HomeMy WebLinkAbout0857 SHOOTFLYING HILL RD - Health (2) 857 Shootf iron Hill Rd
Centerville P r.
A = 192 010
r'
No 21®
HASTINGS,MN
f
TOWN OF BARNSTABLE
LOCATION v ��4r��f��Y�r �iLG. ��, SEWAGE # 0 7/
V.LLAGE ASSESSOR'S MAP & LOT MPep j
INSTALLER'S NAME&PHONE NO.�0 f ' � 50 7 -76G PARac
SEPTIC TANK CAPACITY /54o
LEACHING FACILITY: (type) L �Gr�//�� C�YI91 MS (size)
NO. OF BEDROOMS
BUILDER OR OWNER ACI�6eld
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility A'b t`,'gT� 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) IY16 Feet
Furnished by
(I
f i
inn
jib
Oor
i�/
No. I.LIJ Fee.
THE COMMONWEALTH OF MASSACHUSETT � Entered in computer:
j, t'
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASS Yes
�l� "F'T LE
01pp1icatfon for 30i.5pogal *pgtem Conelmi't'i'> W rittft: 20
Application for a Permit to Construct( . )Repair OO Upgrade()()Abandon( ) X Complete System ❑Individual Components
Location Address or Lot No. 85? $6,o 4171 n Jc H'o h Rco Owner's Name,Address and Tel.No.
CCv.h _orviI ,K,
Assessor's Map/Parcel 12l C�vocct Y1larsh 1Q Q
MAID tcrZ PFg2CL—'r, In, YkIn &69.1
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.C�$� l7�
f3U-rJ�r,
dui �z rrui I s l�,��+
Le
bz�5.5
Type of Building: r
Dwelling No.of Bedrooms T+yr Lot Size 3 701 sq.ft. Garbage Grinder(4/o)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
-
Design Flow 1 to g p,4P I 6admam gallons per day. Calculated daily flow gallons.
Plan Date T�& Number of sheets emino Revision Date ^
Title
Size of Septic Tank /.7(aQ �Q.1/ors Type of S.A.S. ��h�<u C/tudhPPs /Z x 35 x
Description of Soil 2e �o 150i I to A vn ra lc wt (� 1 b if 6 y
Nature of Repairs or Alterations(Answer when applicable) A bo,-,d&A c?r� ecs-any& u
Date last inspected: FDA A�'n y
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 5 theL7vironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu b hi o alth.
Signed' Date
Application Approved y Date 3h)210 3
Application Disapproved for the lowing reasons
N
Permit No. ��5 -'�1 1 Date Issued 1,2
• Nu. t, Fee �d h
••t
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS � Yes
Zipprication for 30iopont 6potem Conotruction���erinit
Application for a Permit to Construct( )kepair Upgrade Abandon'(',) Complete System ❑Individual Components
4
Location Address or Lot No.857 'S hc:*{ j 71n Jc H•11( (?Cp Owner's Name,Address and Tel.No. i* "
C Gv��Lru� I to
Assessor'sMap/Pazcel 121 waur+- ynar•sh
M1000 14Z PA ti Ins Wc-st- fLcw-rnsFabLe MR OZ669
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.CSat) y28-9,/3/
(30_z.}Lr W�a N of�4 M-,T.r-
la
�" .�. > [J�. I� V✓ �� e�V ( �Z Y✓la�n 5 �+ Oz�.55
Typo Building:
Dwelling No.of Bedrooms _ Lot Size 3 3. 701 sq.ft. Garbage Grinder(Aj.)
L Other Type of Building r No.of Persons Showers( ) Cafeteria( )
Other Fixtures a; 1
Design Flow Ile) 112gPI edr=om gallons per day. Calculated daily flow gallons.
Plan Date 3 ro 5 Number of-sheets 42,1,o Revision Date ^
Title ns*�sr aQ �.-cy h c- sug 1Z�.,� ✓<e��`Fi r r*
Size of Septic Tank /-,15700 Type of S.A.S. .4uchinf C{i�•n/x/s /Z x 35
Description of Soil Re_f-er- -lo sic>i I !0 ric an 121 a Nl 10, d$y
4
t
Nature of Repairs or Alterations(Answer when applicable) A Igo.J&A cxis/fin4 Lc5s•yi'crr4-- g.
ovtr�(�WS .
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�Ti/d 5 of th ironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued'b, th' oar alth.
Signed' , ol Date
Application Approve y Date 3 2 2 0 ,>
Application Disapproved for the ollowing reasons
1•J Permit No. o S —��l 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 0 t_
at c, , A u 0 W A o � ` has been constructed in accordance
with the provisions of Title 5 and the f r Disposal System Construction Permit No. zQ00 6 67�/dated -5 1/7/6 S
Installer Q Designer _,..__._� 1 k SGryl
The issuance of this pe t sha I not be construed as a guarantee tha the system ill notion as designed.
