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Home My WebLink About0046 STONEY CLIFF ROAD - Health '46 Stoney Cliff Road Centerville P j A = 189 015 j 6 *Pendaffwr *AsSe% ` 1521/3 ORA 10% P2 ii TOWN/OF BARNSTABLE L(.JCATION 5TO�Y�YCC � SEWAGE # 6c� VILLAGE _ �f��S�j L-e— ASSESSOR'S MAP & LOT �� "0/S INSTALLER'S NAME&PHONE NO.,", SEPTIC TANK CAPACITY M t LEACHING FACILITY: (type) 30 S-TN1C( (size) NO. OF BEDROOMS BUILDER OR OWNER t—OCiC PERMITDATE: III , J'L COMPLIANCE DATE: L -1— 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 � ��c-1L. � �< _ \ � O O /, i i g'� �!, � 5, �: tea, ' f Commonwealth of Massachusetts /16 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r 46 STONYCLIFF RD �z7y Properly Address NOWAK Owner Owner's Name information is CENTERVILLE required for MA 02632 7/1/08 every page. Clty/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. ImpoWhen filling A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do use the em tut Name of Inspector key. D.A. BROWN Company Name tab P.O. BOX 145 Company Address Im II CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the insp? ction. T inspection was performed based on my training and experience in the proper function and maiptenanci�f o"Ite sewage disposal systems. I am a DEP approved system inspector pursuant to S6ction t5�340:& Title 5(310 CMR 15.000).The system: I ® Passes ❑ Conditionally Passes ❑ Fail—sr". ❑ Needs Further Evaluation by the Local Approving Authority ` tv 1710 7/1/08 _.. Inspector's ture Date The sy em inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is CENTERVILLE required for MA 02632 7/1/08 every page. Clty/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: SYSTEM MEET MINIMUM PASSING REQUIREMENTS AT THIS TIME B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2-of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is CENTERVILLE required for MA 02632 7/1/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 • 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is CENTERVILLE required for MA 02632 7/1/08 every page. City mown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 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. 0 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Title V Inspection Form.doc•08/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is CENTERVILLE required for MA 02632 7/1/08 every page. Cl mown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'y( 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is CENTERVILLE required for MA 02632 7/1/08 every page. Cltyrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® F-1 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)] Title V inspection Fonn.doc•0&06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is required re wired for MA 02632 7/1/08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 06-222/07-126 Sump pump? ❑ Yes ® No Last date of occupancy: UNKNOWN Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Tide V Inspection Fonn.doc•08106 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 't 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is CENTERVILLE required for MA 02632 7/1/08 every page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) General Information 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: 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) ❑ 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 IN 2002/OFF AS BUILT CARD FROM B.O.H Were sewage odors detected when arriving at the site? ❑ Yes ® No Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '< 46 STONYCLIFF RD Property Address NOWAK Owner owner's Name information is required for CENTERVILLE MA 02632 7/1/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: .5 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: 1500GALLON Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle @3FT Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Title V Inspection Form.doc•06106 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is required for CENTERVILLE MA 02632 7/1/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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.): 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): Title V Inspection Form.doc•08/06 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is CENTERVILLE required for MA 02632 .7/1/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cant.