HomeMy WebLinkAbout0596 OLD STRAWBERRY HILL ROAD - Health 596 Old Strawb6rry Hill Road-
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`~LOCATION ,SEWAGE #
LAGEWAASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACII.TTY: (type) (size)
NO.OF BEDROOMS
{
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist _
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
,M 596 Old Strawberry Hill Rd CT7-3'
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is � ���
required for every— tC�'G MA 02632 12-15-12
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Shawn Mcelroy -
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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
12-15-12
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.
****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-11/10 i. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
A
7"
Commonwealth of Massachusetts '
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,•''r 596 Old Strawberry Hill Rd b
Property Address
Bank Owned (Contact David Holt Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
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:
System is in good working order with no sign of failure.
I
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):
. y
t5ins•11/10 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.
596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12`
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
44W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) '
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. City/Town 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,
r 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.
1, 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
El ® Backup of sewage into facility or system component due to overloaded or
.clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. City/Town 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-
1 0,000g pd.
❑ ® 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•11/10 , Title 5 Official Inspection 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
w 596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
El ® 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.
® n Determined in the field I"f of the failure criteria related to Part C is at issue
a❑
( Y
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
im o Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 11-2012
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-11/10 Title 5 Official Inspecbon 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
° 596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt c@7oday Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. Cityrrown 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:
N/A
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)
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):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
596 Old Strawberry Hill Rd
Property Address t
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is
required for every Centerville MA 02632 12-15-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2005
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
{
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
12"
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: 1000 gal
Sludge depth:
12"
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
w Title 5 Official° Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. City/Town 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
20"
Scum thickness 211
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
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•11110 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 .
�M 596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
Alam1 level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
ti
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. Cityfrown 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.):
Good condition with water at working level and no sign of back-up from field.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
r
Commonwealth of Massachusetts
m Title 5 Official .Inspection Form
Im Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
r Type.
❑ leaching pits number:
® leaching chambers number: 5-Infiltrators
❑ 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.):
Leach field in good condition and empty at inspection with no sign of back-up into d-box or
surrounding stone.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
I
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° M 596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
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•11110- 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.
VA
596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. City/Town 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
�. &.ck
F �
t5ins-11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. Cityfrown 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: 12
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:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
- Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
596 Old Strawberry Hill Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 12-15-12
page. City/Town 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
3,
Town of Barnstable
of Regulatory Services Barnstable
THE T
�P� c Thomas F. Geiler, Director i 11"mericaCity
Public Health Division
* snxtasrnsLE.
9 MASS. Thomas McKean, Director 2007
1639.
1 3.e, 200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
February 10, 2011
Carl J. Rufo
596 Old Strawberry Hill Road
Centerville, MA. 02632
RE: Assessors,(map-parcel) 273-100
As of October 1, 2006 a new rental registration ordinance was put into affect,requiring all
property owners of rental units to register`in accordance with Chapter 170 of the Town of
Barnstable Code with the Town of Barnstable Health Division. According to our records, you
own the rental property at 596 Old Strawberry Hill Road, Hyannis. Enclosed is an
application. Please use a separate application for each rental unit you own. Should you need
• more applications, they are available online at www.town.barnstable.ma.us. Go to the Health
Division page by looking in the Department Menu. There is a link to the Rental Registration
information on the Health Division page. You may print out as many as you need, and return
them to the Health Division with the appropriate 2010 fees included.
Please contact me to schedule inspection of the property as soon as possible. If there are tenants
presently occupying the property please provide the contact information being sure to include a
daytime phone number for all tenants. For your use an.occupant's permission form has been
included to allow for inspections to be performed in the tenant's absence.
Failure to comply with this ordinance will result in the issuance of a non-criminal
ticket citation in the amount of $100. Each day of non-compliance is., considered a,
separate offense.
Should you have any questions, please feel free to call 508-862-4072. Thank you in
advance for your cooperation.
Teresa Wright
Division Assistant = y
• Health Division .'
Direct#508-862-4072
Wright, Teresa
rom: Crocker, Sharon
ent: Monday, February 07, 2011 3:05 PM
To: Wright, Teresa
Subject: Two Items
1) Robin Anderson, Bldg. Dept., said that there is a rental at 596 Old Strawberry Hill Rd, Hyannis. They are not
listed in the database.
Please send them a letter when you have a moment. Thank you.
2) 1 noticed in the excel database: There is a listing on Old Strawberry Hill Rd which appears under nterville:
please change this to Hyannis. And update where-ever necessary (move paperwork to Hyannis, etc.)
Thanks.
Sharon
•
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or PO BoxNo. �� rf4Lt/jn✓c'(/ _
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A.
Certified Mail Provides: .A
o A mailing receipt
a A unique identifier for your mailpiece
o A record of delivery kept by the Postal Service for two years
Important Reminders:
a Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail&
o Certified Mail is not available for any class of international mail.
o NO INSURANCE COVERAGE IS PROVIDED with Certified Wo
r
valuables,please consider Insured or Registered Mail.
o For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
o For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the.
endorsement"Restricted Delivery".
a If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt Is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
1
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. ❑Agent
X
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. Received by(Printed N C. Date of Delivery
■ Attach this card to the back of the mailpiece,
qmMkkthe front if space permits.
D. Is d ry add from item 1,?., ❑Yes
1. Addressed to: If enter delive ss below: ❑No
.. 9 �ia-pG
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Carl J. Rufo �
z' 596 Old Strawberry Hill Roa ce s. se
Centerville, MA. 02632
EF
Centerville, Mail Express Mail
❑Registered aRetum Receipt for Merchandise
❑Insured Mail ❑.C.O.D.