Date � J� ®.S� Inspecto2
r-- s^
No. �C�JG —O�1 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
wigooaf *pztem Construction Permit
Permission is hereby granted to Construct(��epair�`i Igra e )Aband n i� )
1 System located at 1 rQ _
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 dat of-this, e "4
_' -
Date:_ l� /y Approved
y - I
Town of Barnstable
" Regulatory Services
. Thomas F.Geller,Director
IAss. g Public Health Division
=�s9.. ,e
aw►+. _ Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862A644 Fax: 508-790-6304
Installer& DesiZner Certification Form
Date: Y! D S ' Sewage Permit# a00 S- d 9/ Assessor's Map\Parcel
Designer_ 5jrQ1ek. A. 0*. (sup► * P.F Installer: r--Zaho- + 13. 0I,r.1Ke-
Address: 6 , 0,44, s 9OWa M-t Address: 40.o. G ox 1'5 3 9
Al2 Mattes S+ . 0S rrQirle a1C A flora&c4, ` 4 02G&fS
pn 3 -711c was issued a permit to install a
(date) (installer)
septic system at 652 based on a design drawn by
ad ess)
S'1-.ohe4 .4 GJi 4SIM /fie. dated_.3z/&/Or
(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 septic system r ferenced above was installed with major changes (i.e. .
greater th ,at
relocati of the SAS or any vertical relocation of any component
of a se p c yste but i a ordance with State&Local Regulations. Plan revision or
e fie uilt des' to fp4ow.
H OFAq Snti:
a� STEPHElV
ALLYN N 1
(Installer's Signature) o WILSON
o
No.30216 u'
, "/STEcy •.
/0-AL
esigner'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 BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:Health/Septic/Designer Certification Form 3-26-04.doc
�A2o0 V 6�
i
y
'.OAP I - RECEIVED
PARCEL OCT 2 5 2004
LOT t.
TOWN OF BARNSTABLE
HEALTH DEPT.
DATE 1 0/5/04
PROPERTY ADDRESS 857 Shootflyinq Hill Rd.
Centerville, MA 02632
On the above date, the.eeptic system at the address above was
Inspected.
This system consists of the following:
Based on inspection, I certify the following conditions:
SIGNATURE
Name: Robert A. Paolini
Company: Joseph P. Macomber & Son Ind .
Address: P. 0. Box 66
Centerville, Mass 02632
Phone: 508-775-3338 or 508-775-6412
JOSEPH P. MACOMBER & SON, INC..
Tan ks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
•
` r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r" DEPARTMENT'OF'tNVIRONNNTAI,'PRlbTt+CTION
d
V
TITLE 5
OFFICIAL INSPECTION FORM-N- QT.:FOR VOLUNTARY OSEESSSMENTS
SUBSURFACE SEWAGE DISPOSAL SYS
PART-A
CERTIFICATION
Property Address: 857 Shootflvina Hill Road
Centerville MA
Owner's Name: N ;n cj a u a l i Pv
owner's Address:
Date of Inspection: _ J.(LL4. -0 4 —
Name of Inspector: (please print)
Company Name: omp, e .rS: n Lric.
Mailing.Address': az ,•0 2 6 3 a
2n -Aa c �,
-` Telephone Number: 5 0 8-7 7 :3 3 3 8
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system,at this address and thatthe.informationyeported
below is true;accurate and complete as of the time
maintenance
nt inspection'
of on�te sewage disposal systems-was perfom. a I am a DEP
based on:my
training and experience in-the proper function a
approved system inspector pursuant to-Section.15:340.of-Title 5(310 CM 45:000). The system:
Passes
-Conditionally Passes
Needs Further Evaluation.by the Local Approving.Authority
ail
Inspector's Si-:nature:
Dater Z
inspection.report-to the.Approving Authority.(Board of Health or
The system inspector shall submit a copy of this insp
DEP)within 30 days of completing this pawiloer.shal submit he report to thetappropnate regional office ofqm or has a design flow of 10,000
th e
gpd or greater,the inspector and the system
DEP.The original should be sent to•-the system owner and copies
to the buyer,if applicable,and the approving.
authority.
Notes and Comments
****This'report only describes conditions at the time of inspectim and under the
undercondito same u e t ff at
^ time.This inspection does not address how the system will perform in the future
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION:FORM—NO.T FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. i
PART A
CERTIFICATION(continued)
Property Address: 857 Shootflying Hill Road
Owner: Nanci0 Fjai 1 gy=—
Date of Inspection: 10 j 4T9 4-
Inspection Summary: Check A B;C,D or.E/ALWAYS�complete=all of Section;D
A. System Passes:
no I have not found any information which indie'ates'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:
7ho_ ARplin .sU.s.t_om iA in nn_n?P/z wolLking ojzda.,t o.t .the /22e,32n.t
fimo_
B. System Conditionally Passes:
n o One or more system components as described in.the"Conditional Tass"!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.
i
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.over20 years old*or the septic-tank.(whether metal.or:not)isstnteturally
unsound,exhibits substantial;infiltration or exfiltration.ortank.failure:is:imminent.System will pass inspection,if.the
existing tank is replaced with'a complying septic tanlc.as-Agproved by the Board of Health.