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title V Inspection Fonn.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is CENTERVILLE required for MA 02632 7/1/08 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NO OBSERVATION PORTS Type: ❑ leaching pits number: ® leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE Title V Inspectlon Form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is required for CENTERVILLE MA 02632 7/1/08 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): Title V Inspection Form.doc•08/06 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments •''y 46 STONYCLIFF RD Properly Address NOWAK Owner Owner's Name information is CENTERVILLE required for lty/Town MA 02632 7/1/08 every page. C State Zip Code Date of Inspection D. System Information (cunt.) 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. A . [ 1 Title V Inspection Form.doc•OWN Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 STONYCLIFF RD Property Address NOWAK Owner Owner's Name information is CENTERVILLE required for MA 02632 7/1/08 every page. Crtyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to 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: Title V Inspection Form.doc•0&06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 I Town of Barnstable ' CF ZHE Tp� " Regulatory Services snxxsrnece, : Thomas F. Geiler,Director 7V MASS, prf16 9. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIC\Disclaimer Private Septic lnspections.DOC ��. 2goo COMMONWEALTH OF MASSACHUSETTS z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTE_CTIO-- F-C V E D o,,M Ste MAY 1 0 2005 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION C""�: Property Address: 46 Stoney Cliff Road Centerville,MA OF Owner: Estate of Raymond Kutil Date of Inspection: April 7,2005 JOHN L. CHURCHILLm JR. Name of Inspector: (please print) John L. Churchill,Jr. P.E. CMS Company Name: JC Engineering,Inc. 41807 Mailing Address: 2854 Cranberry Hi hway East Wareham,MA 02538 / Telephone Number: 508-273-0377 ,� 6S CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Eva ation by the Local Approving Authority Fails Inspector's Signature: Date: 5/3 10,�- The system inspector shall s 't a copy of this i ection report to the Approving Authority(Board of Health or DEP)within 30 days of co leting this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments The System passes,installed in 2002. ****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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 46 Stoney Cliff Road Centerville,MA Owner: Estate of Ravmond Kutil Date of Inspection: April 7,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): ti broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 Stoney Cliff Road Centerville,MA Owner: Estate of Raymond Kutil Date of Inspection: April 7,2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 • 1 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 Stoney Cliff Road Centerville,MA Owner: Estate of Raymond Kutil Date of Inspection: April 7,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This 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.l NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46 Stoney Cliff Road Centerville,MA Owner: Estate of Ravmond Kutil Date of Inspection: April 7,2005 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period'? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X — Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site`? