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HomeMy WebLinkAbout0111 VICTORIA STREET - Health III VICTORIA STREET Centerville A = 148 — 050 SMEAD KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FOREST RY MIN.RECYCLED F INITIATIVE CONTENT 10% CeajeaFiberSourcing POST-CONSUMER wwwoproprem.9rp SP41290 MADE IN USA GET ORGANIZED AT SMEAD.COM �I TOWN OF BARNSTABLE LOCATION SEWAGE# rk 0 16 - 3� g V"ILLAGE,',,,±-frv,I/Y ASSESSOR'S Mpp AP&PARCEL B INSTALLER'S NAME&PHONE NO•,��r��x�G S �1 1 G fc,, r,i TA)C SEPTIC TANK CAPACITY(_1- ( Cr>(cjcj)c , C,,/'o ex I Z-D0 LEACHING FACILITY: (type) S-00 c,(;cO C/�IceJa'/S(size) NO.OF BEDROOMS "�, C 2 k4cktn f 0 k, 2+An kI OWNER / AQtS� PERMIT DATE: J 1 —I COMPLIANCE DATE: Separation Distance Between the: ;�,oNe C.f- IOf c- 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 TC BAck- OUT mac, ( > J C, oor-� COat 2 .�T --� iC,,,)k 2, 10 00r-15�S L No. �?� Fee , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplifation for Bispo8ar ,*pstrm Construction permit Application for a Permit to Construct( ) Repair(b<Upgrade( ) Abandon( ) �mplete System ❑Individual Components Location Addt s�or Lot No. ///dretosiq 5} Owner's Name,Address,and Tel.No. Cep _rv,1(`P Assessor's Map/Parcel y 50 &A a dS Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms " 3 Lot Size /S'OCO sq.ft. Garbage Grinder( ) Other Type of Building (t°Sia&atlrd No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3r) gpd Design flow provided 3 y�� gpd Plan Date 01811r- Number of sheets -- Revision Date Title Size of Septic Tank F_;? 5my& /octq -/-- New Iwo Type of S.A.S. _9-dp �G/�o„i P,�ijc✓�r�Pi C Description of Soil Nature of Repairs or Alterations(Answer when applicable) /NS &,L 44VO e o •P k/5�-r /��� rG//G„� ./c r/ �Ux ��=o ' l/o.�, �fGN� 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. Signe n Date f/ —/Q /G Application Approved by Date f '-Lfci Application Disapproved by Date for the following reasons _ �D Permit No. — Date Issued :e °No. v �� e `i: ^ Fee ,*...> THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 21ppliLation for Misposal 6pstem Construction Fermat Application for a Permit to Construct( ) Repair(Upgrade( =) Abandon( ) Complete System ❑Individual Components Location Addre�s�or Lot No. //i ditfoii4 rj/ Owner's Name,Address,and Tel.No. Cc" lcrv, 1/IP Assessor's Map/Parcel 14/ 5 U A-A Installer's Name,,Address,and Tel.No. Designer's Name,Address,and Tel.No. J Type of Building: Dwelling No.of Bedrooms Lot Size /5 DOO sq.ft. Garbage Grinder( ) t , Other Type of Building (F))O6AA I r, 1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3C) gpd Design flow provided 3 / gpd Plan Date 10&1/G Number of sheets .. Revision Date Title !/ Size of Septic Tank xisf rvc icrx� f- NPw l ono Type of S.A.S. Description of Soil / Nature of Repairs or Alterations(Answer when applicable) /Vs 6 I a Ale ed.- cr>v c // (,,.'Al r�J f G/N r/ �U Pk/StINC //7GfJ fG✓�GnJ f(/iJ�C (/ A,, Sf('rvF Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until:a Certificate of Compliance has been issued by this Board of Health. Signed ' j! Date Application Approved by LX1 ram, 112, Date Application Disapproved by Date for the following reasons lJ ff Permit No. o 1 — Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(d) Upgraded( ) Abandoned( )by�,*2,)6 A :irA U^.) T A)C at �-el/ti)7)e has been constructed in accordance fo with the provisions of Title 5 and the for Disposal System Construction Permit No. fb-il dated Installer ,j�k, r),S A B/c-,,� S ,vc Designer E-rQ N.yv� py vc ( c,✓ )C 7!�, #bedrooms Approved design ow '$ U gpd The issuance of th's pe it shall not be construed as a guarantee that the system will cti as designed. Date a t l Inspector ---------------------------------------------------------------------- No. o`CAI p Y� Fee o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6pstem onstrULtlon Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at /(/ . t/ic /GviG, �fP� vi�/`f' 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 permi. j Date �' l7' �o Approved by f 1 Town of Barnstable Regulatory Services Richard V. Scah,Interim Director sAxNsrnst,E, MASS. Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: y 2 Z 1 U l Sewage Permit# ZK, �' _Assessor's Map\Parcel Designer: e nc I vie r,y €vc las 1y. Installer: _C-zfv,Jyk Address. 1 Z i ti, Cci Ic^.