•A metal septic tank will pasi 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:
n o- 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(wih
approval of Board of Health):
broken.pipe(s)are replaced. .
obstruction is removed `
distribution box is leveled or replaced
ND explain:
n o 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:
Page 3 of 11
OFFICIAL INNS�PECTION l@'OR117I-NOT SYS E INSP.MT 6N. RM TS
SUBStRFACE SEWAGE IXSROSAL .
PART A . .
CERTIFICA ION•(eontinued) :
Property Address: Hi—Ll—Road
Owner:.
Date of Inspection:
C. Further Evaluation-is.Required by the Board of Health:
no Conditions.exist whichxequire further.eualuationby..the Bmd,.of°Health;in-order:toAdtermine if-the systemi
Ts failing to protect public•health, safety or the environment.
.iw ( ) that the
i, System will pass unless Board in a-manner-wbiebmmill protect public health,safety and:tbe en.ironment:
system is-not fuVctionfng
no
Cesspool or privy is within;50 feet of asurface water
n oo Cesspool or privy is within 50.feet of•a bordering vegetated wetland or a salt marsh.
2. S stem will fail unless the Board of Health(and Public Water Supplier;-if any),determines:that the
Y.
system is Sanctioning in a manner.that protects the public tiealth,safety and environment:
no The system has aseptic tahk and soil absorption system.(SA-S)..and the S. A.S is within 100 feet.of a
surface water supply or-tributary to a.surfacr water supply.
n o The system-has-a.septic tank and SAS and the=SAS is VIthin a Zone 1 of apublic watensuPPY•
3'he system has a septic tank and.SAS:andthe SAS is within,-
feet of a private water.Supply well.
n
—. y '
_n$'he system has a septic tank and SAS and the?SAS is less than 100 feet.but 50 feet or:rtiore frottf a
private water supply well**.Method used to determine distance
for colifOrIn
**This system passes if the well water analysis,performed
Well DE free from1-pollution fred om that facility and
bacteria and volatile organic compounds indicates that provided that no other
the presence of ammonia nitrogen and nitrate nitrogen is equal to or than 5.pd to this form..
failure.criteria are triggered.'A copy of the analysis must be.attache
3. Other:
Page 4 of 11
OFFICIAL INSP.ECTIO'N FORM NOT'FOR VOLUNTARY ASSESSMENTS r
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 857 crootgi Arm Hill Rd.
Owner:
Date of Inspection: 10/4/64
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 f ChJty.:or system component due to overloaded.or.clogged SAS.ur.cesspool
_ x Discharge:or ponding of effluent to the,surface of the:gound 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 1A.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 A iy.portion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface
T water supply.
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. r
x 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.syste.m.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:fr..om that-facflity 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 fort{.]
�O (Yes/No)The system fa_i1s.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 theaysttem mustserve.a facility,with a design flow of 10;00.0 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
z the-system is within400 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 Qnterim 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 11
OFF ICI'AIL INSPECTION FORM°-NOT'FORT M��AR`)LION FORM ASSESSMENTS
r- �i�SURFACE SEWAGE DISPOSAT�.SYS
PART B
CHECICLIST
Property Address: 857 'Shootflyin Hill Rd.
C'r�n1-Prvi p,
Owner:
Date of Inspection:
Check'if the following have been done,You must indicate` f or"no"as�to each.of the oilowin :
yes No "'�
_ — Pumping information was provided by the Owner,occupant,or Board. Health
e
_ 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?
Y
_ x Were as built plans of the system'obtained and examined?(If they were not available.hote is 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,opene � of li d the luidrde ior oth the
of s udge and-depth of scum?condition
of the baffles or tees,material of construction,dimensions,dep. q p
x _ cupants if different from owner)provided with information on the proper
Was.the facility owner hand oc
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 no
x 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 approximationof distance
is unacceptable)[310 CMR 15.302(3)(b)J
.... Sir.
.
5
Page 6 of 11
OFFLOIAZ t;NSP '�IOi'!1::1FO1?Mt-NOT FOR YOL UINTARY ASSESSMENTS
SUBSIIRFACE-SEWAGE DIROSAL SYSTUMIN-SPEC TION:FORM
PART..0
SYSTEM INFORMATION
Property Address: 857 Shootflvincr Hill Rd.
Centerville. MA
Owner: Nand a Halley--
Date of Inspection: 11 X 8 4
FLOW CONDITIONS
RESIDENTIAL 3
Number of bedrooms(desip): ,, . Number of bedrooms..(ictual): 3
DESIGN'flow•based on'310 CIC A 15.203':(for exp4le:•1 I0'gpd z#•of bedrooms): " x_� /0=3 3 0 g�d
Number of current residents: .: 0
I7oes4esidence have,a garbag&.grj der(yes or no): no -
Is laundry on a separate sewaae.system.(yes or.no):.c _Aif yes sepWp - sp.e;tlon required]
Laundry system inspected(yes or no): ,e z
Seasonal use:(yes or no): n o Nb
Water meter rG.adings,if available(last 2 years usage(gpd)): q rx w,(�z
Sump pum (yes or no): n o
Last date of occupancy:u n7 n o ion
COMMERCI' UST UAL
Type of esta-4_ ,Qon-310CMRI5.203)%
nt: n a. '. ,• . - .