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum? _ _ 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 X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 46 Stoney Cliff Road Centerville,MA Owner: Estate of Raymond Kutil Date of Inspection: April 7,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no):_ Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 189(2003) 167(2004) Sump pump(yes or no): NO Last date of occupancy: C OMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 4/26/02 Board of Health Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 i Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Stoney Cliff Road Centerville,MA Owner: Estate of Ravmond Kutil Date of Inspection: April 7,2005 BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: 12" Material of construction: X concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1500 Gallon 10'6"X 5'8" Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 22" Scum thickness: '/2" Distance from top of scum to top of outlet tee or baffle: 8 ''/2" Distance from bottom of scum to bottom of outlet tee or baffle: 26" How were dimensions determined:Measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): I Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Stoney Cliff Road Centerville,MA Owner: Estate of Raymond Kutil Date of Inspection: April 7,2005 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/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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Slight solids carryover,39"BGS to top,recommend installation of riser to within 6"of grade. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 i Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Stoney Cliff Road Centerville,MA Owner: Estate of Ravmond Kutil Date of Inspection: April 7,2005 SOIL ABSORPTION SYSTEM(SAS): X(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: X leaching galleries,number: 4 32' long X 9' wide X 2' Eff.Depth leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 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.): Title 5 Inspection Form 6/15/2000 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Stoney Cliff Road Centerville,MA Owner: Estate ofRavmond Kutil Date of Inspection: April 7,2005 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. G &L 1 I 2 A 8 C i Z j`y Z9 7°/ �Z Z, i v 356 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Stoney Cliff Road Centerville,MA Owner: Estate of Raymond Kutil Date of Inspection: April 7,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 13 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 design plan reviewed: X 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: Used level and shot top water elevation in Cranberry Bog at rear of property Bottom SAS to water elevation in Cranberry Bop,is 8' Title 5 Inspection Form 6/15/2000 11 Health Complaints 25-Jun-03 Time: 3:00:00 PM Date: 6/9/2003 Complaint Number: 4087 Referred To: SAM WHITE Taken By: DAVID STANTON Complaint Type: TITLE V SEWAGE Article X Detail: Business Name: Number: 46 Street: Stoney Cliff Village: CENTERVILLE Assessors Map_Parcel: Complaint Description: septic hole in backyard, is concerned about it. Roberts installed it. Actions Taken/Results: SW attempted to investigate complaint, but no one was home. Business card was left asking to call the Health Dept. SW returned to address to investigate complaint with complainant. Observed a sinkhole near footing of deck most likely over the old cesspool. Mr. Kutil stated that Rodger Roberts installed the system in April of 2002. Mr. Kutil called Rodger Roberts back to fix the hole problem where Rodger filled the hole with dirt from the backyard. Mr. Kutil has now called Rodger Roberts back a second time for the same problem and when he stated he would do the same thing, Mr. Kutil stated he would not allow him to dig up more soil from the backyard and that he would have to tell the Health Division about the problem. Rodger Roberts then apparently stated that he refused to come back