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0568 SHOOTFLYING HILL RD - Health
568 Shootflyin Hill Road, Centerville llll UPC 12534 ' No.21_ 53L R NW-w MAST1N100 ION a i � 75" PRIOR 32"x 48" CLOSET SHOWER AREA EXISTING 3 1/2" EXTERIOR EXISTING WALLS SHALL BE WINDOWS 22"CLEARANCE INSULATED USING R-15 (2) (REQ'D MIN=21") FIBER GLASS BATTS W./6 MIL POLY VAPOR BARRIER. 0 - - - WALLS ARE CURRRENTLY >- 1UNINSULATED. z Q 11 '-5 1/2" N 0 34" X N Edge of jamb 15" X 20" LINEN CLOSET HARRINGTON BATHPLAN Scale = 1/2" = 1 '-0" Drawn: 12-17-18 v t Town of Barnstable jWE'Of+ti Regulatory Services Richard V. Scali, Interim Director . + BARNSrABLB. S. ��$ Public Health Division iOrEc�ne�s Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 7 Sewage Permit# 'ZO1'7 -0'70 Assessor's Map\ParceiIV Designer: XTAJ Installer: S3+re B EXC xVo1A%o n Address: Address: crrM ttQ a� 31 On t2 ) I �'� �j was issued a permit to install a (date) Q� / ,(instiller septic system at 66 Y4&o &// �V' based on a design drawn by (address) J / 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. Strip out (if required) was inspected and the soils were found satisfactory. 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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructe e with the to of the IAA approval letters (if applicable) RPM nstaller' Sign rel0. 1 -(Designer's Signature) (Affix Designer amp Here) t, PLEASE RETURN TO B S ABLE 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:\Septic\Designer Certification Form Rev 8-14-13.doc a � - 6qo No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYitation for "is saf *pstrm Construction 3permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 5&2 �jyh p cT ' y /� Owner's Name,Address,and Tel.No. -Sc.)8 -17 ct o-g e Z Assessor's Map/Parcel i Q3f)*J.�1 l —Ba.40-baJa S[ L170 r t Z. Installer's Name,Addres ,and Tel.No. Designer's Name,Address,and Tel.No. I3t-3 �kcnva4 ton Soa-y 77-0&S.3 GIe eZ r-Sons 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 3 3 gpd Plan Date 1 D �z� (� 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) QS'oo gal sr pureyo charn bakl n vrno w i-Fh al-a-,-m 112o d.bDY_ pmf=ylpa ano s fence_ 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 Boar alth. Signed A01j3d Date3 Application Approved by Date - ©—( Application Disapproved by , Date for the following reasons Permit No. Cat 07V Date Issued e �� No. Fee + ( Entered in computer: THE COMMONWEALTH ✓ NWEALTH OF MASSACHU:SETTS p Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for bis oral 6pstem Construction Permit _ Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 5 s' p UT �'Y I n p Owner's Name,Address,and Tel.No. SCI� -''7 c(J. �� 7 Assessor's Map/Parcel 09� I ti I W IJCI r f j CX r C j 1 G I JC r i z, Installer's Name,Addres ,and Tel.No. Designer's Name,Address,and Tel.No. 1�1 /3 ?' ,k( ri�)a 1 ion 50S- 9t77 0(a5.3 S&( ) S SU -� 36 3 /I Type of Building: Dwelling No.of Bedrooms �� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) I i Other Fixtures Design Flow(min.required) 33 U gpd Design flow provided gpd Plan Date 1 U 'I Z I (e Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r Nature of Repairs or Alterations(Answer when applicable) (Ju f G` 7 '/a h i,rrlo i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance,of the afore described on-site sewage disposal system in y 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` alth. Signed 2 -'1 Date - 7 Application Approved by ` 1,- Date s-.2O'-f iz- Application Disapproved by Date for the following reasons i i, Permit No. C9 0 — D Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS , (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by IJ i X C (I V Gt I c-,n at f I,),^ (70 has been constructed in accordance with theprovisions`of Title 5 and the for Disposal' ystem Construction Permit No.ap(T -b y dated 3 O— Installer � c�'s 1 r ( I (i\ Designer P u P_ ,j 'E _ #bedrooms a Approved design flow, f 3 ( god The issuance of this permi shall not be construed as a guarantee that the system will functi as designed. f / T Date C1 I� Inspector ( (/1_ �S .. ------------'------------------------------------------ . No. ,�C��� � � ✓ , ---- -- -------------- - ----- f-1-------- --- ---- ------ ----f --- Fee . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposar 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at �1 \(,(�( !r4 �, o t') ( � r SD J and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit./ , Date �2 U 7 Approved by 1 TOWN OF BARNSTABLE LOCATION S4'9 oO S7Jc1 nc 14►11 Rd. SEWAGE# ZO 1'n - 0-7 O ",,-VILLAGE ASSESSOR'S MAP&PARCEL 193-Lx32 INSTALLER'S NAME&PHONE NO. q 4,a EXev►Vo.�►o!