�i t l��� Address: orl! G' 4-ar,U _ I On - P t jLAi^ j 'uC permit was issued a to install a (date) (installer) septic system at 1 t. l V� LVe�'� based on a design drawn by p (address) L G,t- e: f L5 dated (designer) I certify thit 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. Strip out (if required) was inspected and the soils were found satisfactory. .I certifv that the septic system referenced above was installed with major changes (i.e. greater than, 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found 'satisfactory. I certify that the system referenced above was constructed in co fiance with the terms of the AA approval letters(if applicable) N\\ PETER T. MCENTEE nstaller Signature) CIVIL No. 35109 Afr�stE��° F V� (Designer's Signature) (Affix Desi Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE .ISSUED UNTIL BOTH THIS FORM AND AS: BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC.HEALTH DIVISION. THANK YOU. Q:\SepticWesigner Certification Form Rev 8-14-13.doc - Town of Barnstable P# Department of Regulatory Services 1ABNBTABr.&, j Public Health Division Date �p 16J� 200 Main Street,Hyannis MA 02601 rfv MA't� I Date Scheduled UTime-�- ! Fee Pd. i'Q0�dcj Soil Suitability Assessment for Sewage DispolSal p Performed By: [-4 -Kt%64" ,1p(F S-E—(, Witnessed By: I LOCATION& GENERAL INFORMATION Location Address 1 l •V'i C V-o f-ick 9 f.- Owner's Name Address r Assessor's Map/Parcel: Engineer's Name 1V%C NEW CONSTRUCTIOtN REPAIR Telephone# --7 '7_.L Land Use % 1 2 Slo es _� 0 AI� P ( ) Surface Stones Distances from: Open Water Body 111 ft Possible Wet Area ft Drinking Water Well Drainage Way ft Property Line 1 d ft Other _ i ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands(n proximity to holes) j__-7L I V lc_- 6` �`i A 5 -r - Parent material(geologic) Depth to sedrgck. A/j4A Depth to Groundwater. Standing Water in Hole: N a'f-C Weeping from Pit Face..." Estimated Seasonal High Groundwater t z f DETERMINATION FOR SEASONAL HIGH WATER TABLE � Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole- In, Groundwater Adjustment.,.,. Index Well# Reading Date: _ Index Well level ..r Adj,factor,,,,,. Adj.Groundwater 1oev�l , o PERCOLATION TEST Ditto�,..., p. Time Observation Hole# /� _ Time at 9" Depth of Perc 28 _ Time at 6'. ray s i�w Start Pre-soak Time @ _ - t .�- Time(9"-6") , End Pre-soak _ Rate Min./Inch. G' Z__ Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y _ Original: Public Health Division Observation Hole Data To Be Completed on Back-------, -- ***If percolation test is to be conducted within 100' of wetland,you must first:notify t e. Barnstable Conservation Division at least one (1) week prior to beginning. Q\SEPTICIPERCFORM.DOC I I i ]DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surfac.(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,% rave (L �— Cc SL Lo y(L S/ Is -ri3F7 C- iM L_SP11 'DEEP OBSERVATION HOLE LOG Hole#Depth from from Soil Horizon Soil Texture Soil Color Soil Other Surfac (in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% rave I' r� `_ �o 12.`I lz ]DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other -Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsistency. o Gravel) .1D1±EP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surfacg(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. of si ten °b gel) Flood Insurance Rate Maw Above 500 year flood boundary No_ Yt Within 500 year boundary No Yes.� Within 100 year flood boundary N0X Yes Depth of Naturally Occurrine.Pervious Material Doeslat least four feet of naturally occurring pervious material exist in all areas observed throughout the area 1 roposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? __. ...._ Certific ation I certify that on _ (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required tratni xpertise and experience described in 310 CMR 15.017. Sign,lture _ :Date Q:\U, CTERCF+ORM.DOC ZFIE Tn. The Town of Barnstable r w * w * BARNSTABLE. • 63 A.9 Growth Management Department 1 �f°1A0�A 367 Main Street, 3rd Floor Hyannis, MA 02601 Tel:508-862-4678 Fax:508-862-4782 March 20,2008 John C.Minim,Town Manager Janet Joakim, Town Council President Barnstable Town Hall 367 Main Street Hyannis,MA 02601 Re: Richard Morse; 111 Victoria Street, Centerville; one-bedroom accessory unit This letter is to inform you that the Accessory Affordable Apartment (Amnesty) Program has received a request for a project eligibility letter under the Community Development Block Grant (CDBG) Fund and under Article II of Chapter Nine of the Code of the Town of Barnstable and the criteria for the Local Chapter 40B Program. This office is reviewing the request. If the Town has any comments on the project, please forward them to me so that they can be addressed in the site approval letter. This letter gives you official notice of our receipt of the above application(s). We will issue a decision as to the acceptability of the sites and the consistency of this development within the guidelines of CDBG. Sincerely, (_7 Elizabeth Dillen Special Projects Coordinator Growth Management Department cc: Building Division Health Division o/ AsBuilt Page 1 of 1 LOCA ION SEWAGE PE V I L IN LLER'S NAME A ADDRESS D• • U 1 E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED /3ac—k e - V �-�S �— 3' 3' 40 http://issgl/intranet/propdata/prebuilt.aspx?mappar=148050&seq=1 