HomeMy WebLinkAbout0022 SKUNKNET ROAD - Health 22 Skunknet Road
Centerville P
A = 192 047
Q
TOWN OF BARNSTABLE
LOCATION Z ,Shun Lntj SEWAGE# ZAl 1
VILLAGE 0,41J.,c[ [t, -ASSESSOR'S MAP&PARCEL -A 3 2
INSTALLER'S NAME&PHONE NO. l,C�oc✓il� �I g
SEPTIC TANK CAPACITY iigu u ( f t b
LEACHING FACILITY.(type) &re 3 G t V to Zu (size) /.Y, V
NO.OF BEDROOMS q
1 f
OWNER
PERMIT DATE: COMPLIANCE DATE: U! -7 -Zb1A
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility .4/0 It Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 2.00 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY � _ � �4;�e-5 �,,-�
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r Town of Barnstable
of Regulatory Services Barnstable
THE 1p�
Thomas F. Geiler,Director ;;mericaCiiy
" Public Health Division I I
BAMSTASLE,
MASS. Thomas McKean, Director 200�
�0r 1639. a`e 200 Main Street
FD MA'S
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
April 4, 2014
Sent Via Certified Mail— 70121010 0000 28513078
Joshua and Deborah Shapiro
124 Culver Rd.
Orlando, FL 32825
As of October 1, 2006 a new rental registration ordinance was put into affect requiring
all property owners of rental units to register their rental units with the Town of Barnstable
Health Division. According to our records, you own the rental property at 22 Skunknet Road,
Centerville, MA (Map-Parcel: 192-047). Enclosed is an application. Please use a separate
application for each rental unit you own. Should you need more applications, they are available
online at www.town.barnstable.ma.us. Go to the Health Division page by looking in the
Department Menu. There is a link to the Rental Registration information on the Health Division
page. You may print out as many as you need, and return them to the Health Division with the
appropriate 2013 fee of$90 included. This must be completed within (14) fourteen days of
your receipt of this letter.
Failure to comply with this ordinance will result in the issuance of a non-criminal ticket
citation in the amount of$100. Each day of non-compliance is considered a separate offense.
Should you have any questions, please feel free to call.508-862-4644. Thank you in
advance for your cooperation.
Sarah Donnelly
Division Assistant
Public Health Division
Direct#508-862-4072
.� Official Website of The Town of Barnstable - Property Lookup Page 1 of 3
Assessinq Division Property Lookup Results - 2014
367 Main Street,Hyannis,MA.02601
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Owner Information-Map/Block/Lot: 192 1 0471-Use Code:1010
r Owner
Owner Name as of 1/1/13 SHAPIRO JOSHUA A&DEBORA C Map/Block/Lot GIS MAPS
124 CULVER ROAD 192/047/
ORLANDO,FL.32825
Property Address
Co-Owner Name 22 SKUNKNET ROAD
Village:Centerville
( V \ Town Sewer At Address:No
GIS Zoning Value:RC,/�
Assessed Values 2014-Map/Block/Lot:192 1 0471-Use Code:1010
pp-_-....... .......... ..... ......... .........
2014 A raised Value 2014 Assessed Value Past Comparisons
Building Value: $125 400 $125,400 Year Total Assessed Value
Extra Features: $22.600 $22,600 2013-$253,100
Outbuildings: $0 $p 2012-$262,000
2011-$263,700
Land Value: $105,100 $105,100 2010-$256,300
2009-$312,100
2008-$323,100
2014 Totals $253,100 $253,100 2007-$333,200
--- -- ..._..... .........
Tax Information 2014-Map/Block/Lot 192/047/-Use Code. 1010
.......... ........
Taxes
C.O.M.M.FD Tax(Residential) $382.18
Community Preservation Act Tax $69.25 Fiscal Year 2014 TAX RATES HERE
Town Tax(Residential) $2,308.27
$2,759.70
—. ......... ...... - --- ...._.._...._....
Sales History-Map/Block/Lot:192/047/ Use Code:1010
...... .......................................................
History:
Owner: Sale Date Book/Page: Sale Price:
SHAPIRO,JOSHUAA&DEBORA C 7/15/2010 24685/76 $176000
KARATH,SCOTT L&RITA A 8/15/2008 23106/2 $220000
FREITAS,DEUSELINA M 6/30/2005 19993/224 $322500
MCCULLOUGH,JOHN J&CAROLYN S1/4/1999 11965/250 $127000
ONEIL,KEVIN TRS/SKUNKNET TRUST8/15/1990 7269/88 $1
ONEIL,MICHAEL D 4/5/1974 2023/84 $0
Photos 1 92 1 047/-Use Code:1010 �
Sketches-Map/Block/Lot:192 1 047/-Use Code:1010
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http://172.16.1.50/Assessing/propertydisplayscreen l 4.asp?ap=0&searchparcel=192047&se... 3/31/2014
No. t/ 1 Fee `66
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Th5pogar �&pmem Cou5tructiou Permit
Application for a Permit to Construct( ) Repair(/ Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Loot No. } / I Owner's Name,Address,and
Tel.No.
Assessor's Map/Parcel j tl4V a 3 2
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. t{7 7 33 13
Cc y, V t hots `t,'i-Gln t C"15 r r`q�'�`�^ tJUoY tc S
Type of Building:
y (�Xr;�ru O�ivr •� �!`y 4:75&,.lam,rk 141,dvf 4
Dwelling No. of Bedrooms ) Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building 122 S No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) Cf Li 0 gpd Design flow provided lf�� gpd
Plan Date 4 - a(s - fl Number of sheets / Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil ^-tc1 s.�hcs 3 b `'
Nature of Repairs or Alterations(Answer when applicable)
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 this B of lth.