Design flgw. na gpd
ow(seats/persons/sgft,etc.): na
Basis.of d6ign'`fl
Grease trap•present(yes or no):` r�
Industrial waste holding tank present.(yes or no)tL
Non-sanitary waste discharged to the Title 5 system•(yes or no): na
Water.meter readings,if available: na
Lasfdate of occupancy/use: na
OTI�ER(describe):.
GENERAL INF99MA'TION
Pumping Records
Source of information: na
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for.pumping: r
TYPE'OF SYSTEM
_Septic tank,distribution box,soil absorption system • .
x Single.cesspool
n Overflow cesspool
_Privy
Shared system-�yes or no)(if yes,attach previous inspection recbrds,if array)
Innovative/Alternative.technology.Attach a'eopy 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:
30 yea2�
Were sewage odors detected when arriving at the site(yes or no):
6 _
Page 7 of 11 r .
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM ASSESSMENTS INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Hill Rd,
Owner: ,
Date of Inspection: y
BUILDING SEWER(locate on site plan)
Depth below grade: 16"
Materials of construction:x_cast iron 40 PVC_other(explain);
Distance from private water supply we�or suction line: 10 f '
Comments(on condition of joints,denting,evidence of leakage,etc.):
�nt� eat t i ht. No evidence .o ieakage.,
Sy,tem vented .thaougfz hou,3e vents.
SEPTIC TANK: n o(locate on site plan)
Depth below grade: n a
Material of construction: concrete_m
_other(explain) n as etal•_fiberglass—polyethylene
If tank is-metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no);_(attach a copy py of
Dimensions: iz a
Sludge depth: n a
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: a a -----_
Distance from top of scum to top of outlet tee or baffle: n a
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined; n a
on
Comments
. ( pumping recommendations,inlet and outlet tee or baffle conditio
as related to outlet invert,evidence of leakage,etc.): n'structural integrity,liquid levels
Se tic. tank not 2e3en.t.
GREASE TRAP:n o(locate on site plan)
Depth below grade: .n a
Material of construction:_concrete_metal_fiberglass n _polyethylene I
_other
Dimensions: n a
Scum thickness: n a
Distance from top of scum to top of outlet tee or baffle: ri a
Distance from bottom of scum to bottom of outlet tee orTaffle: n a
Date of last pumping: n a
Comments(on pumping recommendations,inlet and outlet-tee or baffle condition,structural
as related to outlet invert,evidence of leakage;etc.): integrity,liquid levels
2ea�e .tea no.t 2e�sen.t,,
TMA S Tnonartinn limn,4/1 i/,)nnn 7
Page 8 of I 1
OFFICIAL WS•PECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
M%-V-RF:ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: S;7 ghnnf-f1 j7j ng Hill Rd.
--GenteEville,-?4A
Owner:• •
Datt of hrspec on:
n
TIGHT or HOLDING TANK: nO (tank must be pumped at time of insp ;ction)(locate on site plan)
Depth below grade: na
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions: na
Capacity: na gallons
Design Flow: HE gallons/day
Alarm present(yes or no): na
Alarm level: na Ala:rm in working order(yes or no):
Date of last pumping: na
Comments(condition of ai.arm and float-switches,etc.):
light o2 ho edina tanks not 2aezent.,
DISTRIBUTION BOX: no (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: na
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
leakage into or out of box, etc.)
D-4ox not paezen.t.
PUMP CHAMBER: no (locate on sife.plan)
Pump's in working order(yes or.no): na
Alarms in working order(yes or no): na
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc,):
Pump chain e2 not �2e�ent.
8.
r
Page 9 of 11
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INNSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 857 Shootf lying Hill Rd.
centeryi l_ le,MA
Owner:. Nand P u.al 1 ay
Date of Inspection: 1 n144/o 4
SOIL ABSORPTION SYSTEM(SAS): .(locate on site plan,excavation not required)
If SAS not located explain why:
L rated .6pp- 12age 70 ,
Type
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,
etc.):
CESSPOOLS:Y e-3 (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 6 x 8'
Depth—top of liquid to inlet invert: d z U
Depth of solids layer: d2 y
Depth of scum layer: alLy
Dimensions of cesspool: 6 'x 8'
Materials of construction: conc/Let e Leo ck
Indication of groundwater. inflow(yes or no): n n
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
No v y t enc o hud2au��c Hai eu2e.• V e 9e.t at.ion .ins ao4ma e
PRIVY:no (locate on site plan)
Materials of construction: na
Dimensions: na
Depth of solids: na
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
�2,ivy no �2e�ent .