4 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Numberi ;
(Transfer from service label).I r i i 7 0 0 8 j 3 2 3 0 0 0 0`'2 f 51,7 8 f 2 ,7,5 r i
jBPS Form 88114 February 2004Domestic Return Receipt 102595-02-M-1540
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UNITED STF� F .J.0 t e
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:Pos�ga,Paid
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• Sender: Please print your name, address, and ZIP+4 in this box •
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Town of Barnstable
Public Health Division
200 Main Street
Hyannis, MA. 02601
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' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owner's Name
information is ��T�
required for Q& P 6E MA 02632 1/31/07
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information ,� T, / v
When filling out (j
forms on the ^, m
computer,use 1. Inspector: r
only the tab key to move your MICHAEL DEDECKO _
cursor-do not Name of Inspector
use the return = t
key. COMPASS REALTY DEV CORP
Company Name E�
P.O. BOX 2384 "-
Company Address I
MASHPEE MA 0�649
�tr0 Cityrrown State Zi 'Code
508-221-5003
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:
V Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
1/31/07
Inspector's Signature NJ 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.
I
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281OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 j
t
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owners Name
information is required for CENTERVILLE MA 02632 1/31/07
every page. Citylrown 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:
di have not found any information which indicates that any of the failure criteria described
In 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced I
❑ obstruction is removed
281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
% Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOIITH ROAD ,CENTERVILLE ,MA 02632
Owner Owners Name
information is
required for CENTERVILLE MA 02632
every page. Cityrrown 1
State Zip Code Dateate of of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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.
I. System will pass unless Board of Health determines in accordance with 310 CMR 1
15.303(1)(b)that the system is,not functioning in a manner which will protect public health,
safety and the environment:
i
I
❑ 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 an
determines that the system is functioning in a manner that protect t he 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.
2810LD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
' Commonwealth of Massachusetts
a o Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owners Name
required on is CENTERVILLE
required for MA 02632 1/31/07
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is-equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ 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/day flow
Required pumping more than 4 times in the last year NOT due to clogged or i
El obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS, cesspool or privy is below 9
high round water elevation:
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 15
I
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owner's Name
information is required for CENTERVILLE MA 02632 1/31/07
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.)
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owner's Name
information is required for CENTERVILLE MA 02632 1/31/07
every page. Citylrown 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?
❑ M Has the system received normal flows in the previous two week period?
❑ ml_� Have large volumes of water been introduced to the system recently or as part of
this inspection?
El El 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?
U/ ❑ Were all system components, excluding the SAS, located on site?
Lld' ❑ 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?
LIQ ❑ 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)]
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281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
i
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owner's Name
information is required for CENTERVILLE MA 02632 1/31/07
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions: +�11
Number of bedrooms (design): "t Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): `
Number of current residents:
Does residence have a garbage grinder? ❑ Yes M/'No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes
Laundry system inspected? ❑ Yes rNN
Seasonal use? El Yes No
,;'
Water meter readings, if available(last 2 years usage(gpd)):
�V
Sump pump? ❑ Yes 9"No
Last date of occupancy: V0
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:
Last date of occupancy/use: Date
Other(describe):
� I
281 OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
i
Commonwealth of Massachusetts
L Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owners Name
information is required for CENTERVILLE MA 02632 1/31/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records: A
Source of information: tv
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 yytem:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
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I
281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM 596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owner's Name
information is CENTERVILLE MA 02632 1/31/07
required for
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan): C
Depth below grade: feet
Material of construction:
❑ cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
feet
Comments (on"pcondition of joints, venting,, evidence
�o�f_leakage, etc.):
NTS �✓�n�CS' il�U�s�% �,
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:
1IS00
t
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 3 1(
Scum thickness
3 it
Distance from top of scum to top of outlet tee or baffle
�If
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Vow
2810LD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
1
`I
i
3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�M 596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ;TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owner's Name
information is required for CENTERVILLE MA 02632 1/31/07
every 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.):
V-63,
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
i
{
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owner's Name
information is required for CENTERVILLE MA 02632 1/31/07
every page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert �
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
281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
yf 596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owners Name
information is required for CENTERVILLE MA 02632 1/31/07
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
r❑ 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.): nn
281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
i
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owner's Name
information is required for CENTERVILLE MA 02632 1/31/07
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l
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i
r
i
i
281 OLD MEETINGHOUSE-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owner's Name
information is required for CENTERVILLE MA 02632 1/31/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
s�4
b �
3 z
t
143"l)"
281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
r
Y -
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora'
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
Owner Owner's Name
information is required for CENTERVILLE MA 02632 1/31/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam: 1
Check Slope
urface water
heck cellar
Shallow wells
Estimated depth to ground water: 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:
You must describe how you established the high ground water elevation:
MAPS
- I
i
I
281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
i TOWN OF BARNSTABLE
LOCH T IQN g� 4 C d' V�/7 wirrY /71i/1 SEWAGE # -
/' l ASSESSOR`S MAP&LOT
VILLAGE -
1
INSTALLER'S NAME&PHONE NO_ ►
SEpInC TANK-CAPACITY �v
LEACHING FACH ITY: (type) I- '( (size)
NU.OFBEDROOMS—2 ff
BUH,?,ER OR OWNER
• I
PERMITDA iE: COMPLIANCE DATE:
Separation Distance Between the: t�
Maximum Adjusted,Groundwater Table to the Bott m of Leaching Facility - ---Feet
t r itq�t�
Private Water Supply Well and Uaehing Factfi� Of"Wells exist
on site or within 209.feet of leaching facility) i, _ ]Feet
Edge of Wetland and Leading Facility(If any wet exist
within 300 feet of eaching facility) 1 Feet
/� � � AID �� ��
I2 Furnished by
T Q TKO
TOWN OF B ST�BLE
LOCATION SEWAGE # 5�
'✓Il_AGE SESSOR'S MAP & LOT2
INSTALLER'S.NAME NONE NO.
SEPTIC TANK CAPACITY rs4y ,,
LEACHING FACILITY: (ty ) /c ��1 S� (size) ✓ l o/
NO. OF BEDROOMS � l
BUELDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private.Water Supply Well and Leaching Facility (If any wells exist
on siteor 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
61
w
e� 4
1
rr
o � .
