HomeMy WebLinkAbout0591 STRAWBERRY HILL ROAD - Health 591 STRAWBERRY HILL, CENTERVILLE
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TOWN OF BARNSTABLE
LOCATION S91 ,-1 rawyt� N►1 1 Rol. SEWAGE# e1607- /a y
ILLAGE Ccn-lcr u i 1 I c ASSESSOR'S MAP&PARCELS 9 /G
FNSTALLERS NAME&PHONE NO. r Q XCAVATto�l SOS 5�77-�GS�
SEPTIC TANK CAPACITY 16-oo
LEACHING FACILITY:(type)Xn4;'/4ro--)ors (size) /o x Vo x 2_
NO.OF BEDROOMS y
OWNER 4V c i
PERMIT DATE: y-a- 07 COMPLIANCE DATE: / C�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
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TOWN OF B��A//RNSTABLE
LOCATION Vr9/ �L �lGGl� �� SEWAGE #
VILLAGE �i,LCP� ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of a 'ng acility) / Feet
Furnished by
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No. Fee 160
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Di5po5a[ 6pftem Cott5trUCtion Permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. J` 5{f Q w��f y }lI(� Owner's Name,Address,and Tel.No.
Center v t l t LIB Gy y i a neat
Assessor's Map/ParcelMato Z.4 9 -PQ ( b 59,
+rave be r r Y Hitt 1Z E) (-r—n}er v t t( t-
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�RDbm-r G1LfoI- 13-rlB ExCdva+l.nn Dovwr\ Lape, Fn ►reercneq
t 9 cl%6 S+- br
Type of Building: I Li If
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures uu
Design Flow(min.required) —1 ` d gpd Design flow provided and
Plan Date 1eo Number of sheets ( Revision Date
Title Ti ale S G,+r -P(art
Size of Septic Tank 1506 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Date 3 1 Zq 101
Application Approved b Date
Application Disapproved by: Date
for the following reasons
Permit No. "� lv'�-y Date Issued �"
Fee
_THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
,• PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pprication fouDi.5po.5ar 6p!gtem Cougtruction Permit
Application for a Permit to Construct O Repaid 4 Upgrade( Abandon( ❑Complete System ❑Individual Components .
d
Location Address or Lot No. 59( j rCt Wf 1 \j 00040 Owner's-Name,Address,and Tel.No. 1
>' Assessor's Map/Parcel C\ cl I CI r c e 1 ( 6 5 Gi 1 5' r C1 v i( �t
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Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Robe 1- &ILroj- Bt l FYCRvGIr ,( 1 1`�r�wt-� CCU e n 11ne lir1i
i -rec1v) r 1_n
Type of Building: ,,, '
Dwelling No.of Bedrooms, Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building P, No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(mintrequired) H L` U gpd Design flow provided gpd
Plan Date 3��3 10-7 Number of sheets { Revision Date
Title -r fi{C 15 &A P P( Ci t"l
Size of Septic Tank 00 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: s"
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in w'
accordance with the provisions of Title 5 of the Environmental Code and not to place the.system in operation until a Certificate of
Compliance has been issued by this Board of Health.
ned t Date 3 4 9
Application Approved b��PP PPDate
Application Disapproved b 1
PP PP Y� Date
for the following reasons i
Permit No. a ' /c q Date Issued 1_ 'Z)- 0 1-7
- ---------------------------------------------
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 f3 t R) E*, 6 r2� n
at J < rca w)IDIC r r t`I l N 1) has been constructed iin accordance �i✓/a I
with the provisions of Title 5fand the or Disposal System Construction Permit No. �` dated
Installer ry e l l a I L�E!��I Designer (,i ic) ( t i 67 P r 1 CAd 11 9�'E'C i C 1 r
#bedrooms Approved design flow gpd
The issuance of this permit shall not be cons rue as
a guarantee that the system wi:�* eigned.
