HomeMy WebLinkAbout0563 STRAWBERRY HILL ROAD - Health 563 Strawberry Hill Road
Centerville P
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THE COMMONWEALTH OF MASSAC,HUS;WTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN-:OF BARNSTABLE, MASSACHUSETTS Yes
9ppliLation for Nspo8al *pstem ConstrULtion permit
Application for a Permit to Construct( ) Repair(4 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.,Z 3 5�� 14i Owner's Name,Address,and Tel.No. u_Tdw')39- 417YO
C e s-t4 cu i((Q, Su(Y 11 V&n 8Q Ken no-S& -) Acne.
Assessor's Map/Parcel o
I}�staller' Name,Address,and Teel.No.609-7 9/- 93 g9 igner's Name,Address and Tel.No. 0 y -
! `Fp�o i �nS�fUC1-i on,2n ,
0 i O�G'7S
Type of Building: 2
Dwelling No.of Bedrooms V Lot Size _111413 sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
45'Deslgnf w i.required) 33� gpd Design flow provided �9 gpd
Plan Date A,,4 '2v-3 Number of sheets Revision Date
Title
Size of Septic Tank JSoo 9,g Q Ty e of S.A.S.a - 5,-,( 0�Q 4,)s
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
a
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 Environme Co d not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt
Signed Date (6 /11
Application Approved by Date ( 1
Application Disapproved Date
for the following reasons
Permit No. Z_® ( ( 3/3 Date Issued
1
No..I ~: 4•- ** ~ i Fee
THE COMMONWEALTH OF MASSACH-_USE--,TTS Entered in computer: i
Yes
PUBLIC HEALTH DIVISION - TQt F BARNSTABLE, MASSACHUSETTS
01ppYication for Misposal *pstem Construction permit
Application for a Permit to Construct( ) Repair(✓f Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. " I+I I Rd, Owner's Name,Address,and Tel.No. S 7 08 39- Q rl S/Q
C'r4p.r°ui lle, &! Sulli van SQ KennQSa.L0 /�UL
Assessor's Map/Parcel l f ter ;Re M 11t 0,x30-L �
Installer' N me, ddress,and Tjel No.DSO?-7 /- 93 Designer's ame,Address and Tel.No.
=40�0 I �1�S{ 00 -1 oil Tr< C i/XC?rf/y
�fS i 4ra Ad• M r<-4�s v il-s ;�1 t� 0� � �n S ✓fir 0.)695`
Type of Building:
Dwelling No.of Bedrooms Lot Size WV3 '" sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Ontherl fixtures p
Design Flow(min.required) 330 gpd Design flow provided gpd
Plan Date c&f 30 • o c>l I Number
.of sheets � Revision Date
Title 4
7i C V S� �e t'/Q l 1" -03 JT Ct.cL&( 1-6
1 Ad i F
5°C(�t
Size of Septic Tank 1500 Ty e of S.A.S.a -�{+-�� h3 S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) }�� Cr-SS,0�5 ��� 14[XS�rn t7 �e,�11 - )
SgO��Q
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 Co and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health ""-�--- ��/f
Signed Date (� / 1l
Application Approved by ` - r" Date
Application Disapproved y . _ Date
for the following reasons
Permit No. ZO ( ( _ -3 Date Issued %6 1 !
--------------------------
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 Z7C'
at563c- ,ato6er'rq 4 C'en 4("-Vl '1F_ ' has been constructed in accordance
with the provisions of Title 55'and the for Disposal System Construction Permit Noe} l(- 313 dated ct `/Z o I
Installer l`.UC�csJo`h`) l OAS 410y) �.�t1C. Designer awn QQ f nC ►nF1o('tf�S` I CE
#bedrooms 3 Approved design flow v and
The issuance of this permit(t h 11 not b construed as a guarantee that the syste f:11 functio as d sued.Date / t Inspector --'-
---------------,-`---- ------ ------------------------ _-----=----=--- ___- =-=------- - ---`-------- ------------- ---------
No. !�' ( � 3 t 5 Fe�/00 .
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Misposal :&pstem Construction permit
Permission is hereby granted to Construct( ) Repair(v' ) Upgrade( ) Abandon( )
System located at ��r3 �ra t,)&_r-rt i 14►1( {\j _ ��n •�e r'v( ( `Q
101
r
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 2/��ZZ O/ 1 Approved by ----�'�
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PRO _11?111 D
NOV 2 12002
TOWN OF BAiNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A 1`41 Z�
CERTIFICATION
Property Address: 563 Strawberry Hill Road(Back System)
Centerville MA 02632
Owner's Name: Elizabeth Russell
Owner's Address: Same
Date of Inspection: November 2 2002
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford Map: 249
Mailing Address: P.O. Box 49 Parcel: 013
Osterville MA 02655-0049
Telephone Number: (508) 862-9400 Lot: 6
CERTIFICATION STATEMENT
e 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:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: November 9 2002
The system inspector shall sub 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 563 Strawberry Hill Road(Back System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
c
✓ I have not found any information which indicates that any of the failure criteria described in 31.0 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 563 Strawberry Hill Road(Back System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
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:
3
I
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 563 Strawberry Hill Road(Back System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/2 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 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 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.]
