Info
Owner JFANNIE MAE F/K!A FED NAT'L MTG ASSOC Co Owner i%CITIMORTGAGE, INC
Streetl 11000 TECHNOLOGY DRIVE ( Street2 I
City O'FALLON State MO zip 63368 Country�J
Land Info
Acres i[0.45 use i FS�" ngle Fam MDL-01 I zoning 1RD-1 Nghbd[0105
Topography Level Road[Paved I
Utilities!Public Water,Gas,Septic I Location F --
Construction Info
Building 1 of 1
Year 1960 —I Roof Gable/Hip Ext 1sbe Ast Shingle
�_�
Built f Struct, Wall
Living 1360 I Roof As h/F GIs/Cm AC None
Area _ Cover p p ( Type l I �4
Ir
Style Ranch 1 wali Drywall ( Rooms 12 Bedrooms I r
Model Residential I Floor 1Hardwood I Rooms i1 Full+ 1 H x saH
�
_ _ Y ."
Grade Average I Type Hot Water ( Rooms�4 Rooms I L V
.,
stories 1 storyHeat[ Found Conc. Block
Fuel I ation
Gross 295E 4 —' " I
Area i
Permit History
http://issgl2/intranet/propdata/ParcelDetaii.aspx?ID=13564 5/20/2013
Town of Barnstable Barn
'THE
Regulatory Services Department j` ca j
BAMSTABM
Public Health Division 2007
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7012 1010 2834 5178 1846
January 3, 2013
David HoltL ��
Today Real Es �� �
1533 F outh Road/Rte 28
C erville, MA 02632 /
RE: 785 Shootflying Hill Road, Centerville MA
• ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 785 Shootflying Hill Road, Centerville,MA was last
inspected on 12/13/2012, by Shawn Mcelroy, a certified septic inspector for the Sate of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• 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 with the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
s cKean" �RS., CHO.
• Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\785 Shootflying Hill Rd.Cent Jan 2013.doc
r
Parcel Detail http://issgl2/Intranet/propdata/PareelDetail.aspx?ID=13564
}
Logged In As: Parcel Detail Tuesday,June 11 2013
Parcel Lookup
Parcel Info
Parcel ID;192-014 I Developer;Lot'LOT 26
Location 785 SHOOTFLYING HILL RD I Pri Frontage 150
Sec Road
I Sec
Frontage
Village rCENTERVILLE I Fire District;C-O-MM
Town sewer exists at this address No I Road Index 1484
Asbuilt Septic Scan: Interactive
192014_1 map -
�,. z _
Owner Info
Owner'FANNIE MAE F/K/A FED NAT'L MTG ASSOC— I Co-owner %CITIMORTGAGE, INC
Streetl 11000 TECHNOLOGY DRIVE I Street2 l
City!O'FALLON I state,MO zip 63368 Country
Land Info
Acres!0�45 use,Single Fa MDL-01 I zoning RD-1 Nghbd r0105
......_____.__._-.____.._---
Topography I Level I Road Paved I
utilities:Public Water,Gas,Septic I Location I
Construction Info
Building 1 of 1
Year'1960 I Roof,(Gable/Hip Ext;Asbest Shingle I
Built Struct Wall I
Living,1360 Roof Asph/F Gls/Cmp AC None I
Area Cover' Type
Style;Ranch Int:Drywall Bed 2 Bedrooms -
_.__._. Rooms
Wall Rooms
_ ._ -_..._
Model Residential I Int Hardwood Bath 1 Full+ 1 H
Floor' Y• ,
----.—. ._ _. ... ...__. ........._..._.._.... 7 s ' x
Total
Grade;Average I TYPe Hot Water I Rooms 4 Rooms. I '
Heat=_____. _._ ,--. .._
Found-
stories'1 Story I Fuel"Oil I ation!Conc. Block
Gross!2954
Area
Permit History
I
I
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=13564 6/11/2013
r
Commonwealth of Massachusetts i f.✓ ''L
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Centerville MA 02632 12-19-12
required for 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.
A. General Information M
1. Inspector:
� I
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluatio y the Local Approving Authority
12-19-12
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Auffibrity (Bard
of Health or DEP)within 30 days of completing this inspection. If the system4 a sharedtyste�rrt or
has a design flow of 10,000 gpd or greater,the inspector and the system ouvn r shall sAmit ft e
report to the appropriate regional office of the DEP.The original should W96 t to the system'caner
and copies sent to the buyer, if applicable, and the approving authority. L
****This report only describes conditions at the time of inspection and under(the contl tions�f use
at that time.This inspection does not address how the system will perfoin the;fjmturw•mnder
the same or different conditions of use.
t5ins-11/10 Title 5 Official Insp F rm:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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: r '
❑ 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): .
t5ins•11/10 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 785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Centerville MA 02632 12-19-12
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cunt.):
❑ 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-11/10 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
785 Shootfl in Hill Rd
Y 9
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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 aseptic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.'
