HomeMy WebLinkAbout0384 STRAWBERRY HILL ROAD - Health .Strawber -. Hill.Road
Hyannis, 's
A= 248 - 153
I
i
P
No. 6 J60 APi—� Fee ,�—
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
..PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipprication for �hgpoe;al 4p!5tem Construction Permit
Application for a Permit to Construct O Repair O Upgrade(14 Abandon O ❑ Complete System Individual Components
Location Address or Lot No. 33 Owner's Name, dre s d Tel.No.
1'-j n �s IYWM i en
Assessor's Map/Parcel dyy j 5
Installer's Name,Address,and Tel.No. 3pgg"
l Designer's Name,Address and Tel.No.
tWano
Type of Building: nJ �� C_
Dwelling No.of Bedrooms /] Lot Size S �sq. ft. 4rbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 760
Design Flow(m'n.required) app� gpd Design flow provided s �J' o gpd
Plan Date Z Z Number of sheets r Revision Date
Title Size of Septic Tank O Type of S.A.S. k
Description of Soil
i
Nature of Repairs or Alterations(Answer when applic ble)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by thi oa o Health. ]� J
Signed Date
Application Appro b Date
Application Disapproved by: Date
for the following reasons
Permit No. �� Date Issued
s,.. A
No. ./J�-'���JJ L Fee—
THE ti THE COMMONWEALTH OF MASSACHUSETTS Entered incomputdi:
ti �-':r a 4- *c: r� �..,r' Yes
..PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,�MASSACHUSETTS
2pplication for Mi5po!gal �&p!5tem Con.5trUction. Permit �
Application for a Permit to Construct O Repair O Upgrade(V Abandon C ❑ Complete System YIndividual Components
Location Address or Lot No. �� v� ( Owner's Name,Addre d Tel.No.
1������ � S /V,�,ICQYI �i �v�►eir0
Assessor's Map/Parcel a y�
Installer's Name,Address,and Tel.No. -KOS-L, Designer's Name,Address and Tel.No.
Type of Building: [ T nJ z 0 C- j
DwellingNo.of Bedrooms r���d Lot Size �/,//� SLR� sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 0
- -�q
Design Flow(min.
/�required) /% a y /,gpd 'Design flow provided 5)` O-1 r� gpd
Plan Date Nu V• 2/ �yi Number of sheets / Revision Date i
Title
Size of Septic Tank e/ ' 5� /U�Q ^Type of S.A.S.
Description of Soil
c D
t NX/�--
r
Nature of Repairs or Alterations(Answer.when applicable)
Date last inspected:
}.k4
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this�Board of Health. AA �} -') �/(]^� /
( '` Date Al� ' (I /n OVV 10 -
Signed n �}
1 Application Approv by I5 bate 1
Application Disapproved by: ? ��i✓�/ ate
for the following reasons
Permit No. (o ` 5O 6 Date Issued U ll
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage ;Disposal System Constructed ( ) Repaired ( ) Upgraded ( x)
Abandoned( )by 3++�__-�J L(
at � atk l P r-Y-14 GYM •as been constructed in accordance b
with the provisions//oyyfgT-i Ike S a the for Diis'posal System onstruction Permit No. e � dated [Dk
Installer i,�l(itt�� CCi Designer
#bedrooms r�7 Approved design flow a�v gpd
The issuance of this,permit shall not be wnstruisd as a guarantee that the system will f nu on as �ied.
Date ' Inspector ( ,...•--.
No. �/Q W —50 (0 Fee l 0 O
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
X"Ui5flont *p!9tem Con.5truction Permit
Permission is hereby granted to Const ct ( ) Repair ( ) Upgrade O Abandon//(
System located atS ` '
I
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be c.mpleted within three years of the date o i�fh s permit.
Date l dval b Approved by
" /2017 06:34 FAX la 001/001
Town of Barnstable
Regulatory Services
a Thomas F. Geller,Director
• BAWWAOM
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644
Fax: 508-790-6304
Installer& Desianer Certification Form
Date: 11-29-06
Designer: Shay Environmental Services. Inc. Installer: Robert Septic Services.
Address: P.O. Box 627 East-Falniouth Address: 5 Trenton Street
MA 02536 Yarmouth, MA
On 11/28/06 Robert Septic Service was issued a permit to install a
(date) (installer)
septic system at 384 Strawberry Hill Road, Cie,MA based on a design drawn by
(address) / a vvua
Shay Environmental Services,Inc. dated 11/21/06
(designer)
XX I certify that the septic system referenced above was installed substantially accorduig 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 U4
CARMEN 4^r.