\ t4) )- 0653 SEPTIC TANK CAPACITY Z$cx� qr�l LEACHING FACILITY: (type) pc�pc-- y.lck (size) /S'x 30 NO. OF BEDROOMS a OWNER a PERMIT DATE: 3-2O- I71 COMPLIANCE DATE: 3b G/ Separation Distance Between the: ` Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Al (31 AZ 51 (o 3 As' A 5' B5 45' 3'' V, 3 4 I i Town of$arnstable Pit Department of Regtilatory Services 04 Public Health Division Date KAM •63q ems$ 200 Main Street,Hyannis MA 01601 ArfD µ1.I► A. Date Scheduled /2( Time d! Fee Pd. D C ►foil Suitability Assessment,fog- Sew K e Di posal J Performed By.1 4►.�ey^ 1"��'C/�' Witnessed By:By: j LOCATION & GENERAL WORMATION Location Address�(o$ S�d 0 T l t 4 'l Ownerts Name'• �v�PZ Y 3�5. �.�fw•J Ave- c�, e ,V,y� �,,,� Address Assessor'sMap/P�rcel: 4 ?J� I Engineer's Name nAey".i�S LytG NEW CONS1'RULnON l REPAIR .�_ j Telephone# r�UI ' ) ) Land Use Res D E^n -V Slopes(90) Surface Stones f AD i >! Distances from: Open Water Body. Possible Wet Area>_� ft Drinking Water Well ft i 1 . Drainage Way �4 0 ft Property Line �/0 ft Other ft SKETCH:(Street name,dimensions'of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) See, s i t I • �1� Parent material(geologic) li✓�5r1 I Depth to Bedrock Q11 Depth to Groundwater. Standing Water in Hole: Q l D n i Weeping from Pit Face N Estimated Seasonal;"igh Groundwater y D TERMIN T ON�FOR SSEASO�AL HIGH WATER TA-tLE Method Used: taS S to sail mottles;th ln. Depth Clbperved standing tt obs.hole: in. Depth tt. Depth toiweeping from side of obs.hole: in. Oioundwater AdJuntntent ! _ A �fietor.�._.� Ad,Groundwaterlevel.,,,,e, Index well# __ Reading Date index Well level -- �• . I PERCOLATION TEST' ' Dnte Observation ` I I Tune at 9" Hole# 5�- - Time at 6" • Depth of Pere ' Start Pre-soak Time.@ 1114 1 Time(9"-G') ' 2 D End Pre-soak Rate Minllnch Y Additional Testing Needed(YIN) Site Suitability Assessment: SitePassed �`• Site Failed; ' Original:.Public 14e'alth Division Observation Hole Data To Be Completed on Back— - ***If percolaOn test is to be conducted within 100' of wetland,you ou must first notify the Barnstable C4#servation Division at least one(1) week prior to beginning. DEEP OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel oil �i11 N A I OY P- S/g G meo S,o 2• y DEEP OBSERVATION HOLE LOG. . Hole# �V Depth from Soil Horizon Soil Texture Soil Color Soil Other; Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. -/ Consistenc %Gra el h tl V11-{ �l -: A DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, o Gravel DEEP OBSERVATION HOLE LOG Hole# —' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc ra Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No X Yes Depth of Naturally.Occurrina Pervious Material Does at least four feet of naturally occurring pervious material exist,in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? . Certification I certify that on I 0k0% (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 training,expertise and experience described in all CMR 15.017. Signature t/ - Date Q:\SEPTIC\PERCFORM.DOC Town of Barnstable Barn Regulatory Services Department C " 39. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0001 2273 2619 April 26„ 2016 Barbara Schwartz 315 Claflin Avenue Mamaroneck,NY 10543 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 568 Shootflying Hill Road, Centerville, MA was last inspected on 1/15/2016 by Chad Hathaway, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995.TITLE 5 (310 CMR 15.00) due to the following: • Any portion of the SAS, cesspool, or privy below high groundwater elevation. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH FeZ R. 0 S. HO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\568 Shootflying Hill Rd Cent Apr2016.doc Commonwealth of Massachusetts 93 -032- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address, -5 ar4k Owner Owner's Name information is Bar ble Ma 12/17/15 required for every page. Citfrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms ,5k-0" 113�b on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. � Company Name P.O.Box 151 Company Address Forestdale Ma 02644 Cityrrown State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am,a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ❑ Fails ® Needs Further Evaluation by the Local Approving Authority 12/17/15 Inspector's 5 ature ,le Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. V t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is Barnstable Ma 12/17/15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exflitration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner owner's Name information is Bamstable Ma 12/17/15 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ® Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °yr 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 12/17/15 . page. Cityrrown State Zip Code Date of Inspection B. Certification (cons.