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3: Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool ,
❑ ® Discharge or ponding of effluent to the surface,of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) .
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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 31 b 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
El ❑ 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.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts t •.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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?
t
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
P
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ =Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts z.
Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
5a°'y 785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Centerville MA 02632 12-19-12
required for every �
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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 Z No
Seasonal use? ❑ Yes ® No
Water meter readings, if available past 2 years usage (gpd)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: 11-2012
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day Y(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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts t
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not forVoluntary-Assessments
785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)' -
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:' gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.'Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM , 785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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:
1980's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"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.):
Good condition.
{ a
Septic Tank(locate on site plan):
Depth below grade: 14"feet
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 gal
Sludge depth:,
12"
t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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
20"
Scum thickness 0
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
16"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage.
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-11/10 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
785 Shootflying Hill Rd
Property Address
l Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts :
Title 5 Official Inspection •Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) -
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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 0
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.):
Good condition with water at working level and stain lines above outlet invert.
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 Ian p y (SAS) ( plan, not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 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.):
Leach pit was empty at inspection with stain lines above inlet invert.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
_ I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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 solid
s
ds
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11110• 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
785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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
BaC K
tt i
a r_ . -
F �' o
376
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
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: 20
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:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
,A -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
,M 785 Shootflying Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-19-12
page. City/Town 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town(which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1`FL.,367.
Main Street,Hyannis,MA 02601 (Town Hall)
DATE:
Fill in please:APPLICANT'S YOUR NAME: QG ?� �. ! atV
BUSINES,9 YOUR HOME ADD ESS: 5 1��L�
TELEPHONE # Home Telephone Number tV�/ S $ `
NAME OF NEW BUSINES TYPe or-:susiNE85
IS THISA HOME OCCUPATION';' :-;YES Na ,
Have you been given a'pprrival from th+�b Idirig:division?`YIDS D
ADDRESS OF BUSINESS � �' MAP PARCEL:NUMBER
When starting a new business.there are several thing ust do in or to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - oorner of Yarmouth
Rd.&Main Street). to make sure you have the appropriate'permits and licenses required to legally operate your u in in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual,has been informed of any permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
2. BOARD OF HEALTH
This individual h b n i or d of the r it requirements that pertain to this type of business.
horized Signature** '
COMMENTS:77- / E NCO �2
3. CONSUMER AFFAIRS(LICENSING UTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
TOWN OF BARNSTABLE
MASSACHUSETTS T1111� '" 11
BUSINESS CERTIFICATE BARNS`fiB!EE' M0.
'
DATE ISSUED: 05/09/2005 DATE RENEWED: 10 MAY —Y Ari
BOOK 191 RENEWAL BOOK: RENEWAL PAGE:
PAGE 05-145 DATE DISCONTINUED:
CERTIFICATE EXPIRES: 05/09/2009 DISCONTINUED BOOK: DISCONTINUED PAGE:
Inconformity with the provisions of Chapter One Hundred and Ten(110), Section Five(5)of the General Laws, as amended,the
undersigned hereby declare(s)that a business is conducted under the title below,located as shown, by the following named person, persons
or corporation:
ACR PAINTING
MAILING ADDRESS: 104 QUAKER RD HYANNIS, MA 02601
ADELINO S PEREIRA 104 QUAKER RD HYANNIS, MA 02601
Signatur >
THE ABOVE NAMED PERSON(S)PERSONALLY APPEARED BEFORE ME AND MADE OATH THAT THE FOREGOING
STATEMENT IS TRUE.
TITLE
Identification Presented:
DATE: May 9, 2005
PLEASE NOTE: IT IS THE RESPONSIBILITY OF THE APPLICANT TO OBTAIN ANY LICENSES AND PERMITS REQUIRED BY THE
BUILDING,HEALTH AND CONSUMER AFFAIRS DEPARTMENTS FOR THE LEGAL OPERATION OF THIS BUSINESS IN.THE TOWN.
CONDITIONS: HOME OFFICE ONLY
In accordance with the provisions of Chapter 337 of the Acts of 1985 and Chapter 110, Section 5 of the Mass General Laws, Business
Certificates shall be in effect for four years from the date of issue and shall be renewed each four years thereafter. A statement under oath
must be filed with the city clerk upon discontinuing, retiring or withdrawing from such business or partnership.
Copies of such certificates shall be available at the address at which such business is conducted and shall be furnished on request during
regular business hours to any person who has purchased goods or services from such business.
Violations are subject to a fine of not more than three hundred dollars($300)for each month during which such violation continues.
A TRUE COPY ATTEST
----------------------------------------------------------------------------------------------- --- - - -- ----- -- ---- --------- g----------
CERTIFICATION CLAUSE • � C%4 ( t�
I certify under the penalties of perjury that I,to the best of my knowledge and belief, ve tled;alj'state tax returns apd paid '11 state
P J YrOw .Cterk'.
taxes required under law. � ®ARN§TAB�E
*',Signature of Individual or Corporate Name(Mandatory) By: Corporate Officer(Mandator rff-hpplicable)
** or Federal ID Number
* This license will not be issued unless this certification clause is signed by the applicant.
