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0945 SHOOTFLYING HILL RD - Health
945 Shootflying Hill :Rd Centerville. . P A = 191 035 S a1 ff z UPC 10259 ' No.H�R �° ,��►`� HASTINGS. IIN t, TOWN OF BARNSTABLE fL LOf'ATION �� nn' rri WY SEWAGE # VII LAGE ASSESS R S MAP.& LOT INSTALLER'S NAME&PHONE NO. �•� SEPTIC TANK CAPACITY ` LEACHING FACELrrY: (type) tp7 C.: [= �.L�'rc,r (size) NO.OF BEDROOMS BUILDER OR OWNER ��,Jn rfii iA PERMrrDATE: . Ua ___,;--COMPLIANCE DATE: 2 4 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 t �n lie , FEE 1 5� O O No. Ec- COMMONWEAITH OF MASSACHUS ETTS Board of Health, �Byt 15 ms' tS MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair Upgrade( Abandon( - U Complete System Andividual Components Location VrL`Tlls fo ` Owner's Name WN Map/Parcel# Ka? I ,fie Address - , �k� Il Lot# I 4ISA Telephone# Installer's Name �C ; Designer's Name Address Address Telephone# _ •� _ Telephone# Type of Building \ Lot Size '9 V sq.ft. Dwelling-No.of Bedrooms Garbage grinder (N,IrA-- Other-Type of Building-:a). * ,6,oA Si'1p, No.of persons Showers W,Cafeteria (kf Other Fixtures Design Flow(min.required) Z7 V gpd Calculated design flow......' Design flow provided 'gpd Plan: Date � ,.T�O�a� Number of sheets ( Revision Date d� Title t Description ofSoil(s) r,;ZeCQr t :'KkC c t Q' Soil Evaluator Form No. ��'_� Name of Soil EvaluatorC{�Q:�q 1� DQ ate ofiEvaluation n DESCRIPTION OF REPAIRS OR ALTERATIONS The unders' ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr t place th s s e in o n until a Certificate of Com fiance ha toard of Health. Signed Date -- INSTALLN ABEREC UST SUPERVISE E SYSTEM WAS INST TIFy IN WRITING Inspections ACCORDANCE TO PLAN_ IN STRICT 4 R � ,CJ 0 0 No. �• � � FEE ` `7 ""-Board-of Health, S,R _r15Tfl P�l F MA. t " APPLICATION FOR DISPOSAL SYSTEM STEM CONSTRUCTION PERMIT ,Application for a Permit to Construct( Repair Upgrade( AbandonO - ❑Complete System Individual Components Location LA-':; no4 F'L.Y00 Owner's Name Map/Parcel# , 9 M d 5 C� �CV'\1e Address Lot# Telephone# Installer's Name ° !\ Designer's Name < Address Address -,,)", Telephone# - _(�� _ Telephone# Type of Building R E9- Lot Size �J��LC' V sq.ft. Dwelling-No.of Bedrooms MC c PQ C�j ) Garbage grinder (``/A Other-Type of Building 1 J 2�cC,C�c r� S j ` No.of persons p�_Showers (0,Cafeteria (1� Other Fixtures I r y C r�ct� E k� C'V�o-� �\c>k F Lc yn6 o—A Design Flow (min.required) 331D gpd Calculated design flow 0 Design flow provided 3�Lf gpd Plan: Date � �© � ()a Number of sheets Revision Date Title Description of Soil(s) n C: C`r`�� ` \� P�1c,.���C C9(, Soil Evaluator Form No. \ \c Name of Soil EvaluatorCf�1QM-�v,\ S\a,;�%Y Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS � � The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further afire) s to "o�'t t�o•place th /�s/te in op ation until a Certificate of /om fiance has been issued by the Board of Health. Signed /7 W �( 1 Date / t Inspections •, No. W0 J / I _- FEE (/ 00 COMMONWEALTH OF MASSAC14USETTS Board of Health,7 1A` MA. CERTIFICATE Of COMPLIANCE Description of Work: Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ,Upgraded ( ),Abandoned ( ) by: ' e 2 .K T at QL hno-r U I►- 9 4111 . (sntLryt J� has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.aLw -5-1/A rrdated Approved Design Flow (gpd) Installer ,n N /, Designer: Inspector: , A M . Date: ( )!A h 7, The issuance of this permit shall not be construed as a guarantee that the system will function as designed. '7 G 00 No. � ! - DFSI FEE_ GNZNG C®MM®NWFALTH OF MASSACHUS A� rs TioN GlNFFR cc� TF4i qNo a��sr Board of Health, 1 Y,1-� �_U��.--- MA. RDq,41C wGgS S�RTj�,/"UpFRVi DISPOSAL SYSTEM CONSTRUCTION PERMIT PAN q�EO IN SI G r Permission is e hereby granted to; Construct( ) Repair(X Upgrade(( ) Abandon( ) an individual sewage disposal system at q q S 5f I o-b ��I U �l7Cl 4- 11 , 0 oly a +' I LV as described in the application for Disposal System Construction Permit No.ZQ�-S 7 dated Provided: Construction shall be completed within three years of the date ofthis permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date' �''�U� Board of health 16 TOWN OF B STABLE �L • LOCATION SEWAGE # I / VILLAGE ASSESS R'S MAP,& LOT INSTALLER'S NAME&PHONE NO. SEPTIC-TANI CAPACITYJe- LEACHING FACILITY: (type) ��C,. 1`"y► L '—yr C (size) j�'f �� NO. OF BEDROOMS ---� BUILDER OR OWNER.: �J(1 r-fiJA, C PERMITDATE: 1 Ua - COMPLIANCE DATE: �2 4 " 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 'r v J I jIt � b r f 01�,L �7' i t FORM 11 — SOIL EVALUATOR FORK Page 1 of No.: Date: 12/10/02 COMMONWEALTH OF MASSACHUSETTS Barnstable , Massachusetts Performed By: Carmen E. Shay Date: 12/10/02 Witnessed By: Waiver Location Address or#945 Shootflyinghill Road Owners Name: Mr.Donald Dornback Centerville,MA Address and #945 Shootflyinghill Road, Centerville Lot# (Map— 191,Parcel 035) Telephone Number: New Construction : X Repair :' OFFICE REVIEW: Published Soil Survey Available: No ❑ Yes ❑ Year Published: Publication Scale: Soil Map Unit: Drainage Class: Soil Limitations: Surficial Geologic Report Available: No Yes❑ Year Published: Publication Scale: Geologic