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Cesspool is within 6"of ground water determined by Barnstable Health Dept. 1998 as described in previous report dated 1998. there are 2 500 Leach Chambers installed behind cesspool that were installed in 1986. with estimated 2'6"ground water seperation D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6°below invert or available volume is less than %day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [E 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.] ❑ E] The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. Cityrrown State Zip Code Date of Inspection C. Checklist -Check if-the following have been done. You must-indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: seasonal Does residence have a garbage grinder? .❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal-use? Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: .Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sahitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owners Name information is required for every Barnstable Ma 12/17/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: none Was system pumped as part of the inspection? ❑ Yes ❑ No If'yes, volume pumped;-gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ® Overflow cesspool- El Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 6'x 6'cesspool with 2 500 gal leach chambers behind cesspool. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address ShwartZ Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: cesspool 1958. leach chambers 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ' Depth below grade: 1 feet Material of construction: -Z-cast iron 0-40 PVC ❑other(explain): Distance from private water supply well or suction line: 30 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on-site plan): Depth below grade: 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 Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address ShwartZ Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. Citylrown 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.): 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 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address -Shwartz Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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 plait): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 6 Official Inspection Farm:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 cesspool with chambers as overflow Depth—top of liquid to inlet invert 5' Depth of solids layer Depth of scum layer 0" Dimensions of cesspool 6'x 6' Materials of construction block Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 pfficial Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) -Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name required fo is Barnstable Ma 12/17/15 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below Q drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water Z Check cellar ® Shallow wells Estimated depth to high ground water: 8' ` N ,�ck � feet V�S� b�n G,W t 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: 1998 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: prev. title report indicated barnstable health dept found ground water to be at 8'deep ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Prev. title report desribed barnstable health dept. indicated ground water to be at 8'deep in area of cesspool. Bottom of existing cesspool is 7'6" below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 �s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartr Owner Owner's Name information is required for every Barnstable Ma 12/17/15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 y►� Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 568 Shootflying Hill Rd a Property Address Shwartz V Owner Owner's Name information is r) required for every Barnstable Ma 1-5-16 i page. City/Town State Zip Code Date of Inspection W Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 07 1. Inspector: key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. Company Name P.O.Box 151 Company Address Forestdale Ma 02644 City/Town State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of .Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 1-5-16 Inspector's Signature Date The system inspector shall submi copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 d of compldting this inspection. If the system is a shared system or has a design flow of 10,000 gp o greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner. ,* and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. City/Town State Zip Code Date of Inspection 1 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M , 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4M , 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS.is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3: Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ® ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: cesspool is in ground water Number of current residents: seasonal Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: none Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? _Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 6'x 6'cesspool with 2 500 gal leach chambers behind cesspool. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: cesspool 1958. leach chambers 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 30' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 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 Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® 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.): cesspool with leach chambers behind cesspool Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 cesspool with chambers as overflow Depth—top of liquid to inlet invert 5' Depth of solids layer 8° Depth of scum layer 0.1 Dimensions of cesspool 6'x 6' Materials of construction block Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 4) r ►D t5ins•3/1 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 568 Shootflying Hill Rd M Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4'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: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: used town GIS maps. You must describe how you established the high ground water elevation: Online town supplied GIS topo maps indicate area over cesspool to be 4'above lake Wequaquet in elevation. I met with health agent Donna at front counter of barnstable health dept to review and confirm topo maps. bottom of cesspool is 7.5 feet below grade putting cesspool in ground water Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r , y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 568 Shootflying Hill Rd Property Address Shwartz Owner Owner's Name information is required for every Barnstable Ma 1-5-16 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file s t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Wllllam F.Weld Trudy Coxe Comma 8111aatny Argeo Paul Celluccl Davld B.Struhs U.Governor CommhttbrNr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 568 Shoot Flying Hill Rd. Nancy O'Neil Property Address: C e n t s v i l l e, MA Address of Owner. Date of Inspection: 11" f 5 % '7 (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA 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: _/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspectoe's Signature: � ) I Date: 1z)1J^9 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 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] 8Y9 PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: j ne or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes spection. ,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, cracked, structurally unsound, shows substantial infiltration or exfdtration,.or tank 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. 1/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)5WI049 a Telephone(617)292-3S00 06 Printed on Recycled Paper X ' t• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) property Address 568 Shoot Flying Hill. Rd. Centerville, MA Owner. Nancy O'Neil Date of Inspection: I/--I S-j III SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled 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 CI THER 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 water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply 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 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. S) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 568 Shoot Flying Hill Rd, Centerville, MA Owner. Nancy O'Neil Date of Inspection: D YSTEM FAILS: 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. Backup of sewage into 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 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 1/2 day flow. Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s). Number 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 I 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. El GE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: 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: 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 o r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program req ' menu of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST property Address: 568 Shoot Flying Hill Rd, Centerville, MA Owner. Nancy O'Neil Date of Inspection: 1--l S-9 /7 Check if the following have been done: Vamping information was requested of the owner,occupant, and Board of Health. �ne of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. -L A built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. V'The system does not receive non-sanitary or industrial waste flow 'The site was inspected for signs of breakout. tAll system components, excluding the Soil Absorption System, have been located on