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 System:
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.
4
I
Y
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 563 Strawberry Hill Road(Back System)
Centerville, AM
Owner: Elizabeth Russell
Date of Inspection: November 2,2002
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 ?
n/a 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:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
I
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 563 Strawberry Hill Road(Back System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 1.10 gpd x#of bedrooms): n/a
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/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: Unavailable
Was system pumped as part of the inspection(yes or no): 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:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 563 Strawberry Hill Road(Back System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan) Cesspool acting as septic tank
Depth below grade: Cover to grade
Material of construction: concrete _metal _fiberglass _polyethylene
✓ other(explain) Cesspool block
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 5'Wx 5'Tx 9'bottom to grade
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: I'
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: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
The cesspool had approximately 4'of water on the bottom. An outlet tee was present.
GREASE TRAP: None (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.):
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: 563 Strawberry Hill Road(Back System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
TIGHT or HOLDING TANK: None (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: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
PUMP CHAMBER: None (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.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 563 Strawberry Hill Road(Back System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
✓ overflow cesspool,number: 1
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.):
The overflow cesspool was dry. The scum line was approximately T up from the bottom. There were no signs of failure. The
cover was approximately T below grade. The bottom to grade was approximately 10'6". Note:a gas line was next to the cover.
CESSPOOLS: None (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: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 563 Strawberry Hill Road(Back System)
Centerville, AM
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
� Map:249
Parcel: 013
Lot: 6
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.
1
1
Gas l�•�t.,
A �
10
Page i l of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 563 Strawberry Hill Road(Back System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25' +/- 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:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom ofthe overflow cesspool to grade ww approximately 10'6". Using the Barnstable topographic map and the Cape Cod
Commission water contours map, the maps were showing approximately 25'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROT_E_C_T_ION
RECEIVED
NOV 2 12002
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 563 Strawberry Hill Road(Front System)
Centerville, MA 02632
Owner's Name: Elizabeth Russell
Owner's Address: Same
Date of Inspection: November 2, 2002
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map:249
Osterville,MA 02655-0049 Parcel: 013
Telephone Number: (508)862-9400 Lot: 6
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:
✓ Passes
Conditionally Passes
Nee urther Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: November 9, 2002
The system inspector shall su t 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 563 Strawberry Hill Road(Front System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 563 Strawberry Hill Road(Front System)
_ Centerville. AM
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 563 Strawberry Hill Road(Front System)
Centerville, AM
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/2 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 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 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.]
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 System:
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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 563 Strawberry Hill Road(Front System)
Centerville, AM
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
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?
✓ _ 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:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
I
5
Page 6 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 563 Strawberry Hill Road(Front System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2. 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 1
DESIGN flow based on 310 CMR 1.5.203 (for example: 11.0 gpd x#of bedrooms): n/a
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIALANDUSTRIAL
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: Unavailable
Was system pumped as part of the inspection(yes or no): 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:
Nov. 23182-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
f
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 563 Strawberry Hill Road(Front System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx. 12"
Material of construction: ✓ 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: 1000 gal.
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness: 8"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 8"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping.
GREASE TRAP: None (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.):
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: 563 Strawberry Hill Road(Front System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
TIGHT or HOLDING TANK: None (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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. There were no signs of leakage.
PUMP CHAMBER: None (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.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 563 Strawberry Hill Road(Front System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 6'x 6'-1000 gal.
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.):
The nit had approximately F of water on the bottom. The scum line was approximately 4'up from the bottom. The bottom to
grade was approximately 8'. The cover was approximately 2'below grade.
CESSPOOLS: None (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: None (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.):
I
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 563 Strawberry Hill Road(Front System)
Centerville, MA
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
Map:249
Parcel:013
Lot.6
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.
�ron-1—
� 6
Oi
1 as !- a
a 3 Q 3
3 3(o ag
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 563 Strawberry Hill Road(Front System)
Centerville. AM
Owner: Elizabeth Russell
Date of Inspection: November 2, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25' +/- 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:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom ofthe leach pit to grade was approximately 8. Using the Barnstable topographic map and the Cape Cod Commission
water contours map, the maps were showing approximately 25'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
McKean, Thomas
From: McKean, Thomas
Sent: Thursday, January 23, 2003 4:24 PM
To: Giangregorio, Robin
Subject: . 563 Strawberry Hill Road".
The front septic system consists of a 1,000 gallon septic tank, distribution box, and one 6' by 6' leaching pit. This system
meets the provisions of the 1978 Title V State,Environmental Code. This system"passed" an inspection conducted by
James Ford on November 2, 2002. The rear septic system at the above reference property consists of two cesspools.
This system also"passed" an inspection conducted by James Ford on November 2, 2002. These systems will be allowed
to remain in the ground until such time a system component malfunctions (e.g. until such time sewage overflows onto the
ground, or until a back-up occurs within the dwelling).
