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Home My WebLink About0100 HOLLY HILL ROAD - Health (2) 1295 Shootflying Hill Road Centerville A= 188-091 I//� J�QEcvafo�o UPC 12543 No. 53LOR o$p�ST•CpNSV�� HASTINGS,MN �• I +1 No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliLAtion for Disposal *pstem Construction j3Prmit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. I-actS S't Cor-rcN(06 441 tx 71)p Owner's Name,Address,and Tel.No. �lvl -cc r,INADA RvcjF6 Assessor's Map/Parcel 9Q � 1a75 Sf6 'irF(_Y1W t la-P-1) '(�-'4`I WE7 Installer's Name,Address,and Tel.No. 509—411— 19 fs 77 Designer's Name,Address,and Tel.No. �peLo,u4g Ei��c��¢t SAS (-Lc- N/4 153 Gowcc QAL 6r oW?6C-- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision D to Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt Signe Date Application Approved by Date —7 -_2`7 — 2,- Application Disapproved by V Date for the following reasons Permit No. a(,1 y 6 - ��f'1 3 Date Issued •'�Gj°� .p I k No. THE COMMONWEALTH OF,MASSACHUSETTS Entered in computer: e� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplicatlon for Misposaf *pstem Construction permit Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. (:jc?S S'1.0a rLq t pa 441 cl� Owner's Name,Address,and Tel.No. C�V( -cC- Ld�t�,� R�ci1F Assessor's Map/Parcel 90 0 ��4� S FC / u. C tV/LCI' Installer's Name,Address,and Tel.No. 50B-411 S 8 71 Designer's Name,Address,and Tel.No. 4APEv,)t 4G 67JTE:R041 MS e Lc- 15.3 tout Q.4 G-r MA _%4p6-- N��' Type of Building: ` Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) S Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided IVIA gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed A Date 3 -;tq ;Z8/4 Application Approved byIK� Date 3 -.2 Application Disapproved by V Date for the following reasons Permit No. 2 Q4 - U .7 Date Issued 3 --2C1^-2 r/ /6 --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS 1 C Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by CA?Gwaac ENh)- A sL=s C.Lc at la's SdmTneL V/ll!rz H1U. QD C V/UL has been constructed in accordance- with the provisions of Title 5 and the for Disposal System Construction Permit No.2 b WCI dated 7- InstallerOWC-tAnDig (,QC_ Designer jA #bedrooms- 1 A- Approved design flow N gpd i The issuance of th's pe ' it shall not be construed as a guarantee that the system will fungi io as signed. Date L Inspector V --------------------------------------------------------------------------------------------------------------------------------------- No. - v ? Fee 7 S THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Vermit Permission is hereby granted to Construct( ) Repair X) Upgrade( ) Abandon( ) System located at 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. I Provided:Constru tion mf st be completed within three years of the date of this permit. {` Date Z� �(o Approved by 1 � ' AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION k;Ai h(NSEK V'Q1 i►AG ` '"-"SEWAGE oZgo�-Q�5 VILLAGE eC>x'�E2v°i� ASSESSOR'S MAP&LOT l�o(104. INSTALLER'S NAME&PHONE NO. �Ac�1l.s�eR- yd8-SSa�( SEPTIC TANK CAPACrI'Y k SC•O C�� LEACHING FACILITY: (type) �QO CA\�ChA+ ��s (s1Ze) NO.OF BEDROOMS BUILDER OR OWNERS PERMrrDATB: I _ b'�S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility FCet Private Water Supply WeU 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 I Ion _ 3- i`7f r►Ql� 6�pGE Ll 1, r 3 1 http:Hissgl2/intranet/propdata/prebuilt.aspx?mappar=190109&seq=1 3/29/2016 Z COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS A DEPARTMENT OF ENVIRONMENTAL PROTECTION r ; TITLE 5 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM . PART A CERTIFICATION Property Address: 1295 Shootdying Hill Road Centerville, MA 02632 �} Q Owner's Name: Karen Crocker Owner's Address: Date of Inspection: November 22 2009 Name of Inspector: (Please Print) James M. Ford. Company Name:. James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 perfonned 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 - :, eds Further