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0018 STONEY CLIFF ROAD - Health
18 STONEYCLIFF RD., CENTERVILLE A=189-018 No. 42101/3 O. lA ESSELTE 10% 0 0 0 0 TOWN OF BARNSTABLE LOCATION S'r DNEy C L(;ZC lJ) SEWAGE# 269'3. .) , VILLAGE GZV(4C,6_ ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. dAPL=-WQ .O p e� SEPTIC TANK CAPACITY J t . Qq{ -eta la 0®0 GALL01U LEACHING FACILITY:(type)(2)56r3!RAL_ (size) (at,2"?C a.S NO.OF BEDROOMS 3 OWNER Doty4L8 t?pucw PERMIT DATE: 9—4—c'�O l q COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) 114 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) /(,Po Feet FURNISHED BY 0,,V,6 L06 1904exr, a 6"L 430 3 L' Ll � S Cl� L-�t P fa�N� a G- S (3' D-1- Lfo( - D�'� - l9� - i = (Z' 6 E-3 31 ' D-3 - , a Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plication for Disposal 6pBtPm ConstCUttion Permit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Iljs- S-rWL'c{ Cc.in_- A'0 Owner's Name,Address,and Tel.No. t b�alv4t,� t-Id>y�3� Assessor's Map/Parcel Vs 02 (, V I LCL 1,9 S'T-mi caf;F AL) Installer's Name,Address,and Tel.No.r5( -'F`rZ-e8717 Designer's Name,Address,and Tel.No. 5CQ-"2-53(3 CgG11_)Lt)&jA668XT $ 0114 140 7-vc e a M Cam' epos 7=c iv2 .c4ZZ Type of Building: Dwelling No.of Bedrooms J Lot Size l'S o OOp sq.ft. Garbage Grinder( ) Other Type of Building P-4651DW 1 A Q No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 O gpd Design flow provided 3 gpd Plan Date 9-Ao-'�LO(9 Number of sheets 0--k, Revision Date Title I S(Qr+ l L',C•I;ZF kb ° .�✓�C-Crta Size of Septic Tank (.a56 M I.C10b W SatGS Type of S.A.S. Description of Soil Fl, S r) PC.Ax) Nature of Repairs or Alterations(Answer when applicable) U-156- 1500 Ti f%..)C- _M- 060 6(XX) G-Ol LOL, `;W7cL VagA- 1-3 VQU 14-alcy -(fink �ot) aop Cmc 6-alp L- iLek <C r 404S Le)cT14 4 Fc!kr 0CP A-46�444-7V �'eAkx.)X)ba— 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 Heal Signed Date / Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ;Lot Date Issued — f e �{ No. Fee.. THE COMMONWEALTH OF MASSACHUSETTS Enteredincompuier w PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9pplitation for Misposal *pBtem Construction Permit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. is S-Tui&i Cum AD Owner's Name,Address,and Tel.No. Assessor's Map/Parcel t V t bp�,ri , D l'�iV Installer's Name,Address,and Tel.No.� _ ,�_RE-r-r Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms $�j Lot Size 7:5.t)06-E-sq.ft. G,3rbage Grinder( ) Y Other Type of Building �t ,rl AA No.of Persons Showers( ) Cafeteria( ) t Other Fixtures Design Flow(min.required) 3.O gpd Design flow provided 'Z c1�,-� gpd Plan Date Z--�koeZp(q Number of sheets Revision Date Title 12 S6�F Size of Septic Tank 1 Q0 Type of S.A.S.��, ( -- - Description of Soil Nature of Repairs or Alterations(Answer when applicable) (026c, C)C`S-,.�X2 �` �7 y�G "04� Date last inspected: Agreement: m 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 —T ,tU is Application Approved by ` Date r Application Disapproved by Date for the following reasons Permit No. got 9 35 L- Date Issued 9 -- 1H � ---------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by g:�A(JEX n6� /Ar-> 37- :& otw D(2 0 at Q � C�jrr.- 11) ,+ tj,,eLI Ft has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Q e/q-332- dated �/' " L�`I Oi Installer d A47" yt � -_- 6,�jp jp -_ Designer—E�jr=tk IM 6, k)&4CS t ' #bedrooms ' 3 Approved design flow _��� gpd The issuance of t is permit shall not be construed as a guarantee that the system will design �Vlttlj ed. Date I I� Inspector ---------------------,-------------- ----------------------------------------------------------------------------------------------- No. o!! / 7 3 91 - . . Fee�( THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal bpstrm Construction Permit Permission is hereby granted to Construct( ) Repair O Upgrade( ) Abandon( ) System located at Q .C7y%X bd=li Ci IT-7—� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. �^` Date —1 t Approved by 11. "r �- � V © v -Steve Goulet From: PETER MCENTEE <peter.mcentee@gmail.com> Sent: Tuesday, September 03, 2019 11:02 PM To: Steve Goulet Subject: Fwd: 18 Stoney Cliff Rd See forwarded message ---------- Forwarded message --------- From: Karle,Darcy<Darcy.Karleng,town.barnstable.ma.us> Date: Wed, Aug 21, 2019 at 10:23 AM Subject: RE: 18 Stoney Cliff Rd To: PETER MCENTEE <peter.mcenteeggmail.com> Hi Peter, No,you can proceed with the work. Not a big deal. Thank you for asking. Darcy From: PETER`MCENTEE [ma i Ito:peter.mcenteeCabgmail.com] Sent: Tuesday, August 20, 2019 9:04 AM To: Karle, Darcy Subject: 18 Stoney Cliff Rd Darcy, I am inquiring to see if an RDA would need to be filed for trenching a pipe fro the