HomeMy WebLinkAbout1064 SHOOTFLYING HILL RD - Health (2) I 1064 Shootflying Hill Rd. , Centerviug
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14 Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1064 Shootflying Hill Rd. �
Property Address
William & Kelly Sanforda
Owner Owner's Name
information is
required for every Centerville ✓ Ma. 02632 9/2/2011 "
page. City/Town State Zip Code Date of Inspection6
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Robert Paolini
use the return Name of Inspector
key.
Robert A. Paolini Septic Service
Company Name
17 Playground Lane
Company Address
Yarmouthport Ma. 02675
City/Town State Zip Code
(508)362-3555 S14454
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:
❑x Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
9/2/2011
Inspector's Signature Date
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.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
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:
❑x 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:
The septic system is in proper working order at the present time.
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
r
Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
I
❑ 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
�M 1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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
❑ ❑x Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
99 p
Static liquid level in the distribution box above outlet invert due to an overloaded
El ❑ or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
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:
❑ 0 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.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 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.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ 0 The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
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
❑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 SAS stem Absorption S on the site has
p Y (SAS)
been determined based on:
❑ ❑x Existing information. For example, a plan at the Board of Health.
❑ Z 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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 1064 Shootfl iinng Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
3
Does residence have a garbage grinder? ❑ Yes ❑x No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑x No
Laundry system inspected? ❑x Yes ❑ No
Seasonal use? ❑ Yes 0 No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes Z No
Last date of occupancy: 9/2/2011
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�^M 1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes x❑ No
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) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
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:
Were sewage odors detected when arriving at the site? ❑ Yes ❑x No
Building Sewer(locate on site plan):
Depth below grade: 30"feet
Material of construction:
❑cast iron ❑x 40 PVC ❑other(explain):
Distance from private water supply well or suction line: 1 +
fee e t
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
Depth below grade: 2'
feet
Material of construction:
❑concrete El metal ❑fiberglass El polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gallons
Sludge depth:
5"
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
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
27"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle 101,
How were dimensions determined? Measured
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 every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
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
M 1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
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 El metal ❑fiberglass El 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
' r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 1064 Shootflyinq Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
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 No
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 Ievel.Box has two outlet Iaterals.Speed leveler in box diverting flow to newer pit.No evidence of
solids carryover.No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in workingorder: El Yes El No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
,M 1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
0 leaching pits number:
2
❑ 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.):
Sandy soil.No signs of hydraulic failure.Old pit was dry at time of inspection.Stain line observed up to
invert.New leaching pit water level was 8" below invert at time of inspection.No stain line observed
higher.
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 Forth:Subsurface Sewage Disposal System•Page 13 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ICI
1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
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:
Dim
ensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
°M 1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑x Check Slope
❑ Surface water
0 Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LP 32'
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)
❑x Checked with local Board of Health-explain:
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 1064 Shootflying Hill Rd.
Property Address
William & Kelly Sanford
Owner Owner's Name
information is
required for every Centerville Ma. 02632 9/2/2011
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑x Inspection Summary: A, B, C, D, or E checked
❑x Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
System Information—Estimated depth to high groundwater
0 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
TOWN OF BARNSTABLE °®
LOCATION 10(o t►n Wilt SEWAGE #9 z;
V111AG ASSESSOR'S MAP &
INSTALLER'S NAME&PHONE NO. V)n c ornb e/' SOP) I 'C.
SEPTIC TANK CAPACITY L®O O
LEACHING FACILITY: (type) o�L '2ti'_S (size) i4000
NO.OF BEDROOMS'
's`
B MMIt OR OWNER 6�V/��` ��'U -1 L� q
PERMITDATE: � �`�9� 5;
COMPLIANCE DATE: e^- ' /- ,
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leac 'ng facility) Feet
Furnished by
r j _
No. Fee $ ' 40-100
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
01ppYication for &gozar *potem Congtructfon Permit
Application is hereby made for a Permit to Construct( )or RepairXXl�an On-site Sewage Disposal System at: i
Location Address or Lot No. Owner's Name,Address and Tel.No.