Material: (Map Unit): Landform: Glacial Outwash Flood Insurance Rate Map: Above 500 Year Flood Boundary: No ❑ Yes FT Within 500 Year Flood Boundary: No F-xl Yes ❑ Within 100 Year Flood Boundary: No ❑ Yes ❑ Wetland Area: None National Wetland Inventory Map (map Unit): Wetlands Conservancy Program Map (map unit): Current Water Resource Conditions (USGS): Month Range: Above Normal ❑ Normal [i] Below Normal ❑ Other References Reviewed: USGS Topographic Map DEP APPROVED FORM 12/7/95 I 4 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No.: #945 Shootflyinghill Road, Centerville, MA On -Site Review Deep Hole Number: #1 Date: 12/10/02 Time: 10:00 AM Weather: Sunny, Cool Location (identify on site plan): Refer to Sketch Landform: Outwash Plane Position on Landscape (sketch on back): Refer to Sketch Distances From: Open Water Body N/A feet Drainage Way N/A feet Possible Wet Area N/A feet Property Line 25' feet Drinking Water Well N/A feet Other DEEP OBSERVATION HOLE LOG Depth From Soil Soil Soil Soil Other Surface Horizon Texture Color Mottling Structure, Stones, (inches) (USDA) (Munsel) Boulders, Consistency, % Gravel 0" - 8" AP Sandy 10 YR 3/2 None <5% Gravel, Friable Loam Friable 8" - 30" Bw Sandy 10 Y/R None <5% Gravel, Friable Loam 5/6 Friable 30" - 156" C' Medium 2.5Y 7/4 None Medium Sand, 15% Sand gravel, Loose Parent Material (Geologic): Glacial Outwash Depth to Bedrock:None encountered Depth to Groundwater: Standing Water in the Hole: None Weeping From Face: None Estimated Seasonal High Water Table 156" Assumed - No groundwater Observed DEP APPROVED FORM 12/7/95 FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No.: #945 Shootflyinghill Road, Centerville, MA Determination of Seasonal High Water Table Method Used: ❑ Depth observed standing in Observation Hole: N/A inches ❑ Depth weeping from side of Observation Hole: 156 inches (assumed) ❑ Depth to Soil Mottles: None inches ❑ Groundwater Adjustment: None feet Index Well Number: Reading Date: Index Well Level: Adjustment Factor: Adjusted Groundwater Level: N/A DEPTH OF NATURALLY OCCURING 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: Yes CERTIFICATION: I Certify That on September 17, 2000, (date),, I have passed the soil evaluators 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 310 CMR 15.017. Signature: Date: GL wO 0;1 FORM 12 - PERCOLATION TEST Location Address or Lot No.: #945 Shootflyinahill Road COMMONWEALTH OF MASSACHUSETTS Centerville , Massachusetts Percolation Test Date: 12/10/02 Time: 10:30 AM Observation Hole #: #1 Depth of Perc 30" — 48" Start Pre-soak 10:28 AM End Pre-soak 10:36 AM Time at 12" Would Not Hold 24 Gallon Presoak Time at 9 Time at 6" Time (9-6") Rate Min./inch < 2MP1 " Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Performed By: Carmen E. Shay Witnessed By: Waiver Comments: Would Not Hold 24 Gallon Presoak - <2 MPI Site Passed X Site Failed DEP APPROVED FORM 12/7/95 Se0' 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 P . 02 :NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST A:ND SOIL EVALUATION EXEMPTION FORM 1, hereby certify that the engineered pian signed by me dated \3A.10I.Qa concerning the property located at meets all of the tcl`.o.Y;ng terra • This failed system is connected to a residential dwelling only. There are no -orrmercial or business uses associated with the dwelling. • T? e soil is ciass: .,ed as CLASS I and the percolation rase is less than or equal to �i;nutes per !rich. The applicant may use historical data to conclude th!s fact or may conduct pre!trrirary tests at the si,e without a health agent present • There :s no ncrease in now and/or change in use proposed • There a:-e no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen l;) feet aoove the maximum adjusted groundwater table elevation, lAd_just the �undwater table using the Frimptor method when applicable) Please complete the following: i 'a. I Top of Grouno Surface Elevation (using GIS information) _ COG E3 CNY' E levat:or, 3a ad;ustment for 'nigh G.W. (0-6 F -FPEtNCF. BETWEEN and B OZ`'at S:c,>►rE D - D ATE: NOTICE Basec ,ipon. the above information, a repair permit will be issued For bedrooms dd.tional bedrooms are authorized to t�e future without engineered plans. 'x:un!r,:aci Pc[ccsm9 i Permit Number: Date: j Completed by: HIGH GROUNDWATER LEVEL COMPUTATION I ('1 I Site Location: y S 5TFLYitry _L I O � Lot No. Owner: \n�' �nc^c A dress: q ' Contractor: Q�Q dress Notes. Notes. a�e i I STEP 1 Measure depth to water table i i to nearest 1/10 h. ............. ............ Date d ............................. T monl /"day/yaar i I STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................... FWA © Water-level range zone....................... STEP 3 Using monthly report "Current �. Water Resources Conditions" I determine current depth to water level for index well ......., Silo mo*hy.., i STEP q i; Using Table of Water level Adjustments j for index well (STEP 2A),current depth j to water level for index well (STEP 3), and water-level zone (STEP 28) determine water-level adjustment ............................ i STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water i level at site (STEP 11 ........................ 3� is :................................................... i I i I Cape Cod Commission: USGS Well Data-November 2002 Page 1 of 2 United States Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties, the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey (USGS) observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For your convenience, we've also provided links to USGS national and state data. See the last column in the table and the footnotes below. For further information, please contact Hydrologist Gabrielle Belfit at the Commission offices (508-362- 3828). November 2002 i:T.SGS Site Departure from Number**** Location Well No. Water Record Record e Averag " (links to USGS Level* High* Low* Monthly Overall national water-level database Barnstable 230 25.6 20.5 26.6 -1.1 -1.9 413956070164301 Barnstable 24W 27.4 20.5 28.6 -2.2 -2.9 414154070165001_ Brewster BMW 21 13.4*** 6.9 13.6 -2.6 -3.2 414518070020301 Chatham CGW138 25.4 20.9 26.6 -0.8 -1.4 414100070011101 Mashpee MIW 29 9.2 5.6 10.0 0.0 -0.6 413525070291904 Sandwich SDZ 47.8 45.9 48.2 -0.2 -0.5 414418070241601 Sandwich 2DW 54.6 45.8 55.1 -3.8 -4.5 414124070265901 Truro TSW 89 12.1 10.2 13.0 0.1 -0.1 1 420206070045901� Wellfleet [M[ 1EII:EE 1E]== 415353069585401 http://www.capecodcommission.org/wells.htm 12/11/2002 CARMEN E. SHAY (508)-548-0796 ENVIRONMENTAL SERVICES, INC. P.O.Box 627,East Falmouth,MA 02536 December 16, 2002 RE: Certification of Title V Septic System Installation: Residential Property—945 Shootflying Hill Road, Centerville, MA Dear Sir or Madam: On December 13, 2002, Roger Roberts, Inc.'was issued a permit to install a Title V Septic System at 945 Shootflying Hill Road, Centerville, MA, based on a design drawn by Shay Environmental Services, dated, December 10, 2002. XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan I Certif4 That the Referenced Above Septic System Was Installed With Changes but in Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow. The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is Required. If you have any questions, please do not hesitate to call the undersigned at (508)-548-0796. Sincerely, CARMEN E. SHAY ENVIRONMENTAL SERVICES,INC. ' H OF&1A CARMEN E. r+ HAY No. 1181 Carmen E. Shay, R.S., President c' T�R SANITAR�P� E. .J � t f r iV 6 COMMONWEALTH OF MASSACHUSETTS EXECUTIV-' OFFICE OF EwfRONMEV'TAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: / Z Da A d C OD- Owner's Name: ,-a i 4 Owner's Address: oo F ,� Date of Inspection: - 9- /0:51' Name of Inspector: (please print) Company Name: �Q 0 - Mailing Address: IUc) 67031 01.71?y Telephone Numbed s CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the info Lion reported below is true,accurate and complete as of the time of the inspection.The inspection was performed biased 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 CM>EY 15.000). The system: !/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature° Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address horn the system will perform in the future lender the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART A CEIRTITTCATION(continued) Property Address: �� S�oa;� F1 v, Zvi �16 30� Owner: ri ie— bate of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D APasses: :��7ave not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CIVIR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. N-D explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System w,'ll pass inspection if(with— approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLuNrrARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Q CERTIFICATION(continued) Property Address: en-. // h Owner- I-/ -R—'�— Date of Inspection: C. Further Evaluation is Required by the Board of health: /1/ 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 CI*IR 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 nnrsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment. _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form_ 3. Other: Page 4 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CER1IFICATION(continued) Property Address: S 7, ��� F� vJ/ ./� �L✓ YvjI� Owner: #cp " ���"� Date of Inspection: 3— .7 —0?-3' D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ ackup 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 V/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /V-T 41 l _ _ Liquid depth in cesspool is less than 5"below invert or available volume is less than''/z day flow _L,�equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped Rv 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 �caater supply. tom$/ my portion of a cesspool or privy is within a Zone 1 of a public well. _ (/nv portion of a cesspool or privy is within 50 feet of a private water supply weeR i/ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppno,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this fformeI (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The follo ing criteria apply to large systems in addition to the criteria above) yes n 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-IW'PA)or a mapped one II of a public water supply well If you have wered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the Iarge 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. Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISP®SAL SYSTEM]rNSPECT ON FORM PART B / CHECKLIST Property Address: �00 J� ���,y��,�, All wc/ O` /® 3T Owner: 01-7 de— Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes o nimping 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? V 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 dwellin_2 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? y Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] i Page 6 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAC-F DISPOSAL SYSTEM INSPEC TON FORM PART C SYSTEM// / INFORMATION Property Address: g�� N�2L 1 A Owner: /�TEA v� 5 �Date of Inspection: 9— FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design): —7 Number of bedrooms(actual): DESIGN flow based on 310 C 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system es or no)/ O [if yes separate inspection required] Laundry system inspected(yes or no):�b Seasonal use: (yes or no): X11'0 Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): 41'0 Last date of occupancy: G(4,9." t4- CONEWERCIAIJINIDUSTRL 4,L Type of establishment: Design flow(based on 310 CW, 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL.INFORMATION Pumping Records [Source of information: ko J' �^Oylo N/ If"" h ,,,� o Leh Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TI'P E SYSTEM _Septic*ard distribution box, soil absorption system _Single cesspool Overflow cesspool _-Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age oqf all components,date installed(if known)and sourc of information• ��7r Tarp. p�4�s��aL �- -o0.2- Were sewage odors detected when arriving at the site(yes or no): �0� i Page 7 of 11 OFFICIAL, INSPECTION FORD(—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT>ON jliORM PART C SYSTEM INFORMATION(continued) Property Address: E� �2 ,// Owner: Date of Inspeetio. . — —Uv BUILDLNG SEWER(lo/caa7te on site plan) Depth below grade: /v Materials of construction: ast iron `40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK_(locate on site plan) Depth below grade: Material of construction: "concrete_metal_fiberglass.polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: _ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: OZ — 7-i a q Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto;�o outlet tee or baffle i How were dimensions determined: rO/,e CyBv� Comments(on pumping recommendations,inlet arxroutlet tee or baffle condition,structural integrity,liquid levels Was lated to outlet invert,evidence of leaky e,etc.): E'yv� r N v"P"-e-. Gs G ati� �G 9�7!L� �'•�1 oC GREASE TRAP:&(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert;evidence of leakage,etc_): Page 8 of i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM ILNSPECITON FORM PAST C SYSTEM WF'ORMATION(continued) Property Address:C`e o� P �1�� 401 !ii 8 of Owner:A Date of Inspection. — —0 y TIGHT or HOLDING TANK:Zr(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTTON BOX:`� if resent must be o ened 1 cate ` 11( p p }(o on site plan) � fit Depth of liquid level above outlet invert:Oc9lk-1,,r 4— Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage to or out of b x, etc.):/ 'O' �er/ l /�v PUMP CRAMBER:&�(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): f Page 9 of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC 10N FOR-M PART C SYSTEM INFORMATION(continued) Property Address: 9 Owner: 114-A C Bate of Inspection: —9— SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not:required) If SAS not located explain why: Type �17'✓l/���.7�D�.� (,✓/ 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. / /G t.• a Gr /� CESSPOOLS: /y (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:zVoocate on site plan) I Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.): Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSAW-,NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: 9-6V SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarl,s.Locate all wells within 100 feet.Locate where public water supply enters the building_ l� 1 ytle 4 � '^' D,°J _yam - �( ,�~ � /^ '•- '• � ,� /�� AL-A3 f Page 11 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE IDISPOSAI.. SYSTEM INSPECTION FORM. PART C �! SYSTEM INFORMATION(continued) Property Address: !� � 0d Fl, !