9
Page 10 of 11
OFFIC AL INSPE—CTION FORM,. NOT,F'OR•,OLUNTAit'Y ASSESSMENTS /
SU-89UWA-CE SEWAGEMISP.OSAL SY'STE".INSPECTION:FURM
PARTC
SYSTEM FNFORMAT,,,I..ON(cbnthmed)`
Property. Address: ill Rd.
Owner: 1ley
Date of Inspection: 1 .. ra 4
SKETCH OF$E'WAGIE•DISPOSA,L SYSTEM
\Provide a sketch of the sewage disposal system including ties to at least two permanent refarence landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters.the. building.
i 0
10
L
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.0
SYSTEM INFORMATION(continued)
Property Address: R 5 7 Sb oo t i l y „n Hill Rd.
0ant-a-r-wille, P4A
Owner: gl�, Hai! y
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar,
Shallow wells ,
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
n o Obtained from system design plans on record-If checked,date of design plan rgviewed:
no Observed site(abutting property/observation hole within 150 feet of,SAS)
no Checked with local Board of Health-explain:
no Checkedwith local excavators,installers-(attach documentation)
ye-3 Accessed USGS database explain: h .t 11 jo,vn 9 n n f ufl,Qe..u's.•ma.,
You must describe how you established the high ground water elevation:
u
h C/ •PP1)PI� ---
u
'®
Leaching
Pit Beet
c •
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Fasinapte4 Method
Therefore,the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is lie-
feet:
f
11
f
I,.,�.,T, T �.•.,...<.RI: IUNN FmmBarn tas ble BOARD OF HEALTH
SU113t1r2FACF 9EXA(;F I){gl'OgA.{ SYSTEM� IN9hFCTION FORM - PART D•- GERTIFICATI0
T-5'I r Irr""RrvrwrN'7� ri"WM*,rVA�'� mmA•RRr7,TIT�"ITtTTlTP•.TI`T'T•1• •^
:•••4t't^T"•'' -T.IIM1^•�'n'M�A 1���*��T-. -Tipt OR PRIN-7,G1.E1h 4I_
PROPERTY TNSPEC7'ED
STREET ADDRESS 8s7 Shnnf flvj„lyg Hill Rom,
ASSESSORS MAP , pOOCK AND PARCEL #
OWNER-Is NAME I
PART D - CERTIFICAVION
NAME OF INSPECTOR ^ - Ro e t- 12, n, -
COMPANY NAh1E Joseph P. Macomber • &, Son Inc
COMPANY ADDRESS Box 60 Centerville Mass 02632
Street Tovn or Clty State E I P
COMPANY TELEPHONE ( 508 ) 775-33.38 FAX ( 508 ) 790-1.578
N
TT
CERTIFICATION. STATEMENT
I certify that I .. have personally inspected the sewage di®posa`1 system a
,this address and that the information reported is true , accurate, and
complete as of the time of ,inspection, The inspection was performed and any
recommendations regarding ui=grade , 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 th.e system fails to adequately protect public
11eRIL11 or the environment, as defined i.n 310 CMR 15 . 303 , Any. failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form . -
System FAILED*
The inspection which I have conatroted has found that the system fails t
protect the Elub.lic health and the environment in accordance with Title
5 , 310 CMR 1513Q.3 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspected for.m.,
f
Inspector Signature .
' t •
;;ne copy of t.fication must be provided to the OWNER, the BUYER
Iwhere applicable ) and the I304RD QF HEALTH
* If the inspection FAILED , xhp- owner orl�op.er4tor. shall upgrade ' the eyetem
within one year of t.l)e dote of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 16 .106 ,
partd . dc
h 4 3
K
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STEPHEN ANDO PAULL CONTRACTORS, INC. EXPLANATION AMOUNT
.
95 TURNPIKE STREET
13373WEST BRIDGEWATER,MA 02379
PAY ^,
OFOUNT C/Jd�L 53-7147-2113
DATE
TO THE ORDER OF LLARS GROSS CHECK
. i
CHECK AMOUNT
d I I NUMBER
�131011
DESCRIPTION '
COMMUNITY �S? 51��, ,,� iX//Eo
- BANK BROCKTON,INA pZ{01
n■0 i 3 3 7 30+11.• •
2 1 13 7 14 761. 56 30 i L 7 3 Lu■
I �
TOWN OF BARNSTABLE
LOCATION s �j i���iiY f�iL[� �� SEWAGE #
V'I LAGE �-N IVn V 1 LLB ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. Ec2%6Uf- 5O pmetL jo
SEPTIC TANK CAPACITY 1500
LEACHING FACILITY: (hype) L6,�CrJJN`� Cz1,19/' 8 (size) / x3s.. a!