This property is located within a State designated nitrogen sensitive area and is therefore restricted to one bedroom per
every 10,000 square feet of land at the parcel. According to the Assessor's records, the property consists of only 0.24
acre. Therefore, in this case, the number of bedrooms which legally pre-exist there may remain. No additional bedrooms
will be allowed
At this time, I suggest that a floor plan be requested from the applicant showing all of the rooms which pre-exist at this
property so that we can attempt to accurately count the number of bedrooms which pre-exist there.
ATTACHMENT HAND DELIVERED: Copies of septic system component drawings
a •
1
Health Complaints
22-Apr-02
Time: 4:00:00 AM . Date: 4/10/02 Complaint Number: 3363
Referred To: DONNA MIORANDI Taken By: FLORENCE SMITH
Complaint Type: NUISANCE.CONTROL REG. 1 RUBBISH
Article X Detail: UNSANITARY CONDITIONS
Business Name:
Number: 563 Street: Strawberry Hill Rd. Apt. B
Village: CENTERVILLE Assessors Map-Parcel:
Complaint Description: The landlord lives at the same address, she
said her tenent has about 8 bages of trash in
the yard. has talked to her tenant
about this and she refuses to do anything about
it. She also said she has seen rats and she has
a small dog she won't let out because of the
rats..
Actions Taken/Results: Lm spoke with landlord on 4/16/2002 at
11:55AM. Landlord explained that the tenant
had started moving out the past wekend, she
watched the tenant remove the bags of trash.
Lm stopped by three times to speak with tenant
and was never able to find her at home. Lm
walked around property and did not see refuse
lieing or thrown around or any sisns of rat
infestation.
Investigation Date: 4/16/02 Investigation Time: 11:55:00 AM
1
P#
7 own ofBarnstabik —
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]Departmolt of Regulatory Services
L MRNErAELZ, 4
Public Health DavAsnoal ]Date
�
AB& 200 Main Street,Hyanuis MA 02601
7 L
Date Scheduled_ Time ��/ aiee Pd. 0(/
`oil Suitability Assessment for Sewage Disposal
Pcrronned ay: V-.4 4E-� SC Witnessed
- LOCATION & GENERAL INTOJRMAATIO --,----_
Location Address ant V Owner's Name C- �`'G `( ✓4.r-
Address
Asscssor's Map/Parcel: ! 9�� Bngincer's Idautc �t7LoVL—
e
NEW CONSTRUC7101'4 ` RBPAJR Telephone it
Land Use. r06-51 OIL"—V//S-` Slopes(%) I �J Surface Shines
Distance's from: Open Water Body "7 30y ft Passible Wet Arco y ft Drinking Water Well O ft
Drainage Way ft Property Llne ft Other ft
S {TCH., (Street name,dimensions of lot,exact locations of test holes SL pert tests,locate wetlands'in pioxinuty to hales)
41- I1
• ►-dT Co
i
yr �
O
_7r �.
Parent material(geologic)_V Depth Lv Bedrock
- Depth to Oroundwalcr: Standing Weser in Flaic: (4 f C Weeping I'tom Pit Roe
Estimated Seasonal High Oioundwater
D ET ERIMNA` ION FOR SEASONAL HIGH WATER TABLE
iVlethai Used:
Depth Observed standing in obs.hole: In, Depth to Mall
Depth to weeping;from side of obs.hole: *,,,I
e In, OruuarJwnlar Adf uslment u T ft.
hidex-Well Rcading Datc: Index Ad,l,ftictor•�,••_� Aqj.C7roundwatei'Level
lFERCOLATI.ONTEST Eli)14 L Tkila ��•�
Observation 41
Holt:ff Tin o tit 9"
I,
Depth of Perc _ 1'lutp at 6" _
Start Pre-soak Time @ Time(9"-6 )
U n r
End Prc-soak mot/ l�I r,b N
Rate Min./Inell Y M
Silo Suilabillty Assessmunt: Site Passed_ Silg''Failed: Additional Testing Needed(Y/11I) \"!
+ Original: Public Hedilh Division Observation Hole,Data To Be Completed on Back----(✓- --
***If Vercolatioa test is to be co➢iducteet vvitYlill 100' of vvetiarac➢, you must first Uotigy tiite.
Barnstable Corlselrvtition Division at lefist olle (a) Week prior to beg➢aA➢.IlQu➢g.
QASBPTIC\PLRCFORM.DOC
------------
]D)FRROBSr-iiVA-T1ON HOLE, LOG
Dcplh from Soil]krrizon
Surface(inJ Soil Tc�cture :soil Color
(USDA).. Soil. Other
(Munsell) Mottling (Con iste °
,
'Stones';Boulders,
% r5 el
� _� L to•y2
`f- k(,,3 Tj LS
/o ti
(i lhes6A
------- �✓ ��g-vim-Z,
]1 REP 0,B S]ER ETA TION ®]L7C ]C,®G
Depth from Soil Horizon ��Dale #
Surface(in.) Soil Texture Sail Color
(USDA) Soil
her
(Munsell) Mottling (Structure,
Stones, Boulders.
