HomeMy WebLinkAbout0020 WILLOW RUN DRIVE - Health yV llo w R_un Drive
Centerville
A= 210 - 071
S M E A D
No. 53LOR
UPC 12543
amead.com Made In USA
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Town of Barnstable
Regulatory Services
Thomas F. Geller,Director
a'9; A � Public Health Division
f0 Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 1_G73. 7 z vt,�>
Designer: Z. %,/y41-Z fZ- - Installer: .✓ t? ��lzz�ai.y
Address: L� i .�,�,3�z�? i 7: Address: 7.S J�W_r P,ce_ 12-p
- T
On was issued a permit to install a
(date) (installer)
septic system at 2—o JAAL4;W few D1 >tlt • based on a design drawn by
(address)
/Z. 171191.- 125, dated
(designer)
I certify that-the septic.system referenced above was installed substantially according to
the design, which•may include minor approved changes such as lateral relocation of 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 with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
64
STETSON
er s ignature) o R.
HALL
*° No.527
,� TFREOSP�� 4. I
C- 4Mesigner's • tore) (AfI•ix D amp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HkALTH DIVISION. CERTIFICATE j
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTIq THIS FORM' AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE P LIC HEALTH DIVISION
THANK YOU.
Q:Health/Septic/Designer Certification Form
-- l
Q, Fnd OVERLAY DISTRICT: ASSESSORS R, F.:
AP — Aquifer Protection District Map 210, Parcel 07
O4 011, ZONES:
�o /��, ✓ohn RC (RPOD) RD-1 RPOD
1 1" �, /l y& ,o�F Area (min.) 87,120 SF Area (min.) 87,120 SF
�a `` o i °�q Br Frontage (min) 20' Frontage (min) 20'
•r� �� 32.9' 28.2' 212 °"wer Width (min) 100' Width (min) 125'
if.O F Setbacks:
Fron t 20' Setbacks:
t 30'
v, p ^ ��$�$ Side 10' Side 10'
Rear 10' Rear 10'
�"Q,°' \\ Sdew,d FLOOD ZONE:
X — Not a Flood Zone
o� Q -. ti ' Approximate FEMA Map No.
r Septic Systen
` �� 410 p..............: '_.._...as 25001 CO561 J
/ ec d per BOH Cord Lot 13
July 16, 2014
24,347f SF 1 00
mI
.c
�F W `� !o
Proposed
a Q� � Sunroom Addition ,i
At
Fnd w
V Plan Showing Proposed Addition
N7676 60 18.9, __ ; h At 20 Willow Run Drive
w Rc TA/4NBLE
1pp 00,
B S/deJvr l S
M°ureen q Daley _ __ 'it (Centerville)
22 ..00• _ �— ,_—, _,_ ; MASS,
NOTES: 100 00• J DATE; 15/AUG117 SCALE:1"- 0'
R"hQIV H 0 15 30 45 60 FEET
1.) The structures shown were located on the ground �Moi & Coro/A
by conventional survey methods on August 8, 2017. �'� N°"an
PREPARED FOR:
2. The line information shown hereon was RICHARD R. r Do ' s
property L'HEUREUX hd"' �
Susan M Christopher L Butler
compiled from available record information. � �%�er�y
p NO. 34312
o o �o
3.) This plan is not for recording and is not to be 'ass w �sTEOSJe,�' PREPARED BY:
used for construction layout or deed description 4 CapeSury
purposes.
23 West Bay Road, Suite G
Osterville MA 02655
DWG #:C318_5g1 cppl FIELD BY: WHK/ASK (508) 420-3994 / 420-3995fox
i
SENDER:COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A Si n ture
item 4 if Restricted Delivery is desired. ❑Agent
■ Paint your name and address on the reverse X ❑Addressee
so that we can return the card to you. ei by(P ted Name) C. Date qf Delivery
■ Attach this card to the back of the mailpiece, I`_
or on the front if space permits.