again to fix anything. SW will contact Rodger . Roberts via order letter to correct the problem. Per Tom McKean, the Health Dept. will require Rodger Roberts to put more soil into the sinkhole. Rodqer Roberts will call the Health 1 Health Complaints 25-Jun-03 Dept. when he is doing this so that the Health Dept. can witness the work being done. Investigation Date: 6/11/2003 Investigation Time: 3:30:00 PM 2 Health Complaints 12-Jun-03 Time: 3:00:00 PM Date: 6/9/2003 Complaint Number: 4087 Referred To: SAM WHITE Taken By: DAVID STANTON Complaint Type: TITLE V SEWAGE Article X Detail: Business Name: Number: 46 Street: Stoney Cliff Village: CENTERVILLE Assessors Map_Parcel: Complaint Description: septic hole in backyard, is concerned about it. Roberts installed it. Actions Taken/Results: SW attempted to investigate complaint, but no one was home. Business card was left asking to call the Health Dept. Investigation Date: 6/11/2003 Investigation Time: 3:30:00 PM F- 1 a TOWN OFBARNSTABLE � LOCATION / (o /D/Y�YCIY ��d SEWAGE # QG VILLAGE �`"titlTC�/l�l�I SESSOR'S MAP & LOT �� d�J INSTALLER'S NAME&PHONE N0 SEPTIC TANK CAPACITY LEACIIII�IG FACILITY: (type) sOtS�fut!��(�`i�rUf?S(size) S�� X�• NO. OF BEDROOMS BUILDER OR OWNER. M-O JkDA PERMITDATE: l 1 b2. COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by � Q tea, r , FORM 11 - SOIL EVALUATOR FORN Page 1 of No.: Date: 4/15/02 COMMONWEALTH OF MASSACHUSETTS Barnstable , Massachusetts Performed By: Carmen E. Shay Date: 4/15/02 Witnessed By: Waiver— Per Barnstable BOH Location Address or #46 Stoney Cliff Road, Owners Name: Rita Lockwood Centerville,MA Address: 46 Stoney Cliff Road, Centerville Lot# Map 189 Lot 015 MA 02632 New Construction : Repair : X Telephone Number: 508-648-5310 OFFICE REVIEW: Published Soil Survey Available: No ❑ Yes ❑ Year Published: Publication Scale: Soil Map Unit: Drainage Class: Soil Limitations: Surficial Geologic Report Available: No❑ Yes❑ Year Published: Publication Scale: Geologic Material: (Map Unit): Landform: Glacial Outwash Flood Insurance Rate Map: Above 500 Year Flood Boundary: No ❑ Yes X❑ Within 500 Year Flood Boundary: No Fx_1 Yes ❑ Within 100 Year Flood Boundary: No ❑ Yes ❑ Wetland Area: None Observed National Wetland Inventory Map (map Unit): Wetlands Consercancy Program Map (map unit): Current Water Resource Conditions (USGS): Month Range: Above Normal E Normal ❑ Below Normal ❑ Other References Reviewed: USGS Topographic Map DEP APPROVED FORM 12/7/95 FORM 11 — SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No.: #46 Stoney Cliff Road, Centerville, MA On -Site Review Deep Hole Number: #1 Date: 4/15/02 Time: 9:00 PM Weather: Sunny,Warm, 65OF Location (identify on site plan): Refer to Sketch Landform: Outwash Plane Position on Landscape (sketch on back): Refer to Sketch Distances From: Open Water Body N/A feet Drainage Way N/A feet Possible Wet Area N/A feet Property Line 25' feet Drinking Water Well N/A feet Other N/A feet DEEP OBSERVATION HOLE LOG Depth From Soil Soil Soil Soil Other Surface Horizon Texture Color Mottling Structure, Stones, (inches) (USDA) (Munsel) Boulders, Consistency, % Gravel 0" — 5" A Sandy 10 YR 3/2 None Friable Loam 5" — 35" Bw Sandy 10 YR 5/6 None Friable Loam 15% Gravel 35" — 168" C1 Sand 2.5 Y 7/4 None Medium Sand, 5% gravel/cobbles, Loose 35" — 168" C2 Sand 2.5 Y 6/3 None Med-Fine Sand, 5% gravel/cobbles, Loose 35" — 168" C3 Sand 2.5 Y 7/3 None Med. - Coarse Sand, 5% gravel/cobbles, Loose Parent Material (Geologic): Glacial Outwash Depth to Bedrock: N/A Depth to Groundwater: Standing Water in the Hole: None Weeping From Face: N/A Estimated Seasonal High Water Table 168"Assumed FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No.: #46 Stoney Cliff Road, Centerville, MA Method Used: Determination of Seasonal High Water Table ❑ Depth observed standing in Observation Hole: inches ❑ Depth weeping from side of Observation Hole: 168" inches (assumed) ❑ Depth to Soil Mottles: inches ❑ Groundwater