Consis'eno %Grave)
�s o
--__—_ -- A- y a rk
D DE,-E,p OBS]E1f VATION HOLE ]L®G
epth from Soil Horizon #
(USDA) (Mu
Surface Soil Texture Soil Color `�--
Soil Other
nsell) Mottling (Structure,Stones,Boulders.
Consistency 9a Onvell
��- —
OLE LOG
Depth fi•om Soil.Horizon 1�D�e#
Surface(in.) Soil Texture Soil Color
(USDA) ,• �OII Other
(Munsell) MpltlIng (Structure,S o e•;t tt S boulders,
C°nsl�tency� 6 OraP"I
Il,Voodl Insurance Rate-Ma p,
Above Soo year.food boundary No Yes Y
Within 500 year boundary No� T�
Yes., .._
Within lo0yem-noodboundary No�
1���t1>I aa!'PJca�t�tr�ll'y� ®_____oaruflra-u_n����'va_or�s 1Vlaterl�9
Does at least four feet of naturally occurring pervious materlal exist in all areas observed thl'aughout the
area proposed for the soil absorption system
if not, what is the depth of naturally occurring l)ervio s matel'11611 w
C'�>rtifan^at�no� r •
A certi',fy that on �7/ �. (date)I have passed the soil evaluator examination approved by the
Department of Environmental.Protection and that the above analy.;is was performed by me consistent with
She required training, expert i e and e;rienee described in 10 CA92 15.017.
Signature r J
Date .
Q:\S.P-P'TICU'ERCrORM.DOC
i
FORM30 Caw HOBBSS WARRENTM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
S It
+ CITY/TOWN
b `1 y DEPARTMENT
70 �6 7 , j f ate.VjA-,
c
ADDRESS
�M
�^ TELEPHONE
Address s-6���'O�W w� / Occupant_.
Floor Apartment No.� No.of Occupants
No.of Habitable Rooms � No.Sleeping Rooms
No.dwelling or rooming unitsZ- No.Stories
]
Name and address of owner ��e /"�i-�lM�� 1 a.w.�, 1 ff 13- 0Z-8Z7,57'
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish tilil
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress: and Obst'n.: o I< --V'o W
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation: l S
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows.-
HEATING Chimneys:
Central ❑ Y ❑ N E ui . Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vents 7,0
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen. Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT OPT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks 7e Y
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4 _
Hot Water Facil. Sup.Ten.,Gas,Oil,Ce-7c /Z® r' ._-d
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink 1'l vL + r
Stove �el e c 41 13
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin, Shower or Tub: G
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES P RJUR
INSPECTOR J TITLE
1 r 0 A.M.
DATE 1 Z/-uy ' TIME
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
I ,,:,•.- .r '�,�Ya(:��[:±$��a�;M'°ra}c+:-:.c.1,�wv�;x°'f'r�,���(+arHnwd*:aY,ry:}rlk*t.-:a�yg.,;ri"c'�'"S`ri.,��,y1';�':t"tM"eC'sn.�`av�Fe`iU."J��`l�J�'`�'A`kp�tt�9r�Ci.7.'.�;a"yVa"'�„tC..r.r .�:;:`'rx'.,;y; .. . ,
410.750: Conditions Deemed to Endanger or Impair Health or Safety A
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the heaith, or safety and well-being of a•person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes.of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.4821.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting,;or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A) and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
� _ I
FORM 30 CH HORRSB WARREN'"" THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Rb14
CITY/TOWN
W r M, t _
DEPARTMENT
ADDRESS
G9M + N ,.
SVOy`0
pff TELEPHONE
Address s tW�OLv✓_ Occupant_.
Floor _Apartment No. No. of Occupants
No.of Habitable Rooms,___ No.Sleeping ROOmS._L___ ___
No. dwelling or rooming units_---;'Z.- No.Stories �C� / _c/OZ-FZ�7S`
Name and address of owner_.��� c7__. j_j� � _L�n Cj U
,r
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish OA
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual E ress: and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen. Sanitation: ( 110rm
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway: .
Obst'n.:
Hall, Floor,Wall,Ceiling: -(A v_. DIk
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N E ui'. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Su I Line: e,, H t,,c ,-
❑ MS ❑ ST, ❑ P Waste Line: - -1 S'
H.W:Tanks Safet and Vent s - 7,0
ELECTRICAL Panels, Meters,Cir.: ;f
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT _9"0(�
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks t7..e 'f"
- Kitchen L//d /
Bathroom .
Pantry
Den
Living Room
Bedroom(1)
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, ec . // 1` - O
Stacks, Flues,_Vents, Safeties:
Kitchen Facilities Sink I J 1 vl 04- r i rvvr d�
Stove ...e (cc' N 13 r
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: fw 0
Wash Basin,Shower or Tub: G,--
Infestation Rats, Mice, Roaches or Other:.
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES 0- P -RJURY."
INSPECTOR / TITLE
l A.M.
DATE / /2 / TIME
3 " J y _ P.IIA.