the site. /Se 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. size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. iThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 568 Shoot Flying Hill Rd, Centerville, MA Owner. Nancy O'Neil Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: llons Number of bedrooms:— Number of current residents: , Garbage grinder(yes or no):_45a Laundry connected to system(yea or no): Seasonal use(yes or no):A., O Water meter readings,if available: 1995 — 37 , 000 gals. Last date of occupancy: fin/ —9 COMMERCIAL/INDUSTRIAL: Type of establishment: Design,flow:_gallons/day 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: OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS d source of information: /U 1i System pumped as part of inspection: (yes or no)--Y(e'S If yes,wohune pumped:_& :4 gallons Reason for pumping 15,26 TYPE OF SYSTEM Septic tanlc/distribution box/soil absorption system mgie cesspool L"', OverflOw,cesspool Privy Shared system(yes or no) (if yea,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: �� S Sewage odors detected when arriving at the site: (yes or no)�� a (revised 11/03/95) 5 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 568 Shoot Flying Hill Rd, Centerville, MA Owner. Nancy O'Neil Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction• concepts_metal_FRP—other(explain) Dimensions: Sludge depth Distance from to of sludge to bottom of outlet tee or baffle: Scum thickness• Distance from p of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: Commen (repo ndation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, eviden of leakage,etc.) GRE dLSE TRAP:_ (loca on site plan) Dept below grade: Ma of construction:_concrete_metal_FRP—other(explain) nsions: thickness. from top of scum to top of outlet tee or baffle: from bottom of scum to bottom of outlet tee or baffle: Cc eats: ( ndation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, avid ce of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 568 Shoot Flying Hill Rd, Centerville, MA Owner. Nancy O'Neil Date of Inspection: HT OR HOLDING TANK_, ( on site plan) Depth low grade: Ma of construction:_concrete_metal_FRP_other(ezplain) Dimensio Capacity. ons Design fl ons/day Alarm level: Comments: (condition of tee,condition of alarm and float switches,etc.) DISTRI ON BOX:_ (locate on ite plan) Depth of liq 'd level above outlet invert: Comments: (note if leve and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) PUM CHAMBER_ (locate o site plan) Pumps in working order-.(yes or ao) Commen (note co tion of pump chamber,condition of pumps and appurtenances,etc. (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropbetyAddrees: 568 Shoot Flying Hill Rd, Centerville, MA Owner. Nancy O'Neil Date of Inspection SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits, number: leaching chambers, number:_.�-- leaching galleries,number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool,number: Comments: note condition of soil,signs of hydraulic failure, level of pon condition o`fj vegetation,etc.) 6 .11 _ / '�-• S la n c: n tC c 76 A i /A-S CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: zf Depth of solids layer: 4 Depth of scum layer: 3 " Dimensions of cesspool: 6� err �. Materials of construction: Y3 l c c l<S Indication of groundwater: /L- O inflow(cesspool must be pumped as part of inspection) 4 ) Co eats: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRIV V. — (1 on site plan) Ma of construction: Dimensions. Depth solids: Co ts:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) g 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION(continued) Property Addreaw 568 Shoot Flying Hill Rd, Centerville, MA Owner. Nancy O'Neil Date of Inspection: '��S'•-�jlj SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' o � n I ti\ V) d I DEPTH TO GROUNDWATER Depth to groundwater: '5 feet Q 6 method of determination or approximation: I� a (revised 11/03/95) 9 j _ - -V - ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH QW ... ....................oF... Appliration for Disposal Works Toustrurtion Verudi Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .................... ............................................................................. .. Lo ati. ................... Address or Lot N ----------------------------------- ..... ..a.... .......................................................... ...la.un_ .............. Installer Address Type of Building _S' Size Lot.............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers Cafeteria Other fixtures ....................................................................................................................................................... WW Design Flow............................................gallons per person per day. Total daily flow........................