3/19/2008 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #111 Victoria Street Centerville,MA Owner: Mrs.Margaret Morse Date of Inspection: 12/11/07 SKETCH OF SEWAGE DISPOSAL SYSTEM p Provide a sketch of the'sewage disposal system including ties to at least two permanent reference landmarks or f; benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. i Rear of House A O B Swing Ties: O 1500 Gal Tank A- Tank IN—28 B- Tank IN—6' A-Tank Out —33.5 B -Tank Out —8.5' A—D-Box-34 B—D-Box— 13.5 O O A—Leach Pit#1-50 B—Leach Pit#1-18 _: Leach Pit#1 Leach Pit#2 A—Leach Pit#2-38 B—Leach Pit#2-24 r e � COMMONWEALTH OF MASSACHUSETTS z d EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION eW i�qM Svey TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: #111 Victoria Street Centerville, tors Owner's Name: Margaret Morse Owner's Address: #111 Victoria Street Centerville, MA Date of Inspection: 12/11/07 Name of Inspector: (please print) Mr. Carmen E.Shay Company Name: Shav Environmental Services,Inc. Mailing Address: P.O. Box 627 East Falmouth,MA 02536 Telephone Number: (508)-548-0796 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.ji am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste> 4 XX Passes 1 _ ndit' lly Passes _ l t N s er valuation by the Local Approving Autls'o ity �-_j Fa s v; N� Inspector's Signature: Date: 12/11/07 -- The system inspector shall submit a copy of this inspection report to the Approving Authority(Boar of HeaWor r " DEP)within 30 days of completing this inspection. If the system is a shared system or has a design zf 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 No evidence of hydraulic failure observed in PIT#1 or Pit#2. Excavated SAS Cover. No Liquid Present in PIT. 5.5 feet of liquid noted in Pit#1, Pit#2 Empty. Risers Installed on all components. ****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: #111 Victoria Street Centerville,MA Owner: Mrs. Margaret Morse Date of Inspection: 12/11/07 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #111 Victoria Street Centerville,MA Owner: Mrs. Margaret Morse Date of Inspection: 12/11/07 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #111 Victoria Street Centerville,MA Owner: Mrs.Margaret Morse Date of Inspection: 12/11/07 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped XX Any portion of the SAS, cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone I of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. . . r .,. 4 'Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #111 Victoria Street Centerville,MA Owner: Mrs.Margaret Morse Date of Inspection: 12/11/07 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period? XX Have large volumes of water been introduced to the system recently or as part of this inspection`> XX _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up`' XX _ Was the site inspected for signs of break out XX _ Were all system components,excluding the SAS, located on site? XX _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of t he baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? XX _ 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 XX _ Existing information.For example, a plan at the Board of Health. XX _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #111 Victoria Street Centerville,MA Owner: Mrs.Margaret Morse Date of Inspection: 12/1.1/07 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 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):_ Seasonal use: (yes or no): no Water meter readings, if available(last 2 years usage(gpd)): Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): gpd Basis of design flow(seats/persons/sqft,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: Unknown 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 XX 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: 1989-per Owner Records& BOH Records Were sewage odors detected when arriving at the site(yes or no): No 'Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #111 Victoria Street Centerville, MA Owner: Mrs. Margaret Morse Date of Inspection: 12/11/07 BUILDING SEWER(locate on site plan) Depth below grade: 36" Materials of construction: XX cast iron XX 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: XX (locate on site plan) Depth below grade: 24" Material of construction: XX 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: 5' deep x 5'wide by 8' long (1000 gallon) Sludge depth: 4.75' Distance from top of sludge to bottom of outlet tee or baffle: 3.00' Scum thickness: 2"Scum Laver Noted Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Structural integrity of tank was ok. No evidence of cracks, leaks, or water infiltration/exfiltration. Inlet and Outlet Baffle present and in good condition. Liquid level equal with outlet invert. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): ,,. 