D. Is delivery address different from Item 1? Yes
1. Articl\e_Addressed to: If YES,enter delivery address below: ❑No
3. Service Type
0 Certified Mail ❑Express Mail
❑Registered ■Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?Pft Fee) ❑Yes
2. Article Number 7007 0710 0005, 5820 .7465 R
(transfer from service labeo
I—
I PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
LISPS
I Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
I
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I L01Town of Barnstable
Health Division 200 Main Street
I
Hyannis,MA 02601
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/�HE TOh,
Town of Barnstable Barnstable
ti AS-flmericaCily
; Regulatory Services Department
"Ass. 04
1639. Public Health Division�� J.F
ArfD µAI a' 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
January 2, 2008
Robert Levine
20 Willow Run Drive
Centerville, MA 02632 r*-
2
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 20 Willow Run Drive, Centerville MA was inspected on
September 18, 2007, by Reid C. Ellis, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system FAILED under the
guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
Backup of sewage into facility or system component due to overloaded or clogged
SAS or cesspool.
Leaching pit is in hydraulic failure.
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
N
OF TH BOARD OF HEALTH
7007 0710 0005 5820 7465
Thomas McKean, R.S., ,
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures\20 Willow Run Drive.doc
7007 0710 0005 5820 7465
7007 0710 0005 5820 74f,S
i
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M 20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every 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. S� 1A
Important: A. General .Information
When filling out
forms on the
computer,use 1. Inspector:.
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC
Company Name
f� P.O.Box 763
Company Address
.Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
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
❑ Needs Fu Evaluation by the Local Approving Authority '
I M�
8/9/2007 CD
;ram_
Inspector's Signature Date cs
='
The system inspector shall submit a copy of this inspection report to the Approvi g Author)*ty(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared $ysterfi`or
has a design flow of 10,000 gpd or greater, the inspector and the system owner hall submit the
report to the appropriate regional office of the DEP. The original should be sent t 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.
20 willow run•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
V
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
required for
is Centerville Ma. 02632 8/9/2007
required for
every page. City[Town State Zip Cpde Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR.15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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
20 willow run•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
;M 20 Willow Run Dr. \
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the.Board of Health):
❑ broken pipe(s)are replaced
❑ ' obstruction is removed
ND Explain:
1
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.
20 willow run•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform'
bacteria,indicates absent and the.presence of ammonia nitrogen and nitrate nitrogen is equal to or.
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® ❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due-to an overloaded or clogged SAS or cesspool
El ® 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 Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
20 willow run•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence'
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
20 willow run•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town 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?
® El available
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)]
{
20 willow run•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town State Zip Code Date of Inspection
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
Number of current residents: unknown
Does residence have a garbage grinder? ❑ Yes E No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes'® No
Water meter readings, if available last 2 ears usage d 2005:66,000
g ( y g (gp ))' 2006: 62,000
Sump pump? ❑ Yes ® No
Last date of occupancy: 8/9/2007Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding'tank present? ❑ Yes ❑ No
,Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
20 willow run-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town State Zip Code Date of Inspection
.D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped,as part of the inspection? ❑ Yes 2 No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® . Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1975
Were sewage odors detected when arriving at the site? ❑ Yes ® No
20 willow run•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 14"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
Depth below grade: 1.5'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy
)of certificate Yes ❑ No
--------9 ----------------- ------------------------ ---- -------------- ----
Dimensions: 8,6"x4'10"x57'
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
23"
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 13"
How were dimensions determined? measured
20 willow run-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Willow Run Dr.
'M
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town 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.):
Pump tank every 2-3 years. Inlet and outlet tees are in place.No evidence of leakage.Tank appears
structurally sound. 1
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
I
20 willow run-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 16
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.,)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ .No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No D-Box present.
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 ❑ No
Alarms in working order: ❑ Yes ❑ No
I
20 willow run•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Willow.Run Dr.
M
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
I
❑ 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.):
Leaching pit was full at time of inspection.
20 willow run-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is Centerville Ma. 02632 8/9/2007
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information(cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer '
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil; signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
20 willow run•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is required for Centerville Ma. 02632 8/9/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.
t
/2
. d
20 willow run•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 20 Willow Run Dr.