------------------"gallons. Septic Tank—Liquid'capacity............gallons Length...........:.... 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 1-4 Percolation Test Results Performed by.—...................................................................... Date-...................................... 1.4 Test Pit No. I................minutes per inch Depth of Test Pit...._.........._.... Depth to ground water............_........__. 14 Test Pit No. 2................minutes per inch Depth of Test Pit..._.............._. Depth to ground water...................... 0 Description of Soil...................... 7 ....................................w..................................................................................m.................................. -------------*------*-------------------*--------------------*--------*-"**,.................................................................................................................. .................................................................................................................................... U Nature of Repairs gr Alterations—An5wer when applicable..4�qg------ r...... ............. ...QZt .......... Ij Mad......1Vj:kb\.......... Agreement!' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in " A operation until a Certificate of Compliance has been issued by the b and of health. ...... I" issued by the D a,, Date ul"p .......... . ....................... ..... �:_L r(i6 .... ..................... c ul ................................................. ......... Q...... By 7. Application Approved By.......... ... ........... Date Application Disapproved for the following reasons:.....................................................................................7.......................... ......................................................................................................................................................... ............................................... Date PermitNo......................................................... Issued....................................................... Date r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ......................o f F s� � ---- .-.:.--.-.:.------------- s } Appliratio t for Di-n#ooal Workii Tonstrurttnn rams# Application is hereby made for a Permit to Construct ( ) or IZepair an Individual Sewage Disposal System at: a $...SI>.... ...Fl »c�. . ..---...... ------------------------------------ - 1 Locatio2-Address i 1 �^ or f / .._... ...��¢lk ..�t c�l:►C�{..................... ... s...S�to�-t _! .�S,t1h�c /.ill.•.- =( de. leml Owner f 1 (Address 7 ................ .....� n fir. •...---•------..........----•---------------------........ -2.i5.........t1�. ...!e :, 6.:�?._ (fir C�t� 1��............ Installer Address f/ Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder a Other—Type of Building a yp g -••--•-.................... No. of persons............................ Showers ( )f— Cafeteria ( ) d Other fixtures . W Design Flow............................................gallons per person per day. Total daily flow............................... ...........gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter..._._...:.._...Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching are ....................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......:..............................................................:. ►.a .._ Date.:.............................-........ ,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4y ----•--•---------------------------------•----•----•------•--•-•-•••-----•---------........--•---.....--•--•-•---.......-•---•---•--•--•----................. 0 Description of Soil..................................................................................... -----------------•--•--------....-------•--------------------...-------••-•-..._.. . -- . U Nature of Repairs car Alterraatiions—Answer when applicable.4. ...... . s »�U- __Cp5_ CS.. I.S_ �Xl ........... .,.t e. tr d' '�!�s. r; .n :---------------------------------------------------------------------------------------------------------- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:IT?� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. i _34,_ Signed 411`4/.'/�j�mr/.....................•---------....------........... -_.... Date Application Approved By --^` 1 Date Application Disapproved for the following reasons---- ----------•--••----•------••-----....---•-•-••--•-----------•-•----------.................................. .........................••-•----•--•-------•----•-•---•----.....-••--------•-----•-....-••-•••--................--•-•---•---•-----•----............---•-=------......----------••................................................ Date PermitNo...........