** Your social security number will be furnished to the Massachusetts Department of.Reyenue to determine whether you have met tax filing
or tax payment obligations. Licensees who fail to correct their non-filing or delinquency will be subject to license suspension or revocation.
This reouest is made under the authority of Mass. G.L. Cha 62C, S. 49A.
Date:
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: M G PA l &/-t 1,N
BUSINESS LOCATION: $ 25 k0 01 FZ H de"b INVENTORY
MAILING ADDRESS: " 5 S k 00 t / N f-t 1`2 L GOAD TOTAL AMOUNT:
TELEPHONE NUMBER: 1 5 OS Jr 6 6 l /,S
CONTACT PERSON: i 6-0 S 3 6 Y 6 O
EMERGENCY CONTACT TELEPHONE NUMBER: S OR 360 - (�* 69 MSDS ON SITE?
TYPE OF BUSINESS:
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous,waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
_ Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor & furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers
(including bleach) -J 4,���
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
r
DATE 1 1 /01 /0 5
PROPERTY ADDRESS 785 Shoot Flying Hill Rd
Centerville
MA 02632
On the above date, the septic system at the address above was
Inspected.
This system consists of the following:
1.� 1-1000 ga2Pon zept.ic tank.,
2., 1- Di,3bt.igut.ion Box
3.� 1- 1000 ga eion eeach.ing 12 i.t.. .
Based on Inspection, I certify the following conditions:
4.! 7h.iz .iz a 7.itie Five zept.ic zyatem (78Code)
5., The zeRt.ic .6yhtem .ins .in /22opea woak.ing o2de2 at the
pzeaent t.ime.�
SIGNATURE
Name: Robert A. Paollnl ,a
Company: Joseph P. Macomber & Son Inc
Address: P. 0. Box 66
Centerville, Mass 02632
Phone: 508-775-3338 or 508-775-6412
owl.,
JOSEPH P. MACO:�ER & SON,. INC.
Tan ks-CesspoLeachfields
Pumped nstalled
T own Seweonnections
P.O. Box 66 Centle, MA 026.32-0066
775-333875.6412
•
i r
COMMONWEALTH OF MASSACHUSETTS
ExECUTIVE OFFICE'OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: .. 785 Shoot Flying Hill Rd
CPnfi _rvi 1 1 P MA 02632
Owner's Name: Irma Tokee
Owner's Address: . Same
Date of Inspection: 1 1 1 n i /o r;
Name of Inspector:(please print) beet ;"A "'Ra:o�lc %rni.
Company Name: g. P.Aacoml~ea & Sio-n Inc.
Mailing Address: Pox 66
CP_n e)zv c e, a.s•s. 026 32
Telephone Number: 5 0 8-7 7 5-3 3 3 8
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:
XXXPasses _.
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F ils
Inspector's Signature: Date: 5
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is,a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
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 1
F
Page 2of11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �~
PART A
CERTIFICATION(continued)
Property Address: 785 Shoot Flying Hill Rd
Centerville MA 0.2632
Owner: Irma Tokee
Date of Inspection: 1 1 01 05
Inspection Summary: Check A,B,C,D or E/ALWAYS-complete all of Section:D
A. System Passes: qES
NO 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:
Se/2.t.ie zyh.tem .izin /220/2e/L woak.ing oade2 at the /22eZent time.-
B. System Conditionally Passes:
NO 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.
NO 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:
NO 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:
NO The system required pumpingg 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 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. I PART A
CERTIFICATION(continued)
Property Address: 785 Shoot Flying Hill Rd
CentervillP MA 02632
Owner.: Irma Tokee
Date of Inspection: 1 1 /01 /0 5
C. Further Evaluation is Required by.the Board of Health:
No Conditions.exist which require further.evaluation by the Board-of Health4n 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:
no Cesspool or privy is within 50 feet of a surface water
no 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:
no The system has aseptic 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.
no The system has a septic tank and SAS and the:SAS is within a Zone 1 of a public water supply.
no The system has aseptic tank and.SA&and the SAS is within 50 feet of a private water supply well.
no The system has aseptic 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 visual
"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
I
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 785 Shoot Flying Hill Rd
Centerville MA 02632.
Owner: Irma Tokee
Date of Inspection: 11 /01 /0 5
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following:for all inspections:
Yes No
X Backup of sewage into facility or system component due;to overloaded or clogged SAS or-cesspool
X Discharge.or:ponding of effluent to the surface of the.ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box.above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or.available volume is less than'%.day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the.SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
watersupply.
X Any portion.of a cesspool or privy is within a Zone.1 of a.public well.
X Any portion of a cesspool or privy is within.50 feet of a private water supply well.