✓/ , /7//, �� Owner: Date of Inspection: SITE EXAM Slope 117-V Surface water Check cellar 4�'-i Shallow wells Estimated depth to ground water < 5g feet p_ & Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: `rved site(abutting property/observation hole ay'thin 150 feet of S¢S) B Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must escri how you e tabus ed the high,ground water elevatio�" �S! � G i E N ° S A (508)-548-0796 VIRONMENTAI.SERVICES, INC. F.O.Box 627,East Falmouth,MA 02536 December 16, 2002 RE: Certification of Title V Sepl°System Installation: Residential Property—945 Shootflying Hill Road, Centerville, MA t: Dear Sir or Madam: On December 13, 2002, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at 945 Shootflying Hill Road, Centerville, MA, based on a design drawn by Shay Environmental Services, dated, December 10, 2002. XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan I Certify. That the Referenced Above Septic System Was Installed With Changes but in Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow. The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is Required. If you have any questions, please do not hesitate to call the undersigned at (508)-548-0796. I Sincerely, CARMEN E SHA Y j wy ! ENVIRONMENTAL SERVICES, INC. -N OF V rylf,� CARMEN E. HAY No. 1181 Carmen E. Shay, R.S., C. �o President . G{;S`T ER Sq N I TA?0 I i i i 1 3 1 i i r Town of Barnstable OF 1HE 1p� ' Regulatory Services sAxrvSrAsz a Thomas F. Geiler, Director ATf16.19.D��p, Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. i - - 4000* __ Commonweatth of Massoctwsetts _ ExeCutiv9 Office Of Envlfonn�enfOi Affairs Grad Fs D.E.P. Title V Septic Inspector _ Departrlfent o� -: P.O.Box 21-19 - Environmentol Protect on Te 508)t,MA 02536 564-6813. - A - SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM k PART A CERTIFICATIONt � � _Property Address: 945 Shoot Flying HIII Rd.Centerville,Ma Address of Owner: Date of Inspection:8120/95 (If different) 1 — Name of Inspector:John Gract -Domback « i Company Name-,.Address and Telephone Number: - t 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:_ X Passes _ Conditionally Passes Needs Further E aluation By the Local Approving Authority Fails inspector's Signature: Date: sl2o196 The System Inspector shall su mit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.): The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(61T)556-1049 • Telephone(617)292-5500 1 _ - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION (continued) - Property Address: 945 Shoot Flying Hill Rd.Centerville,Ma Owner: Domback Date of Inspection:W0196 Sewage backup or breakout or high static water level observed in the distribution box is 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 leveled.or replaced _-The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of_the Board of Health): - broken pipe(-s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: . _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has aseptic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public 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 volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM 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 in facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A CERTIFICATION (continued) Property Address: 945 Shoot Flying Hill Rd.Centerville,Ma Owner: Oornback Date of Inspection:8120196 D]SYSTEM FAILS(continued) - 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"belowinvert or available volume is less.than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped _ _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.- Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 ll of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 945 Shoot Flying HIII Rd.Centerville,Ma Owner: Dornback - -- Date of Inspection:8120196 Check if the following have been done: - X Pumping information was requested of the owner, occupant, and Board of Health.. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal introduced into the system recently or as part of this— that period. Large volumes of water have not been _ Y flow rates during p g _ inspection. ruaAs built plans have been obtained and examined. Note if they are not available with.N/A.` X The facility or dwelling was inspected for signs of sewage back-up. X .The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components; excluding the Soil Absorption.System, have been located on the site: 'f X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/15195) - 4 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP.ECT10N FORM - - - PART C, - SYSTEM INFORMATION Property Address: 945.Shoot Flying Hill Rd.Centerville,Ma Owner: Domback Date of Inspection:8120/96 - FLOW CONDITIONS RESIDENTIAL: . . - -Design flow: 220 gallons Number-of bedrooms: 2 Number of current residents: 2 Garbage grinder(yes or no): Na -Laundry connected to system(yes or no):-Yes - Seasonal use(yes or no): No - Water meter readings,if"available: n1a ; Last date of occupancy: rda COMMERCIAL/INDUSTRIAL: Type of establishment: Na Design flow:a' gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:. (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n1a Last date of occupancy. OTHER": (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last two years. System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: k5LQallons Reason for pumping: Maintenance TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of ail components,date installed(if known)and source information: 1987 Sewage odors detected when arriving at the site:(yes or no`) �L7 (revised 11115195) 5 p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C - _. _ SYSTEM INFORMATION (continued) Property Address: 945 Shoot Flying Hill Rd.Centerville,Ma _ Owner: Dornback