existing septic tank to another septic tank, in series. New tank is located outside the buffer and the only work would be trench work within the buffer through the existing lawn area. behind the deck. Thanks - Peter see attachments Peter T. McEntee PE - Principal Engineering Works, Inc. 12 West Crossfield Road Forestdale, MA 02644 Tel/fax (508)477-5313 • 1 i Town of Barnstable o��rle row RegulatorNr Services hWi Bnnxtvsrast•s, Richard V. Scali, Interim .Director b9•� 5. Public Health Division n+ O 7 ♦0 plE° A�a Thomas McKean,Director 200 Main Street,Hyannis,-Vi A 02601 Office: 505-£62-4644 Pas: 508-790-6304 Installer&Designer Certification Form Date: `� `�`�_� Sewage Permit# ��(�_°^ 33 Assessor's i�aplParcel �°1 —C31 Designer: 'c C l ►e-e i �1��r nQ t.�ls��b.�lwtC Instal.ler:C Address: )2.. /c/ Rol _-..._ Addiess: 1.4 3 Ce,v�tY-e�rCi tr. ST- On �c�e w�e�6er))ZA 4&9xas sued a permit to install a !date) (insta septic system at. �` cS're+ne�. Ct,� �� �- J _ based on a design drawn by (address) y � c r Lc.s I� dated_�Zo (des.tgner) _�C_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-tile distribution box and/or septic tank Strip out (if required) ivas inspected and the soils Were found satisfactory. I certify that the septic system referenced above aras installed Nvith major changes (i.e. greater than 10' lateral relocation of the SAS or aj.-iy vertical relocation of any component bf the septic system) but in accordance with State cC Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(ifrequired)was inspected and the soils were found satisfactorv. t certify that the system referenced above was constructed in 1 < . with the teTlns Of the I\A.approval letters (il'applicable) �1a ►�ss'�.yv (Tl taller's Signat e) �'Lr.E iL No.35109 (Designer's Signature) (Affix Desi(yne F ere) PLEASE RETURN TO BARNSTABLE PI TBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WJLL NOT BE ISSUED UNTIL N(-' 1 THIS I.ORNI AND AS- BUILT CARD ARE DECEIVED BY TFIE BAR STABLE PUBLIC REALTI-) DIVISION.THANK YOU. . Q:'Scp1ic'dJesi9ner Certification form Rev S-14-13.doe Engineers note:This certification is limited to an as-built inspection of system components as installed prior to backfili:The engineer did nut supervise construction of the system.The inst211er ssurnes resuonsib+fly for all mafarials,workmanship:backftlling to specified grades with proper compaction and setting risers'covers as shown on the design plan. TOWN OF BA,,INSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ; IyI n r:�10ea SEPTIC TANK CAPACITY ;-do LEACHING FACILITY: (type) 44 /011- /!T64c' (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE ;� .-1 - S COMPLIANCE DATE: 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 leaching facility) Feet Furnished by - C f t 133 G� -- {. No. S� G l Fee _25-a �D THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migogof *ppMem Conttruction Permit Application for a Permit to Construct( )Repair( )Upgrade(V)Abandon( ) D5Complete System ❑Individual Components Location Address or Lot No. I f3 5—tONI:ICti rc— i( Owner's Name,Address and Tel.No. Assessor's Map/Parcel l Olt ,- v N o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 73 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow I—Z7Z,C2 gallons per day. Calculated daily flow `3�� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ( S CM G,,�� --A nn0tn� Type of S.A.S. "\ ` stso s Description of Soil AlW�JC larwp Nature of Repairs or Alterations(Answer when applicable) =W \S" ST. —Z>-•—%Ps6-"C VILA— C,A K_7v— o a c Sro moo- _a (w! Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has o Signed Date Application Approved by Date "y" Application Disapproved for the following reasons Permit No. r �� Date Issued `— �. i rr 1 .• ,[� �y No. `y s Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 21pplication for �Dizpogar *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) Complete System El Individual Components Location Address or Lot No. ,9 5—k oN F Y (i ft ` Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1 8L�, r� 01---_ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Ay V�t CJ�CFA� S'e t'Jtir C_ y Type of Building: 1 Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons d Showers( ) Cafeteria( ) Other Fixtures C, Design Flow gallons per day. Calculated daily flow 1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank A\\(j v_� Type of S.A.S. t`k Vic, f C 11 t L'Cvc.'�o(� Description of Soil S1 .Nature of Repairs or Alterations(Answer when applicable) W `�3 \.5:4?� �a < < - off Date last inspected: _ Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has4een-i5 ed o Signed Date /(D - -50 Application Approved by Date Application Disapproved for the following reasons r ool Permit No. d Date Issued. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ,. Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( 1/) Abandoned( )by t —QA QG S l:0�ti C._ at 5 T Otj E Y G = CJ2 ccrcl t°.U4 f_. has been constructed in accordance✓ with the provisions of Title 5 and the for Disposal System Construction Permit No. / dated Installer Designer The issuance of this permit shall not b construed as a guarantee that the system ill function as designed. Date 3 - / !/ Inspector THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS - -�— mi5pd5a I *pgtetn Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(C.�andon( ) System located at 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 nit. Date: / ` - Approved 10/9/97 -------------- NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. { CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated A? V;)4zo-2 , concerning the property located at ST U-t° �ot.Tev. meets all of the following criteria: /There are no wetlands located within 100 feet of the proposed leaching facility (!• There are rid private wells within 150 feet of the proposed septic system /There is no increase in now and/or change in use proposed i /- There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will nm be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. _. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater.Table Elevation(according to Health Division well map) 16° 0-0 SIGNED: DATE: ' LICENSED 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]. q:health rolder.can I, - L CU U • r - ,t i � f Y _i t Town of Barnstable Barnstable Inspectional Services Department 1&1caC ft BARNBTABLE, 639, Public Health Division i6gq. �6 m ply°rA°�s 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 FAX 508-790-6304 Thomas A.McKean,CIAO CERTIFIED MAIL#7015 1730 0001 4987 9705 June 26, 2019 HOLIGAN, IRENE & DONALD J& RACHEL L 18 STONEY CLIFF ROAD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 18 Stoney Cliff Road, Centerville,MA was inspected on 05/30/2019 by Sean M. Jones, certified Title V Septic Inspector for the State of .Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas r dean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Failed or Needs Further(valuation Letters\18 Stoney Cliff Roil Centerville.doc i Town of Barnstable 9�A 6 9 1. Inspectional Services Department rfD MA'S Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS OW 1 YEAR DEADLINE CRITERIA tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts ra Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information �� filling out forms /3 on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. Lane � Company Address Centerville Ma 02632 City/Town State Zip Code � 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ® Fails 5/30/2019 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 1 of 18 / L� �/ V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. Cityrrown State Zip Code Date rof Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® ❑ 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 L c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): t DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): UO gpd Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface'Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is Centerville Ma 02632 5/30/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: system installed 12/3/98 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks or blockages. Vented through roof t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owners Name information is required for every Centerville Ma 02632 5/30/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? opened covers and tookmeasurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank was structurally sound. water level was even with outlet invert, tank was not leaking. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stoney Cliff Road v Property Address Donald Holigan Owner Owners Name information is required for every Centerville Ma 02632 5/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts r9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 2" 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.): Distribution box was videon inspected from tank and found with water level 2" above outlet invert. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. was video inspected through d-box. Water level was 2" above outlet invert in d-box, pipe between d-box and leaching facility had standing water all the way into chamber due to hydraulic overloading resulting in a failing inspection. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts w� Title 5 Official Ins ection Form p r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 6o. D � � Z • /fir( 3� 13c i 'j2 Llv f3Z ► 2 'F3 K2 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was not established Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Stoney Cliff Road Property Address Donald Holigan Owner Owner's Name information is required for every Centerville Ma 02632 5/30/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Town of Barnstable Health Inspector pU'THE Tqy� Regulatory Services Office Hours 8:30—9:30 �.� Thomas F.Geiler,Director 3:30—4:30 K STABLE, Public Health Division v g 1639. A�O� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE Date: 2009-05-22 1. General Information: Size of Property: 0.34 Acre Address: 18 STONEY CLIFF ROAD CENTERVILLE MA Map 189 Parcel 018 Name: IRENE HOLIGAN Phone#: 508-775-4633 2a. How many bedrooms exist at your property now? 3 Bedrooms 2b. Are you planning to add any bedrooms? 00 If yes,how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 3 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO If the dwelling is connected to public sewer,skip questions#4 through#9.below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an PUBLIC WATER 7. Is a disposal works construction permit on file? YES 8. If yes,how many bedrooms were approved according to this permit? 3 Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to 2 bedrooms at thi property. Special Conditions: ' !�o ,,,,�� t6an 3 Q6Acaws A&r . Signed: i Date: Q:\GMD-Housmg\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnestyappl.DOC a Commonweotm of Mossochusetts Executive Office of Environmentol Affairs P �(1\ -e64 1 Department of 7 ire t E P Environmental Protection o ti 1 j9 C4 Wllllam F.Wald �j `9� C"Werrwr Trudy AM" Paul Celluccl e U.GoMmor e 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �n/ CERTIFICATION 1+ Property Address: I S"�c� ` C114, (U• G�.,t(-�V'V•(l CAddrew of Owner. Date of inspection: (�/ 3 �l -� a•� Name of Inspector. (If different) I)a wtcl p-0 . ZC7A SIO� 1 Company Name,Address and Telephone Number..'7�V%t.S i.` C—, NL&,v , Xo ?,r4tt S-t, �1, /(4A - CERTIFICATION STATEMENT -MAA S i "lot I certify that I have rsonall S6$-3 3`1- C:)-3 S 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspectoes signet g ) Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30)days of completing this inspection. If the system is a shared system or has a design (low of 10,000 gpd or greater, 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: Check A, B, C, or D: A] SYSTEM.PASSES: I have not found any information which indicates that thecriteriasyste m violates fail ure criteria as defined i any of the . Any failure criteria not evaluated are indicated below. n 310 CMR 15.303 'I B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determin ' ex plain why not) the existing septic tank i The septic tank is metal, cracked, structurally unsound. shows substantial infiltration or exfrmined,ltration, ex tank failure is or by the Board of Health. ns replaced with a Conform imminent. The system will pass inspection if' ing septic tank as approved (revised 11/03/95) I One Wlnter Street • Boston, Massachusetts 02108 • FAX(617) 556-to49 • Telephone (617)29 -UW A " Pnnied on Recycled Paper I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ii CERTIFICATION (continued) Property Address: C (I u Owner. l Date of Inspection: e— ��,a-3�91 BI SYSTEM CONDITIONALLY PASSES )continued) — Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets, or due to a broken, settled or uneven distribution box. The system will pass inspectio Health): n if with approval of the Board of broken pipe(s)are 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 pipets). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CI 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 public health, safety and the environment. to protect the 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 IS FUNCTIONING 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 within 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 leas than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile o from pollution from that facility and the r'6anic compounds el too that the well is Ere y presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm S) OTHER (revised 11/03/95) 2 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ii 11 �TIFICATION (oon"ued) Property Address: I S TO -It 4- C I t u Owner. Date of Inspection: B)SYSTEM CONDITIONALLY PASSES )continued) Sewage backup or breakout or high static water level observed in the distrtbution box u due to broken or obstructed pipets: or due to a broken, settled or uneven distribution boz. The system will pass inspection if(with approval of the Board pipets: Health): of