Property Address
Robert Levine
Owner Owner's Name
information is Centerville Ma. 02632 8/9/2007
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
i
❑ Shallow wells
Estimated depth to ground water: Bottom of leaching 25'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used:Gaherty& Miller Model 12/16/94 ground water elevations.' Used: USGS Observation Well Data
June 1995. Used:Technical Bulletin 92-000-01 plate#2 Annual ranges of ground water elevations.
20 willow run•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
V t ,
No. .2 fl0 - o�.Z ., Fee�/i•y —�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for �Btgpogal �&pgtem Con5tructton Permit
Application for a Permit to Construct O Repair Upgrade O Abandon( ❑.Complete System individual Components
a'
Location Address or Lot No. e�v ;//v t,CJ Re-) Owner's Name,Address;and Tel.No.
Assessor's Map/ rcel /(j D
Instals ame,Address,and Tel.No. Designer's Name,Address and Tel.No.
, u
Type of Bui ding:
Dwelling No.of Bedrooms Lot Size 4ZI 'IdCS sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures Design Flow(min.required) gpd Design flow provided - W44rC gpd
Plan Date ��_ 20 U�7 Number of sheets Revision Date
Title �
Size of Septic Tank , U�� Type of S.A.S. Q ' 9—! f
Description of Soil r o G
C wt f' a11
Nature of Re irs or Iterations(Answer when applicable) r
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 Titl/5 o e Environmenh8l Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o Heal• .
Signed / Date
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. g aV c— O D Z Date Issued
TOWN OF BARNSTABLE
sy
`LOCATION 01® W t f 10LO Row -ID2 SEWAGE # 0��� 2a
YILLAGE �e rV���1�� ASSESSOR'S MAP & LOT kJO-0 '
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) r(size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
ry.
f
�y � _e - SQ'
� - ' y� j 73
V
No. af) !`()� Fee i Q -
° H'E COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓'
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for �igpogal �&pgtem Congtruction Permit ,
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑.Complete System Vindividual Components
Location Address or Lot No. l�lr�c lJ /eUjV Owner's Name,Address;and Tel.No. `
Assessor's Map/Pafcel
j 1:1
Installer's-lame,Address,and Tel.No. Designer's Name,Address and Tel.No.
�.
Type of Bui ding: 49
Dwelling No.of Bedrooms �-,� Lot Size y 64 sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow.(min.required) gpd
y;lrj gpd Design flow provided ,
Plan Date 20- 6�7 Number of sheets Revision Date
F
� Title
.,� Size of Septic Tank + Type of S.A.S. { °l Q
Description of Soil /
C„ „n rr l72 to rl r4-1yilap�
Nature of Repairs or Alterations(Answer when'applicable) h ALAI 1 �L CA
ld
lyle
Date last inspected:
Agreement:
f 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 Environmel Code and not to place the system in operation until a Certificate of
Compliance has been issued by this B a .nd o Healt /�,/j Z4
Signed Date
Application Approved by 1 Date —Q
Application Disapproved by.:_ Date
for the following reasons
Permit No. 9 064�- (): 'l
_.. i ' °( i Date Iss ed
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (, ) Upgraded ( )
,�II�n
Abandoned( )by, (fy/�f,
at,�:2 u , `10 ���_,,�1 C -9 1%/11 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ,2 00f- C)-.'>y dated
Installer Designer
#bedrooms Approved design flow 0x gpd
The issuance ofrth's perm shall of be construed as a guarantee that the system POP/
ction as designed.
Date ) Inspector !J'� p
j
————————————————————————————————-�--
No. '_ Fee�w
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
I=igpoga[ �6pgtem Congtruction Permit
Permission is hereby granted to Construct ( ) Repair (vI Upgrade ( ) Abandon ( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
i
Provided: Constructi0 must be completed within three years of the date of this p rtfirt.
,
Date i �� Approved by n, t
f
X
-4;7
-i-LOCIQTION ' ,per 5EW&C.4E PERMIT UO,
VILLAGE-2--b &VO-L'e.)Yy/C Z��Tff ice)
iW* ST&LL ' yS .U&KAE ADDRESS
A BUILDERS Q &ME ADDRESS
D&,TE PERNAVT 155U-ED
D ATE COMPLI W ICE ISSUED :
1 �y
4,
� . 5
,..
t
. , 1
.�
I� � �.