Date of Inspection:8120196 SEPTIC TANK: x- (locate on site plan) Depth below grade: 1' - - -- Material of construction: concreate_metal_FRP_other(explain) x Dimensions: L 8'6'H 5'7'yu 4'10' Sludge depth:1' - _ Distance from top of sludge to bottom of-outlet tee or baffle: 15� Scum thickness:3' Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 15' Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: Na Material of construction: _concrete_metal_FRP—other(expiain) Dimensions: nfa Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integritym evidence of leakage, etc.) n1a (revised 11115195) 6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION (continued) --Property Address: 945 Shoot Flying HIiI Rd.Centerville,Ma _ Owner:..._ Dornback - Date of inspection:8120196` TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade:n1a - Material of construction:_concrete_metal_FRP_other(explain) Dimensions: nla _ Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee, condition of alarm and float switches, etc,) n1a DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) The d•box is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no) Comments: (note.condition of pump chamber, condition of pumps and appurtenances, etc.)- nia (revised 11115195) 7 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION (contfnued) _ Property Address:__"5 Shoot Flying Hill Rd.Centerville,Ma - ..---Property Dornback - Date of Inspection:8120196 s - SOIL ABSORPTION SYSTEM (SAS):x ' (locate-on site plan,if possible: excavation not required, but may be approximated by non-intrusive methods) If not determined to be present;explain: _ n1a Type: - leaching pits, number: 1,000 gallon leach pit leaching chambers,number:nla - leaching galleries, number: n1a leaching trenches,.number, length: nla leaching fields, number, dimensions:n1a overflow cesspool, number:n1a Comments: (note condition of soil, signs of hydraulic failure, level of ponding;condition of vegetation, etc.) The sas is structurally sound and functioning properly. CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) nla PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: nla Depth of solids: n1a Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PriwComments (revised 11115/95) l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C # - - SYSTEM INFORMATION (continued) i Property Address:. 945 Shoot Flying Hill Rd.Centerville,Ma. Owner: Dombac_k - _- Date of Inspection:912/Q198 t SKETCH OF SEWAGE DISPOSAL SYSTEM: - include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' i _ _ l o � - � g A o ya �� 31 DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS MAPS AND CHARTS (revised 11115195) 9 TOWN OF BARNSTABLE LOCATION D /1 SEWAGE # 9 7- i/ 7 VILLAGE �i ��/� K ASSESSOR'S MAP & LOT INSTALLER'S NAME A PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) // (size) Z: I NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 7 DATE COMPLIANCE ISSUED: / ' ,t1 VARIANCE GRANTED: Yes No .0 ���� r� � � � �D - -� � � k ASSESSORS MAP NO: PARCEL NO: THE COMMONWEALTH OF MASSACHUSETTS E30ARO OF HEALTH eLuY1............. .OF Ct*hs y L.......----------------•- ... ......................... Allp iration for UtgpniFal Works Tomptrnrtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (4) an Individual Sewage Disposal System at: Ncl�R ... .....................a...o......F...I...1•-_---------- /--.�...�.....:--�-,--....--..........................------• ...t I oaons s 25 _ .. Owner Address o ...Q.4c 11............ w,a �498 yc�._.......... J Installer /// Addre� Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) P-4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ................................. w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------_--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-__._________._----.-_.. fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----................... 04 •-•-----------------------------•-••-----•-------•--•---•--••••.....•---••--•--•--...._..---•------..........•----•...............................---•....._. 0 Description of Soil....................................................................................................--•------------•---•---...-•----------------------....--•....•••--- x --, -------- ----------------------------------••----------•- :..::.:. U Nature of Repa>rs or Alterations—Answer when applicable_-1-KP. _ __._!L^LQQ_$�. _ �s__,� l&pA ____- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in Accordance with the provisions of iITI L 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. - - Signed----- -`._,'� L ------------------------------------- ....2-— ---•------- Date Application Approved By.............. ------Z.. Date Application Disapproved for the following reasons-----------------------•-------------------------------------•------------------------------•-=---------------==- ....-----••---------•-•---------------------------••-----•------•--------..................••---•--•---...------•----- Date Permit No.---.--. 7 ^ e?.. ...................... Issued................... Date FEB............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Gtun......