Signed Date 7
Application Approved by Date
r— !
Application Disapproved by: Date
for the following reasons
Permit No. s Date Issued r
IdO V _
No. Fee
�l Y I V
i
THE COMMONWEALTH_OF MASSACHUSETTS Entered in computer:
h' I�I t--I- , Yes �1
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0ppYication for Migpogal *pgtem Congtruction Permit
Application for a Permit to Construct( ) Repair(0) Upgrade( ) Abandon O ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
Vt ;� st,,�0. S ,
t-t�v
Assessor's Map/Parcel J Y
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. t/ 7l7 ,3 13
C'a llk w I e4c. 'C�S 1 uu w lam. 1� 1
S-3 e'v-4-A C, rA / SE >'v1 a fk Z k.1 , (f v
Type of Building:
€4L.."7 4T_,A^.I,,.//( �4=;�,44 )
Dwelling No.of Bedrooms Lot Size sq.ft. "Garbage Grinder ( )
Other Type of Building 22 S No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) Ct 1-4 U gpd Design flow provided yCt gpd
Plan Date 4 OIL - b Number of sheets ' Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil M 01
Nature of Repairs or Alterations(Answer wh
en applicable)
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 this Board of Health.
Signed �.. ^` Date E/
Application Approved by Date L( - :2
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 (Z) Upgraded ( )
Abandoned( )by ea.n..¢a.164{ �,��tw�t t $--�
at c�_j S ,,.,K n t`' has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. C20 I v dated LI 27- I
Installer e �',Z Designer � (L�m 4/ufl- I
#bedrooms y Approved desk n fl 4/4/y gpd
The issuance o 4iermit shall not be construed as a guarantee that the system 11 f t' n as desivDate Inspector /• �,
J
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
xigpogal *pgtem Congtruction permit
Permission is hereby granted to Construct ) Repair ( � Upgrade ( ) Abandon
System located at 'P.).
i
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date Approved by
Town of Barnstable
ins>> Regulatory Services
Thomas F Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 0.2601
Office: 508-862-4644 Fax: 508-790-6304
Date: ''�-Z-1- 1 Sewage Permit# Zb t l- Ito Assessor's Map/Parcel _23 Z.
Installer&Designer Certification Form
Designer: 5n 9; „� W o r 4 s, 1,1C . Installer:
Address: )2 W. Crb s s el 1 Address: e,,o z �sc �763
TW� 3-4 (� M �} a z y y .v -� ✓ J����2 i`�I' d 2.h3`z
--
01
On k W t �� as issued a permit to install a
(date) (installer)
septic system at Zz 4vr,-LC,-c based on a design drawn by
(address)
�trr dated
(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. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Stripout (if required) was ' cted and the soils
were found satisfactory. ��H OFM,
PETER T.
taller's Si gn a e Mc CIVIL
) CIVIL �
9 No:35109 0
ST-
(Designer's Signature) (Affix Design;' re)
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:lofce formAesignercertificadon form.doc
TOWN OF BARNSTABLE
LOCA,° TON 5 SEWAGE
VILLAG ASSESSOR'S MAP & LOT - 03�
INSTALLER'S NAME & PHONE
SEPTIC TANK CAPACITY b
LEACHING FACILITY:(type 4e)(size) ' c>291
NO. OF BEDROOMSPRIVATE W LL OR PUBLIC WATER
BUILDER R OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 7
VARIANCE GRANTED: Yes No
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LOCA%ION�o)S car) SEWAGE #
VII, e►��er��, �� A SSE SOR'S MAP & LOTTZ
L��'GE
S(� NAME&PHONE NO-Pnpoo q9
SEPTIC TANK CAPACITY `G�k `
LEACHING FACILITY: (type) �r " pj (size)
NO.OF BEDROOMS
BUILDER OR OCWNF
PERMITDATE: 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
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No � ."37 Fim.......: ....'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diinpwml Wordw C owitrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (•;L)- an Individual Sewage Disposal
System at:
,-,,;.;:k- Jc I-J 20rCr /4-AJN CzArT—&2-0 vu-
.................••-----•----...............•---....---....--•-----------•----•---•---•---••-.... .••••••---•••----•-••-----••--------•.............--••-----••----•------- ........
Location-i\ddrrss ..............
or Lot No.
�� �m O cner
V.'�1 Address
W .... N s_!-Iw e�c<isJ..---74 f L !,f 1.`Installer e�vl I lti.S
,-�
Address �-
Type of Building Size Lot ,A..R....—....Sq. feet
►� Dwelling—No. of Bedrooms._-------------
�------.-.--..-.--_--Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ---------------------- ----- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures -------------------------------------------------------------------
.----
.---------------------------------------------
W Design Flow.....................?--- ..-..-.--.....gallons per person per day. Total daily flow-------.....-3 7�..........--......gallons.
x Septic Tank—Liquid capacity-/01 gallons Length---------------- Width---------------- Diameter................ Depth................
Disposal Trench—No. ........t......... Width------- -.._....-. Total Len gth-----!FP�9...... Total leaching area....................sq. ft.
Seepage Pit No..........-L........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by--------- ---------------------------------------------------------------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit....---------------- Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit..----------------. Depth to ground water........................
U ------------------------------ = ------------------------------------•-----------•-------------------
•---------------------------
........---------
O Description of Soil----------------------------------------------------------------------------------------------------------------------------------------------------------------•---•-
x
V .....•--•••-------------•---•••-----•--•--------•---•-•---•------••--•-•-•••----------•••••••-----•--••----•----------------------•••----------••-•--•-------•-••--•---••......------......--•••-----•-.