-•---•------•--------•--------------•--------• Issued........................................................ Daft THE COMMONWEALTH OF MASSACHUSETTS a nl Q I I BOARD OF HEALTH ...........1.ot ?z 1.................OFrrt.s�l,o '. ................. .......................... (In ifiratr of Tompliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........ .....t --(.--. ...:... ...................... .. ` / �-- it 1Iiistalll V( -�, at--•-••-•......... ..... ---------=.... Yl ul�1.- -. c 1 c `..... .................•--------------•-----------......----......._......... has been installed in accordance with the,provisions of TII'LE, 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------ ...... dated.......... _�_ ..I���"................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....... ...'?r 1_ r.............................................. Inspector-- 1- f G �1 el I THE COMMONWEALTH OF MASSACHUSETTS BOA OF PrALTH l - � n......................oF..........Corns..../..er .....e..------.................--•---••---•............ NO.......... ............ Fn........................ Disposal orkoTuns racoon Errant Permission is hereby granted. (l .... "A 20i..................................•---••--•-••-•.........•-- to Construct ( ) or Repair (�O, an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit No ;_----- Dated.._.�-.�_�.t.�`��................. -.___ Board of Health DATEC .............•-••--•--...--•--•. L O CATION A E>��WbA E PE RMIT NO. ST 'VILLAGE fed V 1 L�,E INSTA LLER'S NAME & ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i i i j f e F ii i Q P`O LEGEND CENTERVILLE \ �O PROPOSED CONTOUR O AKEVIEW DR PROPOSED SPOT GRADE L 1 UPO CB�/m4 —— 98 -— EXISTING CONTOUR G EL 42.1 ° + 96.52 EXISTING SPOT GRADE LOCUS EARSE 5 FT. SOIL REMOVAL W— EXISTING WATER SERVICES POND LAKE TEST PIT WEQUAQUET NECK PINE 12,50OG 2—COMP SEPTIC PARCEL ID: TANK PUMP CHAMBER 193/031 �C.BAS _ Wes, `; � � 3- -- LEWIS5�2�1 OP�� = ONT LONG EL=42.3 OLLY �'' r1•,.o v1 POINT FULLER a F RO, I �' ��� /���� � Fes.• POINT 1 3, � G G`(j 1�, oO,•1 t bP a/%L-OC ' B.M.: STEP LOCUS MAP e HOLLY co ELF 38.1 (NAVD) �� ",s�/�FwgY .•'�� LOCUS INFORMATION UPOLE IN . 00 PLAN REF: 128/33 F-2 & 143/133 9"�t4�____ \ �.• ) , TITLE REF: 11755/239 __ _ ,• PARCEL ID: MAP 193 LOT 32 ZONING: "RD-1" °� ONW �' " • _-_ , FLOOD ZONE: X" COMMUNITY PANEL: .25001CO561J DATED:07/16/14 �° SEPTIC SYSTEM c _ _ °' �y =PARCEL ID: #568 =-_ ' PARCEL ID: REPAIR PLAN �'�' -__ _ LOCATED AT: 193/034 �,g W- � _ = O�G .45-A�RES °oo ,S N 568 SHOOTFLYING HILL ROAD CENTERVILLE, MA. PREPARED FOR SOIL LOG P#: 15166 J�2 � BARBARA SCHWARTZ DATE: SEPTEMBER 21, 2016 SOIL EVALUATOR: DARREN M. MEYER, R.S., 2� 0 - �6� �F /�'�$ OCTOBER 12, 2016 WITNESS: DAVID STANTON, BARNSTABLE HEALTH OF kfjssc. Elev. ID: �� DA R N ev. TP-1 D ate epth . TP-2 oaPcr, 193/033 \,P \ M , 40.80 FILL0" 40.80 FILL0" 114 40.13 A 8" 40.13 8" ;{ LOAMY D LOAMYSAND \Q� ft 1 4/ sl 39.38 17" 39.38 17" MNIT00i`� B LOB SAND B LO 5/8 B SAND 5/8 37.80 C 36" 37.80 C 36" \\{teao G� PERC 036.30 MEDIUM SAND SAND � MEYER & SONS, INC. SAND 2.5Y 7/4 2.5Y 7/4 � P.O. B 0 X 981 GRAPHIC SCALE EAST SANDWICH, MA. 02537 31.47 112" 31.47 112" +� 30 0 15 30 so 120 PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) I PH: (508)360-3311 GROUNDWATER OBSERVED AT 108" EL. 31.80 GROUNDWATER OBSERVED AT 108" EL. 31.80 FAX: (7 7 4)413 9 46 8 WELL SDW-252. ZONE C. LEVEL 47.6. ADJ 3.4' WaJ~ SDW-252, ZONE C. LEVEL 47.6. AW 3.4- \( IN FEET ) m e ye r a n d son s t i t I e 5 Cog m a i I.c o m USE TOWN OF BARNSTABLE APPROVED USE TOWN OF BARNSTABLE APPROVED - ADJUSTED GROUNDWATER ELEV. 33.8 ADJUSTED GROUNDWATER ELEV. 33.8 1 inch 30 ft. SHEET 1 OF 2 J 1864 NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS PROPOSED TANK PUMP CHAMBER D-BOX f INSTALL RISERS W/IN 6" OF FINISH GRADE INSTALL RISERS to FINISH GRADE INSTALL RISERS W/IN 6' OF FINISH GRADE T.O.F. EL.=38.0 EL.38.5f EL.38.5t FINISH GRADE-41.50 •A�EL.38.0f F ...... F.G. EL: 41.5f MIN. COVER OVER S.A.S. = 9" MAINTAIN 2% MIN SLOPE OVER LEACHING AREA \ .: S EL.36.35 SaYTTAARY TEE 6" INSPECTION PORT TO BOTTOM OF STONE ... �II2� 6"10 4" SCH 40 PVC 2" SCH 40 WIN 6" OF FINISH GRADE USE PERF. PIPE (MIN.) " " 14" 14 0 S= 1% (MIN.) FORCE MAIN e" 6 .. 1 poly um a TEE'S ARE TO BE 1,000G INV.= 39.67 L = 39.50 INV.=39.35/ (NOTE 16) X 4" SCH 40 PVC INV.= 35.07 TEE SHALL NOT EXTEND 1,SOOG GAS Exist. Inve J PUMP CHAM. BELOW FLOW LINE INV.= 35.9 rt - 35.32 COMP. BAFFLE S DETAIL L (USE DB-5 H-20 W/BAFFLE) INV.- w/ FILTER ..,, . - 30 :. . . . :. asmMa as 9» MIN. PROPOSED 1,500/1,000 GALLON 'xm PER T/TLE 5 2-COMPARTMENT SEPTIC TANK INV. ELEV.=39.50 BREAKOUT EL. - 40.25 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING END ELEV.=39.35 PIPE INVERTS PRIOR TO CONSTRUCTION. E� ' 2) TANK/PUMP CHAMBER AND D-BOX SHALL BE SET TRUE TO GRADE ON A MECHANICALLY COMPACTED SIX INCH CRUSHED STONE BASE AS BOTTOM ELEV.