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
. .p V
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201.or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) .Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
6000000 r
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�� 00001648 /
OLD TOWN RD 00
i o HYANNIS MA 02601 00 0000 000 "
e # to 000000 r 3416 135
81IyU� sC' RUSSELL, HAROLD
000031000
��/e � 000056700 l�R A 0000000000 �„; ,�r
Lcsca 563 STRAWBERRY HILL ROAD 1546" mt� 0100 /�`
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� fr8�t3io/ CO wV
0000 Fr�a1g" 0000
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E
�u
Health Complaints
12-Jan-01
Time: 12:50:00 PM Date: 1/12/00 Complaint Number: 2663
Referred To: GLEN HARRINGTON Taken By: GLEN HARRINGTON
Complaint Type: CHAPTER II HOUSING
Article X Detail:
Business Name:
Number: 563 Street: STRAWBERRY HILL rD.
Village: HYANNIS Assessors Map-Parcel:
Complaint Description: Three daughters live in main house w/attached
apt. Heating bills are astronomical for apt.
Complainant wants to know if there is more
than one meter or if heat is for entire house.
Main House has 3 BR's. Apt is studio.
Actions Taken/Results:
Investigation Date: Investigation Time:
lv o v Avg.
S L,w 1.,1 n;(d I,tA (� o-� S l x WO (i l,�,v,,.i t� �(f� d"L4-C k (-J" , L
1
'h
Health Complaints
30-May-03
Time: 3:11:58 PM Date: 5/23/2003 Complaint Number: 4053
Referred To: DAVID STANTON Taken By: THOMAS MCKEAN
Complaint Type:
Article X Detail:
Business Name:
Number: 563 Street: Strawberry Hill Road
Village: HYANNIS Assessors Map-Parcel:
Complaint Description: The home is owned
He rented out the apartment, the main floor,
and the basement. The owner has not received
ZBA approval [Appeal#2003-0361; his
application was apparently denied because teh
applicant failed to appear at the two scheduled
meetings per the complainant. Now there are
new tenants (who say"no comprendez") are in
the basement and they excavated the ground
outside. Plywood covers the view of the
windows. The window wells were removed.
Also observed are chunks of cement on the
ground adjacent to the basement windows.
The Building Division was notified today about
the apartment problem. The complainant wants
the Health Division to identify any health
violations there and take action. The
complainant would appreciate a call back on
this after the investigation is complete.
Actions Taken/Results: DS SPOKE WITH RALPH JONES, BUILDING
INSPECTOR, AND ALSO ED SULLIVAN.
CURRENTLY IT APPEARS AS THOUGH
THERE ARE NO HEALTH VIOLATIONS. DS
1
Health Complaints
30-May-03
REVIEWED SEVERAL PHOTOS TAKEN BY
RALPH WHEN HE WAS ABLE TO GAIN
ACCESS. HE STATED IT IS VERY
DIFFICULT TO GAIN ACCESS TO THE
PROPERTY, AND WAS ONLY ABLE TO DO
SO WITH THE FIRE DEPARTMENT. IT
APPEARS AS THOUGH THERE MAY BE
SOME FUTURE HEALTH VIOLATIONS IF
WHAT IS SPECULATED DOES OCCUR,
WHICH WOULD BE TO FINISH OFF
BEDROOMS IN THE BASEMENT.
CURRENTLY THERE ARE NO BEDROOMS
IN THE BASEMENT. THERE IS BUILDING
MATERIAL (INSULATION..) PRESENT TO DO
THE WORK, BUT IT HAS NOT BEEN DONE
TO DATE. THERE IS ALSO A PATH CUT
OUT IN THE CEMENT FLOOR, WHICH
APPEARS TO BE FOR A FUTURE
BATHROOM, THERE IS CURRENTLY A
"STOP WORK ORDER" POSTED AT THE
HOUSE. THE HEALTH DEPARTMENT WILL
REVIEW THE POTENTIAL"BEDROOMS"
WHEN THE PROPER BUILDING PERMIT
PROCESS OCCURS.
Investigation Date: 5/29/2003 Investigation Time: 9:00:00 AM
2
INTEROFFICE MEMORANDUM
TO: TOM PERRY,BUILDING COMMISSIONER
FROM: RALPH JONES,BUILDING INSPECTOR
SUBJECT: 563 STRAWBERRY HILL ROAD,CENTERVILLE
MAP 249/013
DATE: , 4/8/2003
I visited the above referenced property today with Lt. McNeeley of the COMM Fire Department
upon receiving a complaint of an illegal apartment. The tenants allowed us to enter, they spoke very
little English. There is work being done in the cellar with no permits. Two cellar windows have been
enlarged but do not meet the building Code.A trench has been broken through the concrete floor to
the sewer outlet pipe (see pictures). It looks like they plan a future apartment.
The main house has 3 bedrooms and 5 tenants renting it. The illegal apartment has a small bath,
small kitchenette unit and a living room with 2 slider doors going out to a deck. Two people are
currently rent this unit.
The tenants gave me the landlord's cell phone number (774-836-6895)which I called and received no
response. I called the previous owner (Carlos Gonsalves) at 508-292-9273 but he could give me no
information on the present owner.
I posted a stop work order at 2:00 PM on April 3,2003.