X Any portion of a cesspool orprivy 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 wateranalysis,
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 forgo.]
r..
NO (Yes/No)The system fails.I have determined that.one or more of the above failure,criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner.should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve.a facility with a design flow of 1.0,000 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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary,to a surface drinking water supply
_ X 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.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 785. Shoot Flying Hill Rd
Centerville MA 02632
Owner: Irma Tokee
Date of Inspection: 1 1 /01 /05
Check if the following have been done.You must indicate"yes"or"no"as to each.of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS,located on site?.
X _ 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?
X _ 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:
Yes np,
Existing information.For example,a plan at the Board of Health.
X _ 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
I '
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
.SUBSURFACE SEWAGE DISPOSAL SYSTEKINSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 785 Shoot Flying Hill Rd
Centerville MA 02632
Owner: Irma o ee
Date of Inspection: 11 01 0 5
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms.(actual): 3
DESIGN.flow based on 310 CNIR 15.203 (for example: 110 gpd x#of bedrooms):3 3 0.
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 o [.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)): Nl A
Sump pump(yes or no): rz o
Last date of occupancy: /2 a e.6 e n t
COMMERCIAL5AUSTRIAL
Type of estabIisltn ent: NIA
Design flow(iiaed on 310 CMR 15.203): gpd
Basis of design'llow(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: 611104 12ump lrlacomgeit
Was system pumped as part of the inspection(yes or no):n o
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X 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:
Were sewage odors detected when arriving at.the site(yes or no): n o
6
i
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 785 Shoot Flying Hill Rd
Centerville MA 02632
Owner: Irma To ee
Date of Inspection: 1 1 01 0 5
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron X 40 PVC_other(explain);.
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
loirttz aRpea/c tight,, No Zeakagv , Vented fhnnuah houz on.t,'
SEPTIC TAWY e-s(locate on site plan)" 1000 ga to o n
Depth below grade: 24"
Material of construction: X 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: 8' 6"X5 ' 8"X4 ' 10"
Sludge depth.. ?a c e
Distance from top of sludge to bottom of outlet tee.or baffle: 0
Scum thickness: to a c e
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: m e a z u/c e d
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet.invert,evidence of.leakage,etc.):
Pump .tank evezy Z uea/tz Iniet & outiat faaA e7at, .in Pfaro
Tank iz .6tauctu/za-e-9ij .sound
GREASE TRAP: n Qlocate 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.):
glteaze t2a/2 -Lb not /2/LB6ent
7
Page 8 of 11
OFFI:EIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.-SYSTEM INSPECTION FORM r—
PART C
SYSTEM INFORMATION(continued)
Property Address: 785 Shoot Flying Hill Rd
Centerville MA 02632
Owner: Irma Toke
Date of Inspection: 11 0 17 0 5
TIGHT or HOLDING TANK: NO (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.):
light oa hoid.ing tank: aae not /2aezent
DISTRIBUTION BOXY e" (if present must be opened)(locate on site plan) �..
Depth of liquid level above outlet invert: 0
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.):
Box .is 2evei., No zoiid eaaauovea.- No i,eage .in oa oul n�4 P,nx_
PUMP CHAMBER: n o (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.):
/2um/2 chamtea .ia not /2aezent
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: 785 Shoot Flying Hill Rd
Centerville MA 02632
Owner:. Irma T k
Date of Inspection: 11 01 0 5
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Located see 12age 10.�
Type
X leaching pits,number:_
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,
etcLamy to medium sand. No signs oO fa.i.Pu)ze oz 2ond.ing., .So.i—Pi
ate d2y veueta.t.ion .is noamai
CESSPOOLS: NO (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.):
cess12oo1.6 ate not /aizesent
PRIVY: NO (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.):
121L.ivy .Gs not Raesent
9
Page 10 of 11 r
CIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SbBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
\ PART C
SYSTEM INFORMATI.ON(continued)
Property Address: 785 Shoot Flying Hill Rd
Centerville MA 02632
Owner: Irma Tokee
Date of Inspection:_1_1_f n 1 /0 r;
SkKETCH OF SEWAGE.DISPOSAL SYSTEM
Pfbv�ide 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.
\ i
A.
10
Page l l of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION,FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .785 Shoot .Flying Hill. Rd
('cnt[�rvi 1 1 c Mn 02632
Owner: Irma Tokee
Date of Inspection: 1 1 01 0 5
SITE EXAM .