W
x --- --------- ------- --------- --- -••-••---•--••-•-----••--•-------------------•------••••-•----.........-...----------------••-----•••-•----••-•••------•-•••-•••-----•-......-•--•---••-••....
V Nature of Repairs or Alterations—Answer w�hen applicable..-.-...1 ... ...A........ GUg
f..... t•.........-.-••--f......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance an
be issue y Pt of health.
Sign(d GfJ�n. '1---- - ------
Dare
Application.Approved By --------
Date
Application Disapproved for the following redsons- ---------------------------------------- - - ... ..._..... -
....... ........................................... .. -. .. .. ... .. ......._...>------------------------------------------------------------------- ----------------------------------------
Due
Permit No. ------e�. 3.7.9---------------.-- Issued ..........3 - --/ � ��. '- �.........
/9z
No... -J�7 Fss........�6'.. 1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appfiratiou forDi pagal 3Vnrk,i (> omitrnrtinn rruttt
z Application is hereby made for,a Permit to Construct ( ) or Repair (,,L). an Individual Sewage Disposal
System at: \1
5(—un1/2-�6 t`CJAZ C�i Z2.-vl t tF_
------------------------------------------------------------------------------------------------•. -•--------------------•---------••----•---•-•--------....--•----••--------.........---....-----•--
Location-Address_ or Lot No.
/-Ut�nl �C /t N 5 �'YJ��{ i/�1 cat C�tA�Ti "�1f-t/►�.s.L
....................._....-•--....... •-------••-• -•---•- -----------------------------------------•-----------•------•------------_------------------------
G t,_•-__��� Owner Address
a r v1 v Gli N s iL�J vr�r,,.l �` (,4 1��8 lLD ,�vt I t tiS
------------------------•----------------------------- ........................................... ---------•....--•-•---�----•------...-=•-------- ^ ....................................
Installer Address
U -a?�Type of Building Size Lot- ati -_--------Sq. feet
Dwelling— No. of Bedrooms.................17----------------------Expansion Attic ( ) Garbage Grinder ( )
a 'Other—Type of Building ---------------------------- No. of persons-.-----..--.--_-------... Showers ( ) — Cafeteria ( )
QOther fixtures Y--------------------------------------------------------------------------------------------------------------------------------------•--•--••---•-
i
w Design Flow......................S-S--------------gallons per person per day. Total daily flow------------- ...-----.----....gallons.
13' Septic Tank—Liquid capacity. _A!PPgalIons Length-----.---------- Width---------------- Diameter---------------- Depth................
Disposal Trench—No. ........1.......... Width.......V.' --... Total Length-----!_g...... 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........................................
Test Pit No. I................minutes per inch Depth of Test Pit...-..-------------- Depth to ground water.....-------------------
' fT4 Test Pit.No. 2................minutes per inch Depth of Test Pit.-..-.--_----.---- Depth to ground water..--------------:.......
LP4 ................................•------•-•----...-•---.--•---.......--...•..-•-..-•----.....•-•---•..........................................................
ODescription of Soil........................................................................................................................................................................
x
w
U Nature of Repairs or Alterations—Answer when applicable._..-_-!.�/S-E:. -C. ,4___.._ 1600 �S `S
t ...... ..............................................: x w� "!............ ...' ...............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance-with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has be n issy
y tt� board of health.
Signed -------- - � [ f" ...... DaceApplication.Approved By ------ -------- - - . - / - 9
Da"
Application Disapproved for the following reasonf. ....._...........................................................
.......... .........._....-...........................-._-..._-....-----------._--------------- ------------ ------------------------------------------------------------------------ --------------------------------
Dve
Permit No. .... 5..------- ------------------- Issued ..........3.....-1..
_....... -------------
7 c ,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gertiftrate of Q-Tomplianre
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by .............................. - -.-.-G/L7C(_6 '' CL^1si-/1j � /G'J— - - - -
-.._-----------------------------------------
Insrdler
/.1/L�j�'T' �...�ntJ I C
at -------------------------------------------------...._.-<::7' --------.._..----- �' ---------------------
-�....-
has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in
the application for Disposal Works Construction Permit No. --....�---...� 1 --_._- dated .__.._J� -._/.�/.-..c�?5-
THEISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR!YU�p AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISF TORY.
� - �
DATE.-..-... .----------------- ---.._...------------.. .... .. .. .. . ..._..._......-. Inspec or - - - _
-_.-_-_---- ;---r�e..-e.c .1--_,-__v,_,-______-_,___ ----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS it
�9G BOARD OF HEALTH
--77 TOWN OF BARNSTABLE
No.. fir.^?J---� FEE...................
Dispoal Workii Tunitru.r#ilon rruti�
Permission is hereby granted--------------------. G/ GG?T/--------- 1�J--.STG^�
to Construct ( ) or Repair (be_� an Individual Sewage Disposal System .
atNo................................................... =" d✓ 1=r1� '.... -------c- � .
Street
as shown on the application for Disposal Works Construction Permit No.f�`-)75j---Dated---->._�.....���.--.�. .....
----
----...--•---•--••-----------•-• .--f�--- ------------------------------•--------- ..........