(lnsta igna ure) c E.
is Ny
U SHAY
No. 1181
R Gr$T?,
esigner's Signature (Affix De si tamp 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/Designer Certification Form
l
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
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. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector: So
only the tab key
455oto move your Robert Paolini.
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
F r� P.O.Box 763
Company Address
Centerville Ma. 02632
' City/Town State Zip Code
(508)428-4028 S14454
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 _
t
w1d 5/27/2009 -' CAD
Inspector's Signature Date 'a
The system inspector shall submit a copy of this inspection report to the App o ing Authority( oard
of Health or DEP)within 30 days of completing this inspection. If the system is share sysG-n or
has a design flow of 10,000 gpd or greater,the inspector and the system owne shall si�mit 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.
� O
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in prpoer working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system., upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 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
384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every 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 FIND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will ass inspection if with approval of the Board of Health):
Y P P ( PP )
❑ 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:
f Cesspool or privy is within 50 feet of a surface water
❑ P P Y
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every 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,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria 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 Y2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM , 384 Strawberry Hill Rd. -
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every 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-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 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
384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
G
384 Strawberry Hill Rd.
M
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consist of a 1000 gallon septic tank,distribution box and seven infiltrators.
Number of current residents: unknown
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 ears usage d 0227:94,000
9 ( Y g (gpd)): 2008:97,000
Detail:
2007:257 gpd 2008:265 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: Date 009
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every 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:
2006
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 28"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
2'
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 gallon
Sludge depth:
5"
t5ins-09/08 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
^M 384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every 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
27"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
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•09/08 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 384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 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
;M 384 Strawberry Hill Rd..
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every page. City/Town 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 No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type'
❑ leaching pits number:
® leaching chambers number: 7 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.):
Sandy dry soil.No signs of hydraulic failue.Infiltrators were dry at time of inspection.
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
t5ins-09/08 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 384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every 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-09/08 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
384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
59 ' aq-(O
3 A'
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
' r
r
Commonwealth of Massachusetts
Title 5' Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
�M 384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every page. City/Town 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: Bottom of leaching 38'
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: 2006
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:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 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
384 Strawberry Hill Rd.
Property Address
Viviane Pinheiro
Owner Owner's Name
information is required for Hyannis Ma. 02601 5/27/2009
every 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
1
i
DEED RESTRICTION
WHEREAS, S. QINPOW of
(owners name)
394- yrP,guugu • �,MS MA
(address)
is the owner of 4- t TLA4 uPm_I #I LL pi located
(address)
at
MA(hereinafter referred to as
and being shown on a plan entitled "Subdivision of Land in
MA, Property of ,
et al, duly recorded in Barnstable County Registry
Of
Deeds in Plan Book 5 , Page 1 ;
Or on Land Court Plan Number
WHEREAS, MflLC,o�' S= R�+�tl�'I '1 as the owner of said lot has
(owners name)
agreed with the Town of Barnstable Board of Health to a restriction as to the
number.of bedrooms which can be included in any home built on said lot as a
pre-condition to obtaining a disposal works construction permit in compliance
with 310 CMR 15.000 State Environmental Code, Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage;
WHEREAS, the Town of Barnstable Board of Health, as a pre-condition-to
granting a disposal works construction permit for a septic system in compliance
With 310 CMR 15.200, State Environmental Code, Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing
the issuance of a building permit for the construction of a-single family home on
this property, is requiring that the agreement for the,restriction on the number of
bedrooms in any house constructed on the lot be put on record with the
.Barnstable County Registry of Deeds by recording this document,
dw&
4 � i
u
NOW, THEREFORE, PUN s- Q INHtAO does hereby place the
(owner's name)
following restriction on his above-referenced land in accordance with his
aare�� em�ent.with_thp Toy tmot B.at , whiel -F lt
estrietion sha
run with the land and be binding upon all.successors in title:
1. 3�4 S7�uJ�L-QW NiU, HAfJNls , M,F may have constructed
(address)
upon the lot a house containing-no more than (9-) bedrooms.
QMM S - PI I bib agrees that this shall be permanent deed
(owners name)
restriction affecting located on 3" Q-&a ul6 U, MA, and
being shown on the plan recorded in Plan Book i S , Paged 41
Or on Land Court Plan
For title of seethe following deed: Book 4X , Page
ISq . Or Land Court Certificate of Title Number
Executed as a sealed instrument day of
Owner's signa re
n
O` ner's signature
Owner's signature
COMMONWEALTH OF MASSACHUSETTS
o a 3`l c� t � . ss
i l . 20 0-7
Then personally appeared the above-named
known to me to be the person who executed the foregoing instrument and
acknowledged
the same to be free act and deed, before me,
Notary
_ Public � oAwt�emu.