Date J � ,/ Inspector
--------------1-- ------
No. 0,0C ! p� Lr ��� �3
Fee-�--
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Wi5pogal *VsAem Cougtructiou Permit
Permission is hereby granted to Construct ( ) Repair `Y.Q Upgrade ( ) Abandon ( )
System located at 5 91 l 5A'.t`nw Lf-ram— 1 i1_�? Q P I f,
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must e completed within three years of the dat o ffMe,!L6t
Date D Approved e b`y
FROM :down cape engineering inc FAX NO. :15083629880 Mar. 12 2007 09:2eAM P1
Town of Barnstable
Regulatory Services
Thomas F. Geller,Director
K AM Public Health Division
Thomas McKean, Director
200 Main.Street, Hvannis, MA 02601
Office: 508-962-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: Z a Sea,age Permit# o��Q 2 - Assessor's Map\Parcel
Designer: 1-,bo VJ ki GLe C, Installer: /3 be
Gi
Address: l� & V � Address:
On V Z P 7 ��h" / f _Was issued a permit to install a
date) ( )
installer
septic system at ( � S 7• -- based on a design drawn by
(address)
dated /l 7 0 6
(desi er)
'y I certit, that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance unth State & Local Regulations. Plan revision or
certified as-built by designer to follow.
N OF MA6,, o
ARNE H.
U OJALA
CIVIL Cn
(Installer's Signature) No. 30782
' S1ON,4L EN
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABI.E PUBLIC. HEALTH DWISTON. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DWISION. TIL&NK YOU.
Q:Hcalt.h/Septic/Designer Certification Form 3-26•.04.doc
TOWN OF BARNSTABLE
LOCATION ,Tq/ 5-1 rca r,_,Ac rrU I.1►) I Rol. SEWAGE# e7o0'7 - /a y
�''ILLAGE Ccn4r-r u i I I c ASSESSOR'S MAP&PARCEL
Ii(."STALLERS NAME&PHONE NO. B Q EX(zAUA-rxrw s08'. y77-DGs
SEPTIC TANK CAPACITY /6,00 9 a I'
LEACHING FACILITY. (type) gn r,'14rcx-)or (size) lox Vo x ;L
NO.OF BEDROOMS Ig
OWNER Lu c i
PERMIT DATE: y- - O 7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
o
Subsurface Sewage Disposal System Form - Not for Voluntary,Assessments
°M 591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:key to move your
cursor-do not Michael DiBuono
use the return key. Name of Inspector
DiBuono Sewer and Drain
Q Company Name
8 Johns path
Company Address --
B S Yarmouth MA _ 02664
City/Town State Zip Code
508-364-9587 _ S113522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by,the Local Approving Authority
12/1/2014
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
***"This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use..
t5ins•3/13 Title 5 Official Inspect Fo :Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 p Y rY
591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is Centerville Ma 02632 12/1/2014
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system contains a 1,500 gallon plastic septic tank as well as a concrete Distribution box. All tees
and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of
several leaching chambers and at time of inspection levels appeared to never have been at abnormal
levels.
13) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
• , Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is Centerville Ma 02632 12/1/2014
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
.pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
,. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is Centerville Ma 02632 12/1/2014
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® 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 '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® 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 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
(
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M •''v 591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
page. Cityrrown 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?
® ❑ 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
1_
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is
required for every Centerville Ma 02632 12/1/2014
page. City/Town State Zip Code Date of Inspection
D., System Information
Description:
The system contains a 1,500 gallon plastic septic tank as well as a concrete Distribution box. All tees
and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of
several leaching chambers and at time of inspection levels appeared to never have been at abnormal
levels.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected?
® Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)): 2013 33,000
Detail: 2012 32,000
for a total of 92.7 GPD
Sump pump?
❑ Yes ® No
Last date of occupancy: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ® Yes ❑ 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)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M ,•'' 591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is
required for every Centerville Ma 02632 12/1/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
7 years
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan)
Depth below grade: 18 "s
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.):
System is vented through the roof
Septic Tank (locate on site plan):
Depth below grade: 1 ft
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene
❑ other(explain)
1,500 gallon
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gallon
Sludge depth:.