broken pipes)are 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 pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed Cl FURTHER EVALUATION IS RE QUIRED 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 tect the public health, safety and the environment. to pro 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) SAFETY AND THE ENVIRONMENT PUBLIC DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PROTECT THE HEALTH AND — 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 within a Zone I of a public water sul — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ppy wet). — The system has a septic tank and.soil absorption system and is teas than 100 feet but 50 feet a more from a private water supply well, unless a well water analysis for ooliform bacteria and volatile organic compounds indicates that the well is ter mmonia nitrogen and nitrate nitrogen is equal to or leas than 5 ppm from pollution from that facility and the presence of a 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address Owner. Pa^ ^, 4c. Date of Inspection: DI SYSTEM FAILS: 1 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 failure. will necessary be nessary to correct the — Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. — Discharge or ponding of elTluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. — Liquid depth in cesspool is leas than 6" below invert or available volume is less than lf2 day flow. — Required Pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _, Any portion of the 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 is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analvais. If the well has been analyzed to be acceptable, attach copy of well water analysis for coldorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater( System) health and safety and the environment because one or more of the following condtns and the system is a significant threat to public -- the system is within 400 feet of a surface driabng 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) The owner or operator of any such system shall bring the system and facility into full compliance with the requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the De tier informataterion. treatment program Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address 1 f( S11) 7 e Owner. A Data of Inspection: Check if the following have been done: Pumping information Was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates /f,during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. !"CFAs built plans have been obtained and examined. Note if they are not available with N/A. (,Y\ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non•aanitary or industrial waste flow The site was inspected for signs of breakout. X,All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: O �`I'cu n L_ C. Date of Inspection: RFSIDE11rrIAI: FLOW CONDITIONS Design JIow:_ajW yLaons Number of bedrooms:, Number of current residents: Garbage grinder(yes or no): Lp Laundry connected to system(yes or no): 5 Seasonal use(yes or no): .JO 7— ' Water meter readings, if available: Ian date of occupancy: fl d,Ls;., C O M M ERC IAL 11 ND U S TRIAL• Type of establishment: Design flow:___g&uona/day Grease trap present: (yes or no)_ Industrial Wane Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Lan date of occupancy: OTHER (Describe) Lan date of oavpancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yea or not c j If yes, volume pumped: �!E gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system single cesspool Ovorflow cesspool Privy hharedsystem(yes or no) (ifyes, attach previous ins ion records ifan ) Other(explain) C y � APPROXIMATE AGE of all components, date installed(if known)and source of information: l)✓�k n,,,;� Sewage odors detected when arriving at the site: (yes or no) Le (revised 11/03/95) 6 SUBSURFACE SEVYAGE DISPOSAL SYSTEM INSPECTION FORM PART C ( SYSTEM INFORMATION (continued) Property Address: i cS •,,� C Owner. }-/>r✓�/l.� ✓VL/� Date of Inspection: SEPTIC TANK (locate on site plan) Depth below grader Material of co cition:_concrete_metal_FRP_othene:plain) r Dimensions. Sludge depth:_ Distance from top o sludge to bottom of outlet tee or baffle: S 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: ly Comments: (recommendation for pumping, condition ;inlet and outlet tees or baffies, depth of liquid level in relation to outlet invert, structural integrity, evide ce of leakage, etc.) A „, _ l GREASE TRAP._ (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP_otheria:plain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or beffie: Distance from bottom of scum to bottom 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.