��
xy
No. FEic
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
/el 44o�..........0F...f/.. .. ! .��../ '.�~..............
Appliration -for Di-qVviitti Works Towitrurtiott Prrutit
Application is her Ay made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
L cation- ddr s or Lot No.
p Owner / Address
(' �ra
Installer Address
U Type of Building Size Lot...���®�......Sq. feet
Dwelling—No. of Bedrooms.............:.............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building .._........................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
f>a Other fixtures ------------------------------
W Design Flow------------------�
---------------gallons per person per day. Total daily flow........ ........................gallons.
WSeptic Tank—Liquid capacityr4044gallons Length................ Width---------------- Diameter........._..._- Depth----..____.._.
x Disposal Trench—No. .......I.......... 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--------------- ---------------------_
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........__._....__..._..
fiq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.._.......--------_--_-
04 = --------- ------------•••----•-------••••-••--------•-----------•------•--••--•----••-•--........................................................
Description of Soil_._.. J_ - F
...A..............•----------------------•----------------------------------- ----------------------••--•-•----•--------------------
V ---------------•-------------------• ----------- -------•----------------------------•----------------•---------------•--• ----- --------
-•-•-----••------------------- --------------------•--•-•-•---•----.-------.....-•------------------------------ ---- --- ------ ---------'-----
U Nature of Repairs or Alte tions—.—Ynswer when appl' .. ......... -._------
--
Ag reement
1►
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary d —The unders* ned further agrees not to place the syst in in .
operation until a Certificate of Compliance has be s b th d of he lth
Signe �"�'
-- --- - ------------- --- - --•-••--
Date
Application Approved By--------------- .. •...... ---• •- - -;-------------- " jP` ---7J----
Date
Application Disapproved for the following reasons---------------••••-•--....-. -••--------------•......•----------------•--------...----------------•--••--•--•-
x
Date
*Permit No............................................................. R Issued......o....... ...................
Date
wP
l
No. �-7............... Fimic :................
THE COMMONWEALTH OF MASSACHUSETTS
EOARD•rOF HEALTH
-- ...OF.....l... f' ..✓ —
. ppliratiun -for Uhip al Workii Tomi rurtion Vrru i#
Application is hereby made for a Permit to Construct (x) or Repair ( } an Individual Sewage Disposal
System at:
a
L cation-Address or Lot No.
G_1Zt..... .t.�� � i L 1�U:/
l Owner 7 Address
Installer Address &1 q
Q Type of Building Size Lot..._J� ')O
.......................S feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ------•_____________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ------------------------------- - -
W Design Flow------------------ per person per day. Total daily flow_._.._._-�-�__e_ ___________.__...-------gallons.
WSeptic Tank—Liquid capacitv/Z,'(Vgalions 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________-----------------------•-------
a
Test Pit No. I________________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--------------------
- -_
D Description of Soil---- �..=? ! •i :4i -- - - - --- -
x
v ..; -- -----.,:, �
W ---------- -------------- --------------------- ------------------ ------------------ '+ --- --'---- .
U Nature of Repairs or Alt e tions Answer when applicabes ....... to
� "�,"�• 'a
---f---, ` ` = f r ------•------•--------------
"_
Agreement: �"` V �"
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bet
e issued by ythh,%od of health/J
ry- -------•. -------------•----------------•-••---- - Date
Application Approved BY---- � -_!' 4'L.l.�'/,,/_: --------
Date
Application Disapproved for the following reasons-----------------=..........•- --------.........................................
...............................