3"s
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 24"s
Scum thickness
3"s
Distance from top of scum to top of outlet tee or baffle 42"s
Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank needs to be pumped
Grease Trap (locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments'
°M •''v 591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
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.):
Septic tank needs to be pumped. All tee's are in place
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 El other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
591 Strawberry Hill rd
M y
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert At Normal Level
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.):
Distrinution Box is level and at normal level with no signs of carry over or decay.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 6
❑ 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 carry over. no signs of hydrualic failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
No signs of ponding or hydrualic failure.
Privy (locate plan):
locate on site :
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
15ins•3I13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
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• , Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014 '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12+ ft
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: 3/23 /2007
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:
Pan on file shows NGWE at 12 ft
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
591 Strawberry Hill rd
Property Address
Juan Marichal
Owner Owner's Name
information is required for every Centerville Ma 02632 12/1/2014
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information— Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
y
941
4e
Commonwealth of Massachusettsan
Executive Office of Environmentol Affairs V/�
Department of Z96'
Environmental Protection
WUllam F.Weld •-�......Trudy_Cox•
ao»�wr 8ici`4`Y
Argoo
Gul Celluccl David B.
o.%rrwr r
ee
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Add,... 591 Strawberry Hill Road *fe_Address of Owner.
Date of Iaspectjon: 4/24/96 (If different)
Nameoflnspootor. Joseph P. Macomber Jr.
Company Na:ae,Addressand Telephone Number.
J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632
CERTIFICATION STATEMENT 508-775-3338
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accumts
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: B' l%�,/l�Lt�ll.%l.�'f�- Date: �6 .
The System Inspectors submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this
inspoction. If the system is a shared system or has a design flow of 10,000 gpd or groater, the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner And copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
AJ SYSTEM PASSES:
have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are iudicatod below.
B) SYSTEM CONDITIONALLY PA99ES:
QOne or more system components mood to be replaced or repaired. The system, upon completion of the replacement or repair,passes
inspection.
Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain.why not)
Nib The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,-or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
`J by the Board of Health.
(revlsed 11/03/95) 1
One Winter Street 0 Boston, Mattachusetts 02108 0 FAX(617) 556-1049 9 Telephone (617)292.55o0
i
: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinuod)
pipe ,Ad Joseph Sloan
Owner. 591 Strawberry Hill Road Centerville ,Mass. 02632
Date ofInspoatlons 4/24/96
B)SYSTEM CONDITIONALLY PASSES(contiaueu
11�Q Sawage backup or breakout or her;tatia water level observed in the distribution box is duo to broken or obstructed pipes)
or due to a broken,eettlad or uneven distribution box. The system will pans inspection if(with approval of the Board of
Health:
broken pipes)are replaced
,�.•;.' i�llijtotion L removed
d at' rution box is levelled or replaced
Ab
The system required pumping more than four times a�year due to broken or obetructed pipe(s). The system will peas
inspection it(with approval of the Board of Health):
broken pipes)are replaced
Obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTM
Conditions wrist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS'NOT FUNCTIONIN(l IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT
SOCesspool or privy is within 60 feet of a surface water
Cesspool or privy is.within 60 feet of a bordering vegetated wetland or a salt marsh.
R) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMRjFj THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENTt
The system has a septic tank W'd soll absorption system and is within 100 feet to a surface water supply or tributary to a
surfaca water supply.
�j The system has a septic tank anj soil absorption system and is within a Zone I of a public water supply well.
�Q The
system has a septic tank and soil absorption system and is within 60 feet of a private water supply well.
The system has a septic tu&and soil absorption system and is lass than 100 feet but 60 feet or more from a private water
supply well,unless a well water Analysis for colVorm bacteria and volatile orgarrIc compounds indicates that the well Is free
from pollution from that facility,pAd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm.
3) OTHER
_✓ The system consi +s of 2 6 r xR r 'Rl nr+lr 008G nn �; _i inn.
gallon eaC 1nQ�lt Has town WAtPr anti i e not near _any
wetlands or tributaries or surface water.