Adjustment: None feet Index Well Number: Reading Date: Index Well Level: Adjustment Factor: Adjusted Groundwater Level: N/A DEPTH OF NATURALLY OCCURING PERVIOUS MATERIAL: Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system: Yes CERTIFICATION: I Certify That on September 17, 2000, (date), I have passed the soil evaluators examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature: Date: S DEP APPROVED FORM 12/7/95 FORM 12 - PERCOLATION TEST Location Address or Lot No.: #46 Stoney Cliff Road COMMONWEALTH OF MASSACHUSETTS Centerville , Massachusetts Percolation Test Date: 1/14/02 Time: 9:53 AM Observation Hole #: ##1 #1 Depth of Perc 42" Start Pre-soak 9:53 End Pre-soak 10:00 Time at 12" Will Not Hold 24 Gallon Presoak Same Time at 9 Time at 6" E (9-6") Min./inch < 2MP1 Assumed @ 42 " Same * Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Performed By: Carmen E. Shay Witnessed By: Waiver per BOH Comments: Would Not Hold 24 Gallon Presoak - <2 MPI Assumed (a- 42" Site Passed X Site Failed DEP APPROVED FORM 12/7/95 S-ep-20-01 13:52 BARNSTABLE . HEALTH DEPT 5087906304 P.02 5/25lQ1 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AIND SOIL EVALUATION EXEMPTION FORM 1, C��Gi� S"+)Y hereby certify chat the engineered plan signed by me dated concerning the property located at a6�Qo 4 Cl t meets all of the following c nterla: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is ciassired as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fac; or may conduct preliminary, tests at the si,e without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen .(14) feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicabtel Please complete the following: Al Top of Ground Surface Elevation (using GIS information) 4-o-co B) G.W. Elevation O Q_+ adjustment for nigh G.W. DTFEREENCE. B ET'vVEEN A and B (�J S1G�fED : DATE: 4 IS C)a v TICS Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered sepc system plans. q:h:_IIh lrldcf perccxmp Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 1 Lot No. Owner TAG L0C} W00 Address: _�fN MC_ i Contractor: u*11w 9_Nu, Address: (-a-4 L• 4�t(�C.L1'�'� Notes: STEP 1 Measure depth to water table tonearest 1/10 h. .............................................................................. Date mon May/year I STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: i O Appropriate index well.................................................... iW I OWater-level range zone STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to I, water level for index well ........................... I mo h/yea I I i 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 28) i determine water-level adjustment .......................................................................................... I STEP 5 Estimate depth to high water by subtracting the water. level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ............................................................................................................. I i I f � CARMEN E. SHAY (508)-548-0796 ENVIRONMENTAL SERVICES, INC. P.O. Box 627,East Falmouth, MA 02536 April 26, 2002 RE: Certification of Title V Septic System Installation: Residential Property—46 Stoney Cliff Road, Centerville MA Dear Sir or Madam: On April 24, 2002, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at, 46 Stoney Cliff Road, Centerville, MA, based on a design drawn by Shay Environmental Services, Inc, dated, April 15, 2002. I Certify That The Septic System Referenced Was Installed Substantially According to the Plan I Certify That the Referenced Above Septic System Was Installed With Changes but in Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow. The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is Required. If you have any questions, please do not hesitate to call the undersigned at (508)-548-0796. Sincerely, CARMEN E. SHA Y ENVIRONMENTAL SERVICES,INC. CArZi,9EN GJ S � � HAY . 