Board of Health
DATE.................... ... (--.........?-----------------------•--•-
FORM 36508 HOBS&WARREN.INC.,PUBLISHERS
f
COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL.PROTECTION
r-f-c x a I r-
�� _m3 .r;D
AP �._ DEC a 1 2004
RCE1.. 6 4
TOWN GF BA,ZNSTABLE
HEA'.TH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 21D SA
0
Owner's Name.:001
14t j �+
Owner's Addres .
Date of Inspectio : l
Name of Inspecto . (please print)
Company Nam W"A
Mailing Address: �0Co%-�Y Telephone Number:
4
fj;3
CERTIFICATION STATEMENT '3t
I certify that I have personally inspected the sewage disposal system,at.this address and that the information reportied
below is true, accurate and complete as of the time of the_inspection. The inspection was performed based,on myr
training and experience in the proper function and maintenance of on site sewage disposal systems. I am fiyDEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
t✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F
Inspector's Signature: Date: l/lef
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 shred 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
Page 2 of I 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: < `
s�-
Owne k
Date o spection. a (j '
Inspection.Summary: Check A,B,C,D or E./ALWAYS complete all of Section D
A., lSystem Passes:
V I Have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B.' System Conditionally Passes:.
One or more system components as described in the"Conditional Pass"section need to.be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the.following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is.structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank.is replaced with a.complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in.the distribution box due to broken or.
obstructed.pipe(s)or due to a broken,.settled or uneven distribution box. System will pass inspection if(with.
approval of Board of Health):
broken pipe(s)are,replaced
obstruction is removed
distribution box is.leveled or replaced
ND explain:
The system.required pumping more.than'4 times a year due to broken or obstructed pipe(s).The system will
-pass inspection if(with approval of the Board of Health):.
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
j
i
Page 3 of I.1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
CERTIFICATION(continued)
Property Address:
Owner: 14
Date of pectin •..
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.
System will pass unless Board of Health determines in accordance with 310 CMR 15.30.(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
system is functioning in a.manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone I 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 DAP certified laboratory, for coliform
bacteria and volatile or 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.
it
3. Other:
3
Page 4 of 11
OFFICIAL.INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM
PART A
CERTIFhCATION(continued)
Property Address: . .
Owner:
Date of LVPectio�9
00(
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 ondin of effluent to the surface of the round or surface waters due to an overloaded or
— b P g g
/clogged SAS or cesspool
d Static liquid level in the distribution.box above outlet invert-due to an overloaded or clogged— q g�bged SAS or
/ cesspool .
V Liquid depth in cesspool is 3ess.than 6"below invert or available volume is.less than '/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
/ of times pumped
1/ 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 l 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 acceptFble water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen.is.equal to or less than 5 ppm, provided that no other failure criteria.
are triggered.A copy of the analysis must be attached to this form.]
!1_(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 10,000 gpd to.15,000
gpd•.
You must indicate either"yes"or"no"to each of the following:
(The following criteria applyto large systems in addition to the criteria above) .
yes no
_ the system is within 400 feet of a surface drinking water supply
— _ the system is within 200 feet of a tributary to a surface drinking water supply
— — the system is located in a nitrcgen 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 3.10 CMR
15.304..The system owner should contact the appropriate regional office of the Department.
4
t
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner.
Date of pection Q�
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 previo--is two weeks?
Has the system received normal flows in the previous two we&period?
V 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 breakout?
Were all system components, excluding the SAS, located on site
Were the septic tank manholes uncovered,opened, and the int:rior of the tank inspected for the condition
of the�ffles 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:
Yes no
/ Existing information.For example,a plan.at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is cceptable)[310 CMR 15302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SE WAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: kzj lit-
Owner.
Date of pectio
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): . Number of bedrooms(actual):
DESIGN flow based on 310, R 15.203 (far example: 11.0 gpd x#of bedrooms):
Number of current residents: goLezY
Does residence have.a garbage grinder(yes or no)./L),/-)
Is laundry on a separate sewage system(yes or no)-;9/).[if yes separate inspection required)
Laundry system inspected(yes.d no):
Seasonal use: (yes or no): ...
Water meter readings, if available(lasr2 years usage(gpd)): !�3 ��
Sump pump(yes or no): (�
Last date of occupancy:
COMMERCIAL/INDUSTRIAL/`/Z`
Type of establishment:
Design flow(based on 310 CMR.15.203): gpd
Basis of design flow('seats/persons/sgft,eic.):�.
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: )
Was system pumped as part of the inspection(yes or-no- )
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for.pumping:
TYP OF SYSTEM .
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
Shared system.(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP.approval
—Other(describe):
Q oximate a e of 11 c m on its,d install d(if nown)and source of information:
i
Were sewage.odors detected when arriving.at the site(yes or no
Paee 7 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: C
Owner:
Date of IirWecti6n
BUILDING SEWER(locate on site plane
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK:4zoocate on site plan)
Depth below grade:
Material of construction:_V6ncrete_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) y
Dimensions:2„C 's- _
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 30
Scum thickness:
Distance from to of scum to top of outlet tee or baffle: 2
Distance from bottom of scum to bo 0 of outlet tee,or baffle:
How were dimensions determined
Comments(on pumping recomm4datio , inlet and outlet tee or baf e ca)ndition,structural integrity, liquid levels
related to outlet invert ev i ce of leakage, etc,): ,
/���� c
10
GREASE TRA�i�(locate on site plan) f �Vn����
Depth below grade:_ (�
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to.bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL1NSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWiWE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: C
Owner: w�
Date of ection: V"t
TIGHT or HOLDING TANKA(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons.