V
6 Sj
No. chi L4 Fee /y�
,THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppricatiou for -Migpoml *ipotem Congtructfon Permit
Application for a Permit to Construct( . )Repair Upgrade( )Abandon( ) El Complete System ,'Individual Components
Location Address or Lot No. b4io � t�t>>�Bo(ct� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
o Qn SA
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
C. s�ICS.
Type of Building:
Dwelling No. of Bedrooms Lot Size sq.ft. Garbage Grinder(AI/A
Other Type of Building b No. of Persons L2 Showers( ►/jCafeteria
Other Fixtures Ls u-tn-mI_Y . kc iT E#J SW k-, "LamOV
Design Flow AA-0 gallons per day. Calculated daily flow 444.0 gallons.
Plan Date Number of sheets Revision Date
Title E'
Size of Septic Tank gf 16"m i 1 QQQ�.t'Qkc-�+x,),jrype of S.A.S. IQ` X 4i.0' X
Description of Soil TIC-,sr -k-0TNen
Nature of Repairs or Alterations(Answer when applicable) --kc, �✓�n.;�.
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 provisio s of Title 5 of the Environmental Code and not to place the system in operation until a C rtifi-
cate of Compliance has been issu d this Bo na ealt .
igned Date
Application Approve Date bq
Application Disapproved for the following reasons
Permit No. �C� L&VL4 Date Issued
4 DO
-. No. C.�f�) 1y�.7_C�5 � L
�— ;,� :..it Fee /
" > THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: Yes
µ �= PUBLIC HEALTH.DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
- 01ppYicatiou for,-Migpogar *pgtem Cougtruction Permit
4 Application for a Permit to Construct( . )Repair)Upgrade( )Abandon( ) 0 Complete System XIndividual Components
Location Address or Lot No. 1 (G 00 vt1 c�uJ j Owner's Name,Address and Tel.No.
� 6C,� `�U, Lee
Y Assessor's Map/Parcel
,° �. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
'R� �S SrZp C SVCS. S��Y sNV. SYCS.
6 46-5'3)6 53q -1910
Type of Building:
Dwelling No.of Bedrooms Lot Size ado sq.ft. Garbage Grinder(1411% ✓
Other Type-f Building Oh No.of Persons Showers( ►/f Cafeteria( )
Other Fixtures �. uKa-t-a�Y [ k,TC41E0 S• ttJk-, "w'icald
Design Flow -44o gallons per day. Calculated daily flow 444.0 gallons.
Plan Date a+ I 0S Number of sheets Revision Date "
Title igQ-k r '&Af0,cM VIxrcc,P ti
Size of Septic Tank SX lST I l c,ao GG� -tom_^Type of S.A.S. /D y X 4 0� X, 71e &
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 11_�,Q� 40
tt -
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 Certifi-
cate of Compliance has been issued by this Board o
i-gned Date
Application Approve � Date
Application Disapproved for the following reasons
Permit No. QC Q g,5 �.g'�r Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(tertificate of (Compliance
THIS IS TO CERTIFY, that t O -site Sewage Disposal System Constructed( )Repaired ( )Upgraded)
Abandoned( )b
at I WLW Z4 v- /r has been constructe in acc rdance
with the provis' ns o Tit e and r Disposal System nstruction Permit No. dated �l ate .
Installer C� 5 Designer _
The issuance of this permit shall iqt be construed as a guarantee that the syst till un tion as designed.
Date Inspectotr
.. ���-------------------- ——— e l�� _
No. Fe . .." r THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Iigpont *pgtem (C !9tr ction Permit
Permission is hereby granted.t• , onstruct )Re,.air-( )Upgrade( Abandon
System located at _ �✓
t
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction ust be completed within three years of tate of t 'Date: APP by
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that
O -site S wage
Abandoned ( ) b ispo 1 System Constructed( ) Repaired ( ) Upgraded
at �)
with the provi ' n r-vF it 5 a r Disposal System has been constructe in acc rdance
Installer '� ystem nstruction Permit No.
dated P
The issuance of this permit shall Designer
strued as a guarantee thatth s st
Date Y n tion s(designed
Inspecto
5
s Commonwealth of Massachusetts
Title 5
®fficial Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
596 OLD STRAWBERRY HILL ROAD
Property Address
C/O DAVID HOLT ,TODAY REAL EST ATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632
�. Owner owner's Name MA 02632 _ 1/31/07
t information is CENTERVILLE State Zip Code Date of Inspection
required for CitylTown
every page.
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a kbech of nchmthe arkseLo ate lalPwells wsth n 100 sytem including
9 ties
to at least two permanent reference landmarks o
Locate where public water supply enters the building.
b O
I
c
A3u�1b` �3-3S
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 14 of 15
281OLD MEETINGHOUSE•08/06
i
Town of Barnstable
Regulatory Services
sr ems,
a Thomas F. Geiler,Director
Public Health Hi,visio)n
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: M-862-4644 Fax: 508-790-6304
Installer Designer Certification form
Date: 9130105
Designer: Shay Environmental Services,Inc Installer: Roberts Sentic Service
Address: P.O. Box 627 Address: .5 Trenton Street
East Falmouth,MA 02536 Yarmouth,MA
On 9/23/05 Roberts Se tic Service was issued a permit to install a
(date) (installer)
septic system at . 596 Strawberry Hill Road Hyannis MA based on a design drawn by
(address)
Shay Environmental Services Inc dated September 27.2005
(designer)
KX I certify that the septic system referenced above was installed substantially according to
the design, which may include`minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State&Local Regulations. Plan revision or
certified as-built by designer to follow.