<nvt:ed it/03/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddross: 591 Strawberry Hill Road Centerville,Mass . 02632
Owner. Joseph Sloan
Date of Lupootion: 2
4/ 4/96
DI SYSTEM FAILSs •
I haw determined that the system violate+one or more of the following failure criteria as defined in 310 CMR. 16.303. The basis for
this determination is idantihed below. The Board of Health should be contacted to determine what will be nacessas7 to correct the
failure.'.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Nd Discharge or ponding of ailluent to the surface of the tround or surface waters due to an overloaded or clogged SAS or
cuipooL
Ne-&X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or casspool.
Liquid depth in cesspool It less than 6"below invert or available volume is less than W day flow.
Requirod pumping more tl=4 times in the last year NOT due to clogged or obstructed pipe(&).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Lr(l Any portion of a cosspool or privy is within 100 foot of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
&y Any portion of a cesspool or privy is within 60 feet of a private water supply well.
Any portion of a cesspool or privy is lass than 100 feet but greater than 60 foot from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analy&L for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to largv systems in addition to the criteria above:
AV The system servos a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the onvironmeAt because one or more of the following conditions exist:
.�Q the system is within 400 foot of a"race drin]dng water supply
the system is within 200 feet of&tributary to a surface drinking orator supply
dV the system is located in a nitrogen sensitive area (Interim Wellhead Protection Ara&(IW A)or a mapped Zone II of a public-
water supply well)
The owner or operator of any such system sha.1 bring the system and facility into 1W1 compliance with the voundwater treatment pmV=
requirements of 314 CMR 6.00 and 6.00. Plow:a consult the local regional office of the Department for Auther information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property m&esx 591 Strawberry Hill Road Centerville ,Mass . 02632
Owner. Joseph Sloan
Date of Inspeotion.4/24/96
Check if the following have been done:
Pumping information was requested of the owner, occupant,and Board of Health.
ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
ZAs built plans have been obtained and examined. Note if they are not available with N/A
2The facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non-sanitary or industrial waste flow
ZThe site was inspected for signs of breakout.
ZAll system components,4cluding the Soil Absorption System, have been located on the site.
/1/VOyC,The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or
tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
ZTha size and location of the Soil Absorption System on the site has been determined based on existing information or
a proximated by non-intrusive methods.
The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 591 Strawberry Hill Road Centerville ,Mass . 02632
Owner. Joseph Sloan
Date of Inspectlon: 4/2 4/96
FLOW CONDITIONS
RESIDENTIAL:
Design flow: nJ0 Ions P 4 N��1 R •
Number of bedrooms: V Number of current residents• .4
Garbage grinder(yes or no):_LZ>
Laundry connected to system(yes or noJ"
Seasonal use(yes or no):AX)
= 11% �c ✓ "
Water meter readings,if available (�
$ = , BiY
Last date of occupancy:Qkt f. N-V
COMM ERCIALA NDUSTRIAL:
Type of establishment: A
Design flow:_&B _gallons/day
Grease trap present:(yes or no)AN
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)&4
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe) A
Last date of occupancy: MR
GENERAL INFORMATION
PUMPING ORDS and source of information:
P. . G
System pi6pk as part of inspection: (yes or no)
If yes,volume pumped: ons
Reason for
TYPE OF SYSTEM
Septic tank/distribution bo:/aoil absorption system
Single cesspool
/ Overflow cesspool
Privy
Shared system(yes or no) (if yes,at ch previous inspection recordq if any)
Other( p f/ /G� 1
1
RO AGE fcomponents,date (if kno fo
)and source f inrmations
15
Sewage odors detected when arriving at the site: (yes or no)_
(revised 11/03/95) 6
JOSEPH P.MACOMBER&SON,INC.
P.O.BOX66
CENTERVILLE,MA 02632-0066
Name: Joseph S loan 771-1262 Customer Code:
Address: 591 Strawbem/ Hill Road jslo
Tovn: Centeryille State:Ma zip:02632
jj MWing address:
591 Stray bemy Hill Ad Centerville MA 02632
Mates: 82--
�, 6124188 system LP 1500.00 pay 3117189
�j 915190 pump 1 pool 105.00 1019190
5120191 purnp 2 pools 18 5.0 0 617191
913193 pump 1 pool 145.00 1015193
717195 pump 1 pool 145.00 8111195
E
C
III
ii
b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PtopertyAddros&- 591 Strawberry Hill Road Centerville,Mass . 02632
Owner. Joseph Sloan
Date of Inspection: 4/24/96
SEPTIC TAN _&' fV
(locate on sits plan)
Depth below grade:
Material of construction:Oconcrete_metal_FRP—other(explain)
t
Dimensions:
Sludge depth..—
Distance from top of udge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: A!,A
Distance from bottom of scum to bottom of outlet tee or baffler
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage, etc.)