My commission exp'
Notary PwAc
A CTH OF
( motes
deedr
Town of Barnstable P# L) f
Department of Regulatory Services ))
,AWWmUr, : Public Health Division Date /D It) C
�— 200 Main Street,Hyannis MA 02601
Date Scheduled /i �� �Q
Time Fee Pd.
C
�+ S 't Suitability Assessmentfor age�Di p l
yPerformed ByF Witnessed B LOCATION& GENERAL INFORMATIOl�
Location Address gq C I d � , J� 1 Owner's Name V VIOL L G4V Cp�J
&mi?-cJ 44C,_A_kA f' /y I Address
Assessor's Map/Parcel: 2 q T=- S 3 Engineer's Name r^_s 4
NEW CONSTRUCTION REPAIR Telephone# i57d $ 57'-[,F—jq
land Use. t��%&AA�(AA Slopes(%) a� Surface Stones
•Distances from: Open Water Body y 1 6 ft Possible Wet Area Nj ft Drinking Water Well � ft
i
Drainage Way Property Line 10 —ft Other
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands n proximity to holes)
i
T92-
w�
f1 ��XS
Parent material(geologic) �t1')tlaY psi Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: kl()CYt .005 Weeping from Pit Face
t Estimated Seasonal High Groundwater aat �,,r -_aS Q O-)P—C1
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: � —\ 3�_40.9 `1'
Depth Observed s nding in obs.hole: �P in. Depth 6 Soil mottles:AJ
Depth to weeping from side of obs.hole: In, Groundwater Adjuxtment ft.
Index Well# Reading Date: Index Well level�.� Adj.fhetor Adj.(Iroundwater level,,
PERCOLATION TEST Date o 'l'ltnel o—be
Observation
Hole# / ) lime at 4"
a i
�> Depth of Perc _ Time at 6" O i
Start Pre-soak Time @ (n:l lD Time(V-611) rn In
End Pre-soak
Rate Min,%ch P i
Site Suitability Assessment: Site Passed_X/ Site Failed: Additional'Testing Needed(YIN) f v
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the,
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:ISEPTICIPERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#�.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency. rave
- Fr�;ab
?1J D tM -C Leos L6 t-70
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.% a e
0 ye 3JA,
-c SCCA 5Y11 Ls4,,
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
DEEP OBSERVATION HOLE LOG Hole# -
Depth from Soil Horizon Soil Texture ` Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders.
Consistency,
lk
Flood Insurance Rate Map: j
Above 500 year flood boundary No— Yes ._._
Within 500 year boundary No u Yes
Within 100 year flood boundary No Yes
Depth of NaWrally Occurring Pervious Material
Does at least four feet of naturally occurring perviou material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification ,
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environm ntal Protection and that the above analysis was performed by me consistent with .
the required train-14g, e experience described in 310 CMR 15.017.
Signature Date
Q:\SEPTlMERCFORM.DOC
w
COMMONWEALTH OF MASSACHUSETTS �
;t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
,s
rF
}
TITLE 5 "€r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ,4
PART A `
CERTIFICATION
s
I Property Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384 �
Owner's Name: ESTELLE MACCARON
Owner's Address: BOX 2056 r�`^''T� "��7 MA.02632 ' .
Date of Inspection: 11/5/01 41.
RECEIVED
Name of Inspector: (please print) JOHN GRACI wit
n Name: SEPTIC INSPECTIONS
Company
Mailing Address: PO. BOX 2119 TEATICKET,MA.02536 Nov 2 0 Z001
Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF 6ARNSTABLE
,i p HEALTH DEPT. !:
CERTIFICATION STATEMENT
I certify that I have personally p P d the sewage dis osal system at this address and that the information reported below.is
1
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and 4
i experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system
g P Y
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). ,The system:
X Passesr '.
_ Conditionally Passes
1 Needs Furt er valuation by the Local Approving Authority
_ Fails
Inspector's Signature: Date: 11/5/01
Ins '
�
P
The system inspector shall submry copy of this inspection report to the Approving Authority(Board of Health or DEP)within:.
4 30 days of completing this inspection.If the system is a shared system or has a design now 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 44
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
1 a�N`w�
Notes and Comments ` i4
THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE s '
. `
SYSTEM'S USEFULL LIFE.