1064 Shootflying Hill Road William Sanford
Centerville,Mass . 02632 1064 Shootflying Hill Road Centerville,Mass'
Installer's Name,Address,and Tel.No. 5 0 8—` 7 5 .3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber Jr. J.P.Macomber Jr.
Box 66 Centerville ,Mass . 02632 Box 66 Centerville,Mass . 02632
Type of Building:
Dwelling X No.of Bedrooms 3 Garbage Grinder(NO
Other Type of Building 'RE$ No. of Persons 4 Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 330 gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil 3_1 T,namRr Sub Soi 1 3 t—1 2 t Medium sand.
Nature of Repairs or Alterations(Answer when applicable) Adding an additional 1000 gallon
leaching jiit. to an existing tank box and pit.
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 e E ironmental Code and t to place the system in operation until a Certifi-
cate of Compliance has been issu by this d He
Signed 42 Date _5/2 0/9 6
Application Approved by
Application Disapproved for the following reasons
Permit No. Date Issued
r.,.
No. Fee $ 140.00
THE COMMONWEALTH OF MASSA&USETTS 1
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2pplication for Mis;pooar bp!5tem Construction Permit
Application is hereby made for a Permit to Construct( )or RepairY(XX)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
a°064 Shootflying Hill Road William Sanford
°Certerville,Mass . 02632 1064 Shootflying Hill Road Centervi le,MasE
Installer's Name,Address,and Tel.No. 5 0$-'7$5 5 3 3 3$ Designer's Name,Address and Tel.No. 5 0$_'7 7 5_3 3 3 g
J.P.Macomber Jr. J.P.Macomber Jr.
Box 66 Centerville,Mass. 02632 Box 66' Centerville,Mass. 02632
Type ofRBuilding:
Dwelling X No. of Bedrooms 3 Garbage Grinder(NO
Other Type of Building RFS No. of Persons L_ Showers( ) Cafeteria( )
Other Fixtures
Design Flow 14 gallons per day. Calculated daily flow 330 "_: gallons.
Plan"Date Number of sheets Revision Date r
Title
Description of Soil 31 Loam& Sub Soil; 31--12 t Medium sand.
Nature of Repairs or Alterations(Answer when applicable) Adding an additional 1000 gallon
leaching bit. to an existing tank box and pit.
Y''
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system f
in accordance with the provisions of Title 5 of a Environmental Code and t to place the system in operation until a Certifi-
cate of Compliance has been issu by this and e
Signed Date 5,/20/96
v
Application Approved by
Application Disapproved for the following reasons
r-
Permit No. 'y Date Issued �_gj /9 b
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced )on
by J.P.Macomber Jr. for William Sanford
as 1064 Shootflying Hill Road Genterville,Mass . h constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions sqoDrth Belo -
.01
I' =------------
No. �/ Fee � /�0.00
THE COMMONWEALTH OF MASSACHUSETTS
� k
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwis�po.ar *p!tem Conttruction Permit
- Permission is hereby granted to J.P.Macomber Jr.
to construct( ))repair(M)an On-site Sewage System located at 1064 Shootflying HIll Road
Cehherville,Mass .
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.
All construction in co P t d within two years of the date below.
I
Date: Approved by
9
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
o
•
I, Joseph P. Macomber JiWeby certify that the application for disposal works
construction permit signed by me dated 5/20/96 , concerning the
property located at 1064 Shootflying Hill Road meets all of the
following criteria Centerville,Mass .
There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is ;4 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED • a DATE: 5/20/96
LICE I'S SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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LEGEND
EXISTING SPOT ELEVATION Ox0 aw�La, CERTIFIED PLOT PLAN
EXISTING CONTOUR --- O --- OF"
sic
FINISHED SPOT ELEVATION ? LBCRT ya C'E/1/TE2 /'L_L�
FINISHED CONTOUR 0 }- ,� N
APPROVED 1 BOARD OF HEALTH �' N.10951 o 'N
.ono- 1 ,ISTE���`�'
DATE AGENT
FSS/ONAL. SCALE, / �=�0 DATE$ g /9Lffl/
L DREDGE ENOINEER/NS CQ /N o c�AN cvE
CLIENT i CERTIFY THAT THE PROPOSED
EOISTERE REG18TE-RED JOB N0. 2- BUILDING SHOWN ON THIS PLAN
CIVIL LAND / CONFORMS TO THE ZONING LAWS
DR. 1
E OINEER R OF BARNSTI�LE �ii�AS3.