/V,, Co,41 .n0,V
GREASE TRAP:A/oNe
(locate on site plan)
Depth below grade:A2A
Material of oonatruction:4Aoncrete_metal_FRP—other(explain)
Dimensions: Ill
Scum thickness: !U
Distance from top of scum to top of outlet tee or baMe:_,&Q
Distance from bottom of scum to bottom of outlet tee or baffle: AM
,,
Comments:
(recommendation for pumping,condition of inlet and outlet tees or bafYlles,depth of liquid level in relation to outlet invert,structural integrity,
evidence leakage,etc.)
AZ e 4,44 AMA 3
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 591 Strawberry Hill Road Centerville,Mass . 02632
Owner. Joseph Sloan
Date of Inspection:4/2 4/9 6
TIGHT OR HOLDING TANY-AbNe,
(locate on site plan) s
Depth below grade:
Material of construction:j&ncreta_metal_FRP--other(explain)
Dimensions•, A9 A
Capacity:_ 11�A�ns,
Design 11ow: ona/day
Alarm level:,_
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:,jV0ye-
(locate on site plan)
Depth of liquid level above outlet invert:,._
Comments:
evidence of solids over,evidence of leakage into or out of box,etc.)
(note if and distribution is equal,ev: �'rY
/Tfd 1y1 GAT
PUMP CHAMBER;d!dVe.
(locate on site plan)
Pumps in working osder:(yes or no)
Comments:
(note ndit' n of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
PART C
SYSTEM INFORMATION(oontinued)
Prop erty Address: 591 Strawberry Hill Road Centerville ,Mass . 02632
Owner. Joseph Sloan
Date of Inspection: 4/2 4/9 6'
SOIL ABSORPTION SYSTEM (SAS):,
(locate on site plan,if poew'ble;excavation not requir4 but may be approximated by non-intrusive methods)
If not determined to be present,explain: e
Type:
leaching Pits,number.
leaching chambers,number:_
leaching galleries,number.
leaching trenches,number,length:
leaching fields, number,dimensions:
overflow cesspool,number:
Lomments:(note tion f il, s' ofh�dra c failure, level of nding,condition of vegetation,etc.)
oamy sand, anc� I gravel. `fine san4No signs of hydraulic failure or
Donding.All vegetation is normal All components are structurally sound
No repairs are needed at, the =rPsPnt time _
_ CESSPOOLS:
(locate on site plan)
Number and configuration:_ 01— 1�
Depth•top of liquid to inlet invert: On
Depth of solids layer.
Depth of scum layer.
Dimaa:ious of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of ins ion) C Q
el
' 1
Comments:(note condition of soil,signs f hydraulic failure level o ponding,.condition f vegetation,etc.)
Soils same as aboa�e.I�o signs of hyraulic failure or ponding,All
ve e a ion norma Cessnoo s are s ruc urally sound.
PRIVY:
(locate on site plan)
Materials of construction: A4 Dimensions:_ 100
Depth of solids:.&&_
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95). g
C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
ProperVAddresa: 591 Strawberry Hill Road Centerville ,Mass . 02632
Owner. Joseph Sloan
Date of Inspection: 4/24/96
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all well within 100'
Centerville Osterville Marstons Mills Water
Company
428-6691
Cj
Y
DEPTH TO GROUNDWATER
Depth to groundwater. 2 0 r feet
method of determination or approximation: Installed leaching pit in 1988. Dug hole f o r
6r helow new pit No water encountered.