OF MASS
° 91flA`r U
' No:1181
� o
poi 57Sp
(Desi r s ignature) (Affix De Here)
PLEASE RETURN TO STABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH TMS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE,PUBLIC HEAL
THANK YOU. TH DIVISION,
Q:Health/Septic/Designer Certification Form
9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, f_Qa 91 C- (�)0,-RY hereby certify that the engineered plan sig
ned by me
dated Ci 65 concerning the property located at
meets. all of the
following criteria:
• This failed system is connected to a residential dwelling only. There.are.no commercial or
business uses.associated with the dwelling.
• The soil is.classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or.may conduct deep
test holes and percolation tests.at the site without a health agent present.
• There is no.increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The.bottom of the proposed leaching facility will-be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information). , QO
B) G.W. Elevation O +adjustment for high G.W.
DIFFERENC ' ETWEEN A and B
SIGNED : DATE:
NOTICE
Based upon the above information;a repair permit will be issued for bedrooms
maximum.. No additional bedrooms are authorized in the future without engineered septic system
plans.
o
gASepbc\pff=emp.doc
12/27/2015 21 :03 FAX 0 002/002
Town of Barnstable
Regulatory Services
Thomas F. Gezler,Director
enRiverAaw,
� Public Health Division
°1
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 9/30/05
Designer: _Shay Environmental Services, Inc. Installer: Roberts Septic Service
Address: P.O. Sox 627 Address: 5 Trentorx Street
East Falmouth, MA 02536 ., Yarmouth.MA_
On 9/23/05 Roberts Septic Service was issued a permit to install a
(date) (installer)
septic system at 596 Strawberry Hill Road,Hyannis.MA based on a design drawn by
. (address)
Shay Environmental Services, Inc. dated September 27, 2005
(designer)
XX I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank,
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
�X,OF 44's'q xs
c�' CARMEt1 ��
� a
staller's Si a SHAY
No. 118i
0
C+15TS �
SA N l7AR%
(Desi er's ignature) (Affix Designer p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designcr Certification Form
�glra old S f rAcd6 ert y IIJY/. 4
Bulk
-22
b
i
A
DATE: 6/17/99
PROPERTY ADDRESS:
596 Old Strawberry Hill Road
------------------------
Centerville, Ma.
------------------------
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 gallon septic tank
2. 1 -1000 gallon leaching pit
3. 1 -Distribution box
Based on my Inspection, I certify the following conditions:
4. This is a title five septic system. ( 78 Code
) 3 ��
5. fTh'eTseptic system is in proper workingorder
at the present time . i
6.' Pumped septic tank at time of inspection .
&. Wates water is 42" below the invert pipe
in the leaching pit .
SIGNATURE:1
Name:_,LL�L_Macomber �1r-_____—
Company: Jose_2h_P. Maco.mber_& Son , Inc .
Address: Box 66
--------------------
__Centerville , Ma__02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
9 _ !410
„o
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds MOO
O
Pumped & Installed
Town Sewer Connections J U L 1 3 1999 �
P.O. Box 66 Centerville, MA 02632-0066 � OFea►tNST
775.3338 775-6412LT1iDEpEABIE
4
At q,
E
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500
TRUDY COX
Secretes•
ARGEO PAUL CELLUCCI DAVID B. STRUH
Governor Comm.:sstoai
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
P►ovor Address: 596 Old Strawberry Hill RA'•of 0.,r,erFrancis Hufnagel
Centerville address of owner:
Data of inspection: /� '7 LqC]
Namw of tnspector:�tslagsa'Y A J o s e p h P.Macomber J r .
I am a DEP approved system inspector pursuarrt to Section 15.340 of rrtle 6 (310 CMR 15.000)
Company Names: J. P.Macomber & Son Inc .
TTelephone Number:Rom�6 �'e a 1=e � e—,n a ss. .02632
CERTIFICATION STATEMENT
I certify that I have personally Inspected the sewage disposal system at this address and that the Informatlon 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:
asses
Conditionally Passes
Needs Further E aluation By the Local Approving Authority
_ Fails 7
inspector's S19rature• . 4 , Date:
The System Inspect shall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)within thirty (301 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 oKnvkonmental Protection. The original should be sent to'trrs
system owner and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page IofII
n
`jT Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 596 Old Strawberry Hill' Road, Centerville,
Owner: Francis Hufnagel
Date of Inspection: 6/1 7/9 9
INSPECTION SUMMARY: Check A, B, C, or A
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure
.criteria not evaluated are Indicated below.
COMMENTS:
S. 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.
Indicate yes, no, or not determined(Y, N, or NO). Describe basis of determination in all Instances. If "not determined", explain why not.
The septic tank Is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal,Is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass Inspection If the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
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 pipes) are replaced
obstruction Is removed
distribution box Is levelled or replaced
- The system required pumphiMore than'fourtimes-a-year-due to broken or obstructed pipe(s). The system wi t-pass--
Inspection If(with approval of the Board of Health):
broken pipes)are'replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (wthin d)
PropomAddreas: 596 Old Strawberry Hill Road; Centerville
0wra: Francis Hufnagel
D`t'art tna°"`i°"' 6/1 7/9 9.
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
N.v the Board of Health in order to determine If the system I+ lolling to protrct me
Condidons exist which require further svaluadon by
public health, safety and the environment.
1) SYSTEM WALL PASS UNLESS BOARD OF HEALTH DETMUINES W ACCORDANCE WfTTi 310 CIdR 16.303 (1)(b)THAT THE SYS
WA
IS N 0 T FU N CT10N W 0 IN A i tANNEA WH1 CH LL PR ETY Q=CT THE PU B U C BEA.Mi AN D S AF AN D THE DX T 0 KS-L _
4)0 Cesspool or privy Is wIWn 60 fost of surface water
Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a sell marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH"D PUBUC WATER SUPPLIER,IF ANY)DETERl. LNES THAT THE SYSTD
FUNCTIONWO W A wANNER THAT PROTECTS THE PUBUC HEALIAi AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS) and the SAS Is within 100 feet of a suriacs water supply
uibuury to a surface water supply.