1a1 Carmen E. Shay, R.S., C. �o President s T ti.R S�+N17A�a FEE COMMONWEALTH OF MASSACHUSETTS Y � Board of Health, s �� MA. APPLICATION fOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - XComplete System ❑Individual Components Location 4 C I t wner's Name Map/Parcel# I B 9 /5 Address 't\ke Lot# A Telephone# Installer's Name - Designer's Name ` S� cs- Address Address MA 4�53� Telephone# 5o6 UX46 -53\0 Telephone# Type of Building �1'- ��a2�CY�1d� Lot Size sq.ft. Dwelling-No.of Bedrooms o1 exys+% s, " Garbage grinder (A�/j'} Other-Type of Building 1 'l'�Q\ No.of persons ( Showers 00,Cafeteria (V� Other Fixtures L4fW A32g�A K%kCk QS> 1S t nl I~ . LDJQC1Xr A Design Flow (min.required) 2A gpd Calculated design flow 3ZC�j Design flow provided 33n-4R gpd Plan: Date �1 15 1 EQ Number of sheets I Revision Date Title u C Description of Soil(s) F130. vc:'�O Soil Evaluator Form No. T�o� Name of Soil Evaluator_ E1J �hKY`� Date of Evaluation �Jr DESCRIPTION OF REPAIRS OR ALTERATIONS DESIGNI 1 %-AUr & 6; iON AND CERTIPI INWRITING THE SYSTEM WAS INSTALLED IN STRICT ACCORDANCE TO PLAN. The unders ed a ees to install above described Individual Sewage Di osal S stem in accordance with the provisions of TITLE 5 and further a �@ o lace th e n until a Certificat om 'nnc as been issued by the Board of Health. Signed Date 6 In:�p ions Gfo ��G�-- No. '�� ✓ 6 9 FEE •->� �i�G 'COMMONWEALTH O MASSNCHUSETTS Z/cs Board of Health, X.c S"TG.�1 MA. APPLICATION FOP DISPOSAL SYSTEM STEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - Complete System ❑Individual Components Location Q_C� �_ •wner's Name TR L i Map/Parcel# I �j' �, Address v Lot# 4F) Telephone# Installer's Name -k5 Designer's Name c, Address Address ": Telephone# 5p8 - U�-3 8 - S�J�U Telephone# SO(?- 548_O�'9Ca Type of Building iC Y-, A2(1��C.� / , Lot Size sq.ft. C�QS1C'ni'1 Dwelling-No.of Bedrooms 11. V Q..X1S'�'-«1G- " � Garbage,grinder 0410 Other-Type of Building No.of,persons yp g d�.S1S 1�CQ.C"1'�c'�.� `r ,p Showers W,Cafeteria (1/f Other Fixtures LG u C`Ai,5%A Design Flow(min.required) 3 gpd Calculated design flow ` J0 Design flow provided gpd Plan: Date A 15 CQ ----} Number of sheets Revision Date Title `E_Sr1 V D C.$ C Ce Description ofSoil(s) A�'Ce G GCy`H� JbA Soil Evaluator Form No. � '� � o� Name of Soil Evaluator S4an`? Date of Evaluation s oa ` DESCRIPTION OF REPAIRS OR ALTERATIONS �C a4C7.CVIQ ��(1 The enders ed agrees to install th above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a to lace the system in o •ion until a Certificat omp'�a�nce as been issued by the Board of Health. a Signed tX?. U/ Dat� (J basper&ons No.f�'��/�/ ,('' NW 11 Of MA�� FEE ,('' �T SYS SITTS Board of Health, MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) Complete System The&dersi ned hereby certify that the Sewage Disp sal System; Constructed ( ),Repaired ( ),Upgraded (/,Abandoned ( ) by: f at 4110 eU CLi has been installed in accordan/ce_w�'ith the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application N 910, L7Rte 10/- PApproved Design Flow✓2.3D (gpd) Installer / ti1/( j) t Designer: Inspector: 41-4 IW. Date: t I ia�1 It r. The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. FEES Board of Health, I 7 MA. DISPOSAL. SYSTEM CONSTRUCTION PERMIT Permission is herebyranted to; Construct("') Repair( ' Upgrade( Abandon( ) an individual sewage disposal system g P Pg . g P / rr 4 at TU ,L/ / ., ,�. as described in the application for Disposal System Construction Per �dated Provided: Construction shall be completed within three years of the datXofth' permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date��,�/--OeBoard of Healt ' , sa'- 0 16'-0" 14'-0" 38'-0" 9'-7 7/8" 10'-4 7 8" 7'-5" 11'-2" 9'-10" 4'-11" �4 14'-0" 16'-0" 10'-6" 00 EXISTING BATH EXISTING DEN/OFFICE of io o � I EXISTING GARAGE EXISITING ENCL05ED FORGH EXI5TING KITCHEN co M o � � ...................... ------------ ...................... 