---•••--.._..-----•-•-.._..•••...•-------•-••-----••-----•--------------------•-•-•••••••---•--------•---••---••••--------••-----•------•-----_._...---•---•--------------------------..__....-•--
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
__-�--- BOARD,--OF HEALTH
1e` .jfw.'................0F..... S3/.1.—` ...............
err#if ir�#le rrf f�nm�littnrr
THIS IS TO CERTIFY.That thejndividual Sewage Disposal System constructed ( or Repaired ( )
� 7
b .. .r- . •.••-t••-•-•••..__.._._. -----------------•-------•-•-•-------------------------------------••------------------
1 !- Installerat
_
......................................
has been installed in accordance with the provisions of _ icl- XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 7,l
__ '.'�' ___________ dated.t�a_.::':__2__`;/_-...� -._____
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON RUED A A GUARANTEE THAT THE
SYSTEM L FUNCTION SATISFACTORY. 0,DATE......r- •. ........................... Inspector-------f •
-----•-
THE COMMONWEALTH OF MASSACHUSETTS
(: s- BOARD�OF HEALTH
....../... .........................OF.....,.....- ...----------... .- . -----..............
No......................... FEE.. - .:�.........
= -' f ° --------------------------------•--•--:-•--•--------•--•-------••---•-•--•-•---•-•....•----
Permission is hereby granted
to Construct_ }-or Repair ( ) an Individual Sewage/D`Wosal System _/
at No..- // �J
Street
as shown on the application for Disposal!Works Construct'onn li No..�s J_r �ated_. _.i.'2 `�-
l l / d� eaitl�, .� LYyJ,
_ /may
--------
DATE........ -�`�
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS /,R /
h.
- r
22 �
L3D
s
VIKING
CONSTRUCTION CORP.
-- 1T
® 27 MILLSTONE WAY CENTERVILLE, MASSACHUSETTS 02632 (617) 771.2376
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p pprok, t i•an (-A •
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M c es5�va�S I \ • � �
77
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. • r:s .an _.. "MO C/ OAMIOTA" MAWACWOMS
.00 ant M
TOP OF FOUNDATION YY �® .'° .tt. f� --- - ---�— —
'"' "•• w.. ... j
INSPECTION �' ..«.....
l CONCRETE COVERS
X�I PORT
;1 9 =T -
-177777le,7_77117x-
FIN. GRADE _ .93 -•. Y 4 .4 - ,
4.14 3 4"CAST IRON OR— ` — //�i i r /� - 49 .� " i j !y �• a /. «
+ms t J u
SCHEDULE 40 4 SCHEDULE 40 P.V.C.(ONLY) j�� .� ,�" s r yi
�:�� PIPE - MIN. PITCH 3t 1 a �t
1 :r PTC.PIPE MIN. 2 TO BE CLEAN SAND BACK FILL � a «
' w t fl
: � PITCH I/4"PER Fr I/4" PER.FT. EL.46.93 "" -' �•
LEVEL „ ,
'•J.�.
C.� INVERT GAS BAFFLE T ,� INVERTli. 5 EL..4 +« r « N . ® �
•p4 „ 1 I
EL.49.86 SEPTIC TANK i N 49 36 E�STQNE EL.47,93. tl„ -,�" N ."" ,,,�',,,, , •. '..,, h � 'r»
EL
INVERT EXIST. 1500 ~ . •" •~ y
EL. 49:6.�.. GAL. INVERT DIST. INVERT EL. 4F.60 •': ; 0 4•„ Y .
EL. 48. 0 BOX ..............36. .. ... CHAMBERS
CRUSHED STONE EL.47.6I .. N,. • " r , r
10' —� 26' —+- DB 7' T015' 4 4�0�� OVER 9.0 FEETP .-~ M
._� . 3 0
� 6 ,
- PROFf LE OF �•<< ; K � � � � •�
w„
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P - 12029 ADJ. GROUND WATER EL......_....