The system has a septic tank and soil absorption system and the SAS Is wltNn a Zone I of a public water supply wou.
The system has a septic tank and toll absorption system and the SAS Is wlWn 60 teat of a private water supply weu.
The system has a septic lank and soil absorption system and the SAS Is lass than 100 foot but 60 foot or more from a
private water supply well, ur>loss a well water analysis for collform bacteria and volatile org"c compounds indicates tl.a
well Is free from pollution from that facility and the p( sencs of•mmonla nitrogen and nitrato nluogen Is equal to or loss
than 6 ppm. Method used to determine distance_ _(approxlmadon not valid).-
3) OTHER
revised 9/2/98 Pago3of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddit"s: 596 Strawberry Hill Road, Centerville
Own,w' Francis Hufnagel
Date of Irtspecton:6/1 7/9 9
D. SYSTEM FAILS:
You must Indicate either 'Yes' or 'No' to each of the following:
1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
1/ Backup o1•sewage inw IlaciRtY-or-vratem component•due¢o an overloaded orclogged SASor•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 a distribkuon box above outlet.lnvert due to an overloaded or clogged SAS or cesspool.
YPZA
Liquid depth In 0e0ePoal is less than 6' below invert or available volume is less than 112 day flow.
Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped-L.
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 lest from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic-compounds, ammonia nitrogen-and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
You must indicate either 'Yes' or 'No' to each of the following:
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:
Yes No /
the system Is within 400 feet of a surface drinking water supply
the system4&-wi0kln 200 teat ol-a it"tary-io a ourtaoollrinkwsg watersuppty --
the system Is located in a nitrogen sensitive area(Interim Wellhead Protection Area -IWPA) or a mapped Zone II of a puolic
water supply well)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further inforpation.
revised 9/2/98 Page 4ofIt
i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prop-WAd&—: 596 Old Strawberry Hill Road, Centerville
Owrw: Francis Hufnagel
Data of Inspection: 6/1 7/9 9
Check if the following have been done:You must Indicate either "Yes" or 'No' as to each of the following:
Yes No
Pumping Information was provided by the owner, occupant, or Board of Health,
-None of the systemcon*o"nt.s l% ",.b" n pWrnpad+toFai�east nvo•weaks and tba'system hasbaaazecaiu6ag wwsaal AO-
rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note If they are not available with NIA.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,otecluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the Interior of the septic tank was Inspected for condition of batfl.
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:
_ Existing Information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C Is at issue, approximation of distance is unacceptable
,l 115.302(3)(b))
4 _ _ The facility owner.(and.ocrupaats,If diffarant Srou>_nxcnerl.Lvaraprnwdad.with informatiomon th4nsna=�I*�intn� �t
SubSurface Disposal Systems.
1
revised 9/2/98 Page 5of11
l
i
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
ProgenyAddre.ss: 596 Old Strawberry Hill Road, Centerville
Owner: Francis Hufnagel
Date of Inspection: 6/1 7/9 9
FLOW CONDmoNs
RESIDENTIAL:
Design flow: >IV g.p.d./bedro m.
Number of bedrooms dasi Number of badrooms(actual):
Total DESIGN flow
Number of current residents: 11
Garbage grinder(yes or no): U
Laundry(separate system) kes or If y,,s, saparste.irts c on.reguired
Laundry system Inspected or no) �J���all�S
Seasonal use (yes or no): r� Cl/�`/_�
Water meter readings, If avpilable (last two ye It's usage (gpd): r ((�
Sump Pump(yes or no):0
Last date of occupancy:l I
COMMERCIALANDUSTIILAL:
Type of establishment:
Design flow: W1Y qpd ( Based on 15.203)
Basis of design flow_
Grease trap present: (yes or no)
industrial Waste Holding Tank present: (yes or no)
Non sanitary waste discharged to the Title 5 systjim: (yes or no)"
Water meter readings, if avails le: -- iL✓7
Last date of occupancy:
OTHER:(Describe)_�
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS a d ourc of information: 1 q� n eC�� ,
I n� 91 �r tl 0�(Y1(Vu1 1�`(le_ �C 1 C) ,
System pumped as part of ins ection: (;es or no�
_ �
If yes, volume pumped- caticns
Reason for pumping: �r��
TYPE OF TEM /
Septic tank/distribution box/soil t,tsc�rpt on system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, a:tech previous Inspection records,If any)
I/A Technology etc. Anach copy of up t) date operation and maintenance contract
Tight Tank -� -Copy of DEP Af proval
Other
APpFj�X1MA f pll_corn nent ct1, i,ls;r known)-and sowce.o(rnformation:
lSewage odors detected when arriving at the s:ta: (yes or no)
revised 9/2/98 Page 6ofII
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM tNSPEC'nON FORM
PART C
SYSTEM INFORMATION (corrdnu&d)
propartyAddrass: 596 Old Strawberry Hill Road, Centerville
Dom' Francis Hufnagel
Dots of lnspoctIon: 6/1 7/9 9
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
li—
Material of constructlon: cast Iron 240 PVC—other(explain)
Distance horr?,g�lvote water supply well or suction line
Diameter ``YY``
Comments:(condition of Joints,venting, evidence of
K; ouse vent .