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S v�• z�� C ` , Owner. �A✓�.�:L �1.4 (... Date of Inspection: , I�L3 h 1 TIGHT OR HOLDING TANK:_ (beau on site plan) Depth below grade: Material of construction:_concrete_metal_FRP_other(esplain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addreaa: skcy Owner. F0. n .L l✓V1..4 �` , Date of Inspection: 1/-1-3/-1 SOIL ABSORPTION SYSTEM (SAS): (locate on arta plan, if possible: excavation not required, but may be appraaimated by non intrusive methods) If not determined to be present, ezplain: Type: leaching pits, number:=L laaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note ndi ion of&oil. signs of hydra c failure, level of ponding, conditio pf vIgetat'on etc.) .` CESSPOOLS:_ (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(oenpool must be pumped as part of inspection) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of oonstruction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic bihue, IMI of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ( SYSTEM INFORMATION (continued) Property Address: C 1 4— ( Owner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: iuchide ties to at least two permanent references landmarks or benchmarks locate all wells within 100, Q. DEPTH TO GROUNDWATER Depth to kPoundwater q * feet method of 45lweE011tion or approximation. o GAJQ �,�;n (revised 11/03/95) 9 i r V Commonwealth of Massachusetts Jolui Grad Executive Office of Environmental Affairs D.E.P. Title V Septic Inspector D epartment of P.O. Box 2119 ' Environmental Protection Te 08) 5 MA 02536 (5(18) 564-6813 f . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART A CERTIFICATION Property Address: 18 Ston liff Rd.Centerville Address of Owner: j - Date of Inspection:11/19198 (If different) �'° j§� 9911 jc^, Name of Inspector John Graci Gulko:340 Main St.Worcester ``s Company Name,Address and Telephone Number: t ` L CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes Conditionally Passes Needs Fu her Ev luation By the Local Approving Authority _ Fails Inspector's Signature: Date: 11N9196 The System Inspector shall su mit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 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: Check A, B.C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as 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 completion of the replacement or repair, passes inspection. Indicate yes, no,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 septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 e FAX(617)556-1049 • Telephone(617)292-5500 1 i v � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 18 StonyCliff Rd.Centerville Owner: Gulko:340 Main St.Worcester Ma. Date of Inspection:11119/96 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 IS FUNCTIONING 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 of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 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 volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER 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. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 18 StonyCliR Rd.Centerville Owner: Guiko:340 Main St Worcester Ma. Date of Inspection:11119196 D] SYSTEM FAILS(continued) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped 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 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. 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 large systems in addition to the criteria: The system serves a facility with a design flow of 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 (IWPA)or a mapped 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. (revised 11115195) 3 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 18 stonycllftRd.Centerville Owner: Gulko:340 Main St Worcester Ms. Date of Inspection:11/19196 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the 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. n1aAs built plans have been obtained and examined. Note if they are not available with NIA. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 18 StonyCllft Rd.Centerville Owner: Gulko:340 Maln St Worcester Ma. Date of Inspection:11119196 FLOW CONDITIONS RESIDENTIAL: Design flow: 0 gallons Number of bedrooms: 2 Number of current residents: 3 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: n1a Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n1a Last date of occupancy: n1a OTHER: (Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped In 1990 System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1200 gallons Reason for pumping: cesspools TYPE OF SYSTEM Septic tank/distribution box/soil absorptions system x Single cesspool x Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: Late 1960's Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 8tonycllff Rd.centervllle Owner: Gulko:340 Main St Worcester Ma. Date of Inspection:11119196 SEPTIC TANK:_ (locate on site plan) Depth below grade: n1a Material of construction:x concreate_metal_FRP_other(explain) Dimensions: n/a Sludge depth:n/a Distance from top of sludge to bottom of outlet tee or baffle: n1a Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:nla Distance form bottom of scum to bottom of outlet tee or baffle: n1a 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.) rda GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n/a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a 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.) n1a (revised 11/15195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 StonyClllr Rd.Centerville Owner: Gulko:340 Main St.Worcester Ma. Date of Inspection:11119/96 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_other(explain) Dimensions: n1a Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nla DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Iva Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n1a PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) ` Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 StonyCliif Rd.Centerville Owner: Gulko:340 Main St Worcester Ma. Date of Inspection:11119196 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: nla Type: leaching pits, number: nla leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number,length: n1a leaching fields,number, dimensions:n1a overflow cesspool,number:6'x6' Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The overflow was empty at the time of the inspection.It is structurally sound. CESSPOOLS: x (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert: 1" Depth of solids layer: 5" Depth of scum layer: 3" Dimensions of cesspool: 6'x6' Materials of construction: block Indication of groundwater: none inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Main cesspool and all components are structurally sound.Recommend pumping system every year for maintenance. PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PrivyComments (revised 11115195) B SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 StonyCliff Rd.Centerville Owner: Gulko:340 Maln St.Worcester Ma. Date of Inspection:11/19/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within'100' A 1614 i RA 4� � 01 DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9 L� 3/ / / �b 0 18 Stoney Cliff Dr Centerville, Holigan Kk s `4 WAS `. 8lIt�C A, 0 p .1. CD N n ® F Nouset Ln v Tomahawk �t 0 as Powderhorn Way o q G� t.,nel ��NA� Dee wood SET 5 EL.=100.26 ND 102,60 clr LOCUS N g'tchill w V-0 o 102,09 0 Route 28 102.51 LOCUS MAP 4 NOT TO SCALE \ — EXISTING CONTOUR . 100.98 EXISTING SPOT GRADE PROPOSED CONTOUR l e 01 ��;. PAVED .' :'. .::: —Wy EXISTING WATER SERVICE DRIVE .:J TBM2/PK SET ed 10 31 `� �:..... —G EXISTING GAS SERVICE 100.26 \ la`+ —�.fl:W.—OVERHEAD WIRES \rL \ \ ` WETLAND SYMBOL 22 ( 12.130 WF-12 WETLAND FLAG 101.72;:.. \ TEST PIT fiP -_N BENCHMARK G� \ 991. �. ...: P500 1.43 01. 9\ \ •, 4TP-1 G \\ ' l �•�•� LEGEND GARAGE �cP•t." /• EXISTING S.A.S. VENT 101.18 . y. TO BE ABANDONED ,y EXISTING 0 SHALL `s' HOUSE( 18) 100,E T.O.F.=101.9E \0o 00 APPROVED ._ BY OWNER 99, �0��%' 9 .00.O. 0 +5.le• O EXISTING SEPTIC TANK 062 (1500 GAL—TO REMAIN) D % x 98,6,6 INV.(0UT)=97.10t(VERIFY) BM OR, ECK i ��. 98,70 x / 1 .27 i 96.48 x 0 99.50 / i �" OR./DECK 00, 00. _ x ' � _ O O �i/ EL.=102.27 94.40 6 x PROPOSED SEPTIC TANK 95.54 / 93,0,k,- —— 1000 GALLON CAPACITY(H-10) / BVW101 BOA / / 92.11 ��F� // /// 86.23 x /„/ B85 8102 0 LOT 1 610000 / 4BVk,(10)3 ,ABANDONED 15,000±SF / \A / 8-85.82 CRANBERRY BOG � + 87,32 . 1 x 87.62 ` BVW104� 86.35 1, / BVW04 �� \ / —85-98--" ` \ 88.27/ /�•� \ ` BVW10N j/ / zk_ �•� �86.28\ BV963 BVW05 __ 85.20 Ay � --, ` BVW106 OF M.4S OF / VEGETATED '086,20 / BVW02 WETLAND o PETER T. �, G McENTEE U CIVIL No. 35109 BVW01 FCISTE � �� 87.99 PARCEL ID: 189-018 FEMA FLOOD DESIGNATION PROPOSED SEPTIC SYSTEM UPGRADE PLAN NON HAZARD �t?��1� 18 STONEY CLIFF ROAD, CENTERVILLE, MA WETLAND CONSULTAN Prepared for: Donald Holigan, 50 Megan Rd, Hyannis, MA 02601 T MARSH MATTERS ENVIRONMENTAL OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO. HOLIGAN, IRENE & DONALD J, Engineering Works, Inc. P.O. BOX 554 & RACHAEL L g g t"=20' P.T.M. 212-19 978-4 4-1ALE, MA 02644 12 West Crossfield Road, Forestdale, MA 02644 DATE 978-434—.1228 18 STONEY CLIFF ROAD CHECKED SHEET NO. CENTERVILLE, MA 02632 (508) 477-5313 8/20/19 P.T.M. 1 of 2 v NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL: 95.3 FOR A DISTANCE OF 15' AROUND THE SEPTIC TANK PROPOSED D-BOX PERIMETER OF THE S.A.S. INSTALL RISERS & COVERS OVER THE INSTALL RISER & COVERS PROPOSED S.A.S. INLET & OUTLET AND SET TO WITHIN AS REQ'D AND SET TO 6" OF FINISH GRADE. WITHIN 6" OF GRADE. INSTALL RISER & COVER OVER ONE CHAMBER AND SET TO WITHIN 6" OF FINISH GRADE, TO SERVE AS INSPECTION PORT. F.G. EL.