=38.85 SPECIFIED IN 310 CMR 15.221(2). SEPTIC SYSTEM PROFILE 2.s 5' 5=-�--2s 3) INSTALL PVC INLET/OUTLET TEES IN SEPTIC TANK AS REQUIRED. SEPARATION s.osFT. 5' TYPICAL SECTION 4) GAS BAFFLE W/ FILTER TO BE INSTALLED ON OUTLET TEE N.T.S. ADJ. GROUNDWATER EL 3380 SOIL ABSORPTION SYSTEM (SECTION) AS MANUFACTURED BY . . . . . . TUF-TITE, ZABEL OR--EQUAL. "•TA INSTALL 1' PVC CONDUIT TO HOUSE FOR WIRING NTH WATERTIGHT JOINTS. WARE HIGH WATER ALARM NTH SECURED D WATERTIGHT OVER TO GRADE RISER GENERAL NOTES: AOF, FLOAT TO GP 2000 HIGH WATER ALARM PANAL ON eA CIRCUIT SEPARATE FROM CIRCUIT TO THE PUMP. NEMA 4 JUNCTION BOX CORROSION RESISTANT I. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL s & LIQUID-TIGHT CABLE CONNECTORS SUPPORTED BOARD OF HEALTH AND THE DESIGN ENGINEER. DESIGN CRITERIA R HOISTING CABLE 7x19 STAINLESS STEEL BY 1-1/4" PVC CONDUIT. JOINTS TO BE MADE 'as. THE 1/8" DIAMETER. / 1,760 LB. STRENGTH. WATERTIGHT 2 OUIRMF_NTS OF THE STATE EMARONMENTALALL WORK AND MATERIALS SHALL CONFORMTCODE, TITLE 5, NUMBER OF BEDROOMS: 3 BR DESIGN °IV-, C 2"BALL VALVE w/ UNIONS SCH. 80 PVC AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. SOIL TEXTURAL CLASS: CLASS 1 0- 1140 PC INV.(OUT)=35.32 GEORGE FISHER CO. MODEL NO. 560 OR EQUAL 3.THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 2"SCH. 40 DISCHARGE TO D-BOX TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND DESIGN PERCOLATION RATE: <2 MIN/IN THE DESIGN SANITARIAN. Q'1 T ALARM ON EL: 33.15 2"SCH, 40 TEE W/ CLEAN-OUT CAP 4.ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING DAILY FLOW: 330 G.P.D. l PUMP ON EL 32.65 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE PROVIDE 1/4" WEEP HOLE IN DISCHARGE DESIGN SANITARIAN BEFORE CONSTRUCTION CONTINUES. DESIGN FLOW: 330 G.P.D. 1� PIPE FOR SELF-DRAINING FORCE MAIN 5.ALL EI-EJATIONS BASED ON NAVD DATUM. PUMP OFF EL- 32.32 Z?" �s. GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) 1 12 2' BALL CHECK VALVE SCH. 80 PVC 6.THE THE SANITARIAN IS NOT RESPONSIBLE FOR THE FAILURE SEPTIC*TAN K PUMP CHAMBER: 330 d x 200% = 660 d BOTTOM OF INT. P.C. EL. 31.32 100 P.S.I. FLOWMATIC MODEL No. 208S OF THE CONTRACTOR IN OWNER TO NOTIFY THE LOCAL BOARD O / 9P 9P HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. • � - USE 2-COMP 2,500G TANK (1,500G/1,OOG) PROVIDE 2- WADE ANGLE FLOATS: 2" SCH. 40 PVC DISCHARGE PIPE 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE FLOAT NOA: PUMP ON/OFF (BARNES 073618 OR EQUAL) 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE LEACHING AREA REQUIRED: (330)/0.74 = 44.5.94 S.F. FLOAT NO.2: ALARM ACTIVATION (BARNES 073612 OR EQUAL) BARNES SEV412 PUMP .5 H.P. 115 V RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND 2" DISCHARGE PASSING 2" SOLIDS OR EQUAL CONTRACTOR. DISTRIBUTION BOX: (3 OUTLETS (MINIMUM)) NOTE: SEPTIC TANK AND PUMP CHAMBER TO BE FACTORY WATERPROOFED AND SEALED NTH THOROSEAL OR EQUAL. 9• IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY PRIMARY S.A.S. PUMP & ACCESSORIES AVAILABLE AS A UNIT THE LOCATION AND/OR PRESENCE OF ALL EXISTING SEWER THROUGH WIGGEN PRECAST CORP., BOURNE MA. (800) 564-6774 OUTLET PIPES AND UTILITIES PRIOR TO BEGINNING CONSTRUCTION. USE 30'L X 15'W X 6"D LEACHING FIELD- W/ 3 LATERALS .� PUMP & ACCESSORIES AVAILABLE THROUGH WILLIAMSON ELECTRIC (781) 444-6800 10. EXISTING .LEACHING TO BE PUMPED, CRUSHED, AND REMOVED PUMP DETAIL REPLACE WITH CLEAN MEDIUM SAND PER TITLE 5. 11. 48 HOUR NOTICE FOR CERTIFICATION INSPETION. BOTTOM AREA: 30 X 15 = 450 SQ. FT. N.T.S. 12. THIS PLAN IS USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY BUOYANCY CALCULATIONS DOSING & STORAGE REQUIREMENTS 13. REMOVE ALL UNSUITABLE SOILS 5 FT. AROUND LEACHING TO DAILY FLOW: 330 GPD EL. 37.80 OR TOP OF "C" LAYER AND REPLACE WITH CLEAN DESIGN FLOW PROVIDED: 0.74GPD/SF(450SF) = 333 GPD > 330 GPD req'd DOSING REQUIRED: 330 CYCLES/DAY83 GALLONS/CYCLE ( MEDIUM s„"° PER TITLE 5• 2.000 2 COMP-SEPTIC TANK 14. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING PROPOSED SEPTIC SYSTEM UPGRADE PLAN mam 12' x 7' x 4 x 62.4 = 20.966.4 Ibs DISTANCE REQUIRED BETWEEN PUMP 15. ALL PIPING TO BE 4' SCH 40 0 1/8-/Fr (UNLESS SPECIFIED) 568 SHOOTFLYING HILL ROAD CENTERVILLE MA around cover. 12' x 7' x .75 x 120 = 7,560 Ibs ON AND PUMP OFF FLOATS: > > 16. PLACE 40ml POLY LINER AROUND ENTIRE LEACHING AT EDGE emn tank: 16.000 Ibs 83 GAL/CYCLE - 250 GAL/FT = 0.33 FT/CYCLE (4") Prepared for: Schwartz aroundeover + empty tank > uplift: OF 5'FT. SOIL REMOVAL FROM EL. 40.25 TO 36.25 TO PREVENT STORAGE REQUIRED ABOVE WORKING LEVEL: 330 GALLONS BREAKOUT. Design and Site Plan by: SCALE DRAWN DATE 7.560 + 16,000 = 23,560 Ibs > 20.966.4 Ibs STORAGE PROVIDED: MEYER&SONS,INC. N.T.S. DMM 10/12/16 TANK BUOYANCY CHECK O.K. PO BOX98! INV. EL: 35.32 - ALARM ON EL: 33.15 =2.17' STORAGE PROVIDED = 2.17' X 250 GAL/FT = 543 GALLONS E4STSANOIMICH,MA02537 SHEET NO. 5M-W2-n22 1 of 2