TOWN OF BARNSTABLE
LOCATION '( _ T. r�c�3�t �� � Q1,,SEWAGE#
VILLAGE (1T ASSESSOR'S MAP&PARCEL 13
INSTALLER'S NAME&PHONE NO. -IZ�-t. l
SEPTIC TANK CAPACITY /kZl -64t .
LEACHING FACILITY:(type) 'Z(FJ CC4 -. (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) - Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility)/ Feet
FURNISHED BY DWO (
O 4 -
no .
e
3�'6"
TOWN OF BARNSTABLE
LOCATION S�3AtN ��t t SEWAGE #
V1i,LAGE Ceei,E t ASSESSOR'S MAP & LOT-a-'/2 O 3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY .. .ssttn 1
4
LEACHING FACILITY: (type) �k�6p I (size)
NO. OF BEDROOMS BUILDER OR OWNER C JZ✓-1 L4 l'[ JAJ
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching acility) ��� Feet
---
Furnished by --V1 S�C l� 0r1 J . FOed
Gas h•�t
A oZ
I a3 alp
s
No. Z.��0.y.J�... FEB. ,5� .. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................�..................OF_.......J.J..`.$:.'`�^......................................................
Appliration for Biapasa1 ork,5 Tomitrurt' n rrmit
Application is hereby made for a Permit to Construct ( ) or pair- Individual Sewage Disposal r,
System at:
...... ... --------------- ------------------------ .
--------------- -------- I e
,y O Roca' s W v .....1/ A7
Owne ` Address
Installer Address
Q Type of Building I_ Size Lot........................1q. feet
U Dwelling—No. of Bedrooms....__...............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons. .........._..._.. Showers ( ) — Cafeteria ( )
C4 Other fixtures ----------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Len'9th.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) - Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit'No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------_.................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -------- ---------- ---- /
ODescription of Soil------------------�� �k l--. --------......................................... .....---'. --- -----------------•---------------
V ....-••-----------••---•••••••••-•--•-----•-••.......---••-•---•-•-•--•----•-------•..... ...........••---•---------------------•----••••---•------•-•----•--------•-•-.......-•--------...--••...-
W
x ...................... -••••----••-...
U Nature of Repairs or Altera ' s—A er when applicable--__ .E3 j..j.. . . - /�-- -
-- •• --• ....... --•• ----•-•• ...... ............
Agreement: Gh�
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss by the board of health.
S- ed. ....-----•---- ........................................................ �. ..--�r.........
A Application Approve Date
PP PP Y ------•-----....-•-•--•-••.............................. ----•-1-----l.. --
ate
Application D' PPro ed or he following reasons:-----•-----------------------------------------------------------------------------------------------------•-•--
----------------------------------------------------------------------------
Date
PermitNo......................................................... Issued-.......................................................
Date
;l
d
�y
No......... Fps... ........ ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_OF......... . ---------------------------------------------------
Appliration for Dispatial Works Tnnitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (j an Individual Sewage Disposal 1
System at:
....................... .......... ....... .•--•-•--•-
��?�
.........................-•• :
_
yyocatedn dress w r It No. / Jj'f
........., .:r7 • p/ :1 l �'a . i',CJ r?�-+�: 1 .: C%/
..`
Address
'� .... S
Installer ••••-
� Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms........ ...............................Expansion Attic ( ) Garbage Grinder ( )
a4 Other—Type of Building ............... No. of ersonss2.............................. Showers
YP g -------------------------------------------P ( ) — Cafeteria ( )
dOther fixtures .........--•---•-- ......-...................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
14 Percolation Test Results Performed by.......................................................................... Date........................................
W
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--_-----________---_--_
LZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Rai --•-------•--
ODescription of Soil 1�. +....... .................•------------------------------------------------------------------------•--••--•--------
U -••--•-••---•-•---------•--------------•----••---•--•-------•-••----•----••-•-----•-•----I----------------------------------------------------------------------------...._..---------...............
W
x
V Nature of Repairs or Alterat' s—Answer when applicable._... g ,x_ _____...% ,l
Agreement: [ G ^
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu by the board of health.
i /.�
ate i
Application APpro��'BY .4.e . '------------------------•-••----------•--------•--•---•----------..--.----... --•---�-�1.� ----�. --
� r
* 6 � Date
Application Disapproved or the following reasons:................................................................................................................
.................... .....................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD„ ,OF HEALTH
Tntif iratr of Tamplinnrr
ThVS IS_-TO CERTIFY, 'Rat they Individual Sewage Disposal System constructed ( ) or Repaired ( )
by......t. _"t... ..... �. 'wt�
at - ------------------ --------•--•----•---•--------------------------_. .- .. f..�.' ---------•-----•--- -•----- r >� �`� ---
has been installed in accordance with the provisions of TI`F 5 T e State Sanitary Code ;age c ' ed in the
application for Disposal Works Construction Permit No-------------.w __......... da.ted___.,�Xfl.U.� --•---
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. \`
DATE.................. 1\`�•3 -••--.. Inspector---•-----•..................•--•• /f�'d�-•--•......._........
v
THE COMMONWEALTH OF MASSACHUSETTS
—� BOARD OF HEALTH
'� ,,�� +��+ ��r✓...?'�>.-►.....................OF.. .`71. " ' '__...................................................
aXv _. / FEE........................