(revised 11/03/95) 9
z
w
LO
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title -
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the ' -ion of Water Pollution Control
TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSIIFCTION FORM - PART D .- CERTIFICATION
—TYPE OR PRINT C1.EARLV—
PROPERTY INSPECTED
STREET ADDRESS 591 Strawberry Hill Road Centerville,Mass . 02632
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Joseph Sl6an
PA R 7' V - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 7 3338 FAX ( 508 790 1578
5 08
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal System at
this address and that the information reported is true , accurate , and
complete as of the time of .,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Che-1, one :
Systeui PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CHR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED
The inspect*!on which I have conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 3.10 CHR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector 8ignature 4-1 Vw'; Date L
One COPY of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEAL'I'll.
If the inspection FAILED, th'e- owner 0 r,,,o.perator shall upgrade ' the aYstem
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CHR 15 . 305 .
-2 -1
<
Fizs........ .... .:.00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........T.ow.n...................O F............Bar.n.s_t~ab.le--------------------...._....._.....----------
Applira#ion for MivaiiFal Workri Cnomitrurtion rrmit
Application is hereby made for a Permit to Construct ( ) or Repair kX� an Individual Sewage Disposal
System at:
5 91 ---.S--t--
a wp ... e n t r v.11.1 e .........-••--•-------------------------••-----•--••------••--•---------------......-•.........••.
Location-Address or Lot No.
3.)_S3all.........................................•.....................................---
Owner Address
jI.-P—Mac.amber---------------------------------------------------------------- ....----••-•-•-•-•--••----............------•---------....------.....-•--
Installer Address
Q Type of Building Size Lot............................Sq. feet
U DwellingX-XXNo. of Bedrooms.......... ................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________•_______ Showers — Cafeteria
p' 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 Length.................... 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____--____.-_--__-__--
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ••-•••-••-••....................•-•••••••--••-•--•••-•••-...........•--••-••••..........--••--------------••---•-••••--------••-•-•---•---------------------
0 Description of Soil........................................................................................................................................................
---•-------•••-
V .Sand & G:rve-1
W ----- --------------------------------------------•---------------------------------------------------------------------------------------- ............................................................
UNature of Repairs or Alterations—Answer when applicable......1---L&OD---ga,11-on---pit._......................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of AI:IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n issued y -bod of healt .
Signed
6-/-14/.aa......
Date
Application Approved By................... .......•...... ... ...........
Date
Application Disapproved for the following reasons:................................................................................................................
...................•....................................................................................................................................................................................
G G Date
PermitNo.............d-G2 .................. Issued_.......................................................
Date
FEs........ ....20.00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T ata U...................O F............n.2t r n.s-t.?"1b.1 e....................
Appliration for Uhipw gal Works Tangfrnrtinn rnmit
Application is hereby made for a Permit to Construct ( ) or Repair ftjr an Individual Sewage Disposal
System at:
......................................S r'� ....y1�s..1._R _..d Ge.... r�a_.... ..................................................................................................Location-Address or Lot No.
Sloan
Owner Address
............................................................... ------....--------------------•-•-------.........---•-••---------•-..................---......--
Installer Address
Q Type of Building Size Lot............................Sq. feet
DwellingX XVo. of Bedrooms.........3................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther 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 Length.................... 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........................................
W
a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water..--_----_---.-..-----_.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...---_-----_--..-..---.
---------------------------------------------------------------•---------••--------.................------•-•--•----•-------•---•---------------------------
0 Description of Soil...........................................................................................................------------------------------------------.................
vS...d e -••--------••-•-------•-••------------------------------•--•------------•---------------------------------••••--•-----
W
VNature of Repairs or Alterations—Answer when applicable_-_-.-1--. 000___9411®n. nit
------------------------------•--•••--------•.......--••••--
Agreement:
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 riot to place the system in
operation until a Certificate of Compliance has be issued by/t46 board of heals
Signed %tf' ° r' /e�r� sP� � - 6/14/88
. . ..................
Date
Application Approved BY ( t,..,.. ,.....} ...............
... ------
Date
Application Disapproved for the following reasons-....................`............................................................................................