NO. OF BEDROOMS 7=
BUILDER OR OWNER 'S Lvl 6,srj
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 's �` E Feet
Private Water Supply Well.and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 1�d Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
p.
o �
• 4W ..
ss 5,r
P
SEWAGE INSPECTIONS /
LOCATION S r TE j 5 do
VILLAGE _ ASSESSOR'S MAP & LOT 1 0 D
INSPHC'POE b� l'YLa,
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS _
Ct
BUILDER OR OWNER
r„
OWNER MAILING ADDRESS
1
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{� R LEGEND ABBREVIATIONS
h c
* sk CB DH FND
(HELD LINE)
4 ,
0.' -
- UTILITY POLE GUY WIRE
• +`r ..'hba3M$+.o- "' :S 71h nsL,_+'`g .+� a -
M e f e Kt vrx A �- ✓A�
ce FND CATV--CA TV CABLE T.V. LINE
,r p 7J�� (BRKN) G c GAS LINE
S:: s'a• • -ti t A, .t'-' �• ,s+SF ?)di ,tl �' - -
_ W W W = WATER LINE
r T = TELEPHONE LINE
yw t * / #3-1++ .'• ✓ Sr'.. ✓. r,. t r• s w : , sky s, .,,Atw : - N -
TREE LINE
M 00 = TREES & SHRUBS
a2 a,1 4 •r� fr , • # • tfi+ }5 hz r4 4�T
S 88'31r 00" E 252.99' TD ` N a CONCRETE BOUND
PP /�
y a a •r ;' s • • t �a u'. 'r'a,:k�'43 ` i T .+aj,.tE 0.2(1' 252.79' TEST PIT
14 h M { �t ►• .. K is w�5� ..+ k`, °'Y.#,.,k7 � M1 , � -
N MAIL BOX
L
rs y ' • •F • • c c'utl ` n �; OI
• ,, t s � z H ti 1+ •� �Ij m EL = ELEVATION
a s$ t � CB DH FND �+:
x + f , � •"' ` CB = CONCRETE BOUND
,;; = Y� -�.� �.� -, ; �,�,• ��-�. �a _ I z N DH = DRILL HOLE
. . •,• �,. o '"`• I LOT 23 FND = FOUND
PLAN BOOK 130 PAGE 89 INV = INVERT
100,2
LOCUS MAP Scale: 1 n 2WO' PLAN BOOK 60 PAGE 71 CB DH FND N o N/F vlrrOR10 GENTILE tro F.F.E. = FINISH FLOOR ELEVATION
N/F ANNE MARIE S. LANG DETAIL 3 Z F% �O ` EOP = EDGE OF PAVEMENT
LOCUS AREA IS COMPRISED OF : r^ t A
N.T.S. a ,
ASSESSOR'S MAP 192 PARCEL 010 - LOT 1 - PLAN BOOK 222 PAGE 9
O PROJECT BM:
DEED REFERENCE: DEED BOOK 19,249 PAGE 113 I /- 130♦29' 0 TOP HYDRANT SPINDLE
OWNER: THE J. K. HOLMGREN FAMILY REALTY TRUST CB DH FND m 15' WAY PLAN` 99.4
EL- 102.69' (ASSUMED)
JOHN K. HOLMGREN TR. _ (SEE DETAIL 3) 100.. 99 9
Q 112.99' 100,3x r h 100 � 30 PAGE 89 99,5 � 99.2
101.4 �' 140.00' 99 x c D T
ZONING INFORMATION _ _ Q ,�o'` o z '�0`� 2s2.99' TD TEST PR GENERAL� 6 GENE1�1iL N0 '►7�r
ZONING DISTRICTS. RC & RD-1 �- Z ' G g•
RPOD RESOURCE PROTECTION OVERLAY DISTRICT �� LOT 1 GAS LINE STUB m x 9Q , ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE WITH
AP AQUIFER PROTECTION OVERLAY DISTRICT PLAN BOOK 222 PAGE 9 LEACH C BERS 99.8 CLEAN ZSTATE
our 99 V 1
a / 33,701E SO. FT. -Box �,57G x 99.3 �o0 100.2 t�k
(n ANY LOCAL RULESAPPLICAB CODE DATED MARCH 31, 1995
MINIMUM CURRENT ZONING REQUIREMENTS - ZONE RC ;t 0♦77t ACRES / 5 99. PIPE 20' EITHER N �0'`
LEEVEANY CHANGE TO THIS PLAN MUST BE APPROVED IN WRITING
99.1 SIDE OF WATER LINE LAWN O g'• BY DESIGNING ENGINEER
MIN. LOT AREA = 2 ACRES (RPOD) 10.0
MIN. LOT FRONTAGE = 20' x 9�?ES x ,'y MIN. 99,2 99.1 99.5 N 4.