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: #111 Victoria Street Centerville,MA Owner: Mrs.Margaret Morse Date of Inspection: 12/.1.1/07 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Present (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: (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,etch r .,..,. R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #111 Victoria Street Centerville,MA Owner: Mrs.Margaret Morse Date of Inspection: 12/11/07 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type XX leaching pits,number: 2 pits total-6' x 6' pit—V stone around each leaching chambers,number: leaching galleries,number: _leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hydraulic failure, ponding damp soil or stressed vegetation. SAS is 3.0 feet to top No Liquid Pit#1. 5.5' liquid present(&Pit#2. Probed stone with no evidence of hydraulic 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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): r .,, 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: #111 Victoria Street Centerville,MA Owner: Mrs.Margaret Morse Date of Inspection: 12/11/07 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. Rear of House A 0 B Swing Ties: 1500 Gal Tank A- Tank IN—28 B- Tank IN—6' A-Tank Out —33.5 B -Tank Out —8.5' A—D-Box-34 B—D-Box— 13.5 0 O A—Leach Pit#1-50 B—Leach Pit#1-18 Leach Pit#I Leach Pit#2 A—Leach Pit#2-38 B—Leach Pit#2-24 Wage 11 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #111 Victoria Street Centerville,MA Owner: Mrs. Margaret Morse Date of Inspection: 12/11/07 SITE EXAM Slope Surface water -None Check cellar -Yes Shallow wells—None Estimated depth to ground water 75 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: XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Per USGS MAP PLATE 2: Elev.of Ground=Elev.-54 Elev.Of Groundwater=Elev.-30 Feet Elev.Of Bottom of Leach Pit 9 Feet below grade or Elev.45 Therefore: 45-30= 15 feet separation between Bottom of Leach Pit and Groundwater. Groundwater Adjustment using Index Well SDW 252 (Zone D): 3.5 feet Adjusted Groundwater Separation=45'—34.5.5=10.50 feet between bottom of pit and ad*.groundwater Grade=Elev. 54 Pit#1 Septic Tank Bottom of Pit=Elev.=45 Adj. Groundwater=Elev. 34.5 THE Town of Barnstable OF Tp� ' Regulatory Services sAxxsrnB Thomas F. Geiler, Director �$A 0 9.. � Public Health .Division rED MA'S A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. r Commonwealth of Massachusetts Executive Office of Environmental Affairs kip Dept. of Environmental Protection John Grad One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket,MA 02536 (508)564-6813 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI .41 Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO M,,., , PART A I CERTIFICATION �kj r Property Address: 111 Victoria St.Centerville 02632 Lo+ .\t Q Address of Owner: �A N 1 4 199 Date of Inspection: 1112198 (If different) g tip` Jim Miko � TOWN ALTHDFSTABLF Name of Inspector: John Oraci ITHDF,p I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) T Company Name,Address and Telephone Number: 10 ; 7 14 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: % P855e5 This lns CMpecd n is based on criteria defined In TRIe V code 310 R 16.303.My findings are of how the system is _ Conditionally as performing at the time of the inspection.My Inspection does Needs Furth r uation By the Local Approving Authority notImpyanywarrantyorguaranteeofthelongevityofthe septic eystem end any of its components useful life. Fails Inspector's Signature: Date: 1112198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A) SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,-or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltiation, of lank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04417197) One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 111 Victoria St.Centerville 02632 Owner: Jim Miko Date of Inspection:1112199 _ Sewage backup or.hreakout.or. high.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the.following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. — SAS is in hydraulic failure. (revised OW7)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 111 Victoria St.Centerville 02632 Owner: Jim Miko Date of Inspection:1112198 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 111 Victoria St Centerville 02632 Owner: Jim Miko Date of Inspection:1112199 Check if the following have been done-YOU must indicate either"Yes"or"No"as to each of the following: _x_ _ Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _t_ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)(15.302(3)(b)] (revleed 0417D97) f. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: III Victoria St Centerville 02632 Owner: Jim Miko Date of Inspection:1/12mg FLOW CONDITIONS RESIDENTIAL: d/bedroom for S.A.S. Design flow: 330 g p Number of bedrooms: J Number of current residents: 2 Garbage grinder(yes or no): Yea Laundry connected to system(yes or no): Yes Seasonal use(yes or no): Yea last two 2 year usage d Water meter readings,if available: � )y g (gp ).- rda Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow.o gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nra Last date of occupancy: rJa OTHER:(Describe) rds Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: I year ago. System pumped as part of inspection:(yes or no)No If yes,volume pumped:g gallons Reason for pumping: roa TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no).( if yes,attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(If known)and source Information: 1986 Sewage odors detected when arriving at the site: (yes or no) No (revised OU2707) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Add ress: 111 Victoria St.Centerville 02632 Owner: Jim Miko Date of Inspection:1112►99 SEPTIC TANK: x (locate on site plan) Depth below grade: 3" Material of construction:x concreate_metal_FRP_Polyethylene—other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L6'6"H57"w410" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness:1" Distance from top of scum to lop of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:1T" How dimensions were determined: measured 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.) Septic tank and all components ere structurally sound.Recommend pumping now.Then every 1.2 years. GREASE TRAP: (locate on site plan) Depth below grade: nla Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:We Distance from top of scum to top of outlet tee or baffle:rds Distance from bottom of scum to bottom of outlet tee or baffle:nia Date of last pumpin%l. 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.) We BUILDING SEWER: (Locate on site plan) Depth below grade: a-- Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction lineS— Diameter: 4 rdemments: (conditions of joints,venting,evidence of leakage,etc.) (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: III Victoria St.Centerville 02632 Owner: Jim Miko Date of Inspection:1112199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Na Material of construction:_concrete_metal_FRP_Polyethylene other(explain) Dimensions: nla Capacity: Na gallons Design flow: Na gallons/day Alarm level:_nla Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) Dibox Is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)_vea Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Na travlsed 04r1r197i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: III Victoria St Centerville 02632 Owner: Jim Miko Date of Inspection:1112f98 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: ma Type: leaching pits,number: 2 leaching chambers,number:nla leaching galleries,number: r9a leaching trenches,number,length: Ma leaching fields,number,dimensions:nla overflow cesspool, number:ma Alternate system: rda Name of Technology:_we Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The overflows are atmeturaly sound and funeNoning property.The p@ tt has S'In It and pit Q2la empty. CESSPOOLS: (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: rda Depth of solids layer: nfa Depth of scum layer: rda Dimensions of cesspool: nla Materials of construction: rva Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) rda Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda PRIVY: (locate on site plan) Materials of construction: We Dimensions: rda Depth of solids: rda Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla (revised 04127)9T) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 111 Victoria St.Centerville 02632 Jim Miko 1112198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) I� ------------- CDC LJ4 �g a p AA �G A-e I ` �g 33 gc 3y Page ! of 10 (revleedOW197) i ~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 111 Victoria St.Centerville 02032 Jim Miko 1112199 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts (revised002T197) page 10 of 10 TOWN OF BARNSTABLE �► LOCATION 11I V 1CkMiC 3 SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ax--,"��P—r SEPTIC TANK CAPACITY I ©Qtl qp,\` rvi LEACHING FACILITY: (type) 11QG C�n 7%-'Ys (size) Lc�� X(o E'ClC NO.OF BEDROOMS w A BUILDER OR OWNER PERMITDATE: `G�� ? COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well Leaching Facility (If any wells exist on site or within 200 feet ofLaci ng fa Feet Edge of Wetland and Leaching ands exist A( within 300 feet of leaching ) !" A Feet Furnished by It' ll ' 0-1 t r TOWN OF BARNSTABLE LOCATION )/I V)'rTurj'r, 57 SEWAGE VILLAGE ASSESSOR'S MAP Cz LOT INSTALLER'S NAME & PHONE NO.'k:y L= SEPTIC TANK CAPACITY j,2Go.y� LEACHING FACILITY:(type) �j (size)_. NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �i13�rt��}t: DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No r O, rN119 ter. T �9�n..137 Ficz....... �� .00 No - _ THE COMMONWEALTH OF MASSACHUSETTS BOAR® O HEALTH D� F` Town.......... ....................OF.........