Evaluation by the Local Approving Authority Falls Inspector's Signature: Date: November 26, 2009 The system inspector shall sul a copy of�Ls inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments **"This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different. conditions of use. f � Title 5 Inspection Form 6/15/2000 page I U''I A Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1295 Shootflying Road Centerville, MA Owner: Karen Crocker Date of Inspection: November 22, 2009 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 f • Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1295 Shootgying Road Centerville, MA Owner: Karen Crocker Date of Inspection: November 22, 2009 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 CNVIR 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,perfonned at a DEP certified laboratory, for coliforn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 w Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1295 Shootflving Road Centerville, MA Owner: Karen Crocker Date of Inspection: November 22, 2009 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an,overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/i day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of.a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria.and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15,303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system'must serve a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone.II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I 4 OFFICIAL INSPECTIONYORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1295 Shootflyng Road Centerville, MA Owner: Karen Crocker Date of Inspection: November 22, 2009 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner, occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection.? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,.excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees;material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(andoccupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 i Page 6 of 11 4 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1295 Shootflyinn Road Centerville, MA Owner: Karen Crocker Date of Inspection: November 22, 2009 FLOW CONDITIONS RESIDENTIAL 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: 3 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd Basis of design flow(seats/persons/sgft,etc.):' Grease trap present(.yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonnation: 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 ✓ 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: Installed on 116105-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1295 ShootllvinQ Road Centerville, MA Owner: Karen Crocker Date of Inspection: November 22, 2609 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:. _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 a� 1_ Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). The Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 I Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1295 Shootflvinz Road Centerville, MA Owner: Karen Crocker Date of Inspection: November 22, 2009 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _inetal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alai-in level: Alarm in working order(yes or no): Date of last pumping: Continents(condition of alarm and float switches, etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alanns in working order(yes or no) Conunents(note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 1295 Shoot6ying Road Centerville, MA Owner: Karen Crocker Date of Inspection: November 22, 2009 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: - 3-'500 gal. chambers 33 5'x 13'(per as built card) leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): The chambers were clean. There did not appear to be any signs offailure A camera was used for the inspection CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Commments (note condition of soil,signs of hydraulic-failure, level of ponding, condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note.condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1295 Shootflving Road Centerville. MA Owner: Karen Crocker Date of Inspection: November 22..2009 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. y O CA(A : A 3 i a3 syb 10 f J i! Page I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1295 Shootflving Road Centerville, MA Owner: Karen Crocker Date of Inspection: November 22, 2009 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water. 