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX:�Zof preser_t must be opened)(locate on site plan)
Depth of liquid level above outlet invert4-6 ✓��JU"`"
Comments(note if box is level and distribution to outlets an,ual evidence of.solids carryover,any evidence of
q Y
akage into r out of box, tc :
PUMP CHAMBER: /M xlocate on size plan)
rd ' —
Pumps inworking.order(yes or no):
Alarms in working order(yes or no):
Comments(note.condition of pump chamber,condition of pumps and appurtenances, etc.):
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of I ection
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type '
Teaching pits,number:_
aching chambers,number:
aching 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 por-ding, damp soil; condition of vegetation,
_7_ (,V,(/ 15y�'4 pj'.�J"a
CESSPOOLS(cesspool must be pumped as part of inspect ion)(lxate on site plan)
Number and confieuration:
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 failurejevel of ponding, condition of vegetation,etc.):
PRIVY/jAlocate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
9
Page.10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:CQDd 6j/`,, oaej)
Owner: QY4.
Date of I ectio mow.� (�
SKETCH OF SEWAGE DISPOSAL.SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the.building.
Ito
,o
ace -(Icy
iSep
pi
10
Page 1 I of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
.Property Address: Q
Owner:
Date of pectin • �, 000
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:
Obtained from system design plans on record-If checked, date of&sign plan reviewed:
Observed site(abutting,property/observation hole within ISO feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
V/Accessed USGS database-explain:
You must describe how you established the high ground water elevation: P
11
Permit Number: Date:
Completed by: 6 �
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: 2— 5 Gef �fYl(Y Lot No.
Owner: J7� Address:
Contractor: Address: r7sl '�` V
Notes:
STEP 1 Measure depth to water table f
to nearest 1/10 ft. ............................................................................... .Date
month/day/year
i
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
AO Appropriate index well................................ate .y.. .... Zj Z
OB Water-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ........................... q 7.6
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level.for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment ..........................................................................................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water /
levelat site:(STEP 1) .............................................................................................................
Figure 13.--Reprobucible computation fxm.
15
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Town of Balt7atable. P# :,
' Department of Regulatory Services
F t��►aa
Pub1>ic Health Division Write,
tbl9• 200 Maui Street Hyannis MA.02601
Date Time ' Fee Pd.
S?opil'',Suni^tabiLty Assessn�,ent for �ewae�l.? pa, aLl
Performed ay- D�'ll� /"� 7'Q�E Witnessed By: yt Gt kt y►:a �'vl
LOCATION& GENERAL INFORMATION,
Location Address gfL &-j/��.��. OrQ-
wner's NarrieTT� {{ p
o!0-� ICJ s� J
kc
Address. SOL v"
Assessor's.Map/Parcei: 2 —Z3 z- Engineer's Name , -t� _
NEW CONSTRUCTION REPAIR _. Telephone#
Land Use ` 1 Slopes(%j t -' Surface Stones
Distances from: Open Water Body r26 ft Possible Wet Area. ft Drinking Water Well 7
Drainage Way ( ft Property Line �'-"" ft .,Other A
SIMTC'M(Street name,dimensions of lot,exact locations of test-holes&perc tests,locate wetlands fn proxlmity to-holes)
22.
� � FT�
Parent material(geologic) Depth t0 Bedrock
Depth to Groundwater. Standing Water in Hole: N�4- Weeping from Pit Face
Estimated Seasons!High Groundwater
DETERMINATION FOR:SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole __._in, Depth to soilInottles: ith
Depth to weeping from side of obs.hole: In, Groundwater Adjustment fC.
Index.Well.# Reading Date: Index Well level Adj.f actor Adj.'d,91indwcttr- ei
PERCOLATION TEST Date Thee
Observation - .
Hole# Time at 4"
Depth of Penc : � ec 2�. �j � .Time at 6"
Start Pre-soak Time® 64..o a v-e_4 15me(91#=691)
End Pre-soak
Rate Minllnch
Site Suitability Assessment: Site Passed Site Failed: Additional Teshng-Needed(YIN)
r_
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:\SEPTICTBRCFORM.DOC
DEEP'.OBSERVATtON HOLE LOG Hole#
Depth from SoILHormon Soil Texture Soil Color Soil biller
Surface(tn.) ,.; (USDA) (Mansell) Mottling (Structure,Stones;Boulders♦.
DEEP OBSERVATION H01 E OG Hole
Dept 00111 '' Soil Hodion Soil Texture Soil Color Soil Other
Surface(,n.). (USDA) (Munsell) Mottling (Structure,Stones Boolders
Con8jStengVr'%.".0jrRV,6l')
re
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Haaizon Soil Texture. Soil Color Soil Other
Surface(in.) (USDA) (Munsell)' Mottling (StruCancture,Stones,Boulders:
i
DEEP OBSERVATION HOLE-LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Bouldars.
Flood It�ttcance Rate,Map: , '` > _
Above"SQO4year flood boundary° No Yes .,
Withi6'S00 year boundary No Yes...: .
Within too year flood boundary No Yes
Depth of Nt�turallv`Occtirrina Pervfous>Matexiai
Does'rat leasE four fat.of naturally'occucring pervious material'exist in all`aretis observed`througtaout,the;
area proposed for the sail absorption system? r—v
If not,what is the depth of nattirally occtitring ptsr°totis maCeri'al? _...