Binplasn , Ferkii. T.nnoir ion rr i#aPermission is hereby granted.--d'`._. .. .-:�.. -. ......-- --------------------------•-•-----...........•..
to Construct ( ) or e9ait man Individual , ewage SysIAm, ! 1102r,)
at No....Y f �a �t<<. �_�_ _.✓. ....... " . lz�r .-r1er tl
---...---- . --•--•. •. .
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..............................._....__.... -
•....................................•------------------------------...----------••--•---.....--•-•-•--
DATE -
Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 'y
CTTOWN OF BARNST)ABLE �i'1
LOCATION �63 S !���^�"�trr�j ��1t SEWAGE # O c �-6�3
YMLAGE Ctefrtrv,I�. ASSESSOR'S MAP & LOTo14/9 Ol 3
INSTALLER'S NAME&PHONE NO. T"roi►T S�l�e>rtn LUT'- C�
SEPTIC TANK CAPACITY I UUD
LEACHING FACILITY: (type) PJ7— (size) Ulm
NO. OF BEDROOMS
BUILDER OR OWNER i 14 b i—t-� ruse- 1
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachi g facility) 11 Feet
Furnished by=4s*aC inn —Z 7 rOrC
rronT
A � B
O �
Fl 6
a30 33 p 3
3 36 ag
{
L O CATION �SMI A G EC CE-R,M 1T CN O -
VILLAGE_
ma
INSTA LLER'S NA Ill E i ADDRESS
I CR E1ROS v�5,s ji
Twtq R—Ir..
142 CorRgration Street
OR" OWNER Hymnis, Mass. 775-0328
DA T E PERMIT ISS"U E D
DATE COMPLIANC-E ISSUED / / -
CSt�j�d0(.�
e
e / S
v /
i
E�
CL
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0
SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES
MARKED WITH MAGNETIC TAPE OR A,
(NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION.
PROVIDE MIN. 20" DIAM. WATERTIGHT 1. DATUM IS APPROX. NGVD
ACCESS COVERS TO WITHIN 5" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE
2" PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING
TOP FOUND. EL 58.4' FILTER FABRIC OVER STONE " Phi��eYs v° r I
57.0' MINIMUM .75' OF COVER OVER PRECAST F2% SLOPE REQUIRED OVER SYSTEM 57.0' 3. MINIMUM PIPE PITCH TO BE 1/8 PER FOOT. Route Q°
4. DESIGN LOADING FOR SEPTIC TANK TO BE H-10.
PRECAST H-10 H-20 D'BOX AND RISER BLOCKS OR D'BOX AND CHAMBERS TO BE H-20. ° o
RISERS (TYP.) PRECAST RISERS a
2.0 4"OSCH40 PVC MORTAR ALL a r
PIPES LEVEL 1ST 2' 4' COMPONENT(TYS H-20 L. 53.0 4 5. PIPE JOINTS TO BE MADE WATERTIGHT. �o Locus boo
55.0' W 54.0'
* 1500 GAL H-10 ENDS SIDES 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE s�'9h oa
y Poop°`'o`P° ..';° ';°° r; o ono o^
54.78' TEE SEPTIC TANK TEE ° ° ° ° ooaa o oo��� oo®a o ��ao >a°a°a°a° �� 310 CMR 15.000 (TITLE 5.) = PIs, ooi
. : o000 00 o0 0 0 � 00 ° ° ° °
4.53 ° °'°`° 6" MIN SUMP '>0000a- �El =01®OCjMI!El ao�000a�oaa o000000a 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND �'� cc
°°°°°°°°°°°a 12" MIN TNT. DIM. '°°°°°°°° Oa�00�®�C i®!� Daa�®a�a��0 °°°° J
GAS BAFFLE::` ° ° ° ° ° ° ° ° ]1NOT TO BE USED FOR LOT LINE STAKING OR ANY
° �i '°°°°°°°° Q�11( � °°°°°°°° OTHER PURPOSE.
)°°°°°°00 I�®I�I�I�I�®®I�IJ[� I�I�I�I�I�®I�®I�I�IJ °°°°°°°O
53.23 53. 0000
06 ° °°° °°°°°°°° 51.0
4 LIQ. LEVEL (ACME' OR EQUAL) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. in o �\ R
.,•,, .. e
o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o a o o t
°o°o°00000ao°000°o°o°a°o°oao°oao°o°o°o°o°o°o° LH-20 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL.
0�0 000aoao�o°o�o�o,0000000000o�o�o„o 0 0�00000. 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. 9. COMPONENTS NOT TO BE BACKFILLED OR
ALL AROUND PRECAST STRUCTURES (2) UNITS REQUIRED CONCEALED WITHOUT INSPECTION BY BOARD OF \a
6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.0' X 12.83' HEALTH AND PERMISSION OBTAINED FROM BOARD
COMPACTION. (15.221 (21) OF HEALTH.