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater feet `
Please indicate(check)all methods used to determine the high ground water elevation:
-NO Obtained from system design plans on record-If checked,date of design plan reviewed:
y e a Observed site(abutting.property/observation hole within 150 feet of SAS)
V e.�Checked with local Board of Health-explain:"z a„10 f r e d
no Checked4ith local excavators,installers-(attach documentation)
t e�®ccessed USGS database=explainAttR t t o wn.,ga inht ag-ee.,ma.,uis
You must describe how you established the high ground water elevation:
11.sed. : Ca e Cod Comm.ihion !date.¢ 7agie Cohtou2� And %u�2ie fdatea Su12P2y
kleU head paoteet.io.n alteah man.- Sen-t 1995
ldatea aesou2ces o- .ice cane cod comm.L.5.con
Leaching
Pit �, I:,eet
Groundwatk4eet Below Bottom;of Pit High Groundwater Adjustment 1.8 ft per Frim ter Method
. ... .} P P 1 ]dS(
Therefore,the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is JZ.
feet.
11
' r
a•rmnrn.-n.rr�•'re�raen:nm+s•eenaenrrsr:•n•.rrsrrfnr'a+•m++naenas++a�rarcae -.r+e•.ra-r-.•emn=`•;t-.r••`
TOWN OF BARNSTABLE 130ARD. OF 11EALT11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
•••r.rs�r•:-::,--.+sa".-rn;nr.n•erm�e-sT•e•s•varm:'r•••z+trtsre+e�mnterT '�+erRs•senrtta�nee7Opel I Iiatrtn :.•r+^sr•r.•�r•-r•�
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 785 .Shoot Flying Hill Rd Centerville '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER's NAME Irma T+okee
PART D - CERTIFICATION r
NAME OF INSPECTOR Rogea.t Pao t in.i
COMPANY NAME aoseph % flacomgez"l' Son Inc
COMPANY ADDRESS Box 66 Centeavt'iie Na6.6 02632
Street Town or City state LIP
COMPANY TELEPHONE ( 508 1. 7:75 - 3338 FAX ( 508 1790 1578
R
CERTIFICATION STATEMENT
I certify that I have personally. inspected the sewage disposal system at
INILthis address and that the information reported is true, accurate, and
omplete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , . maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems
Check one:
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR: 15- 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED* \
t •
The inspection which I have con �Tcted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 30.3, and as .specifically noted on .PART C FAILURE
CRITERIA of this inspectio for ,
Inspector Signature Date '
ne copy of this certification must be provided to the OWNER, the. BUYER
where applicable ) and the DOARD OF HEALTH,
* If the inspection FAILED, the owner ox gparator shall upgrade ' the eyetem.
within o'ne year of the date of the inspection, unless allowed or required
otherwise as provided in 3.,10 CMR 15 . 305 , '
TOWN OF BARNSTABLE '
LOCATION °7��a�� SEWAGE #
V,3,L:AGE 6- (Z0 eY✓'i 4 e- ASSESSOR'S MAP & LOT 1 gd O�d�
A1S I&ERI NAME&PHONE NO.,20b e r� ,r�.�i�O.0//7/ • T cS;0 eT
SEPTIC TANK CAPACITY _ 1 1 d°O A o ept. at-
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: �� O! O
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (lf any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
� -�, i
�- �
=- � , � �
' 4
'?$5 5itio��[ys�t���i nd . �x1�-�i��e,� I�A
TOWN® BARNSTABLE
7e5 ckco f���� i � ll SEWAGE #
,,AGE �e_� ¢e ✓ l(e ASSESSOR'S & LOT
NSTAL-4X t'S NAME& ,PHONE NO.
;EMC TANK CAPACITY d
,EACH NG FACILITY- t��e) — ��.� (size)
IU DER OR
IE IT®ATE: - COMPLIANCE DATE:
leparation Distance Between the:
Raximurn Adjusted Groundwater Table to the Bottom of Leaching Facility Eee
Yivw Water Supply WoOl and Leaching Facility (if itny walls exist
on site or within 200 feet of leaching facility) • _feet
idge of Weda.nd tuad l eaciting Facility(if any wetlands exist.
within 300 feet of caclung facility} Feet!
W �.4IBurnished by (�1�. Ca,�--�
BAGS a
t
je
� r
el� 00,
3,3
710
Fss......�. ..-....._.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-----_.....own.................oF... rnsmlo�
Appliration for 11hipas a1 Work, Cfonstrur#ion rami#
Application is hereby made for a Permit to Construct ( ) or Repair (�() an Individual Sewage Disposal
System at:
:._.:._'.785•-S ao ..���.11�.. .1��. f... zx Cvl!'J�Q ....-•---•--------•-•--•................... ---•------••---........_---_.. .......
Loc lion-Address t ,,��o,,.,,��
Owner Address
W /d.. -_ n cc 3.6o- -�c..n S r -y Gu .y r!?�a�s +...,.a ------ .........•-----...---•............•--.
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling lf!�No. of Bedrooms.............Z...........................Expansion Attic ( ) Garbage Grinder ( )
�`4 Other—Type T e of Building ._..... No. of persons............................ Showers
YP g --------•-------•---- P ( ) — Cafeteria ( )
Q Other fixtures .
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
.4
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P •---------------------------------------------------------------------------------------------------.........................................................