MIN. LOT WIDTH = 100' 10112 / Sp�K x w , ,
/ � 9 99 --
� __--w -�--w -w w �-w -w w -�
WHEN CONSTRUCTION IS COMPLETED PRIOR TO BACKFlWNG
FRONT YARD = 20' SIDE & REAR YARD = 10' ; x 100.4 ' 99A ate-- .3 g'• N NOTIFY THE ENGINEER & BOARD OF HEALTH AGENT
0KT� 99.2T�99`'c� N to o�
.--� cr � s FOR INSPECTION.
i PUMP CESSPOOLS do ' 99.1 / \
MINIMUM CURRENT ZONING REQUIREMENTS N ZONE RD-1 FILL WITH SAND cEssP00 CAST I N a+ ,, 991
eb { OR REMOVE INV - 97. c, �x `a' tT THESE ELEVATIONS MUST NOT BE CHANGED WITHOUT WRITTEN
MIN. LOT AREA = 2 ACRES (RPOD) w m , 4 CAST IRON APPROVAL BY DESIGNING ENGINEER
/� 98,7 N p
MIN. LOT FRONTAGE = 20 LOT 35 *CV " I INV = 97.8' LEAN OUT C�POO�, �+ �.
99.2
PLAN BOOK 260 PAGE 710 I OVERFLOW w00� PUMP CESSPOOLS & C,4 x
MIN. LOT WIDTH = 125 1 , 98.6 / 01 � ,��i��� , 9 FILL WITH SAND ALL SANITARY DISPOSAL SYSTEM PIPING TO BE 4 PVC., SCH 40
N/F HAROLD L ROBINSON to m LIGHTLY I 1 � Dw�""N 99.1 OR REMOVE 98.5 98.6
FRONT YARD = 30 SIDE & REAR YARD = 10 • e, ' LAWN E 7�/ 99.5
i WOODED iNo• 85 31' T / T g`8 77 7 x'-T '�-r T ----}T 7 UP24 t EXCAVATE AND REPLACE ALL UNSUITABLE MATERIAL SURROUNDING
99,7 n SURROUNDING THE LEACHING FIELD FOR A DISTANCE OF 5, PER
COMMUNITY PANEL NUMBER. 250001 0015 C ='' x \ 99.2 ® O
THE FLOOD INSURANCE RATE MAP DEFINES THIS AREA AS ZONE C, 10 N `�� I x 99.4 98'4 t 99,0 �� x 9 \ ` 310 CMR 15.255.
AN AREA OF MINIMAL FLOODING. 2 , �► OVERFLOW \
\ ! \ �'' BENCHMARK DATUM: ASSUMED
98.4 •5 �, x 9 PROJECT BENCHMARK: HYDRANT SPINDLE IN FRONT OF LOCUS. (SEE PLAN)
x 100.8 98.5 _ 9 ~G EL = 102.69' (ASSUMED)
i
c�i `� f �' » 98.7 2 A TITLE SEARCH HAS NOT BEEN PERFORMED FOR THIS SITE. IF DETERMINED
Z i r / 8.2 ' > .9 TO BE NECESSARY A TITLE SEARCH SHALL BE PERFORMED BY OTHERS.
THE PROPERTY LINE INFORMATIiON SHOWN IS BASED
LAWN ��0N ON CURRENT AVAILABLE RECORD INFORMATION
' a �� 9c 97.8
- J r- PRpX�1AA� DRAY CONSIST,'NG OF PLAN: AND DEEDS.
98,8 _ . 98.4
-" _-+ 11E EXISTING FEATURES' SHOWN HEREON WERE� N I_ \\ a
101.8 'o o �--------- g9 �
10a8 4.78 CB TO OBTAINED FROM AN ON THE GROUND FIELD SURVEY
s8 `� `99,7 98,3 co 310.41' 97,5 96,2
PERFORMED BY BAXTER. NYE & HOLMGREN, INC. ON
- ,S
CB DH FND 3' POST do RAIL FENCE
LOT 36 (SEE DETAIL 1) t N t 88'31'00' W
� FEBRUARY 28 & MARCH 3, 20�05
PLAN BOOK 260 PAGE 71 CB DH FND ►� ,�� 6' STOCKADE FENCE 96.2 CB FND (TIPPED) �+
N/F TODD R. NASH � 'i SEE .DETAIL 2 �o ` PLAN REFERENCES:
°� ( ) PLAN BOOK 222 PAGE 9
97,3 96.9 97,5 PLAN BOOK 260 PAGE 71
o r SH PLAN BOOK 130 PAGE 89
c6 FND 0i UTILITY INFORMATION SHOWN HEREIN:
o N (BRKN) LOCATION OF UNDERGROUND UTILITIES ARE APPROXIMATE AND MUST
SOIL LOGS DATE: FEBRUARY07,2005 TOT BE VERIFIED IN FIELD BY THE CONTRACTOR AND APPROPRIATE UTILITY
P#=P 10,884 w PLAN BOOK 222 PAGE 9 �gd COMPANIES PRIOR TO ANY CONSTRUCTION.
o N/F EDWARD J. do EILEEN C. FORsrER • o EXISTING SEPTIC SYSTEM LOCATION IS APPROXIMATE.
SOIL EVALUATOR: STEPHEN VENTRESCA, EIT CB DH FND PER INSPECTION REPORT BY ROBERT PAOUNI OF JOSEPH P. MACOMBER
BOARD OF HEALTH AGENT: DON DESMARAIS - CB DH FND Z^ o (HELD) & SON, INC. DATED 10-5-04
N
TEST PIT 1
G.S.E. = 99.6'f 310.41' t o
= 857 Shoot Flying Hill Road
CB DH FND 309.99' y- g
0.