****This report only describes conditions at the time of inspection and under the conditions of use at that time.This h
inspection does not address how the system will perform in the future under the same or different conditions of use." s
-r:rl,. S I.,r.. .1�.,r r•',r1.. /!�G'711(1(1 _
Page 2 of 11 .
OFFICIAL INSPECTION FORM—NOT FORFVOLUNTARY ASSESSMENTS d"
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
" # .
PART A
CERTIFICATION(continued)
}t� ,
Property Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384
Owner: ESTELLE MACCARON .......
Date of Inspection: 11/5/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D r} 1
A. System Passes: { it
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 ,' .
j CMR 15.304 exist.Any failure criteria not evaluated are indicated below. ' ' '
Comments: '
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG 4. .
THE SYSTEM'S USEFULL LIFE. «
B. System Conditionally Passes:
d _ One or more system components as described in the"Conditional Pass'. section need to be replaced or repaired.The system, � t'
upon completion of the replacement or repair,as approved by the Board of Health,will pass. fiY.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits.,:. 4
substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced bl'
with a complying septic tank as approved by the Board of Health.
t *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. �; Er* :
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed;. rY a
pipe(s)or due to a broken,settled'or uneven distribution box. System will pass inspection if(with approval of Board of k� '
Health):
_ broken pipe(s)are replaced
_ obstruction is removed -.
distribution box is leveled or replaced
ND explain: n/a
n/a 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):
z
broken pipe(s)are replaced
r
_obstruction is removed
z ND explain: n/a
I r E Iv
.
i Page 3 of 11 ar r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ,
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM %
.�, :
PART A
4Y
CERTIFICATION(continued)
�. ,
Property Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384
Owner: ESTELLE MACCARON F
L; Date of Inspection: 11/5/01
� .
' C. Further Evaluation is Required by'the Board of Health: x;
_ Conditions exist which require further evaluation b the Board of Health in order to determine if the system is failing to
q y �,> r
: protect public health,safety or the environment.
fq
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system�s
not functioning in a manner which will protect public health,safety and the environment:{
3 _ Cesspool or privy is within 50 feet of a surface water
j _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh "
s fiLf y:
2. System will fail unless the'Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment: � r.
•# The system has a septic tankyand.soil absorption system(SAS)and the SAS is within 100 feet of a surface water "' , H
ace`water supply.
supply or tributary to a surf My "
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. t:` ;F
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. y
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
j supply well".Method used to determine distance n/a
Z'
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
A volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
' of the analysis must be attached to this form.
y ^ '
3. Other:
x n/a
5 t 'iF' � ��•
7
c tcc•cam
- ,` i .
Page 4 of 11 ` 1
F
OFFICIAL INSPECTION FORM—NOT FOR`VOLUNTARY ASSESSMENTS a �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM n ` :
PART A'
i CERTIFICATION(continued)
i Property Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384 .,
Owner: ESTELLE MACCARON
{ Date of Inspection: 11/5/01 �id. t
j D. System Failure Criteria applicable to all systems: s s.
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool h�
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
s SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool'is,less than 6"below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
,...,
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation. £�
X Any portion of cesspool or privylis within 100 feet of a surface.water supply or tributary to a surface water supply :n,J
_ X Any portion of a cesspool or privy is within a Zone 1 of a public well. {;
X An onion of a cesspool or privy is within 50 feet of a private water supply well.
- Y P P P �'Y P PP Y � .
X Any portion of a cesspool or privy is less than 100 feet but,greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes'if.the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free.,;.
from pollution from that facility and,the presence of ammonia:nitrogen and nitrate nitrogen is equal to on"": ftry
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be ;.
attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3.1.0
CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be ;Mr
necessary to correct the failure. '"{ '
E. Large Systems: n
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following: .:
(The following criteria apply to large.systems in addition to the criteria above)
5)
yes no ,
X the system is 400 feet of a surface drinking water supply
.� s w f 1
X the system is within 200 feet ofla tributary to a surface drinking water supply .
',3 -
m X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped `
Zone II of a public water su I wel #
P PP l Y
Id.2f.�,'��tr
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered x nA14
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat of ,
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. '
' � f ,
Page 5 of 11 ;
s -MAl
.
,fir; t
t OFFICIAL INSPECTION FORM—NOT FORNOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLISTAll
VA
`
Property Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384 '
Owner: ESTELLE MACCARON
Date of Inspection: 11/5/01
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or-Board of Health '
_ X Were any of the system components pumped out in the previous two weeks? "� x
X _ Has the system received normal flows in the previous two week period? '
X Have large volumes of water been introduced to the system recently or as part of this inspection? j
fir
X Were as built plans of the system obtained and examined?(If they were not available note as N/A) T.