- --- . / . n n.
� 9
LOCATION SEWAGE PERMIT NO.
GoT S/fooT
VILLAGE
c"
INSTA LLER'S NAME i ADDRESS
III UIL0ER OR OWNER
EDA
PERMIT ISSUED
COMPLIANCE ISSUED
DRIVEWAY
R-nf
io 23
,28 0 33
4
O
...............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
L`. . ..............0F.......... . .... .. "b...-'.--•-•----------------
Appliratiou for Uispuiial Workii Tome rurmitt ranfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system ,
..... _ cad ...........1...( � �.�.J. ... �:..._. . ��....��P ---Ce..&.i-z i;z..--AP
cation-..A Ir ss /� or Pt No./A
O ner Addr.......................T-6............. .............
ess
Installer Address
d Type of Building Size Lot---
?�__Ae...Sq. feet
Dwelling—No. of Bedrooms.._____..__.a.;Z___________________________Expansion Attic ( � Garbage Grinder ( )
Other—Type of Building t.,/SI° � pNo. of persons.............. --------- Showers ( ) — Cafeteria ( )
a' Other fixtures ............................
d - -----
W Design Flow.............. Q.....................gallons per person day. Total daily flow................. gallons.
WSeptic Tank—Liquid capaci,400...gallons Length---�_.-4---- Width----Y*!�°_ Diameter................ Depth....... ..
x Disposal Trench—No._.,/��;___._.- Width.................... Total Length.................... Total leaching area----------_.........sq. ft.
Seepage Pit No-------(------------- Diameter--------J_L�_____. Depth below inlet......?_-___.___-__ Total leaching area...�6�.....sq. ft.
Z Other Distribution box ( ) Dosing tank ) I ^^--�� //
Percolation Test RIm.k.fth-utes
s Performed b �Uke-_d t ._A�.. �fl Date...............l..,l V.
Y f� Test Pit No. per inch Depth of est Pit----------/3-_... Depth to ground water........
r3 Test Pit No. 2......._.........minutes per inch Depth of Test Pit.......... !!T�.... Depth to ground water-___-_
- -- ----- --- ----- -................
---
Description of Soil C� ...'.3 �¢•u....-------------s v 1 f ...------------------------------------------------...-----............----
W -----------------------------------------------------------
UNature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'THE
, of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has AbDe ,issued by the board of health.
u, -�/� �1 �C2
/� (�dLw..2t.0 C�. D !'°.v... }two
Application Approved BYE--•- -- - -- ----- ------ -------------
v
Application Disapprov r th f ollowing reasons----------------------------------------------------------------------•--------------------------------......•...
.................................. •-•••------ -----------------------•------•----.......-----------.._
Date
PermitNo. .....-•--•---•-----••--•-••-•-----•--------•...... Issued.......................................................
Date
f�..... Fxs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-------
.................------------------OF...........................--•----•-• -------------......
AvOration for Dispaii al Workii Tontrndion Vamit
A plicat'on is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
/ 1
S st a��• 1 l� O d f
......__ ....IV-
. t i "'�------•--•-------------r--- ...... -
Location- dress Lot
.�. �� , J ° `' Cie f �.� ,�.�.. ---------------------•-••------•----•----
Owner /\ J` /^ZA ...............
v /( G
Installer Address 2Z to/J
UType of Building _� Size Lot........I..................Sq. feet
Dwelling—No. of Bedrooms------- ._-._,.. •Expansion A is (�) Garbage Grinder ( )
aOther—Type of Bulldillg W......................... No. of persons_.._.__________________. __ Showers ( ) — Cafeteria ( )
Otherfixtures ..............••••-•--•-••-••--......------.---•-•--•---•----------------•-•-•---......................----
.< 7VV -(i
W Design Flow.............................................gallons per persota,q day. Totalydaipy, flow..........................................;•gaups.