-.-........--....Barnbtab1e..-..........- .�ppliratiun for U44pas al Works Tonstrur#iun ramit Application is hereby made for.a-Permit to Construct ( ) or Repair �X) an Individual Sewage Disposal System at: ` 111' Victoria Street Centerville,Mass . .........................•-•---.._..-•--•-•-•--•---•-........._... .............................................----.................---•---................------•- Locaj ;rAod6g. or Lot No. FranciS jVVjj LL --... ........... ................................................. -•---.._.._........-•-•---.._..--•----........-----•••-•--•------••-••••--------_____...----___•-- wner Address W J.P.Macomer Jr. a ..................................................�--•-------•-...•-•-----••--•..__............--- --•-••---•----•••••-•......_..----•--•-------..._.._..............._...._..---•••---...........: Installer Address Type of Building Size Lot............................Sq. feet DwellingX—No. of Bedrooms--.____.___.3 ..............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .-----•-----•-•-•-------------------•--•-----••-------••------•-••-•---•-•-•--•••••---• ---•---•••••-••••----••-••-•-••-••-•-............._....---••- WDesign 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 ( ) a Percolation Test Results Performed by..................................---------------------------------------- Date........................................ Test Pit No. I----------------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........................ ............................................................................................................................................................ ODescription of Soil....................••---••-•-•-•-•-•-••----... .......................................................... W -••-•-•--••----•-------••-•-•-•--••-•-•-•--••-•••--••-•-••----•--••-••• Sand---�---Grave:T_:Tx�b leach__pit w U Nature of Repairs or Alterations l—�Xsl,Sr eaepPpcatle............................................................................................... •---------------------------•------•-----••-•-----------•--•---.....----------•-----•--...---...--------•---•------------------------------------...--------------------------------------------....•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITTIE 5 of the State Sanitary Code— The undersigned further a7xees not to place the system in operation until a Certificate of Compliance has been issued y e b rd of he Signed- �� 8 9.1.9 �2 8 y -Date Application Approved By........... •- .......... -•--- Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- --------------•------..........----•--------•---•-----------•---------•----------•------•--•-•-------•---•-••••••-...-_..•••--•---•----•--•-----•-•--• •-•-•---•---•--•••••-••••----•••---•••••••------- Date Permit No........ -- 7 3_ _----------- Issued_--...-•---------------------- �- -•--�• ----•-------------------- Date Fizz e - /• THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .; trb-i ...........................................OF...-.....`..`..�::........`-......�..-------------•---....----••------------•---_---• Applirtttiou for Disposal Works (noustrurtiou "prrutit Application is hereby made for a Permit to Construct ( ) or Repair Z%.X) an Individual Sewage Disposal System at: Street ,Mass. •..............._•....---_ ........._.......... ..;. ...§ •• ...................••-••--••---•- - •---•----.-..----------------•---•------••----•--...----•-•------........_------•---............_ Viarc)t ; Loc ton-Address a s or Lot No. noc-Is — -•................. ......_._._..._....................-•-- -•••-.... _...------...._..._......---•- .-•••-••--..........._..........._..•--•... Owner Address W �l ......iti{ �l......+..G1" ..... Installer Address Q Type of Building Size Lot___________________________Sq. feet Dwelling/—No. of Bedrooms............. ..................._______....Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building .__. No. of ersons____________________________ Showers � yp g ...............•---••_-- p ( ) — Cafeteria ( ) Otherfixtures ............................................................. •••-•--•----••-••----•-••--•--•••••-•----•----•-----------•--•••--•-•----•---•---•---••- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity............gallons Length---I........ __- Width................ Diameter__-___________.. Depth................ 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.................. f................................................... Date........................................ Test Pit No. I................minutes per inch Depth off Test Pit.................... Depth to ground water...................... fX4 Test Pit No. 2................minutes per inch Depth 'of?Test Pit.................... Depth to ground water........................ a, t 0 Description of Soil. ---...•---••--------•---•- `.... - .:... - -- - - -- pit U •-•••-•-•...•-•--.._...--•••-•---•.............................................................. --- 4 - 7 n r -� W 1 U Nature of Repairs or Alterations—AA wer when applir�a le._______________________________________________________________________________________________ ------------------------------------•--•••-••----•--•-••-•-•••-•••••-••----••--•••--..............;:--••-•----•--_...._..•---•--•••••--•---•--•-•--•••-•--••-----••••....-••---•-•••--........_.._-••--• Agreement: The undersigned agrees to install the aforedescrigf d Individual Sewage Disposal System in accordance with the provisions of TIT1� 5 of the State Sanitary Code The undersigned further a rees not to place the system in operation until a Certificate of Compliance has been issued by the board of he h. Signed <r•, r } iexb r�x Ft TA ----•---------------•-- -------------------------------- Date Application Approved B ;.� `��j-- ��.....4� -mate c Application Disapproved for the following reasons:.........`----------------•-------------------._._..__._---•-----•-------•------------••---••-.-- �'-......_ t ...............................................................................................•- ------............................................................................................... PermitNo.------. . =... ---3-7------...... Issued-....................................................... Date THE COMMONWEALf3q OF MASSACHUSETTS BOARD OF HEALTH o.t,.,`�..................O F'.-.....L a�n c fi;`t h le + ....... t ................................................................... �rr#i�irtt#r (�u�t�littttrr JHVS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (-f$ ) by . ter i? �1' jr. I ----- ------------------------------------------------ -- 11.1 VA c:toria Street Centervi ll4 �66r" . at.................................. ------.-------------------- ---------------•-------------------- ....................... has been installed in accordance with the provisions of -�TIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No"___.__, .� ... ______ dated_.........._................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE ....w,. ,. SYSTEM WILL FUNCTION SATISFACTORY. ^� � � � DATE................. �< ......... Inspector..... ---- ---------- -......................................... THE COMMONWEALTH OF MASSACHUSETTS \ �'^ -------� BOARD OF HEALTH i Town Bo 4-,ab I ......................................... .................. ........................................................... 2 No.(?q...7.... t FEE........................ Disposal Vorks Tons rt ion firrutit M7:'�r --: eL Jr. Permission is hereby granted......`_.'_._} ::.:::.".:: J to Construct ( •) or Repair ( . ) an It�divtdual Sev�=a e Disposal System L ) € �"; G X�'Clt L'^ntr3r`T7 J 3e ,�.i"LsS. at No - . �.t., U, is S, _ ------------------------------------------------------------------=-••------._.-----------------......--------------•--------------------------------•••••-••••-....._•-_--- Street as shown on the application for Disposal Works Construction Permit NC_ � - ..__ Dated.......................................... f V-T'�J .......................... -----•- --------------------------------------••------- '. e DATE...............�ji•....... �� .................................... and of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS wa L_ L--P CA ION SEWAGE PERMIT NO. d I L l n -- IN LLER'S NAME ADDRESS o • o rzel� he, s U t E R OR OWNER D A T E PERMIT ISSUED DATE COMPLIANCE ISSUED 0/0, f3 ► 0 0 1� 3' 40 Y. l� LEGEND —— N 88 —— EXISTING CONTOUR d�,o Rd d Rd X 100.98 EXISTING SPOT GRADE ® ce „ cJ�EOr —IN EXISTING WATER SERVICE Preoio ti Rd Nodrodo �n S Rd —G EXISTING GAS SERVICE U UNDERGROUND WIRES 1^ r TEST PIT 5. Pre""C' Rd LOCUS o<`O BENCHMARK w or N,erideh r o� o RoSemory `O err,ord �o���Ar ° o u °Oo a h� LOCUS MAP NOT TO SCAI F 0 PROPOSED 1000 GALLON SEPTIC TANK IN SERIES S 60.46'18" W FENCE 100.00' EXISTING LEACH PITS N SHED II TO BE PUMPED, FILLED WITH x 102.59 I SAND AND ABANDONED 9102.21 102.40 0 14' T- 25' -j — __— - EXISTING SEPTIC TANK RO A.S. \ 103. (1500 GAL-TO REMAIN) 00 P / INV.(OUT)=101.5f(VERIFY) CV \ / x 1022-4•TP-2 _ 0 i� "x 103.17 103.03 FIRE PIT.' , 103.0 " BENCHMARK 102,89' i SONOTUBE x W 103,14 FOUNDATION x 1 14 COR./BOTT. STEP QS EL.=104.00 BM 0 104,00 PATIO x 1 2,98 �_. x 10'?'75 103.33 x 103.02 - z fV 103.12 04 o EXISTING o C4 HOUSE(#111) o_ � I 1 • T. . .= f N N PA Tl0 GARAGE 0 F 104.3 103.24 - 103.69 -—— 103.87' :. ..'::;:.;. 1114.08 10 41 103,42 / � WALK 102.51 Q` ` LOT 1 102.1 :_.. 