Cec_�t�on
I certify tbataon - ) (dated I:have-passed:tltesoll evaluator examination approved 1Zy the
Departmentof�nvtronmental protection and that the above analysts was performed by me consistent with
the'r jA ed't,aining,expertise and`experience disc, e In l0 CMR 15 017:
Data
Signature
Q.1$Bl'1'iCtPERCf�12M:DOC
IHElp Town of Barnstable
N 0�
Department of Health, Safety, and Environmental Services
* BARNSTABLE,
MASS. ,�r Public Health Division
AIEDtA°�A 367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean
FAX: 508-775-3344 Director of Public Health
March 28,2006
Mr. Devselina M. Freitas
P.O. Box 2795
Hyannis, MA 02601
Dear Mr. Freitas,
The Health Division Office has received reports of six or more vehicles at
your proppertyy located at 22 Skunknet Road, Centerville, MA on or about
March 27, 2006. However, your property is limited to three (3) bedrooms
maximum based upon the septic system capacity and Town's assessor's
records.
Please contact this Office by telephoning 508 862-4640 to arrange an
inspection of the interior of the dwelling.
Sincerely,
omas A. McKean
Director of Public Health
�.1NE Tq Town of Barnstable ��
P ate.
Public Health Division28 � t ••• c „�L`'
,- :, L
DAMSTABLF-a 200 Main Street
.6 Ogeev `�` ffi.W..r�v^
Hyannis, MA 02601
ru 02 1 A $ 00.360
�
ro~P� ,,,�„ 0004606238 MAR 28 2006 I
1iv g MAI LED FROM ZIP CODE 02601
Mr. Dev-selina M. Freitas ;
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BORTOLOTTI CONSTRUCTION,INC. V
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 Z t
508-771-9399 508428-8926 FAX: 508428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:QV� 6z
Bate of inspection: InVector's Name:
;jWners Name and Address:
D IV A
CEBT�ICATION STATEMENT*
I certify that I have personally inspected the sewage disposal system at this address and that the informa
tion reported below is true,accurate and complete as of the time of inspection.The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal Fstems. The System:
V iP ,asses
;Conditionally Passe
'Needs Further E Lion By a ocal Aproving Authority
Fails
oes Si cure: '
Inspect l; .._ Date:
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
eater,
gpd or gr the inspector and the system owner shall submit the report to the appropriate regional
office of the.Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY!
A)SYS✓)VI PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked,structurally.unsound,shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing Sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water.level observed in the distribution box is due
;to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The.
system will pass inspection if(with approval of The Board of Health):
1
� ..m�r ,, 4 'wt t.$'T ^ `y•sx° ray ��; `�' �,,.°l�4 2� '."p ° i� �"� �.
t x`a
*< sy..m'
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IP
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
t 1tM�� PART
CERTIFICATION(continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four 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
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 the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE.)DETERMINES THAT THE SYSTEM.LS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY'AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure. 'I I "
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
`overloaded ouclogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due-to an overloaded or'clog-
god SASorcesspool ,.. r�. ,,. z. ,. , •. •.. ..;�.;.. „ ..�� .,.,�,... _
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NU due to clogged or obstructed
pipe(s). :Number of times pumped
.2-
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy:s 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. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant.
threat to public health and safety and the environment because one or more of the following =
conditions exist:
'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
OWPA)'or a trapped Zone II of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check following have been done:
V Pumping information was requested of the owner,occupant,and Board of Health.
None of the system components have been pumped for atleast two weeks and'the system has
.been receiving normal flow rates during that period. Large volumes of water have not been'
�/�introduced into the system recently or as part of this inspection.
V introduced
plans have been obtained and examined. Note if they are not available with N/A.
LX`the facility or dwelling was inspected for signs of sewage back-up.
_ZThe system does not receive non-sanitary or industrial waste flow.
'The site was inspected for signs of breakout,
_!LAll system components,excluding the Soil AbsorptiowSystem,have been located on site.
_. I7te septic tank`manholes were uncovered,opened,and.the interior of the septic tank was in.
for condition of baffles or tees, t maerial of construction,
,A, n,dimensions,depth of liquid,•'••
of sludge,depth of scum.
The Ve_ e and location of the Soil Absorption System on the site has been determined based on'
existing information or approximated by non-intrusive methods.
-3-
ha` A
�q. ' . j� ti i �K! ' -VkY�1°vk s3S ^a y(
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
Cef&acility
t/ owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
i. SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
/ FLOW CONDITIONS
v
r
Design Flow: d 340jjgallons Number of Bedrooms:� Num r of Current Residents:
un Connected To S stem: Seasonal Use:
Grinder: La Y
Garbage �Y
Water Meter Readings,if a ai ble:
Last Date of Occupancy:
. .
Type of Establishment:
Design Flow: gallonstday Grease Trap Present: (yes or no)
Industrial Waste Holding Talc Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENE FORMATION
9115
PUMPING RECORDS and source of information:
System Pumped as part•of inspection:_ If yes,volum mped:
Reason for pumping:
TYPF�OF SYSTEM:
I Septic TaWd tribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool ;
Privy ,
Shared System(If yes,attach previous inspection records,if any)
Other(explain):
AP O 1'E AGE of all components;date i 1d(if=o ) source of information:
ge odors&tected when arn*vvmg at the sit .�
-4-
L;` 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C'
GENERAL INFORMATION (continued)
SEPTIC TANK: v
Depth below grade: Material of Construction. concrete metal FRP_Other
(expo) i
Dimislons:Ar, ' Sludge Depth: e-;Z?-' Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: /7-
Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth-of liquid
Iwo
1 in lation to outlet i7qrt,strucWpi integrity evidence of leakige.etc.)