WSeptic Tank—Liquid capa .....gallons Length................. Width................ Diameter................ Depth................
x Disposal Trench—No. ................... Width.................... Total Length-----...i.......... Total leaching area---- _�_y.......sq. ft.
Seepage Pit No-----(............... Diameter...... . -__--___ Depth below inlet....-............._ Total leaching area... ....... . ft.
Z Other Distribution box ( ) Dosing Ia k ( ) U �/
Percolation Test Re It Performed by------- J------------------ -------•---------•-J... Date.....................
�z
Test Pit No. I'...__v'.__ "".'minutes per inch Depth of Test Pit.................... Depth to ground water----- }_.._.
f=, Test Pit No. 2................minutes per inch Depth of Test Pit......... ........ Depth to ground water........................
04 r-----------
D Description of Soil---------2.....-- ( 5 ._l%_S:_�.1_�
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
...-.........................................................................................................................................................................-..........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TT L y g g p . y
S of the State Sanitary Code— The undersigned further agrees not to lace the system in
operation until a Certificate of Compli nce has be issued by the board of health.
Sign ---- "....•.� ✓....... r � •4Z�1,4 �...._......
14
ApplicationApproved B ---------- --- � -------••-------•-------�...-•-•-----......_..........--•---•-----•-
Date
Application Disappr f or a following reasons--------------------------------------------------------•-----•---------------------------------------......_...
............................ ...........-•-•-•---•-•••----•-------•-••--••-••--......--------•••-------•--------------------•---------------..................... ......-----Date------........
PermitNo --•-------------•-------------.._._...._.....--•-•-•. Issued........................................................
Date
THE COMMON E" H OF ;4A TTS
BOA
...............................OF..................................................................................
r
ZS ER IF n v Di s tem constructed/ode
r Re aired ( )
by--••...............•--•--•----•---•-•-•--•--•----......... •-----1....... ....----I. .i...................... ..---•------••---•-------•-- -... ........................
✓ - Lf
at.................................................................. -- ..................... "� r -------------------•-----•-------- ...............................
has been installed in accordance with the provisions of TITLE; j of The State Sanitary described in the .
application for Disposal Works Construction Permit No----------------------------------------- dated_....-----......................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION S TIS-� T RY.
QQ
DATE ..__... . .l..t........................... Inspector------.. ... -�-`.....•-----------------•---•-------........--
THE COMMON�/ S , USETTS
/g 4„r..*
( / � BOA D ®F HEALTH �d
F . , wit.....................
No......................... FEE....._.. ........:....
/� t �0� 11 n rranit
Perfi i o is ebY -=-�-- -----------•---•----............_..................................................................
to Construct ( ) or Repair ( ) an di ' ual S ge Disposal System
atNo....................................................................................................... --------------•-•-•----------•--•••-...--•-------------••-•-•-----•••......•--........
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
------•----••.........................................
DATE. Board of Health
�,/ .
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
^PEA
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i �qNp SURV�'yow
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LEGEND --,,5 /°Sv':00 W
, ,,., CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION Ox0 uF'.��;,,
EXISTING CONTOUR --- O -- ������� �,,ss'�y 4Or J? s 00rV4yi.v� � f�.:�. ►
FINISHED SPOT ELEVATION LBRT CF/IOE
FINISHED CONTOUR 0 --- �,` Lp
MORSE v, N
APPROVED# 80ARD OF HEALTH A No.icssi�o w� SAAB SIAS LA,N ASS*
DATE AGENT `FssiorJa% . SCALE, / "'7140 ' DATE, !' /9 81
LDREDGE ENGINEERING CQ /N 0cr_A^/1$wE
CLIENT_.... I CERTIFY THAT THE PROPOSED .
EGISTERE REGISTERED JOB N0. //2,! BUILDING SHOWN ON THIS PLAN
CIVIL LAND DR.BY�,e�,., '� ,. CONFORMS TO THE ZONING LAWS
ENGINEER St
OF BARNST LE, SS.