00 I I 0 O i i r----------------r I I i Z N \ I I EXI5TING LIVING ROOM M I I O EXISTING FAMILY ROOM � I 1 i I I I � I I ' O ' I I ' i I I ' 8'-0" L4'—i 1" 7'-0" 7'-1" 7'-1" 7'-0" -'" �J FLRO R ILNA G Z A L E S O�\/ A E 46 STONEYGL I FF ROAD, CENTERV I LLE, MA 5 / DI �L91 � 68'-0" 16'-0" 14'-0" 38'-0" .r 4'-8" 11'-0" 7'-7" 9'-2 15/32" 5'-6 17/32" 0 11'-9" 6'-9 1/2" 7'-6" I M a NEW BATH NEW MASTER BATH NEW WALK—IN CLOSET \ I \ NEW BEDROOM 2 00 ao 0 N - W N - s to r �I NEW BEDROOM 3 W NEW MASTER BEDROOM o N �J I` co Li IJI 16'-11" 5-8" s 14'-3" Q 4 M 4'-11" 7'-0" 7'-1" 7'-1" 7'-0" 4'-11" 0 5 E C. O N D F L O O R F L AN SCALE: 1/8" _ ;i '-O° V A Z A L E 5 R E 5 I D E N G E 46 5TONEYGLIFF ROAD, CENTERVILLE, MA r PRE-ENGINEERED TRU55E5 24"O.G. . ASPHALT SHINGLE 1/2" G.D.X.PLY 12 5� 2/2"X 4"TOP PLATES 2/2"X 6" HEAVERS I CEILING - R 55 BATT5 O ! '€ CONTINUOUS SOFFIT VENTING co SHOW ALL R-VALUES r NEW 5/4" T 3 G ADVANTEK EX151TING 2" X 8" FLOOR, 16"O.G. # { 5/,2" X I2° BEAM VINYL SIDING TYYEK HOUSE WRAP � I/2° O.S.B.SHEATING M 21 X 4"STUDS- Ib"O.G. i s WALL -R 13 2°X 4"BOTTOM PLATE00 FLOOR-R A 16"O.G. 2° X b"P.T.SILL SILL SEALER-6" 4'BELOW GRADE IO" ANCHOR BOLTS-6'O.G. 4" SLAB W POURED CONCRETE WALLS COMPACTED GRAVEL 10"X 20"SPREAD FOOTING 7 } S G T I O N , 5GALE: 1/5" = 1 '-O" V A Z A L E S R r=; I D E N G 46 5TONE%r 0L I FF ROAD, CENTERV I LLE, MA SECTION A -A 10' min. from 'NOTE: ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C. ALL OUTLET hats FROM THE Existing Foundotion house to septic took PROFILE VIER OF ADDITION TO LEACHING SYSTEM DISTtt611TMON BOX SHALL K { Septic tonk covers n%M be SET LEVU FOR AT LEAST 2 FT 12, CONCRETE cov" within 6 in. of finished erode 3' of 1/8" - 1/2" Woshed Peostone P^ Grove over Sepik Tonle - 97.50 �Grode over D-Dox - 96.25 ----Orode over SAS- 96.25 3/4' to 1 1/2 Washed Crushed Stone ,3- S'OUTLET -••+• 2- KNOCKOUTS ' ' 7 -,ss• 12' N4LET SITE go, S 0.02 3 HOLE H-20 t`.` . .. A,ntFt hs� DIST. BOX 3' maximum cover p t4' NEW 5-0.01 or Greater Top of SAs - ENrv. -94.00 a 2 T 6 NEv PIPE a0 1,500 GAL ` FROM FOUNDATION iA S0• S. 0.010 . PIPE TO BE LOVERED 07 SEPTICIT0 in OANK ' Effective Dept 4' - SCH. 40 T 1•75 AMFS Od PLAN SECTION CROSS-SECTION war ° N e..s.w. m N r. R CONCRETE FULL FWNOA u N 1' F�\�e u ro i rn h 2 d II o+ 4 Units Q 625' SYSTEM PROFILE 6 in.of 3/4'-1 1/2' y N i 1' V STONE UNDER CHAMBERS HOLE H-10 DISTRIBUTION BOX Rw C corr"cl.d stone i o N Not to Scok - c � z' _u A � d 3.5" 5' 3.5' NOT TO SCALE C LOCUS M A P i 3.5' 3.5' i 32• c 9:5 u Effective Length 6 in.of 3/4•-1 1/2" compacted stone Eff.ct,ve vmth m SOIL ABSORPTION SYSTEM (SAS) �altnr+-9l-Ialltels-?-E1e�- 259 CULTEC MODEL I25 (H-20 LOADING)/ SHDREY PRECASTE GENERAL NOTES (OR EQUIVALENT) 1. Contractor is responsible for Digsofe notification Not to Scale and protection of all underground utilities and pipes. 2. The septic tank and distribution box shall be set NOTE: OVERALL HEIGHT OF INFILTRATOR IS IS' /EFFECnVE HEIGHT IS 12' level on 6" of 3/4"-1 112" stone. 3. Bockfill should be clean sond or grovel with no stones over 3" in size. 3-24'DIAM ACCESS MMHOLES 4. This system is subject to inspection during installation �`-y by Carmen E. Shay - Environmental Services, Inc. ,o' -6• ,Sr T O NE y CL IF F 5. The contractor shall install this system in accordance .R OA D with Title V of the Massachusetts state code, the approved pion (40 FOOT RIGHT OF WAY) and Local Regulations. 6. If, during installation the contractor encounters any INLET / ^ 1 soil conditions or site conditions that ore different 1►0.Et / `` / `` / OUT ET soil log or in our desig R -_ •Z56,25' fnstallot on must halt dcrom tho shown on heimmediate notification be n THE ACCESS COVERS FOR THE SEPTIC TANK, 96--___ DISTRIBUTION BOX AND LEACHING COMPONENT _ A = 8 ,86' mode to Carmen E. Shay - Environmental Services, Inc. -�-` ,3 7. No vehicle or heavy machinery shall drive over the SHALL BE RAISED TO WITHIN 6" OF ------ _-__-_ t'"' '' "` '`• "' •' '"'�' �' FINISHED GRADE. c r septic system unless noted as H-20 septic components. STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITS GAS BAFFLES OR EOUALS PROJECT BENCH MARK 3 8. Install Tuf-Tite gas baffles Or equals on all outlet tee ends. PLAN VIEW ON ALL OUTLET TEE ENDS TOP OF FOUNDATION 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. 