30'+1- feet Please indicate(check)all methods used to.detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the liigh ground water elevation: Usine Barnstable topotzraphic and water contours maps, the maps were showing approximately 30'+1-to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will . function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA 190 109 11268 4 MCNULTY, MAUREEN A 00 RIVER VIEW LANE co CENTERVILI...E MA 02632 RC 1:295 SHOOT FLYING HILL RD 4.1 r1c .... .. .. .. THE= COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j CITY/TOWN Z � DEPARTMENT ADDRESS 1 t °gym s�'y 'TELEPHONE"___fit Nor Address ccupant p, Floor Apartment No. No. Occupants No. of Habitable Rooms No. Sleeping Rooms- � No. dwelling or rooming units No. Stories_ Name and address of owner,,�,� _ r' �1_4 r . plc rna a/I_Y-___ Remarks Reg. Vic. YARD Out Bld s.: Fences: Garbage and Rubbish.- Containers: Drainage Infestation Rats or other: ,. '�'p�' r,r• / '" ' i.f �i��a<r�. /1l - ,�,� STRUCTURE EXT. Steps, Stairs, Porches: - - - �✓ Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen. Sanitation: Dampness: Stairs: _ Lighting: STRUCTURE INT. Hall, Stairway: Obst'n.: Hall, Floor,Wall, Ceiling: Hall Lighting: Hall Windows: z HEATING f `., Chimneys: z Central ❑ Y ❑ N Equip. Repair f�,•-/rtit pe s ; �. i°'?%4 ° 1 e:�j='� "' r r. W TYPE: ),!`.7 L Stacks, Flues,Vents: ;');'i'r ' "i i� ^It + , 1,� ,1 .J _r. l _ r/ c. .liN a PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: m H.W.Tank(s) Safety and Vent(s) o ELECTRICAL Panels, Meters, Cir.: - _ ❑ 110 ❑ 220 Fusing, Grnd.: 2 AMP: Gen. Cond. Distrib. Box: 0 Gen. Basement Wiring: DWELLING UNIT Ventil. Lgtng. Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen � t.;�"�. r'4�-'� '� 'f Bathroom , Pantry �- Den Living Room _ Bedroom (1 Bedroom (2) Bedroom (3) Bedroom (4) Hot Water Facil. Sup.Ten., Gas, Oil, Elect.: _ Stacks Flues Vents Safeties: Kitchen Facilities Sink Stove Bathing, Toilet Facil. Vent., Plumb., Sanit'n.: Wash Basin, Shower or Tub E� ' '"' r ti `.f -- '' ,4 -.� , �. , , ,... r . l.'.t' . 1 J t r ' Infestation Rats, Mice, Roaches or Other: ,t Egress Dual and Obst'n: General Building Posted: Locks on doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY.", INSPECTOR .r ° i x�t �' '-TITLE r,; ;, DATE t 1. _/ i `P.M." -. TIME i i A.M. THE NEXT SCHEDULED REINSPECTION P.M. ,r 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 stare minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR-410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. t (B) Failure to provide heat as required by 105 01R 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D) Failure to supply the electrical facilities required by 105 CMR 410.250(B); 410.251(A), 410.253(A), 410.253(B) and the lighting in common area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage system in operable condition as required by 105 CMR 410.150(A) (1) and 410.300. (G)• Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). 1 = (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602 which results in any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of lead-based paint on •a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or dafety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilities as are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven r. or any defect that renders eithej.-operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. (3) any defect in the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted plumbing heating, gas-fitting, or electrical wiring standards that do not create an immediate hazard. (4) failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the board of health. 0 ,. � � te..4 3 t'�a<n ..,)41J �� - - _' �` ��..1 f��•,•' ��•d.r+ .�.,� _ r � i ti { t q, 6qf ` _� ^� r.�� . p_._ � .. _ _�, _ _, .Y ' ' + `" ?. ��` ,:.. � �: F it �; �a... �� &. '• a° a � r:�: � `4 �.� � � �`. ;. ...��..� N;.s..r .: � � �"p .�• F �� 1,f ` �i� �° r, ,.�. ., ,� e �.. _. �,;, r,, , • �. i � �,,. . , a—� , , .� . , — E "' `` '. _. •� .,` ��' I ,..: _. �: fqq�. �. .. .....�..... .' � .. ....: -. .. ��. �' � .. ... .. .. .. .. ... .. .. - ... .. �1- .: .. . � �,* '. ,. � �, "t. N" Pk 4! � �� {{ ., ... .. '> Od VENT PIPE ((• Least 24 Inches tall) Schedule 40 PVC w/ -�-„^-4� Charcoal Odor Filter r � �• .✓' as t' '� 10' min. from 2-18'DIAM. ACCESS MANHOLES house to septic tank *NOTE: ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C. Existing Foundation pott 8' ^ c�•`r'"�+ T.O.F. elev. 100.00 Sothis 6 tank ofe covers must be grade ►, 9/,"NGrade over D-Box- 9e.50 a over SAS- 96.50 SECTION A .4 y, T �crud.aver s.ptla T«,k- 90.50 PROFILE VIER' OF LEACHING SYSTEM ''•� � �•�, �� r b r ig2•ihoet9 RtN►ing MBI >W S- 0.02 HOLE OP OF SAS- 94 75 /1 THE ACCESS COVERS FOR THE SEPTIC TANK, ��8 }akr.oAh Ra_ (H-201 DIST. BOX a • DISTRIBUTION BOX AND LEACHING COMPONENT 10. EXISTING S-0.04 3/4" to 1 1/2 Washed Crushed Stone " INLET o EXIST. PIPE LN 1,000 GAL. BD, 10' par foot 3 of 1/8" - 1/2 Washed Peoetone ` l�. '1 OUT T GRRTA��ALL BENRAISED TO 6 INCHES WITHIN 6FlNOSFIEO FIM FOUNDATION SEPTIC TANK c L FINISHED GRADE. r- H-10 20 a a �• eoo II a. CONCRETE FULL. FOIJNDATIOY II II ati obi ' S•LT' , +�s�-�p;+• �.r� ;err�+ h h: R �' f p r•= n N .;�j ��: INSTALL lUF-11TE GAS BAFFLES OR EQUALS V" •. II N 96 �1.M6Ni B a N, S STEEL REINFORCED PRECAST CONCRETE P r �r �7'""' SYSTEM PROFILE gyp' a o 0 C3 0 0 0 0 Effective vaa, o C3 C3 C3 C3 PLAN VIEW Not to Scale GENERAL NOTES c c c I 3 Un is e 8.5' w/2' Separation - 29.5 �3-24• REMOVABLE COVERS 6 in.of 3/4•-1 1/2• •y8 -29'5-��,ya � 1. Contractor is responsible for Digsafe notification compacted .tone f , ,,, 4• and protection of all underground utilities and pipes. Bottom of Test Hole 1 Elev.=85.00 Effective Length 3'min. clearance % ,�r , 2. The septic„tank o distri uition box shall be set ----- - --- 9 IF mi;. - 2' min. Inlet to outlet :< level on 6 of 3/ -1 1p2 stone. INLET _ _T L--- e•mb. OUTLET ,o•mM. L '"'�,o• 2 3. Backfill should"be clean sand or grovel with no SOIL ABSORPTION SYSTEM (SAS) > _ stones over 3 in size. s' -7• § ' s' -7" 4. This system is subject to inspection during installation 500 - C (H-20) LEACHING UNITS / WIGGINS PRECAST t e h aPti, by Carmen E. Shay - Environmental Services, Inc. Not to Scale �s 5. The contractor shall install this system in accordance with Title V of the Massachusetts state code, the approved plan NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE and Local Regulations. B'-o• 4'-10' 6. If, during installation the contractor encounters any CROSS SECTION END-SECTION soil conditions or site conditions that are different from those shown on the soil log or in our design installation must halt & immediate notification be USE EXISTING 1000 GALLON H- 10 SEPTIC TANK made to Carmen E. Shay - Environmental Services, Inc. 7. No vehicle or heavy machinery shall drive over the FOUNDATION 0' - SEPTIC TANK --$O�- D-BOX ' -o -20'-► LEACHING FACILITY septic system unless noted as H-20 septic components. NOT TO SCALE 8. Install Tuf-Tate gas baffles or equals on all outlet tee ends. 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes. 10. All solid piping, tees & fittings shall be 4" diameter PERCOLATION TEST Schedule 40 NSF PVC pipes with water tight joints. 