6 LAMP 15,000±S.F. J 102.13 PARCEL ID: 148-050 � a x 102.59 0 101.39':.. W,' :.: �� FLAGPOLE 101.60 x 102_27® -— Q0.00' x 101.60—182- —- ioo:3o ~: . N 60'4618"E —1Ofi--- ------- / 99.57 99.79 / 9.98 100.43 VICTORIA STREET OF Mgssq��G o PETER McENTE E PROPOSED SEPTIC SYSTEM UPGRADE PLAN CIVIL N 111 VICTORIA STREET, CENTERVILLE, MA 35109 OWNER OF RECORD GISTER �� Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 MORSE, RICHARD & NATALIE S TRS �'� Engineering by: SCALE DRAWN JOB. NO. MORSE REALTY TRUST Engineering Works, Inc. 1"=20' P.T.M. 222-16 1 1 1 VICTORIA STREET r 9 9 CENTERVILLE, MA 02632 l[t` l 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. U► (508) 477-5313 10/8/16 P.T.M. 1 Of 2 I NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL: 99.5 FOR A DISTANCE OF 15' AROUND THE SEPTIC TANK PROPOSED D-BOX PERIMETER OF THE S.A.S. INSTALL RISERS & COVERS OVER THE INSTALL RISER & COVERS PROPOSED S.A.S. INLET & OUTLET AND SET TO WITHIN AS REQ'D AND SET TO 6' OF FINISH GRADE. WITHIN 6" OF GRADE. INSTALL RISER & COVER OVER ONE CHAMBER AND SET TO WITHIN 6" OF FINISH GRADE, TO SERVE AS INSPECTION PORT. fF.G. EL.=103.1t /-F.G. EL.=103.0t /-F.G. EL.=102.5t F.G. EL.=102.5t � Pl L - 3' L = 17' L - 6'(MAX) S=1% (MIN.); S=1% (MIN.) p S=1% (MIN.) 2" LAYER OF 1/8` TO 1/2`4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC e" DOUBLE WASHED STONE 14" 10"1 " s Baa�aae (OR APPROVED FILTER FABRIC) INV.= 4" a0aa aaa 101.00 48" LIQUID aaaaaaa ---3/4" TO 1-1/2" DOUBLE LEVEL 4' 4.8' 4' WASHED STONE GAS ADD� GAS R4FFLE� ' INV.=99.57 INV.=99.40 PROPOSED D-BOX EFFECTIVE WIDTH = 12.8' EXISTING H-10 INV.=99.00 SEPTIC PROPOSED SEPTIC TANK INV.=100.75 2-500 GALLON LEACHING CHAMBERS TANK H-10 SURROUNDED WITH STONE AS SHOWN INV.=101.50f H-10 RATED (EXISTING) TOP CONC. ELEV.=99.8 NOTES: 1 SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND BREAKOUT ELEV.=99.50 aaaa TRUE TO GRADE ON A MECHANICALLY COMPACTED INV. ELEV.=99.00 eases a®®aB 6 INCH CRUSHED STONE BASE, AS SPECIFIED IN seas aaaaa 310 CMR 15.221(2). BOTTOM ELEV.=97.00 2) INSTALL INLET & OUTLET TEES AS REQUIRED. 4' 2 x 8.5'=17.0' 4' 4' OF NATURALLY OCCURRING 3) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE PERVIOUS MATERIAL EFFECTIVE LENGTH = 25.0' AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. 5' (MIN.) ABOVE G.W. LEACHING SYSTEM SECTION 4) MAXIMUM COVER OVER SEPTIC TANK, D-BOX & S.A.S. SHALL BE 36". NO G.W., EL.=90.9 SEPTIC SYSTEM PROFILE SOIL LOG DATE: OCTOBER 7, 2016 (P#15,178) SOIL EVALUATOR: PETER McENTEE PE (SE-1542) WITNESS: DAVID STANTON R.S. HEALTH AGENT ELEv. TP-1 DEPTH ELEv. TP-2 DEPTH ®®®a 0 ®®®® 102.4 0„ 102.5 01 F' ®®®®®® ® ®®®® 33" ASANDY LOAM ASANDY LOAM N J ®®®®®® ® ®®®® 10YR 4/2 10YR 4/2 ®LZ.�®®® ® ®®®® 101.7 B 8" 101.7 B 10" Z SANDY LOAM SANDY LOAM 10YR 5/6 10YR 5/6 99.4 36" 99.4 37" 102" C c PERC SECTION - T 22"/40" MED. SAND MED. SAND 4" KNOCKOUT 2.5Y 6/6 2.5Y 6/6 20" DIA. COVER 90.9 138" 91.0 138" / PERC RATE <2 MIN/IN. ("C" HORIZON) 4" KNOCKOUT0 4" KNOCKOUT 58" NO GROUNDWATER ENCOUNTERED GENERAL NOTES: 4" KNOCKOUT 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS PLAN OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. 500 GALLON CAPACITY, H-10 LOADING 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE CHAMBERS DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. DESIGN CRITERIA 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS NUMBER OF BEDROOMS: 2 (HOUSE) + 1 (APARTMENT) = 3 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. SOIL TEXTURAL CLASS: CLASS 1 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY DESIGN PERCOLATION RATE: <2 MIN/IN THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. DAILY FLOW: 330 GPD 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS DESIGN FLOW: 330 GPD IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND GARBAGE GRINDER: NO REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). EXISTING SEPTIC TANK: 1500 GALLON CAPACITY (TO REMAIN) 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE PER TITLE INSPECTION REPORT DATED 12/11/07 INSPECTED BY A LICENSED SOIL EVALUATOR PRIOR TO BACKFILL. PROPOSED SEPTIC TANK: 1000 GALLON CAPACITY (H-10) 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND LEACHING AREA REQUIRED: (330) = 445.9 SF IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. . .74 PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 111 VICTORIA STREET, CENTERVILLE, MA SURROUNDED BY DOUBLE WASHED STONE-ALL SIDES SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 SF Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 BOTTOM AREA: 12.8' x 25.0' = 320.0 SF Engineering by: SCALE DRAWN JOB. NO. TOTAL AREA:................................................. ............471.2 SF Engineering Works, Inc. N.T.S. P.T.M. 222-16 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD (508) 477-5313 10/8/16 P.T.M. 2 Of 2