. 712 MAIN S.T. CH. BY' �•'
HYANNIS, MASS. / 2-•
SHEET� OF .—_._ .DATE )MG. LAND SURVEYOR
rYOTg IF EITHER THESEPT/C TAN/C OR
?O F7 MIN L.g,4CM/NG P/T A/tE NOR.
THAN /2"QELOlV
IO M/� _ GRAB DF��4 ?4'O/�1 M ETER CONCRETE COP&'W
t�-- _ S�L�LL GF D.?0116.V7* TO 4S.TA . 'AN EXTRA
9 PVC PrPZ "eAVY CAST IRON COI/ER -T,"ALL !3E USEO
MIN. P/TCN
r,#Cr IN oRi vEw.+r
cc . (4990 CO � ojw FT
!.'= CONCRETE
j MIN.
a • pLr CO✓ER C'L EAN -SANA
A r BAC,4eFI LLAYER
-
-.. -�/s'
P/ ON PlL' l�6lQ +.0 1• fig
• • • • .• • s o •
MIN.
P/Tt/M L-;-- GAL' • /yASHEO S7t7NE
SEPT/C rAAW eGx , . . . .. • .'• •
• /'nF4 »
b - �'i • .. C1'7 OW . 1Vi43/rED/STONE
• DEPTH /
#-. : •.• • s • • . • 0 0 0 PRECAST SA.&.4PAaE'
► s. • • • • .• • • • • P ••� P/7 OR EQUl V
i$8,5 x 2,5 "471 �PD / 0,gap • • • • • • • t • •
/NYGR'�r,c►LFY,�TlO/VS fig.s 'A1.o = -i j &PP • ' E =9�.fo
IntYERT AT SM/LDIN6 �f11 -a FT.
- - pR c^o,w-- rr .54v cwc /0 FT. D/A!W- C(541Ft TAeuLAT/Ow, .
INLET .�'iEPTIC TANK
0071-ET SEPTIC Ti *VjK' 1rrOAlo FT
/ GROuNO PIA7,EIW TABLE
/JVLET D/STR/Dt/T/ON.BOX SECT/ON OF
Ol/TLE7"D/STR/Bt/T/ONQQXT�3F� s�yyAGE O/SPO�S'AL SYSTEM
INLET L&ACNtMG IZ'lT 9S.Co FT -rASULAT140H
LEACHING P/T vr�tErvsroN A Z XT.
DOE'S/6N CRtTE/!/� . se.�t�.: %s' /.-o D/�►�vstow Ste' -PT.
NUMQER OF QEGUtGOMS 3 „. . D/MtyNS/ON C�-`T. r�/w/.
c�ReA�,�O/SPasAL UX/T a SOIL LAG *OIL 7"'17'
TOTAL &V7:1~rED PV PV •�3 C� Q.tL.IAAv SO/L TEST '/ SO/C.TE57'02
AfUMBER QF L�ACAItNG P/T3 f`EtEY. /�3 v �LrFY, L�ATIS aF SOIL TEST
T PT. r. - RESt/LTS It/rTNESSED dY
S/OE LCACH/N6 PEER P! ��•� � -
C?- LEra M! INCH
OOTTOM Li4CN/N0 POR A 7� SQ. PT. �RCOLAT/ON /b4TE /
Lv�:�"t chi. C �'t Est T?tR N rN. INC'V
�..�.� P�erItcot^Tio/v R.aTE 1bE2 -M /
TOTAL LEACNI/e& AREA SQ 'A Su/3 +L S049 L._ v
RESERIA'E(,B,4t:'H/N6 ARE/ �(o J• FT.
OF
o MAD/vim 3
,�'� �F?✓, � . �Ez�lvA�%►. Ld 7' /f3 SNaDTFLY/�'�e
/ Iz�j c t� cyG Ski'el A L114L L-is ALB u, o
Fi
1 No. 10951no v Et1t CA /N6�RNV�s JNG.
p4 4Q .p Ra 29974 o ELOREAP E FN& �
712 -wA//Y ST-
a NYAAIJV1 MASS.
ryo suR��: ivo O�ouND wATrR "COU/vrFeEo ,
v� ` . GROLIMO L✓A4TE� AT FLE✓. Jos NO. S./7 2-4 SHEET?Oi Z