-- OF f}i:.+s . ........ ... Appliration for Disposal Works Tonstrurtion rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......... .......... ......••- �- tl ocation-Address .. 913 �G R_hI..r_3..►..t-k•-- _ ----- I )n"rdrl A11N 4`--- --------------•-------- -_ --- J5`-----•--•---- --------- -------- Owner Address/r:lire) .......... � 56 Ct7rt J .e�. f_a?SF --•------ ................. Installer Address U UType of Building Size Lot............................Sq. feet �I Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—T e of Building No. of persons____________________________ Showers — Cafeteria a' Other fixtures __________________________________ W Design Flow............................................gallons per person per day. Total daily flow-----------_______..........................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth_____________--- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date................-......................... aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-..__-..-__-_--___--.-_. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --•-••-•--••----•-••-•••••--------•••••--•-•••-••••-••••-...--••------•-------------•---••-...-----•......................................................... 0 Description of Soil....................................................................................................-•------•-----....--------------•-...•-•-----•--•-••-•--.._....---- x V ....•-••-••--••-----•-----••-••--•--••--•...................••--•-••------•-...._..•-------•..._._._._....--•••••-•••-•-----•••-•--•••-•-----•-•--•-•-•••-••••-•••-••----•....__...-•••••----•-------- VNature of Repairs or Alterations—Answer when applicable. ??'Ad.._�FiGv Grsf.��t, c .5("5;re�x 11too Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT?. . 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. Signed----- etcrcr� __........ 7 13 _._� . ...... Date Application Approved By_____________ ....... __ ,, ..... ----.............. Date Application Disapproved for the following reasons:_-_-_.._.._•____••_•______••____________••_•___.....__••••_•_____•__-____-____•_____.__..•...................... ..------•--------•------•---••--------------•--•-------•----•-------•-•--------•------.........-------------•-•----•------------••---------............................................................ Date PermitNo.......Z-• --------- ----------------------- Issued_....................................................... Date G`L THE COMMONWEALTH OF MASSACHUSETTS 'POT n BOARD OFHEALTH �I r� �t�...............OF........? . .rn,t.i,?�............._....... CIrrtifirate of ToutpliFaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired O by....................... ......... ---------------------------------------------------------------------------------------------------------------------------------------- Installer at.-•-•----•-••--�f-- •--•-�• 1. J.- ................... - c { has been installed in accordance with he provisions of TITLE E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-----F7------- BLS"______________ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............:. �.. .....`1�.7---- -.fin-_. 7-�• . � ---------------•-------------- Inspector_..--- ____�_ t. ........................... �U�lc THE COMMONWEALTH OF MASSACHUSETTS 7-ys 7 BOARD .OF HEALTH aD...................OF.......:..[.Ir ............................................................ No..S..2 i� FEE._ .....:.....':--_..... Disposal Works Tonotrttrtion rrutit Permission is hereby granted.......A....b----- "'s sl"-------------•-.---------------------------------•---•.._......-••-----._......_.........._..._ to Construct ( ) or Repair (11�0_ an Individual Sewage Disposal System _. U Street as shown on the application for Disposal Works Construction Permit NoZ2-__./�""�:_;;?Dated........................................... ..............�`'"�•-'.-•-- - - -------------------------------- V Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS SECTION A -A 1' = 2000, +/- 10'[ 10' min. from *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. ALL W7 MS AL THE hl,se to septic tank PROFILE VIEW OF ADDITION TO LEACHING SYSTEM SET LEVEL F R A SHALL BE 12• CONCRETE COVER Tli�' Existing Foundation Septc look covers must M SEi LEVEL i1X+AT LEAST 2 FT. 3" of t/B" - 1/2" washed Peaston _within 6 in. of finished grade 3/4' to 1 1/2 Washed Crushed Stone •' w4-„•"�`"`'�' 2' Code over Sepik Tonk - 96-50 Grode over D-Box - 98.00 -code over SAS-98.00 KwOCxOUTS Moonpen\i OOUTLET . �S • 3 HOIf H-t0 ' 1,J L 0.02 6• DIST. Box 3' Maximum Cover Top of SAS - Elev. -96.25 ' 2 3'C Z Ex1$T. S-0.0T u s _ rYtcT. PIPE 10' 0 1,500 GAL. s- O OBO" per foot A 4' - SCH. 40 T r 1 1.75' Q tJ. FROM EXIST. FOUNDATION W SEPTIC TANK N 25 2' EIIecGve Deptn O O H-,o 6 L,nitfa e 6' _ 30 PLAN SECTION CROSS-SECTION u rs,e rn 3' 1' STONE LINDER CHAMBERLn S CONCRETE FULL FOUNGAT j, n Ch Q 1 N u _u 8 S 30' 6 ++.of 3/+--t 1/2' n u rn rn 36. 