N 88'31'00" W CB FND 0.42
0" A (TIPPED) N 88*31'00" W 310.41' TD o N w
SANDY LOAM
. CID
o o 1 Centerville, Massachusetts
6 10 YR 3/2 -
B N.T.S..Q�T 1• CB FND a PREPARED FOR
SANDY LOAM
(TIPPED) w Holmgren Custom Carpentry
22" 10 YR 5/4
DETAIL 2 �
C N.T.S.
MEDIUM COARSE SAND TRLE
: 120" 10 YR 5/8 Proposed Septic System Repair
PM060'
RATE- <2 MIN IN
NO WATER ENCOUNTERED /
UNABLE TO SOAKDESIGN SCHEDULE ELEVATION
TOP OF FOUNDATION 100.27 44-3: =�=
J K HOLMGREN ENGINEERING INC.
-,_3/4"_15" WASHED-STONE;.--- �-
�
• 12 FINISHED BASEMENT FLOOR 93.22 BAXTER,NYE&HOLMGREN
SEWER INVERT AT FOUNDATION 97.8
- -•r_� �� r.�:��-' :- �~ :: :- �.� Registered Professional Engineers and Land Surveyors
SEWER INVERT INTO SEPTIC TANK 96.3
�- ---- 35' SEWER INVERT OUT OF SEPTIC TANK 96.0 812 Main Street, Osterville, Massachusetts 02655 ,�AAA OF 41
SEWER INVERT INTO DISTRIBUTION Box 95.9 Phone- (508)428-9131 Fax - (508)428-3750 � STEP EN cy
PLAN OF L lE AC H CHAMBERS SEWER INVERT OUT OF DISTRIBUTION BOX 95.7
TYPICAL SYSTEM PROFILE NO SCALE SEWER INVERT INTO LEACHING SYSTEM 95.5 No.30210
TOP OF FINISHED GRADE = 98.6t NOT TO SCALE BOTTOM
FouNaanoN OF LEACHING TRENCH 93.5
= 100.27 WATER TABLE NONE OBSERVED AT ELEV. 89.6 20 0 20 40 ��FSS�DIAi V �
FINISHED GRADE OVER TANK = 99.0E 12' •-� D
FINISHED GRADE OVER D. BOX = 99.Ot
- ' FINISHED GRADE MM ,SING TRENCH : 99.Ot F JISHED GRADE Leaching Area Requirements SCALE IN FEET
-� � SCALE: 1" = 20'
4" STCYHPICAL PVC ' ._ := .- - .. 4" SCH. �40 PVC FIRST 2' (ID BE LEVEL) 9" (min) Cover 36"MAx.-9"MIN. /����//��j�j�/�//�/�//��, ��/��/��//��/ COMPACTED FILL 4 BEDROOMS AT 110 GPD/BEDROOM = 440 GPD
- ) 0 2.07E - -- - then A 2.0% 36" max Cover " ............................... ADDITIONAL 50% FOR GARBAGE DISPOSAL GP
r t ► L2 min ( ) 2 OF P� �NA_ D DATE. 03/16/05
_-�: 0 2.ox �- 10" - - -. 2"Layer 1/8"tat/2" + � 3/4' roll/2' •
PERC RATE _ MIN. / INCH (CLASS 1 )
GAS BAFFLE = 6' sump 4" SCH. 40 PVC Peastone LEACHING CHAMBERS LIAR 0.74 GPD S.F.
FINISHED CONSTRUCT ACCESS .
BASEMENT MANHOLE OVER INLET - -
:- _- -.. 24' DOUBLE /
FLOOR = 93.22 TO TANK TO AT LEAST ;•`v =•rr. :•+
WITHIN 6' FINISH GRAD - 6" CRUSHED E FFECTNE '
WASHED STONE MIN. LEACHING AREA OF SAS. 0
_- - - _ O O O O O O O _ IN
REINFORCED
-= 4" PVC�
FOOTING
STONE easE INV. IN 95.5 O O O 440 GIP
D/ 0.74 GPD/S.F.- 595 S.F. M
O O O O O O O O O O NO. BY DATE REMARKS DRAWIMG NUMBER
•. NO' SCALE PROPOSED SYSTEM: SIDEWALL (12'+35) x 2 x 2' = 188 S.F.
• DISTRIBUTION 19OX '
BOTTOM 12 x 35' = 420 S.F.
150o GALLON SEPTIC TANK s MIN � LEACHING CHAMBER DETAIL sob S.F 0: 2004 04-166 SUR wrksht 2004-166EC.dw
TO BE INSTALLm ON A LEVEL STABLE EASE TO BE INSTALLED ON A LEVEL STABLE BASE No .:Groundwater .Observed 0 Elew. 89.6 PLASTIC ':� 2004-166