......--•-----•-----•---....-•----•-•-------•----•-•-----------•-•-------------------------•------.......-•-........-•-...••-•••----•---•-----•-•---------••--•-----•-•-••----•---•-----•----••-•••-•---
Date
C
PermitNo............. .. _:. U-- ------------------ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J. .............OF...... Barnstable
.............................................................................
� C�rr�if irtt�le laf f�nm�li�anrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired JtX�
by.......3.P..nacamber
--------------------------•-•-----•--••---......------••..._.........-••---....•-•-------------------------............•••-----•--•-•--•---------------•--
591 Strawberry Hill Road. CentINVYlle.
at...................................................................................................................................
has been installed in accordance with the provisions of TIT'— 5 o Th State Sanitary Code as described in the
P �i Y
application for Disposal Works Construction Permit No....... --_-......?..-_...-_. dated...... ........................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... �LAti...-. •---------------- Inspector..............._.-D-.....................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
3� .............................OF..................................................................................... $ 20.00
FEE........................
Rapaout Work.5 Tnntrnrtion "Permit
J.P.Macomber
Permissionis hereby granted......................................-.......................................................................................................
to ConstrV9 1 err R X s o System
dd y a ea eer reaw�er at No...............................................................................................................................................................................................
Street Q,
as shown on the application for Disposal Works Construction Permit NO..�5... --._ Dated..........................................
• ..............
DATE. G �7 (J. _______________________ Board of Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
ASSESSOR'S MAP NO. � `Z PARCEL 0 .�
: O CAT ION SEWAGE 'PERMIT NO.
5 0� 1 S
;VILLACEL�
INS A LIER'S NAME ADDRESS
l-
B U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED -
7
10,
e
r
SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC NOTES
TOP FNDN. AT EL. 58.9' TAPE OR COMPARABLE MEANS FOR FUTURE LOCATION. Route 28
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) 1. DATUM IS APPROXIMATE NGVD
" ACCESS COVER (WATERTIGHT) TO PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE
" OF FIN. GRADE 2. MUNICIPAL WATER IS EXISTING
5$,0 MINIMUM .75 OF COVER OVER PRECAST WITHIN s 2% SLOPE REQUIRED OVER SYSTEM 8.0' P 151, ova
RUN PIPE LEVEL 3. MINIMUM PIPE PITCH TO BE 1/8 PER FOOT. �� -o/ I 2
* FOR FIRST 2
56.5 2" DOUBLE WAS EP PEASTONE 3' MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO
L22L-
OR GEOTEXTILE FABRIC Pine St. p
H- 10 �
.98';LE " 56>1
56.23 � s 'AMP 5. PIPE JOINTS TO BE MADE WATERTIGHT.
55.79' 'g 55.62 000
55.6' 3' AT SIDES 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH
( 2.5% SLOPE) �6" CRUSHED STONE OR MECHANICAL - 1.25',AT ENDS MASS. ENVIRONMENTAL CODE TITLE V.
COMPACTION. (15.221 [21) ,
DEPTH OF FLOW = 4 go ogo 14 �o 00 0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
E SIZES: oao ��� 53.6 BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE.
TE
INLET DEPTH = 10„
min 3/4" TO 1 1/2" DOUBLE WASHED STONE 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
OUTLET DEPTH = 14 ( 1 % SLOPE) ( 1 % SLOPE)
11 SEPTIC TANK 15' D' BOX 4' LEACHING 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
FOUNDATION
FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION
6' OBTAINED FROM BOARD OF HEALTH.
LOCUS MAP
*THE INSTALLER SHALL VERIFY THE 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
LOCATIONS OF ALL UTILITIES AND ALL DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION SCALE: 1" = 2,000'f
BUILDING SEWER OUTLETS AND ELEVATIONS I OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO
COMMENCEMENT OF WORK.