(locate on site plan)
Depth below grade:�r
Material of construction:12 concretap—metal��Fiberglass-�Polysthylene�other(explaln)
If tank Is Instal, list age Js..Jage.confvmed),by Certificats of Compllanc• (Yes/No)
Dimensions: ?14jGL''
Sludge depth: 0
Distance from top of ludge to bonom of outlet tee orbatfle:�
Scum thickness:
Distance from top of scum to top of outlet tse or baHls: (J
Distance from bottom of scum to borAm of outie tas or bafile:Q_
How dimensions were d0termined:
Comments:
(recommendation for pumping., condition of Inlet and outlet tees or•batfles, depth of liquid level In relation to outlet rover., svuctuta�- te,w
evidencs of leakage, etc.) PUMP tank every 2 3 ypnrC jnl®t; & eutlet bees are in place The 4P=r; r t,2sak J6 RiFUebtlai±y sound
and
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construcdon�concrete�metal4�Ii7Flberg(assq/�Polyethylene�otherlexplein)
Dimensions:
Scum Wcknsss:
Distance from top of scum to top of outlet lee or baffle:
Distance from bottom of scujn to bonom of outist tea or batfl
Date of last pumping:
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level In relation to outlet Invert. structural integrit
evidence of Isakags, etc.)
Grease
revised 9/2/98 Pagc7orli
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Prop*MAd&aas: 596 Old Strawberry Hill Road, Centerville
0wnw: Francis Hufnagel
Dace of Inspection: 6/1 7/9 9
TIGHT OR HOLDING TANK-AA1(Tank must be pumped prior to, or at time of, Inspection)
(locate on site plan)
Depth below grade:
Material of con3tructlon,,L)1-4concrete(IL4metal_AFiberglass4gPolyethyleneV other(explain)
lhi
Dimensions: VA
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm In working order: Yes N.A154
Data of previous pumping: VW
Comments:
(condition of Inlet tea, condition of alarm and float switches, etc.)
Tight Or hol rli ns raaka—are—Ft
ofc
DISTRIBUTION BOX:y
(locate on site plan)
Depth of liquid level above outlet Invert:
Comments:
(note•if level and distribution is equal, evidenoa of solids carryover, evidence of leakage Into or out of box, etc.)
pistribut; on hnx ha q on No es4deeee of selids
PUMP CHAMBER:/Ova
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms In working order(Yes or No).:2
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
ump chamber is not present _
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (corttirwed)
propartyAd&eu: 596 Old Strawberry Hill Road, Centerville
Owrw: Francis Hufnagel
Data of Inspection: 6/1 7/9. (1�j,' )_. � dl y
-intrusive methods
SOIL ABSORPTION SYSTEM(SAS): �hC�/
(locate on site plan,If possible; excavation not required,location may be approximated by non
II not located, explain:
Type:
leaching pits, number: 1
leaching chambers, number: v
leaching galleries,number:
leaching trenches, number,length:
leaching fields,number, dim aA{Ions:
overflow cesspool, number: (—
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegelation..etc.
Lon ill
ne san o
is r
CESSPOOLS:
(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 (cesspool must be pumped as part of Inspection)
ass ,
Comments:
(note condition of soil, signs of hydraulic tailura,level of ponding,condition of.vegetation, etc.
ass
PRIVY:
(locate on site plan) A
9,d Dimensions: !7
Materjal3 of consuu ti n:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, revel of ponding, condition of vegetation;etc.)
riv
revised 9/2/98 . Page 9of11
I
I -
I
SUBSURFACE SEWAGE DISPOSAL SYSTE14 WSPECTION FORM
PART C
SYSTEM INFORM.AT1ON (condo. )
Nop—YAd&—:596 .Old ,Strawberry, Centerville
;,, , �o�. 5
rancis Hufna el
t. or F 6/1 7/9 9
SKETCH OF SEWAGE DISPOSAL SYSTE1d:
Include dal to atlaast two psrmanant ra)arsnca landmarks or banchmarks
locata all walls wlNn 100'(Loc►ts whara publlc water supply comas Into housa)
Centerville Osterville Marstons Mills
Water Company
428-6691
5 96 Old 5 f 1-Actl6 e rr
Neal
%
b
revised 9/2/98 Pap 10 of II
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 596 Old Strawberry Hill Road, Centerville
owner: Francis Hufnagel
t Date of 4sspection: 6/1 7/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed.Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
hocked pumping records
�hecked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours map .
Gahrety & Miller Model
12/.!(oM9
I
;„4 1
revised 9/2/98 Page 11of11
I
1 a•nnn r�.-n 1•rs.�-rr �rmr•n>'awa�-r.�a•..T.mwn�.++nnrir�T.lnl.�l mrrwy aTr.sTvl rn •. .rn-.-.-T-.a^I.—'.�..-
1 TOWN OFBARNSTABLE WARD OF HEALTH
SUI)SURFACR SEWAGE DISPOSAL .SYSTEM INSI'FCTION FORM - PART D •- CERTIFICATION
��•TII�T•'.•t:a—T.1 IR�•T.TTV anu T.TT1 P'.1af/R.ItT'Ia1T.T—A'I T'11T111�—T�t'1�'I I..N�f1 TnfiTR1TT.T.-r♦"y'�-rT�•.—.r T•.+.�r —..•
TYPE OR PRINT CLEARLY—
PROPERTY INSPECTED
STREET ADDRESS 596 Old Strawberry Hill Road, Centerville
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Francis- Hufnagel
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber- Jr.
COMPANY NAME Joseph P. Macomber & Son Inc.
COMPANY ADDRESS Box 66, Centerville, Ma. 0263.2-0066
street Town or City st.t. Lip
COMPANY TELEPHONE (508 )775 -3338 FAX ( 508 )790 -1578
a
CCRTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time on wa of ,inspection . The inspection
• P s performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Chec one :
. Systeai PASSED
The 'inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection whicl, I have cond"Ucted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signatur Da lA t e 171_2z
On's ceopyy of this rt.ification must be provided to the OWNER, the BUYER
( whNplicable ) and the BOARD OV HEAL111I;
° If the inspection FAILED, thu owner or'" porator aha u
within one ,vear of � ,the date of the inspection , unless allowed dortrequired
otherwise as provided in 3.10 ChJR 16 , 306 ,
partd . doc
J TOWN OF BARNSTABLE
LOCATION J ''`SEWAGE # 87
VILLAGE �Q„ ,,,,_ ASSESSOR'S MAP & LOT a 73- 1 0-a
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY I n O
LEACHING FACILITY:(type) 1 (size) Oc c,
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: J �. - `J -Q/22
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
.Y;.