10. CONTRACTOR SHALL BE RESPONSIBLE FOR (� c A/�
VER FING YING ITHE LOCATION OF ALL233 UNDERGROUND & LOCUS MAP
46.3' BOTTOM TH-1 OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF
( N96 SLOPE) ( 1 •6 SLOPE) ( 1 % SLOPE) NO GROUNDWATER FOUND WORK. NOT TO SCALE
FOUNDATION- 11 SEPTIC TANK 82' D' BOX g' LEACHING G-W EXPECTED AT EL. 22t 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 249 PARCEL 13
FACILITY PER TOWN MAP SHALL BE REMOVED 5 BENEATH AND AROUND THE
PROPOSED LEACHING FACILITY.
12. EXISTING LEACHING FACILITY SHALL BE PUMPED
AND REMOVED OR PUMPED AND FILLED WITH CLEAN
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL SAND.
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS PRIOR TO INSTALLING ANY PORTION 'OF SEPTIC SYSTEM SYSTEM DESIGN.
SYSTEM A
EXISTING 0113EDRooM SEPTIC SYSTEM GARBAGE DISPOSER IS NOT ALLOWED
(RETAIN)
EXISTING 4 BEDROOM DWELLING PER HEALTH AGENT
156.81 RETAIN EXISTING 3 BEDROOM SEPTIC SYSTEM "A"
C-a3.24
99.49' / I ADDITIONAL SEPTIC SYSTEM PROPOSED TO REPLACE
■�7. 4 57.'3 // 51 - I CESSPOOLS: S`tSyEM"t3.,
Czy LOT 6 / I DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD
11,143f S.F. / I _
TEST HOLE LOGS x 57.44 //0 / I USE A 330 GPD DESIGN FLOW FvR
. ARNE H. OJALA, PE, SE X 695 ENGINEER � /y � s� 7.10 55 SEPTIC TANK: 330 GPD (2) = 660
DON DESMARAIS, S� SLAB 5 --- .1 L - 5 __
WITNESS: RS 5 57.45 /�/J��� PAVED DRIVEL
c0 1��. 7 USE A 1500 (SAL.- SEPTIC IC TANK
AUGUST 22, 2011 /�� .79 -
DATE: .92
ALTERNATE BENCHMARK: USE LEACHING:
/ �� � 5
PERC. RATE _ < 2 MIN/INCH X 57.06 7 37.34 .7 57. fo WATER SHUT OFF AT EL. 57.8'5�i.s -sue 1 SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD
CLASS I SOILS P# 13383 a // G7 40 57.38 57w �57. 6 y BOTTOM 25 x 12.83 (.74) = 237 GPD
X 757.17 / 57. 57.42 w 5T 6 -� 1UA
I TOTAL: 472 S.F. 349 GPD
7.3%
Q ELEV. 0
ELEV. c� 1 I USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL)
p" 56.8 p" V' 56.8 EXISTING 2 5 O 56.49
WI
Ln
DWELL. 20' TH 4' STONE ALL AROUND
O A 0 A BENCH MARK - CORNER OF V TOP FNDN. es 56.88
x C = ' S7.33
56. 8 EL. 58.4 m
LS LS CONC. BULKHEAD EL. = 57.8 X 56.85
2" 1OYR 4/2 2" 1OYR 4/2 1 O 5� 56.85 57 1�
E E 101
5i.1 _
FS FS SYSTEM B 56.68 / I
10YR 6 1 C _ - - - 3 / 56.88 (� 156.28
4" 1OYR 6/1 4" / 56. 1 �H
10 0� 92 TH 1 N6.591 APPROVED DATE BOARD OF HEALTH ' MA
B B \ ,� r � 56.9 PAV
-LS LS 6° 6 G- 18 0 6.8ep TITLE 5 SITE PLAN
SHELL PARKING w
56.22
10YR 6/6 10YR 6/6 ' w w8 56.81 I OF
40" 53.5' 40' 53.5' s w� ° --56.68 56.24
11 .5 Q
SYSTEM B 563 STRAWBERRY HILL ROAD
C C CENTERVILLE .
PERC
PREPARED FOR
MCS MCS
W/GRAVEL W/GRAVEL BORTOLOTTI CONSTRUCTION/
2.5Y 6/6 2.5Y 6/6 SULLIVAN
126" 46.3' 126" 46.3'
NO GROUNDWATER ENCOUNTERED AUGUST 30, 2011
rrDAN
AF1
K of o off 508-362-4541
ANIEL $� � �"�� �%a� sq fax 508-362-9880
A. �, �'`� DANI&LA. � 'o` DAINIELc�, downca e.com
OJALA � o 0JALA "�o A. -A f p "
No.40980 �" CIVIL .X OJALA u
No.46502 ¢ po 46502 \° No,40980 down cape eng/neer/ng, MC.
,, \N. , civil
vil engineers
Scale: 1"= 20' �Ss�CSAL�NG� . . F� N �STE � , .� `�� �� land surveyors
939 Main Street ( Rte 6A)
> - 188
0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675