0 Description of Soil.........................................................-..............................................................................................................
x
U ....................... -------•-------•---•--------.....-•-----•-•---------•-•---••------......--•---------------•--------•---•---------------...-•----•---------.........-----•-•------•---------......
w
x
U Nature of Repairs or Alteration :--Answer when ap nL licable_ . .. .._1_PQ01 ta,41._--, .-.80..........
-Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Date
Application Approved By...... _. ,. .. .... ..................... ------.. .....
Date
Application Disapproved for the following reasons-........................................-....................... .........................................
......-•--------•................••-•-----..........---------•-••-----------•----.....--•--•--•--•--•--•.--------....------------------------•-------•-------•--•------•---------------•-----•-••--•----
Date
PermitNo......... �� --•---• Issued......----•----•----------------------.......................................................
Date
* 4
Fxs......t ........
THE COMMONWEALTH OF MASSACHUSETTS
=� BOARD OF HEALTH
7 `' 1t1 'Qr1iri'^�
OF..........................................................................................
Appliratiun for Disposal Works Tonstrnrtion ramit
r
x�
Application is hereby made for a Permit to Construct ( ) or Repair (`,;) an Individual Sewage Disposal
System at: I 1
c_S Sltc+n (; �tl; �, ka � 1Cor ? C :: rui��e
Location-Address ...... ............. ....................� or Lot No............................................
o ......._..... ........._.......
......f.at< E __------- .:..... .................•-................--.......... `%n...J..fit..µ F/vrr,ri /��!l k r f c�r _�frrr;l I
Owner ) ( Address
a r3 ter rr_ 3 Sa ��1 Attl � �c�T �F�r<1 ( /�rrrtr,i�+h........-•--
Installer Address /
U Type of Building Size Lot............................Sq. feet
a Dwelling k No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------•----•--.........---•--.••-•-••-•-•-•---•-•........--•••---•---------.........._---•---
Design Flow........................:...................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
0.4 Y
Percolation Test Results Performed b .......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...................... .
Lzl Test Pit No 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a
0 Description of Soil.........................................................................................................................................................................
------------------------------------------------•-----------------------------------........-----...---• ,.
----- --.:
U Nature of Repairs or Alterations—Answer when applicable_.rr5 '1"1'�e*.�r..<.j174s,�n«7�?C ....;!�:• F�1-.•.•-.•-,
............-••••-•-••-•..••• --••.............•-••-..........•••-•.....7..........--•----------••---......•••••-••----........_••--••--•-•••--•---••••-. ....................._...--•---..--•••-
Agreement: r
The.undersigned agrees to install the aforedescribed Individual Sewage Disposal System'in accordance with
the provisions of TITIS 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate-of Compliance has been issued by the-board of health.
i d._.:. :t5•62ttii:C.......y(... u ���..f� ?..........
.• r
L Date
Application Approved By......... - Q r... .. ..... ..................... ........ Q
Date
Application Disapproved for the following reasons:..........................................................................................................---
---••----••----.......-•••.................•---...........------••-••••••-----•••---•---•--.....---•-........----•----........••-•••------•-•••-•----•-•--...••-•-•-••-•••................--•--........_
.. c Date
PermitNo...... -------==� -_.... Issued....-•--------------------•--------..........._......
Date
�( THE COMMONWEALTH OF MASSACHUSETTS
BOARD"`� OF HEALTH
...................OF.......! ti'Ir►1 �42....................................................................
Tntif utttr of Tomplinnre
THIS IS TO CERTIFY, T the Individu �;.w,ge isposalys m c�struct ( ) or Repaired by-• _...`.° . . :. --- ._
�— In t Il r jr
at-. -------�-f-� -=--..•-•- S Jf "� ;(�@
has been installed in accordance with tl-i rdriAons of TIT F 5 of The State Sanitary C e as de cribed in the
application for Disposal Works Construction Permit No........................ S-....... dated...... ,r.D.I1 ro..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN N ATISFACTORY.
DATE.............. .-• .. ................... Inspector.....• --........--•------...---..............••-•........._...------•--..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
<��cc ! l�us�� ..OF....!:!tf r,..s .. _
NoS�:r- ' ..... . Fas... ...............
1is4to4tt arks Tonstrnrtion Vrrmit
Permission is hereby granted............... Ex
Permission
to Construct ( ) or Re ai dividual Sew ge is oral S stem .............
at No..... .! � ..... s�'1 t�K ..--�... �_ 4
.......- ....................... ..... ....
Street
as shown on the application for Disposal Works Construction Permit No .:_-...,4416 D ted........ . ....... C�.?.......,..,
Board of Health
DATE............ .• -- --• =----��f=1 �
.........