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pp 30 .00
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
Barnstable Conservation Department BOARD OF HEALTH
/' -/ FROWN OF BARNSTABLE ( 1;Z7,3-0
i9ned Appliratilau for Di-tipwial Wurk.6 Tomitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair XX3 an Individual Sewage Disposal
System at:
596 Old Strawberry Hill Road Centerville 0�
------------------------------------•-• •-•------•--•----•••................... .................-••-•--•-••----..••--- •... N Location-Address or t o.
--.....ElLiLmag1 P..................................................................... ...............................
Owner Address
W J..p.xMacamex Jr•!-..............................................
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—X No. of Bedrooms-----------------3_--.-------.---.-__-__--Expansion Attic ( ) Garbage Grinder1-1
( )
04 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.
3 Seepage Pit No...................... Diameter...............--.-- Depth below inlet...----............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
►" Percolation Test Results Performed by.......................................................................... Date--------...............................
a- Test Pit No. l................minutes per inch Depth of Test Pit-------------.-.---- Depth to ground water.........................
ri, Test Pit No. 2................minutes per inch Depth of Test Pit--...---............ Depth to ground water...---........--...----.
a •---•••••••-----------------•---••------••----------------------•------•-•---••-••-•......-•••••••••.........................................................
0 Description of Soil........................................................................................................................................................................
x Sand & Gravel
V ................•-------------••-----....-•----•--•••-•--------------------•---------•••••-•••-----------••--•--•---------•--------••---••••.....•----------•--•-----••-••-•---•-•----•----•-•----•••--.
W
-----------------------------------------------------------------------------------------•.......••----•......-----------------...-------------------•--•----•----•-••---------•-------•-•••-••-•:-....
Nature of Repairs or Alterations—Answer when applicable----------Omit...c e s s-p o 01 s .....I n s t a 1-1---one._......
U 1000 gallon tan!: 1—distribution -box 1-1000 gallon leaching pit .
-----------------------------------••------------------------------------...------........-•-•-----------------------........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has en,issued by th bo d of health.
Signe ... � . .. .12/13/93
.............. ..................... Dare ------'------
Application Approved By ................. -- -- -------'Q. ............................ ....... .... ..-.. ��
Dare
Application Disapproved for the following reasons- -------------------------------------
------------------------------------------ -- ------------------------------------------------------------------
--
Dare
Permit No. " � 7
----- .... . Issued ................................... .. . . .....
Dare
FRic $ 30 00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/z -!I /---i - FROWN OF BARNSTABLE
Appliration for Uhvip ial Worlw Toustrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair X(X)j. an Individual Sewage Disposal
System at: t
596 Old Strawberry Hill Road Centerville -71 t 1191 f
................................................................................................. ---•••----------•------•----------------.----- :....._... ..............
Lbcation-Address { or Lot No.
Nll.f_t3a1 r�.
Owner
�7 t P.Macomber••Jr................................................. ---•--••-------••••.......................
Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling-X No. of Bedrooms-----------------3-----------------------.-Expansion Attic ( ) Garbage Grinder ( )
aOther-Type of Building ............................ No. of persons........................---. Showers ( ) — Cafeteria ( )
Q, Other fixtures ............................... . .
14
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 ( )
aPercolation Test Results Performed-by------------------------------•--•------•-----••------•-•-------•--••••••. Date........................................
Test Pit No. 1----------------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........................
P4 ----•-•-•---------------•----•--•-••-••----•-•-•----•••--••----•••----•------•---•---•---•••-•----_..........................................................
0 Description of Soil........................................................................................................................................................................
W Sand & Gravel
U •-•-••----••-••-•-•----•----•-•----•-••-••-••--•-------••------•---•--•----•------• -•-------------••--•--------•----------•---------••--------•---•••--••••-------•--••-•--------•--••---•----•--------
W
------------------
U atu of Repairs or Alterations—Answer when applicable.--.-------pmi.-t---Less-pon1s...___Instal]..-•one_-----•.
lU6b gallon tank 1—distribution box .1-1000 gallon leaching pit .
--------••------------------•-------------------------------------------------------------------------. •--........-------•
Agreement-.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has eeenn issued by th bo d of health.
Signed /"--� - 1.2/13/y3
.................................. .....
Dace
Application Approved By }=' , ----------- ------------ ..../�2...- ate
1� .�.�..�� Dare
Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------------------------
. ................................................ ... . ............................;- .---------------------------- ---- -------....:.......-............------------------------------
i "- Dace
Permit No. ..... 7 ~ - - (Issued ----------------------------------- -----------------
....... .
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifira#e of (fumplianre
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( XX )
J P.Macomber Jr.
by .
596 Old Strawberry Hill Road Centervi lle
has been installed in accordance with the provisions of TITLE 5 o The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -------Y3------- dated -----------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
_- trf � � �
DATE : D.-_ - ....' /- .... ..... Inspector ---------------------.�-,^.... ..:......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
$ 30.00
No. FEE........................
Permission is hereby granted-
J.P.Macomber Jr.
---- - -------- - --- - - ------ -----------
to Constr ct ( ) or Repair r-X) an Individual Sewa e Disposal System
b 6 Uld Strawberry Hill Road Centerville
atNo.-- •--- --------- ---- - ----------------------------...---------------------------------------------------•-----•---------
Street q ( _
as shown on the application for Disposal Works Construction Permit No-73:4.62- Dated----._
-----------------•---------------- 3.._`.....................................................