11. SITE and Surrounding Properties are Connected Date of Percolation Test: OCTOBER 26, 2002 to Municipal Water. Test Performed By, CARMEN E. SHAY- R.S., C.S.E. ,S'H O O T V.,L YIN G HILL ROAD EX T. Results Witnessed WAIVER - Barnstable BOH Excavator: Shay Environmental Services, Inc. NOTE: Percolation Rate: Less Than 2 min./inch 0 5 FEET BELOW GRADE. (33 FOOT RIGHT OF WAY) THE PROPERTY LINES ARE APPROXIMATE AND COMPILED FROM THE SURVEY PLAN GENERATED BY I / BAXTER & NYE. INC, OF OSTERVILLE, MA Test Hole Test Hole ENTITLED " CERTIFIED PLOT PLAN OF 1320 SHOOTFLYING HILL ROAD", No. 1 No. 2 CENTERVILLE, MA% DATED DEC. 28, 1987 TO BE A SURVEY PLOT PLAN �� DEPTH SOILS ELEV. DEPTH sots ELEv. ITD IS T INTENDED SHOULD BE USED FOR NO PURPOSE OTHER THAN N 33d 31 36 E Sandy Loam 0 99.00 Sandy loam 0 98.5o THE SEPTIC SYSTEM INSTALLATION. " 26.23' 1 10 YR 3/2 10 YR 3/2 1 0•_g• A, 98.50 0"-6" AP 98.00 THERE ARE NO WETLANDS LOCATED WITHIN A 200' RADIUS Sandy Loam Sandy Loam OF THE PROPERTY iOYR 5/6 iOYR 5/6 4 6"-24" 1 Be 97.00 6"-24" 1 8s 96.50 Loamy Sand NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE f / SANDY FILL 2.5 Y 0/6 FROM THE EXISTING SEPTIC SYSTEM TO BE DISPOSED N �� OF AS PER BOARD OF HEALTH SPECIFICATIONS. 24"-60" 94.00 24"-48' C, 194.50 EXISTING LEACH PIT TO BE PUMPED DRY & Mod-Coarse Mod-Coarse ft Sand sand FILLED WITH CLEAN FILL MATERIAL. Qr 2IS Y 7/4 25 Y 7/4 NOTE: SEPTIC SYSTEM MUST BE INSTALLED BELOW C-1 SOIL LAYER Q O CID J C / �� 60"-156" C, 86.00 48"-162" C. 85.00 (ELEV 94.50) OR A 5 ' STRIP OUT WILL BE REQUIRED ALL AROUND jam' IDS G It ; y ASSESSORS MAP - 189 PARCEL - •033/002 VIA ff�J (; GARAGE G ZONING - RESIDENTIAL Y_ Perc FLOOD ZONE C `t 9 Depth#to Perc: 60" to 78" Perc Rate-G2 min./Inch `t\ \ Groundwater Not Observed p THERE ARE NO WETLANDS LOCATED WITHIN A 200' RADIUS J PROJECT BENC MARK BOTTOM OF TEST HOLE Elev. = 162" OF THE PROPERTY EXISTING 3 TOP OF FOUND A ON 0 ADJUSTED H2O Elev. = No Adjustment Required. DECK BEDROOM ELEV. = 100 (ass med) G� HOUSE I � d 36 �, � ALL.OUTLET PIPES FROM THE LEGEND ! V O DISTRIBUTION Box SHALL BE 12. CONCRETE COVER O$d TEST HOLE 1 ` SET LEVEL FOR AT LEAST 2 Fr. i 5 ELEV.= 99.00 ��\ TOF= ELEV, 100 '�p• '• 3-5*UTS 2 I � � � �� 8X0 DENOTES PROPOSED p #1320 �� - - 56• ouET TLEr 6• `• ,r INLET SPOT GRADE �0DEN, 1s5•, '•' os� "'" ' 2 X 104.46 SPO�TES GRADEISTING / I , SCH. 40 T 1.75• / PLAN SECTION CROSS-SECTION \ PL PROPERTY LINE 1 I t'xist. 1000 Failed r Gal.peptic Tank 8 3 HOLE DISTRIBUTION BOX - H-20 LOADING PROPOSED CONTOUR I I Leach Pit \\ NOT TO SCALE 97- - - - - -99' EXISTING CONTOUR 1 We ,�`� � DEEP TEST HOLE & 1 D-Bo a 1 Design Calculations PERCOLATION TEST LOCATION r��\ ��' ERNS P ��.� "`<�• '' , ,,:� �\ :' Number of Bedrooms: 3 Equivalent to 330 Gal./Day 5 FENCE `•. 'Y Garbage Grinder: No PA Y? U-JoL 3 3 - > �\`` ;• J�v 6 t\ Leaching Capacity Required: 330 Gal./Day (MIN. PER TITLE V) I Septic Tank - 2 x 440 Gal./Day - 880 USE EXIST. 1,000 Gallon Septic Tank. PRIVATE DRINKING WATER WELL I SOIL OR 0.96 ACRES. +/- ``- VEN7; PIPE t\ Bottom Area: 0.74 gal/sq9 ft. x percolation 420 sq e f ft. - 310.08ngallons Sidewall Area: 0.74 gal./sq. ft. x 188 sq. ft. = 139.12 gallons REVISIONS TEST�HOLE #2 a�. �` Providing: = 449.20 gallons ELEV.�-4ti5o 3g8• NO. DATE: DEFINITION �p Use: (3) PRECAST 500-C UNITS, HAVING A 2 EFFECTIVE DEPTH, TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES AND 2/06/06 Moved SAS/Added Pool I \ 2.75' OF WASHED STONE ON THE ENDS. per BOH check list UNITS TO BE SEPARATELY PIPED AND TO BE SEPARATED 2 APART. #2 3/21/06 #3 3/22/06 per BOH check list 99 i PROPOSED � E Y4 E' PREPARED E O R '' 3$' S F E� L SUBSURFACE SEWAGE DISPOSAL SYSTEM VP % 5 of /cy' ��. ��o• # 1320 SHOOTFLYING HILL ROAD 0 DEBORAH & PETER RYDER CENTERVILLE, MA J \ 1320 SHOOTFLYING HILL ROAD PREPARED BY: CENTERVILLE, MA OF CARHEY E. SHA Y ASs9 R c ENVIRONMENTAL SERVICES, INC 40 0 20 50 SH o. 34 THATCHERS LANE EAST FALMOUTH, MA 02536 VARIANCE REQUEST: sq IrAR\ TEL/FAX 508-548-0796 1' Request a Variance to install SAS more than 3' Below Grade SCALE: 1 "=20' DRAWN BY: CES DATE: NOV. 22, 2002 H-20 Components and a Vent has been provided. 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