GREASE TRAP:
Depth Below Grade: Material of Construction:—concrete—metal FRP_Other
(explain)
Dimensions: Scum Thickness:,
Distance from top of scum to top of outlet tee or baffle:
Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,.depth of liquid
level in relation to outlet invert,structural integrity,evidence of leakage, etc:j
TIGHT OR HOLDING TANK: A-_)
Depth Below Grade: Material of Construction:_coucrete_metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flog. Qallons/day
Alarm Level:
.Comments: (condition of inlet tee,condition of alarm and float switches, e(c.)
DISTRIBUTION BOX:, z '
Depth of liquid level above outlet invert:
Comments:,(note if lfvel and distribution is equal,eviden o solids carryover,evidence of leaks into
or out ofyox,etc.) 14JI at
PUMP CHAMBER:
Pump is Mi woddng.order:
Comments:(note condition of pump chamber,condition of pumps and appurtenances,'etc.)
11 �a �x�.l,: �.� ��,", � htd to r k ray ;C,'�kcfaos ''�t1 -� wx.raw T[t.i'`t1'�t•'r r� s a�X raY r,. „�,.;> �roty � ,a,�y�`,+l`Ar ;"§.kci,�&yy .��y'S. "}��%,,k` r"" <A '
i �� te,. .' w .�f'7t. s.,:•� .. � ,'. ... _e ... .,. .�.:;v�+� i'Fr t -.k .{! .�• r �.a} ir :x,tf w*@.`.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPLCTION FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive.,,,:,F,.
methods) ''If not determined to be present,explain:
Type:
Leaching pits,number: Leaching chambers, number: Leaching galleries,number
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Commen :(note condition f ' ,signs of hydra is failure level of ponding,conditignof ve e,tation,
etc.)
,ij CAIM
CESSPOOLS:
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(cesspool must be pumped as part of inspection)
Comments:.(note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:. .._.:.....:..-
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegztion, -
etc.) ,
i,
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet. '
C�
a
DEPTH TO GROUNDWATER
Depth to groundwater: Feet
.Method Determination
/I �'� o / ♦ ,e er Age, S
-7-
, i
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�oFIME'° Town of Barnstable
o�
Department of Health, Safety, and Environmental Services
RARNSTAB
:59.
1639• g Public Health Division
�0
ArFD'"0�A 367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean
FAX: 508-775-3344 Director of Public Health
March 28,2006
Mr. Devselina M. Freitas
P.O. Box 2795
Hyannis, MA 02601
Dear Mr. Freitas,
The Health Division Office has received reports of six or more vehicles at
your proppertyy located at 22 Skunknet Road, Centerville, MA on or about
March 27, 2006. However, your property is limited to three (3) bedrooms
maximum based upon the septic system capacity and Town's assessor's
records.
Please contact this Office by telephoning 508 862-4640 to arrange an
inspection of the interior of the dwelling.
,5erely,
ma's A. McKean
Director of Public Health
f
,
x
ZPI LEGEND N Longo
Ben chm ark Set - — 98 —— EXISTING CONTOUR ® ° Copn Crosby Rd
a
OUTSIDE COR. OF BULKHEAD x 100,98 EXISTING SPOT GRADE
100,87 o Pen Ln
x EL.=f03.23(Assumed datum) . W EXISTING WATER SERVICE moo°° aasth��9
S 12.30'00" W 3} —0•H•'N!— OVERHEAD WIRES oP Qa �`° °�t
U 'f P o� oSt` 3 a oµc
x 00.20 104.98�-----100 TEST PIT �O6°°��ot�°r ��o1�a �PF n vow Mosthepd
x 99.55 BENCHMARK zs`
\ �qq a c
w
L4 . c
�? LOCUS
LOCUS MAP
100,33 0+ 100.28 �,\ �, 127 (Lot 2)
NOT TO SCALE
25`-_�__ PG
'v + --I--���16�IA3-� 1� S PB 224
I 0PRPPIlp-_1S.A1S21�C14 GENERAL NOTES:
r--i---Ir--r$Pi-2 ,
__I__1 L__I__ 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
35 44 BOARD OF HEALTH AND THE DESIGN ENGINEER.
+ EXISTING LEACHING AREA
100,14 (PER AS-BUILT) 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
Z TO BE ABANDONED OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
I LOCAL RULES AND REGULATIONS.
101.10 -f C -1-90,16
w 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
c: 90 W } TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
Ln I U+ 01.51 0 \\\� o: o J I DESIGN ENGINEER.
O 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
°: FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ENGINEER BEFORE CONSTRUCTION CONTINUES.
0 Irn �a0��` �: �� �x 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
m 1101,88x 102 2$\ �� THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
U I '83
IG1,93 x 101,37 ,� EXISTING SEPTIC TANK 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
a PA TIO I TOP OF TANK, EL.=100.66E
1EXISTING \j INV.(OUT)=99.33f(verify) 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S.
HOUSE(#22) I 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
T.O.F.=103.23E I 101,45 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
I DIRECTED BY THE APPROVING AUTHORITIES.
I
0 0 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
x p THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
102,36 102.55 102,64I y� i Q j: `��i + CONSTRUCTION.
I u-) Q� 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
0 i IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
(LOT 2) Z _ REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
APN 246-232 a 12 AREAS NSPECTEDQBYIRDESIGNING TEINONEER PRIOR TUT OF IOABACKFIAITERIALS SHALL BE
,.� 14,971 S.F.f v 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
\� 81 101,49 J" �� OF MAS IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY.