Board of Health
DATE-------------------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
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Sch PIPE O Least 4 inches tall
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ITPFR 91 min. r ALI OTLEIPES OM THE 1I
.0 fom edle 40PVC w/ horcal Odor Fitr _ xistn Funaon DISTRBUTON BOX SMALL BE .�E o i G -,e O 12 ,�,,; -C
!g SET LEVU FOR AT LEAST 2 FT. CONCRETE COVER i 1 tpu,t,
tic tank s must e BOX must be —P F FONDATIONTO ELEV 100.00 (Assumed
„ . n. onse rode � 1wtn n. o within ode g - _ - ` : , 4 '!,
- - I 3 " � - 2 I ,
tic T .00 x ver SAS 9.00 � � I"I Grade over Sepank99 Gade over DBo ".00 o 9 . . , % ,,
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..T TO Q. � ,,S 4 PVC CAPPED INSPECTION
PORBE / . , . .3 HOLE H-10 1 1
- , .I ITALED AND TO BE ;3 Maximum CoerS�. BOX - B -`� 696 Old " =ImT OF Ssem Elev. -95.75 .._-.. � _,op y I - 2 ', X
LO EXIST. S= .of o ,
_ at., �EXIST EEL 1,000 GAL - 11s . , I01 .
M 0Lo 5 erP oo 6F EXIST. FOT tROM LNDAION PTIC TA K SE 0 � 1 "�
�, 6, ,0 Effector h " " 4,, 0 „r.s .PLAN SECTION CROSS; SECTION I1 0 r_ � 5 - 24 Effectve ��
.H , 0 J ' iwa CONCRETE FULL.FONDA de ".1, I I I
Z 2 , :> 5 nts 3
T 1 f
- " - TION BO
X
-6 n.of 3/4 _4 I > .SYSTEM PROFILE 5 �1 - 6 % 1cmpctd stone 0
v NOT TO SCALE %0ftS 5 a
c _ RWLNl - N .TEONot to Scale @1 . .) I � try
10 11
c v hEffective Widt felv ngthS EfcteLe i T
i - RAL NOTES6 n.of 3/ 1 1/2 0 ILABSORPTION SYSTEM (SAS)
GENE
compacted stone < SO iof ltif nofcaton, Verficat o esr roni l frDisa1. ontacto sbo
:NO A COMP MUST HA RI TO WITHIN 6 OW RA 0 gL NE VE. S BELGDE - iiER & UNBAR M ) M
a and protection of all underground utlties and pipes.
Z UIVALNTOR EQ . Th eptic tank and distribution box shall be set
4 -1 1 tone.
= TI HEIGT I 4 lave on 6 of 3
: RA HGHT OF INFIRAT 0 FFECVEHS2 NOTEOVELLEI LTORI3EBottom of Test Pit . 3. Backfill should be dean sand or ravel with no
Obs. roundwater - Test Hole1& 2 Elev.= None Observed " •i '
soevr nsize. insllationTh tem s subject to inspection durn YARIANCE UESTE 4. �Q rmen ha nvironmental Services cbyCa ESy EDesign Calculations ! T ntraor hallnstall this system in accordance5. husettsstateode the aproved lanwith Title V of the Massac ,
1. REQUEST A VARIANCE TO REDUCE ISTANCE FROM SAS TO A FOUNDATIOND al Regulations.
Number of Bedrooms: 4 Equvalent to .440 Col./Day 1 A4 I RUR INERHA N PR VI 20 To 3. 0MLBBEL VDED 6. If dorm installation the contractor encounters anGarbage Grander. No y
i i rsite conditions that are different
Leachin Capacit Proposed: 440 Gal. Da Minimum so
g y h soil lo or in our desgn
Se tic : 2 x 440 Gal. USE EXISTING 1000 GAL Septic Tank. from those shown on te g
mmate
notification beinstallation must halt & i i
SOIL ABSORPTION AREA: Usin ercolation rate of <2min./inch madeto rmen E. Sha - Environmental Sevices Inc.a
ttomAra: 0.74 l/ . ft. x400 ft = lonBo s ;a ver h7. cl rheavymachne shall dove o e
No veh:
rY
dewall Area 74 al: t. x 0 ft. 14 llSi . onsgq q g - n se componets.sepcsysemu
Providing: = 444 allons
g n ll utlet tee ends.. InsllTuf-Tite as bafflesor equals o8 g * 4 NSF PVC ipes�4 diameterSchedule 9. All Distribution Lines shall be p
}. rl 4 iametUs 5 305 H- INFILRATOR CHAMER HAIN A F PTH All soli ipin es & fittings shae ee , pg, t i in Wx 7 L TO BEUSEDH 3 OF WASHED-STONE ON THE' AND - hdl 4 NSF PVC ipeswith water tght ots( u
2.5' OF WASHED STONE ON THE ENDS. i h idn Abut in Municpal Water is Connected to ALL OF T e g
Proerties Within 150 Feet.p A PPROXIMAT ANDPOPERY LINE RA AND R T SE PERCOLATION TES T YT COMPILED FROM THE SURVEY PLAN GENERA
ELL B
R F URN MANEW NOW, N NTERVI MA
ENTITLED "SUBDIVISION PAN OF LA C LLEte f Percolaton Tet PTMBR 5 LDa , 49-A T1970PAN 328 2A MA A ATED APRL 22 Test Perormed B CARMEN E. SH , , , )
Results Witnessed B WAIVER er Barnstable B.O.N.(p ) AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
XCAVATOR: Sha nv. Svcs.E IT USD FOR NO PURPOSE OTHER THAN
TPercolation Rate: Less han 2 MPI 0 38 THE SEPTIC SYSTEM INSTALLATION.
i N PPLMP OUT AN FILLED I LACEISING H PIT TO BE ED Dl EX ATest Hole Test Hoe LOT 2
N 1 No, 2a.
NTAININ LAHATET NY TRIPPED'OUT SOL CO GECDEPTH SOILS V. NO :DEPTH SOILS ELEV. ELE
, ROM THE XI TING ACH PIT TO BE DISPOSED
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0 99.00 0 99.00 ATH SPECIFICATIONS.
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