PRIOR TO INSTALLING ANY PORTION OF ASSESSORS MAP 249 PARCEL 16
SEPTIC SYSTEM BOTTOM TH-1 EL. 47.6'
11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND LOCUS IS WITHIN WP OVERLAY DISTRICT
REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
LEGEND 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
REMOVED 5' BENEATH AND AROUND THE PROPOSED
100.0 PROPOSED SPOT ELEVATION LEACHING FACILITY.
13. SEWER PIPE TO BE CUT AND CAPPED IF NOT UTILIZED.
+100.00 EXISTING SPOT ELEVATION IF STILL IN USE, THEN SEWER LINE SHALL BE TIED INTO
100 PROPOSED CONTOUR PROPOSED SEPTIC TANK.
SYSTEM DESIGN:
100 EXISTING CONTOUR
OHE EXISTING OVERHEAD .ELECTRIC GARBAGE DISPOSER IS NOT ALL-OWED
PROVIDE APPROX. 32 OF .40 MIL I LINER AT 5' OFF SAS IN AREA DESIGN FLOW: 4 BEDROOMS 110 GPD = 440 GPD
,
SHOWN. TOP AT ELEV. 55.8; \S], �;° ; j x , .,
TEST HOLE LOGS BOTTOM AT EL 51. 99.14
8' ..
I
o i SEPTIC TANK: 440 GPD (2) = 880
DAVID FLAHERTY, R.S. v� [�JED \
ENGINEER. USE A 1500 GAL. SEPTIC TANK
WITNESS. DON DESMARAIS, R.S. X sraN i (IF PLASTIC, USE THE FRALO "SEPTECH ST-1500" OR EQUAL)
MARCH 20, 2007- PARKfNG I LEACHING:
AREA ���-_ ,
DATE: •� '�-, ______ _ __ _ _
PERC. RATE _ < 2 MIN/INCH 104. xt 10.1' SLAB - Q SIDES: 2 (10 + 40) 2 (.74) = 148 GPD
' EXISTING I I Q
I 1 1692 ;"; DWEWNG /O PAVED i BOTTOM 10 x 40 (.74) = 296 GPD
CLASS SOILS P# TOP FNDN=5� i DRIVE i
600 S.F. 444 GPD
TOTAL:
ELEV. z ELEV. _ I I o--- ---- ----
1 rY PA Oi ---- �_J J USE (6) HIGH CAPACITY INFILTRATORS
0" 57.8' 0" 57.9' - _ i , `W W W i = WITH 1.25' STONE AT ENDS AND 3' AT SIDES
A A o ' ' cP, DEOK o �i } AND 1.2' BENEATH FOR 2' EFFECTIVE DEPTH
__ o i
LS LS TH-20
\ ``�`�' INV OUT
1OYR 3/3 1OYR 3/3 I ELEV=56.5' Uj
12" 56.8' 12" 56.9' TH-1 BH (SEE NOTE13) m
B B >
- , TITLE 5 SITE PLAN
,W �
4
LS LS \cP k® 11s' PARCEL IIBEN OF
10YR 6 6 10YR 6 6 CORCBULKHEAD OHMARK OUT 9,833 SFt ;0 �-
26" / 55.6 26" 55.7' ELEV = 5s.9' LEV=56.5' iQ
co 591 STRAWBERRY HILL RD.
, (CENTERVILLE) BARNSTABLE, MA
i
C C PREPARED FOR
PERCv -A- A--A
L�3x X
i
MS MS 97.53 hIV i B & B EXCAVATION/
/ LUCY GIANNETTI
2.5Y 7/5 2.5Y 7/5 i
DATE: MARCH 23, 2007
off 508-362-4541
" , " , SCale: 1"= 20' fax 508 362-9880
122 47.6 120 47.9 of n�ss ���,°F MASsq
NO GROUNDWATER ENCOUNTERED 0 10 20 30 40 50 FEET o` ARNE q�yG q�� ARNE H- ctiG
g H. s0 �� OJALA �, down cape en gin eerin g, inc.
o OJAt.A N CIVIL N
No.26 8 /'y No. 30792 Cll/lL ENGINEERS
° (J o �Q7 LAND SURVEYORS
G 939 Main Street - YARMOUTHPORT, MASS.
MA DATE N�SA OJALA, h`Jo
DCE #07-041 APPROVED DATE BOARD OF HEALTH
07-041 B&B_GIANETTLDWG (DDF)