FORM 1255 A. M. SU KIN, INC.. BOSTON
r. 0 C A T ION S E W,A GE PERMIT NO.
r�1 L L A G E .SSESSOi S MAP NO:
PARCEL NO.:
I N S T A LLER'S NAME ADDRESS
B U I L D E R OR OWN ER
DATE PERMIT ISSUED �� ���
DATE COMPLIANCE ISSUED ��
�l
do
��
LEGEND N
4 t. BENCHMARK SET -- 98 -- EXISTING CONTOUR ti9h
TOP CTR./CONC. APRON-\ x 100.98 EXISTING SPOT GRADE °0
EL.=74.73 (ASSUMED DATU M 1 0,;
~ OVERHEAD WIRES
� Plan Bk 138 - Pg 89 --0.H. W.
wl EXISTING WATER SERVICE 5
S T4`4-1140;' _ G EXISTING GAS SERVICE 0 °
73.86 150.33' TEST PIT
x <,
o _ \
k $ a BENCHMARK
FISH \ (Y a
POND HED EXISTING SEPTIC TANK Z Ann
0 0 TOP OF TANK, EL.=72.60 c3 LOCU °ble point�0"Wood p�
74,19 73, 11'. INV. OUT =71.27E °
74,33 x �_� x 73.79 `i7 ( )- (VERIFY) °
X p'
x + 74,42 74,10
X��02 EXISTING LEACH PITS LOCUS MAP
TP-1 TO BE PUMPED, FILLED WITH NOT TO SCALE
x 74,19 74,79 SAND AND ABANDONED
X x 74,56 `
74.41 iS 7 73,48 i
TP-2 I ! GENERAL NOTES:
x 7449 x 74.2�1 {
1 t 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
IVI } BOARD OF HEALTH AND THE DESIGN ENGINEER.
W 2.f I ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
74,50 GARAGE EXISTING 1' I�I OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
HOUSE(#785) ,1 Inl' Z LOCAL RULES AND REGULATIONS.
00 x 74.36 T.O.F.=76.It 20-`--awl 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
I00
ol cp Co TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
W 1 0-I 6 DESIGN ENGINEER.
o P CONCRETE APRON 1 I0i Co 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
N 74,96 d ca O FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ITI ;..'.. 75.03 1 i I ' ENGINEER BEFORE CONSTRUCTION CONTINUES.
74,30 X x 74.60 1 I I 5. ALL ELEVATIONS BASED ON ASSUMED DATUM (BARNSTABLE G.L.S.t).
11 I I 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
WALK THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
1 I I ► HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
74.31 74.98 11 i 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
x o 11 31
74,42 7 X43 Q ` 8. THERE ARE NO ABUTTING WELLS WITHIN 150' OF THE PROPOSED S.A.S.
PAYED, x v VENT 73,92 ��� OF MgSS� 9 AGREEDALL E AS UPON EBYEOWNOER R C A�DSTRUCTION CONTRACTOR OR SHALL AS OTHERWED AS
74.47 ��Q cyG DIRECTED BY THE APPROVING AUTHORITIES.
v o PETER T.
McENTEE 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
�- - - o `n THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
74.46 I I x 74.44 CIVIL
`� CONSTRUCTION.
LOT 261 No. 35109
l �FGISTER�� 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
74,74 MBLU 192-014 FS IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
I I L EN REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
Alk
20,063tS.F. t� 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL.
L=43.81 ' 74,26 106.23' �\ 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY
' IS 'NOT TO BE CONSIDERED A PROPERTY LINE SURVEY.
I R=1408.86' ,. 50...: . N 01.04'50" E + 74,48 x 74,23
PK SET
' --U----�L5--------_ PROPOSED SEPTIC SYSTEM UPGRADE PLAN `
74,89 75,21 75,46 edge of pavement z 75.03
785 SHOOTFLYING HILL ROAD, CENTERVILLE, MA
OWNER OF RECORD Prepared for: Fannie Mae, 1000 Technology Dr., O'Fallon, MO 63368
SH 0 0 TFL PING HILL ROAD FA ' MAE F/K/A FED Engineering by: , SCALE DRAWN JOB. N0.
NATL MTG ASSOC 1"=20' P.T.M. 168-13
e. 1000 TECHNOLOGY DRIVE Engineering Works, Inc.
O'FALLON, MO 63368 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
& %CITIMORTGAGE, INC (508) 477-5313 6/27/13 P.T.M. 1 Of 2
� S
4h owl
J,-
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL.=71.27
t FOR A DISTANCE OF 15' AROUND THE
SEPTIC TANK PROPOSED D-BOX PERIMETER OF THE S.A.S.
INSTALL RISERS & COVERS OVER INLET & PROPOSED SAS,
OUTLET AND SET TO 6" OF FINISH GRADE INSTALL RISER & WATERTIGHT
COVER SET TO 6" OF GRADE INSTALL INSPECTION PORT OVER END UNIT
T.O.F.=76.1 t a- I
F.G. EL: 74.2 (MAX.) CHARCOAL
F.G. EL.=74.7t F.G. EL.=73.8t F.G. EL.=73.5t VENT
EXISTING
MAINTAIN 2% GRADE MIN. OVER S.A.S.