103,1� f` G
102,21 too-60' 101,74 ti o PETER T. % PROPOSED SEPTIC SYSTEM UPGRADE PLAN
` McENTEE
N 14'28"10" E_ HYD UP 101.43 o Na CIVIL N 22 SKUNKNET ROAD, CENTERVILLE, MA
edge, of traveled way Prepared for: Joshua Shapiro, 22 Skunknet Rd, Centerville, MA 02632
103.41 9 y 101.95 101.81 101.58 op EGISZE�`�0 P P
• x �F S E� Engineering by: SCALE DRAWN JOB. N0.
SKUNKNE T ROAD �� Engineering Works, Inc. 1"=20' P.T.M. 150-11
I ' 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
(508) 477-5313 4/26/11 P.T.M. 1 Of 2
a
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL.97.8
PROPOSED D-BOX FOR A DISTANCE OF 15' AROUND THE
SEPTIC TANK PERIMETER OF THE S.A.S.
INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT PROPOSED S.A.S.
OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE INSTALL INSPECTION PORT OVER END UNIT
T.O.F.
EXISTING F.G. 100.8(MAX.) �co
F.G. EL.=101.8t � F.G. EL: 100.5t /MAINTAIN
2% GRADE (MIN.) OVER S.A.S.
' INSPECTION
• L = 2( L = 9'(MMIN
� S=1% (MIN.) ® S=1% (MIN.) PORT
4"SCH40 PVC 4"SCH40 PVC
6"
,o"t s" Tr-- -------
4! ? 10.75" TO i
EXISTING 4a" uQUID INVERT : PROP. S.A.S.
LEVEL ADD INV.=97.87 PROPOSED INV.=97.60 5 ROWS OF 5 UNITS AT 5.0'/U IT = 25.0'
GAS BAFFLE
INV.=99.33f D-BOX INV.=97.40 SOIL ABSORPTION SYSTEM (PROFILE) ��--- ----� S.A.S.LAYOUT
EXISTING 1�-25 -I
EXISTING SEPTIC TANK
t
ESTABLISH VEGETATIVE COVER 21 _ 5-4" POLYSEAL OUTLETS
BACKFILL WITH CLEAN NATIVE OR 2" 2" 1-4" POLYSEAL INLETS
NOTES: PERC SAND TO TOP OF CHAMBERS
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE
INVERTS, PRIOR TO INSTALLATION. BREAKOUT=TOP ; •.+.... ••; O O
2) D-BOX SHALL BE SET LEVEL AND TRUE TO TOP ELEV.=97.83
GRADE ON A MECHANICALLY COMPACTED SIX INV. ELEV.=97.40 a Lo z
INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). BOTTOM ELEV.=96.50—''
2 83'
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' MIN. ABOVE BOTTOM OF
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE T.P. EXCAVATION OR G.W. EFFECTIVE•WIDTH=14.2' iv Top View �/ Section
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. EXISTING SUITABLE D—BOX
NO G.W., EL=90.0 4 MATERIAL
USE 5 ROWS OF 5-ADS Arc 36HC UNITS WITH - 63.25"
NO SEPARATION BETWEEN EACH ROW & NO STONE
SEPTIC SYSTEM PROFILE TYPICAL SECTION
N.T.S. JY7�El
SOIL LOG 34.5"
DESIGN CRITERIA DATE: APRIL 22, 2011 (REF#13,260)
SOIL EVALUATOR: PETER, McENTEE (SE#1542)
NUMBER OF BEDROOMS: 4 BEDROOMS WITNESS: DAVID 'STANTON R.S. TOP VIEW
SOIL TEXTURAL CLASS: CLASS I HEALTH AGENT
so"
ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH END CAP END CAP
DESIGN PERCOLATION RATE: <2 MIN/IN 100.0 A SANDY LOAM C„ 106.2 A SANDY LOAM 0" FRONT VIEW SIDE VIEW o
END CAP
" #
DAILY FLOW: 440 G.P.D. 99 7 4 99.9 4"10YR 4/2 10YR 4/2 REAR/TOP VIEW
DESIGN FLOW: 440 G.P.D. B B NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW
GARBAGE GRINDER: NO SANDY LOAM SANDY LOAM TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY
1 OYR 5/8 10YR 5/8 DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY 97.0 36" 97.2 36"
C1 C1 4640 TD, EMANOHIO 302 Arc 36HC DETAIL
LVD
PROPOSED DISTRIBUTION BOX: 5 OUTLETS MINIMUM PERC EMS.HILLIARD, OHIO 43026
48"
ADVANCED DRAINAGE SYSTEMS, INC. ak
LEACHING AREA REQUIRED: (440) = 594.6 S.F.
.74 PROPOSED SEPTIC SYSTEM UPGRADE PLAN
MED. SAND MED. SAND 22 SKUNKNET ROAD, CENTERVILLE, MA
USE 5 ROWS OF 5—ADS Arc 36HC UNITS WITH NO 2.5Y 6/4 2.5Y 6/4
SEPARATION BETWEEN EACH ROW & NO STONE Prepared for: Joshua Shapiro, 22 Skunknet Rd, Centerville, MA 02632
BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF UNIT) Engineering by: SCALE DRAWN JOB. NO.
(Arc36HC Units) 25 UNITS x 5.0 LF x 4.80 SF/LF = 600.0 SF 90.0 120" 90.2 120" Engineering Works, Inc. NTS P.T.M. 150-11
DESIGN FLOW PROVIDED: 0.74(600 S.F.) = 444 G.P.D. PERC RATE <2 MIN R' ENCOUNTERED
HORIZON)
NO GROUNDWATER ENCOUNTERED 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET N0.
(508) 477-5313 4/26/11 P.T.M. 2 of 2