3-24'REW>VABLE COVERS-� ELEV. = 100.00 (ASS ed) 0 10. All solid piping, tees do fittings shall be 4" diameter ~ Schedule 40 NSF PVC pipes with water tight joints. _ 9 V' --- NOTE7 r:, 98 _ 11 nM 1 ed to The Residence andf- 2'nW. Inlettooutlet t) -- ---------- _-__-- --- -- ----- _--98 P p rt1Cs Within 150 Feet. Abutting Mu 'cipol Water 's ConnectINLE OVttET ro e- e..tt.r.. '-O' "'^ THE PROPERTY LINES ARE APPROXIMATE AND L' 04 �'a depth COMPILED FROM THE SURVEY PLAN GENERATED BY M EXISTING CHARLES N. SAVERY, SURVEYORS. OF HYANNIS, MA • ,. ... .. ...ti .►:...;• - 3 BEDROOM ENTITLED PLAN OF LAND IN BARNSTABLE, MA" (DEC. 9, 1966) 1 ,o'-o' S' -6' '; !1 HOUSE AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN I CROSS SECTION END-SECTION GARAGE IT SHOULD BE USED FOR NO PURPOSE OTHER THAN � #46 SLAB THE SEPTIC SYSTEM INSTALLATION. I � • 1 TYPICAL 1500 GALLON SEPTIC TANK 98 DECK� -NOT TO SCALE96 7�\ Foiled DECK 9 .30 LEGEND (H- 10 LOADING) 6U�.F -- \\ F p -2 ST HOLE 1 ---- F -,Cesspool ELEV'=�6 2�f2.75' ------ --- 98 PERCOLATION TEST c�qN \`\�, %41X0. - _' 75 - -96 _ 4 DENOTES PROPOSED C X1 SPOT GRADE Dote of Percolation Test: APRIL 15, 2002 94--__ _ _ cS Foiled Test Performed By. CARMEN E. SHAY, R.S., C.S.E. _ NE 1500 qa[. Cesspool - 2' �� BERRY BOGS DENOTES EXISTING Results Witnessed By WAIVER ---Sept.clQnk _---�_ -_ �_FFER FRONT CRA X 104.46 SPOT GRADE X A 00, Bu Excavator: Shay Environmental Services, Inc. 93.38 PL PROPERTY LINE Percolation Rate: Less Than 2 min./inch � 96P� PROPOSED CONTOUR j Test Hole LOT #4A R• No. 1 18,207 Square Feet +/- 97- - - - - -97 EXISTING CONTOUR Co DEPTH SOILS ELE V. ____ 26 -- 92 DEEP TEST HOLE & 0 96.25 92.Son 26 X PERCOLATION TEST LOCATION 10 YR 3/2 0'-10' A 9535 X 92.74 6 FOOT STOCKADE FENCE Sondy 92.52 Loom X ---- U 10 YR 5/6 - 9080 ' 10"- 34' B. 93.3592 . � . sd '-' o 15" 61 � 5 2 6 r 7/4 d1 • 2 34'-48" G 92.25 - ------------------------------------------"-_ 5 " P LOT PLAN MSanaFk,e OF PROPOSED SEPTIC SYSTEM UPGRADE Perc �, 2.5 r 6/3 tQs- - --__ _____ D E ----- ,. Depth to Perc: 42" to 66" 10.57 -- 4s--72' C2 0.2s '--- -----A = 1 ' - PREPARED FOR Pere Rate=<2 min./inch (In C-2 Layer) `- Groundwater Not Observed Med-CCdoorse 84,- FOG f- _ R - 1 S 1.8y' �� MS . R I TA L 0 C K W 0 0 D No Observed ESN WT � \-� _ ADJUSTED H2O Elev. = None 2.s v 7/1 `QF C $4.02- ---------------_- _ ---- AT 72'-168- 2.25 -------------------- - - 46 STONEY CLIFF ROAD Design Colculations & ------------- _------ -_ 8X.06 . ��S4 CENTERVILLE , MA 83.94 -------- --- �� - - Number of Bedrooms: 2 Equivalent to 220 Gal./Doy (330 Gol./Doy Min. per Title V) NOS GE OF CRANF3ER r q EPARED BY: Garbage Grinder: No RMLeaching Capacity Proposed: 330 Gol./Doy Minimum (Min. Per Title V)Septic Tank : - 2 x 220 Got./Doy = 440 USE 1,500 GAL. Septic Tank. rL i 1 ►' E. AJ HAY SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch 1 ENVIRONMENTAL SERVICES, INC. Bottom Area: 0.74 gol/sq. ft. x 288 sq. ft. = 213.12 gallons Sidewoll Area: 0.74 gol./sq. ft. x 164 sq. ft. = 121.36 gallons EXISTING CESSPOOLS TO BE PUMPED DRY & P.O. BOX 627 Providing: = 334.48 gallons REMOVED TO FACILITATE NEW LEACH TRENCH. 0 20 40 50 ;Sq�,-�F�RN 4i,AgS EAST FALMOUTH, MA 02536 I TEL/FAX : 508-548-0796 Use: (4) HIGH CAPACITY CULTEC 125 CHAMBERS, HAVING A 1' EFFECTIVE DEPTH, NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE (2.5' W x 6.25' L) TO BE USED WITH 3.25' OF WASHED STONE ON THE SIDES, FROM THE EXISTING CESSPOOLS TO BE DISPOSED _ SCALE: 1''-20' DRAWN BY: CES DATE: APRIL .15, 2002 3.50' OF WASHED STONE ON THE ENDS, AND I FOOT OF STONE BENEATH ENTIRE SAS. OF AS PER BOARD OF HEALTH SPECIFICATIONS. SCALE: 1 "=20' PROJECT#SD306 FILENAME: SD306PP.DWG SHEET 1 OF 1