P A . rAP.Ri�I@
SET REBAR FOR LOCATING
L = 30' L = 2'(MAX) ONE 9'Y3'x64' LEACHING TRH .N wlru INSPECTION
® 5=1% (MIN.) 0S=1% (MIN.) CCH 40 PERF. PVC DISTRIBUTION LINES PORT
4"SCH40'PVC 4"SCH40 PVC
6"
10"I B°
14" 2' EFF.
EXISTING 48" LIQUID DEPTH
LEVEL ADD
GAS BAFFLE INV.=70.97 PROPOSED INV.=70.80 SLOPE OF PERF. PIPE = 0.5% 64.8'
INV.=71.27t D-sox 64' EFFECTIVE LENGTH +/
INV.=70.77 INV. EL.=70.45(END)
EXISTING SEPTIC TANK SOIL ABSORPTION SYSTEM (PROFILE) I I
MAINTAIN 2% GRADE (MIN.) OVER S.A.S. I=I
Ic�l
2" LAYER OF 1/8"-1/2' DOUBLE WASHED Iwl
NOTES: STONE (OR APPROVED FILTER FABRIC) GARAGE EXISTING ICI
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE 785
101,00
INVERTS, PRIOR TO INSTALLATION. BREAKOUT ELEV.-_ HOUSE/71.27 `� �
-BOX HALL BE SET LEVEL AND TRUE TO
INV. EL.=70.77 3/4"-1 1/2" DOUBLE T.O.F.=76.1f I�wl
2) D S � WASHED STONE I I
GRADE ON A MECHANICALLY COMPACTED SIX 2 E O E 0-
Fm II
INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.=68.45 ICI
10 CMR 15.221 3 2 .( )
3 °-I
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' MIN. ABOVE BOTTOM OF ONE 2'x3'x64' 20.0'
A T INSTALLED ON OUTLET TEE T.P. EXCAVATION OR G.W.4) GAS BAFFLE 0 BE E
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. LEACHING TRENCH I
NO G.W. EL: 63.5 = I
ESTIMATED HIGH G.W., EL=34.8-0 t
SEPTIC SYSTEM PROFILE (LAKE WEQUAQUET WATER SURFACE) I I
u
SOIL ABSORPTION SYSTEM (SECTION)
N.T.S.
SOIL LOG S.A.S. LAYOUT
DATE: JUNE 25, 2013 (REF. P#14,048)
SOIL EVALUATOR: PETER McENTEE PE, (SE#1542)
DESIGN CRITERIA WITNESS: DONNA MIORANDI R.S. HEALTH AGENT
Elev. TP_ 1 Depth EIleV. TP_2 Depth
NUMBER OF BEDROOMS: 2 BEDROOMS 73.5 A 0" 73.5 A 0"
TEXTURAL CLASS:
CLASS SANDY LOAM I SANDY LOAM
S01 L �
tOYR 4/2 10YR 4/2
DESIGN PERCOLATION RATE: <2 MIN/IN 73.0 B 6" 73.0 B 6"
DAILY FLOW: 220 G.P.D. SANDY I OYR 5/4M SANDY OYR 5/4M
DESIGN FLOW: 330 G.P.D. 70.5 C1 - 36" 70.3 C1 34"
GARBAGE GRINDER: NO, AND NOT PERMITTED WITH THIS DESIGN M-C SAND PERC
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY 2.5Y 6/4 M-C SAND 36"/48"
LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF
20%GRAVEL 2.5Y 6/4
20%GRAVEL..74 GPD/SF PROPOSED SEPTIC SYSTEM UPGRADE PLAN
-
INSTALL ONE 2'DEEP x 3'WIDE x 64'LONG LEACHING TRENCH WITH 66.5 84" 66.2 88"
785 SH00TFLYING HILL ROAD
STONE AND SCHEDULE 40 PERFORATED PVC DISTRIBUTION LINE C2 • C2 , CENTERVILLE, MA
MED. SAND MED. SAND '
Prepared for: Fannie Mae, 1000 Technology Dr., 0 Follon, MO 63368
SIDEWALL: 2 SIDES/TRENCH x 2' x 64. ......................= 256 SF 2.5Y 7/3 2.5Y 7/3
BOTTOM AREA: 3' x 64................................................ = 192 SF Engineering by: SCALE DRAWN JOB. NO.
63.5 120" • 63.5 120" NTS P.T.M. 168-13
TOTAL AREA:...............................................................................448 SF Engineering Works, Inc.
NO GROUNDWATER OBSERVED 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO.
DESIGN FLOW PROVIDED: 0.74 GPD SF 448 SF = 331.5 G.P.D. PERC RATE: <2 MIN./IN. (IN SAND-ON FILE) 6 27 13 P.T.M. 2 Of 2
/ ( ) (508) 477-5313