SOIL LOG SEWAGE DISPOSAL SYSTEM
'~ ~�
h
DATE NOV.8 2007 TIME •I O:OO A.M. NO SCALE • "` p• ` a '"�
It
TEST HOLE f.... TEST HOLE ..2.... HIGH CAPACITY BID ' .~" •"` •��,, ,0 .� '
CROSS SECTION(TYP.) BACIGILL MATERIAL
I ELEV. 50.00.•-• ELEV. 50,.34 DESIGN DATA NATN� OR ..
j FILL PER DEMGN PE fiCITKNMABJSH VEG TATIVE COVER
I '•h NUMBER OF BEDROOMS 4
SANDY LOAM�n'/� A/// r0YR3/3 S N Yn i �A IOYR 3/3 I
�
7 EL.43.42 EL,49.34
SANDY LOAM 1 IOYR6/6 SANDY 1 I0YR6/6 TOTAL ESTIMATED FLOW GAL. DAY 1�1 -+'^� %� -` - .� '� _ rh • ». ,
SEE DQ T4 RFLOW HIGH CAPS �• =�•I-� k LOA ,-.� , •' 3r �j , y1Y� .• I
2-7� B EL.47.76 LOAM „ /� EL.46.01 BOTTOM LEACHING AREA ?73:56 SQ./BED �'���'�= � � titer � ' 'rr ��;� �,� - �'t�'r ,
228�--- + \ HIGH CAPACIT f INFILTRATOR i
` SANDY LOAM IOY SAFfDY 2 I R f ��=`"��_ ``��. 4.p5
• GARBAGE DISPOSAL .:.... �•1`' i g? a LOAM g OY LL6./63 PERC. NONE iY �+ �• \+ M,
42" EL.46.51 42so / EL.46 854 �� + .. `• :ti • '' i l%` d c
TOTAL LEACHING AREA 623.84 SQ, FT. SEE I ~+
+c' ice, `�a .G ...n. .,MAIerA.„,.a. 420 :' o
��i �-/ r S A1RMAr MC.
j ..COARSE SAND I C !, IOYR 5/8 COARSE :C I IOYR 5/8 BELOW �I
LESS 2 M I N. :r �',� • .�`' . bt j .�.... 7''=
<�•.,� SAND '.� EL.45 7`7 PERCOLATION RATE PER. INCH �. �d E L
55 i' EL.45.43 55"
461 65 LoGuS
COARSE SAND �}2 10 YR 6/4,COARSE .'C2 10 YR 6/4 LEACHING AREA PER PERC.RATE......:.... GAL./DAY M
'C, SAND 4 .
96I' -EL.42.00 96 :r, EL.42.34 QUICK 4 HIGH CAPACITI sMIN. PbHAMBERS
MEDIUM SAND 3 IOYR 7/4 ;• '3 MED./FINE , i
C r,C • IOYR 7/4 EACH HIGH = 2.83 X 4.0 = 11 .32 SQ.FT.
„ EL.38.00 ++ • =��� EL_38_34
1 144 --- 144 — OF BOTTOM ' AREA . 33 HIGH CAPACITY
's ....NO.. WATER ENCOUNTERED CHAMBERS X 1 1 . 32 = 373.56 SOFT.
WITNESSED BY.: - LOT 13 - OF BOTTOM AREA X STONELESS
I DONNA MIORANDI PLAN BK...1.9.1..PG. 47 CREDIT FACTOR OF. 1 .67 EQUALS
. . . . . .. . .... . . ....... . . .. BOARD OF HEALTH -
STETSON R. HALL, R•S. ASSESSORS MAP 210 623. 84 SO.FT. X 0.74 461 .65
t ENGINEER GALLONS S PER DAY .
{ G LL R DA
EDWARD E. KELLEY L R,P. L.S PARCEL 071
PETITIONER
.. . . . . . . . . . . . . . . . . . . . ....
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ly
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EXIST PIT .. . `'° Z4 Z S
�! QI �� ti►4 vecjc TO BE DIST
PUMPED 8, BOX -'
�1 FILLED DBIIt�2
( 1 ' (SAND) H
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d F 14 WA ; S0,4'3 35� \ \ +
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I I / y/9 €DrYA REVISED JAN. 14 !l-6GG t ` tE 0 1 ��5
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LLEY 1 . 2008 ,�• G�o = �
No. 26100 $` /2.LC. PA6 F. L%ND 'T&&v4_-y.1z J
�D T Z p Nis 61$1 �EQ QO x �'`/ on
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' LOCUS - 20 WILLOW RUN DRIVE
'
,