3 HOLE H-10 DISTRIBUTION BOX SYSTEM PROFILE compacted stone Effective Length NOT TO SCALE p n LOCUS MAP Not to Scale - c u - 4' -�2 5 4' 5 SOIL ABSORPTION SYSTEM (SAS) e in of 3/+--t t/2' 10 + CULTEC MODEL 125 (H-20 LOADING)/ SHOREY PRECASTE GENERAL NOTES compacted stone Effective ~h o m (OR EOUNALENT)Not to Scale 1. Contractor is responsible for Digsofe notification NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18' /EFFECTIVE HEIGHT IS 12" and protection of oil underground utilities and pipes. 2. The septic tank and distribution box shall be set level on 6" of 3/4"-1 1/2" stone. 3. Backfill should be clean sond or grovel with no 100.69' .46.53 stones over 3" in size. 2-18" DIAM. ACCESS MANHOLES 4. This system is subject to inspection during installation N Old 03' 30" E N 03d 16N 00„ E by Cormen E. Shay - Environmental Services, Inc. 6 5. The contractor shall install this system in accordance 4 4.;;;?,.r:�•:y;.,.,.., with Title V of the Massachusetts state code, the approved plan and Local Regulations. 0 _ ____-- 1 6. If, during installation the contractor encounters any __ --------------- ---- -_-- 102 THE ACCESS COVERS FOR THE SEPTIC TANK, soil conditions or site conditions that ore different INLET --. ____ / DISTRIBUTION BOX AND LEACHING COMPONENT from those shown on the soil log or in our design- - OUT ET SET DEEPER THAN 6 INCHES BELOW FINISHED / ` GRADE SHALL BE RAISED TO WITHIN 6' OF installation must half & immediate notification be FMSHED GRADE - INS PARCEL # 35 >�I �• mode to Carmen E. Shay - Environmental Services, Inc. �.. TALL TUF-TITE GAS BAFFLES OR EOUALS "(-•,-T r,r•�iT• - 'S:,��:� ; 7. No vehicle or heavy machinery shall drive over the 35,690 Square Feet +/- septic system unless noted as H-20 septic components. - C/) STEEL REINFORCED PRECAST CONCRETE 8. Instoll Tuf-Tite gas baffles or equals on oil outlet tee ends. C PLAN VIEW 9. All Distribution Lines sholl be 4" diameter Schedule 40 NSF PVC pipes- ------------------------- --- - _ 3-2+- REMOVABLE covERs� 10. All solid piping, tees & fittings shall be 4" diameter - -------------- R _____ -- � Schedule 40 NSF PVC pipes with water tight joints. .t, . 1 • 4- - 11. Municipal Water is Connected to The Residence and Abutting _min. clearance 1r MET Properties Within 150 Feet. QO/ \ 18 min.fi +Y min. Wei to outlet ,jr}- 1 O INLET _ _--- -t_---- 6'mn- OUTLET -10'1min. � L�'fd Itvel'r � IIIIUUUUIIII 5' -7' '`- I-- 5 -7 THE PROPERTY LINES ARE APPROXIMATE AND PROJECT BENCH MARK E g 4'-0' min. COMPILED FROM THE SURVEY PLAN GENERATED BY TOP OF FOUNDATION LK>,nd depth BEARSE & KELLOG, SURVEYORS OFBARNSTABLE, MA ELEV. = 100.00 (Assumed) +.d ENTITLEDDATED AUGUST 25, 1953. " PLAN OF LAND IN BARNSTABLE, MA, A \! a -,o' f ANDS S NOT INTENDED TO BE A SURVEY PLOT PLAN - IT SHOULD BE USED FOR NO PURPOSE OTHER THAN CROSS SECTION END-SECTION THE SEPTIC SYSTEM INSTALLATION. Chi 36' 39 USE EXISTING 1000 GALLON H- 10 SEPTIC TANK EXISTING LEACH PIT TO BE PUMPED FILLED IN PLACE. • -- �. ,. 1 NOT TO SCALE NOTE: L A ANY STRIPPED OUT S01 CONTAINING LEACHATE g8 . _ • • • • • Q' _� _ - _- _ _ _ FROM THE EXISTING LEACH PIT TO BE DISPOSED i; '�;r.. r•r Foiled �..,.Y ,.... •, ,� ,. OF AS PER BOARD OF HEALTH SPECIFICATIONS. Leach Pit TEST HOLE N1 NEW D-BOX i Design Calculotions LEGEND ELEV = 98.00 EXIST 1000 gal O Septic Tani, Garbage of Bedrooms: 3 Equivalent to 330 Gal./Doy (330 Gat•/Doy Min, per Title V) 30' Garbage Grinder: No P e / Leaching Capacity Proposed: 330 Gal./Doy Minimum (Min. Per Title v) 104X1 DENOTES PROPOSED O Septic Tank : - 3 x 330 Gal./Day = 660 USE 1,500 GAL. Septic Tank. SPOT GRADE SOIL ABSORPTION AREA: Using percolation rote-of <2 min./inch / Bottom Area: 0.74 gol/sq. ft. x 360 sq. ft = 266.4 gollons X 104.46 DENOTES EXISTING / SPOT GRADE Sidewoli Area: 0.74 gal./sq ft. x 92 sq. ft. = 68.08 gallons / Providing: = 334.48 gallons PL PROPERTY LINE DECK �// Use (5) CULTEC MODEL 135 UNITS, HAVING A 1' EFFECTIVE DEPTH, TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3' OF WASHED STONE 9__ -- - PROPOSED CONTOUR GARAGE ON THE ENDS. NO STONE UNDER. - - - - - -97 EXISTING CONTOUR EXISTING •� R 3 BEDROOM o PERCOLATION TEST DEEP TEST HOLE & HOUSE 2002 PERCOLATION TEST LOCATION Dote of Percolation Test: DECEMBER 10, � I I ' #945 Test Performed By CARMEN E. SHAY, R.S , C.S.E. Results Witnessed By. E. Waiver ( Barnstable B.O.H.) ca I I EXCAVATOR: Shay Environmental Services, Inc. -� 6 FOOT STOCKADE FENCE Percolation Rate: Less Than 2 MPI Test Hole / c9 � No. 1 P SOT P LAN DEPTH SOILS ELEV. 0 9800 g6 - ASPHALT - `°°my OF PROPOSED SEPTIC SYSTEM UPGRADE DRIVEWAY Sond 10 rR 3/2 a 0•-8" A. 9725 PREPARED FOR Say MR . DONALD DORNBACK I A 10 vR 5/6AT Medium #945 SHOOTFLYING HILL ROAD _ Sand 25C CENTERVILLE, MA 0 20 40 50 qr t�GF,1 PREPARED BY: % y� CA_RNEY E. SffA Y 96-' I I SCALE: 1 "=20' ( 1_ f,',i:•ENVIRONMENTAL SERVICES, INC. L = 99.98 I � BOX 627 50.029 r a PL R = 1415. 18'__ I S, Sd 53 9 Perc #1 � �CtSTF�< / EAST FALMOUTH, MA 02536 loot W Depth to Perc: 30 to 48" ;, At411TAR�Frr ;i TEL/FAX : 508-548-0796 98 ,S.1Y® ® TF'L YIN G HILL _. �. OA D Groundwater Perc Rate= LNot Observed SCALE: 1 "=20' DRAWN BY: CES DATE: DEC. 10, 2002 (50 FOOT RIGHT OF WAY) - -- '-"-- -' No Observed ESHWT PROJECT#SD369 FILENAME: SD369PP.DWG SHEET 1 OF 1 ADJUSTED H2O Elev. None