=99.8t F.G. EL.=98.3t F.G. EL.=100.8t F.G. EL.=101.1t CHARCOAL VENT L = 65' L = 48' L = 5'(MAX.) �4"SCH40(PVC) �4"SCH40(PVC) ®"SCH O(PVC) 2" LAYER OF 1/8" TO 1/2" s" DOUBLE WASHED STONE top INV= to"I 14' a 2' EFF. eaeaaaaa (OR APPROVED FILTER FABRIC) 95.75 48" LIQUID DEPTH aaaaaaa -3/4" TO 1-1/2" DOUBLE LEVEL 4' 4.8' 4' WASHED STONE cAs ADDFFLE GAS BAFFLE INV.=95.02 INV.=94.85 PROPOSED D-BOX EFFECTIVE WIDTH = 12.8' ISTI G INV.=95.50 H-20 INV.=94.80 SEPTIC PROPOSED H-10 SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS TANK (approved plastic alternate may be used) SURROUNDED WITH STONE AS SHOWN INV.=97.10t H (EXISTING) -20 RATED TOP CONC. ELEV.=95.9 Al NOTES: 1) SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND BREAKOUT ELEV.= 95.30 FF B INV. ELEV.= 94.80 aaa am TRUE TO GRADE ON A MECHANICALLY COMPACTED aaaaa aaaaa 6 INCH CRUSHED STONE BASE, AS SPECIFIED IN aaaa aaaaa 310 CMR 15.221(2). BOTTOM ELEV.= 92.80 4' 2 x 8.5'=17.. ' 1 4' 2) INSTALL INLET & OUTLET TEES AS REQUIRED. 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH O 25.0' 3) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE PERVIOUS MATERIAL AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. 5' (MIN.) ABOVE G.W. 4) MAXIMUM COVER OVER SEPTIC TANK, D-Box & S.A.S. LEACHING SYSTEM SECTION SHALL BE 36". NO G.W., EL.=88.6 EST. HIGH G.W., EL.=86.0t(BOG SURFACE) SEPTIC SYSTEM PROFILE GENERAL NOTES: ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 1 BOARD OF HEALTH AND THE DESIGN ENGINEER. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 2 OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE EXISTING LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: -310 CMR 15.405(1)(b): GARAGE H0USE(#18) 1) A 5' variance, S.A.S. to cellar wall„ for a 15' setback. // 2) A 1' variance to the 3' maximum cover requirement, for 4' of cover over septic tank. Tank shall be H-20 rated. FRONT 3) A 2' variance to the 3' maximum cover requirement, for up to 5' of max. cover. S.A.S. shall be H-20 and vented. LP 31 THE SEWAGE DISPOSAL SYSTEM SHALL "NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE ?�. 44.4'�5� DESIGN ENGINEER. tv 4. ANY CONDITIONS .ENCOUNTERED DURING CONSTRUCTION DIFFERING `S/ FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN � 0��"D �- ENGINEER BEFORE CONSTRUCTION CONTINUES. I� 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. PROP. S.A.S. CN 110 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF \ I'- THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 25,-- 1~--- 8. THERE ARE NO WELLS WITHIN 100' OF THE PROPOSED S.A.S. SEPTIC LAYOUT 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING SOIL LOG CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS DATE: MAY 26, 2019 (REF# TPT 19-65) IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND SOIL EVALUATOR: PETER McENTEE PE(SE#1542) REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). WITNESS: DAVID STANTON R.S. HEALTH AGENT 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE ELEV. TP-1 DEPTH ELEv. TP-2 DEPTH INSPECTED BY A LICENSED SOIL EVALUATOR PRIOR TO BACKFILL. 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 101.1 A 0 101.1 A 0" IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. LOAMY SAND LOAMY SAND 100.4 10YR 4/2 100.4 10YR 4/2 B 8, a 8„ DESIGN CRITERIA LOAMY SAND LOAMY SAND _ NUMBER OF BEDROOMS: 3; 2 (HOUSE) + 1 (APARTMENT) 98.4 10YR 5 6 / 10YR 5 6 32" 98.6 30" PERC SOIL TEXTURAL CLASS: CLASS 1 30"/48" DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 330 G.P.D. F-M SAND F-M SAND 2.5Y 6/6 2.5Y 6/6 DESIGN FLOW: 330 G.P.D. GARBAGE GRINDER: NO-not allowed with design LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF 88.6 150" 88.6 150" EXISTING SEPTIC TANK: 1500 GALLLONON CAPACITY 74 GPD PERC RATE <2 MIN/IN. "C" HORIZON PROPOSED SEPTIC TANK: 1000 GALLON CAPACITY NO GROUNDWATER ENCOUNTERED PROPOSED D-BOX: 1 INLET, 3 OUTLETS, H-10 RATED USE 2-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 18 STONEY CLIFF ROAD, CENTERVILLE, MA SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: Donald Holigan, 50 Megan Rd, Hyannis, MA 02601 BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO. TOTAL AREA:.............................................................. 471.2 S.F. Engineering Works, Inc. N.T.S. P.T.M. 212-19 DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 8/20/19 P.T.M. 2 of 2