X _ Was the facility or dwelling inspected for signs of sewage back up? rA`
' X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site? ,'',�.
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
1 f construction dimensions depth of liquid,de th of sludge and depth of scum? 4
baffles or tees,,material o P q .P
X _ Was the facility owner(and yoccupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?'
z
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no fi
_ X Existing information.For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is + a
unacceptable)[310 CMR 15.302(3)(b)] :
m.-
5
Page•6 of 11 ,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "
PART C , _
SYSTEM INFORMATION.
Property
Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384 f �
Owner: ESTELLE MACCARON *�
i Date of Inspection: 11/5/01
FLOW CONDITIONS Tr
1 RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3 �"
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#.of.bedrooms):330
rt.
Number of current residents: 1 ' '
Does residence have a garbage grinder(yes or no):NO
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO �
Seasonal use:(yes or no):NO
Water meter readings, if available(last•2 years usage(gpd)): n/a
j ,
Sump pump(yes or no): NO ^'
Last date of occupancy: n/a
COMMERCIALANDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd r
Basis of design flow(seats/persons/sgft,etc.): n/a � R
Grease trap present(yes or no):NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a z
OTHER(describe): n/a
��A
GENERAL INFORMATIONi`'yr
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): YES "
If yes,volume pumped: 1000gallons--How was quantity pumped determined?n/a y�
Reason for pumping: MAINTANENCE P ; 1
TYPE OF SYSTEM ��
X Septic tank,distribution box,soil absorption system R
_Single cesspool
_Overflow cesspool r � t�
_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 ti '
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1990 � .
6
l Were sewage odors detected when arriving at the site(yes or no):NO,'.'; r
Page-7 of I 1
}
OFFICIAL INSPECTION FORM—NOT FOR<VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C r° '
SYSTEM INFORMATION(continued)
x*�o
Property
Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384 }ks ,
Owner: ESTELLE MACCARON
i Date of Inspection: 11/5/01
u�
BUILDING SEWER(locate on site plan) �"OU ,
Depth below grade: 18" "
Materials of construction:_cast iron X40 PVC_other(explain): n/a �
Distance from private water supply well or suction line: n/a � .
Comments(on condition of joints,venting,evidence of leakage,etc.): ,
TOWN WATER
SEPTIC TANK:X(locate on site plan) '.
Depth below grade: 12" k r '
i Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) , r �
i
Dimensions: 1000G L 8 6 H 5 7 W 4 10 AK
Sludge depth:4" ,
j Distance from top of sludge to bottom of outlet tee or baffle:30" ►�
Scum thickness: 5"
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: n/a ,s
How were dimensions determined: MEASURED
R Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related
to outlet invert,evidence of leakage,etc.): ' '
THE SEPTIC TANK AND ALUCOMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND S ii'm 4f
FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S
USEFUL LIFE SYSTEM. k ;
GREASE TRAP:_(locate on site plan),.
Depth below grade: n/a r" f
Material of construction:_concrete_metal_fiberglass polyethylene_other(explain): n/a a ,
Dimensions: n/a
Scum thickness: n/a
lfi E f 3 Y� j
Distance from top of scum to top of outlet tee or baffle: n/a fF .
' Distance from bottom of scum to bottom of outlet tee or baffle: n/a 5xK
Date of last pumping: n/a
Comments(on pumping recommendations inlet and outlet tee or baffle condition,structural integrity,liquid levels as related K `f
, `sr �.
to outlet invert,evidence of leakage,etc.):
3
a
n/a
1 . F•E.ir��P
�Z.,
+a
4.
Page 8 of 11 j
r 4
OFFICIAL INSPECTION FORM—NOT FOR�VOLUNTARY ASSESSMENTS .
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .:.,r_...
Property Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384 ftx:
Owner: ESTELLE MACCARON 4}
� .
Date of Inspection: 11/5/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
-
R Depth below grade: n/a x`
Material of construction:_concrete_metal_fiberglass polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A «�
Alarm level:N/A Alarm in working,order(yes or no):NO
Date of last pumping: n/a `;
Comments(condition of alarm and float switches,etc.): a �
n/a
DISTRIBUTION BOX:X(if pre'sentfmust be opened)(locate on site plan) Fes_ R
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF.PIPE , � ��'
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.): Y `
STRUCTURALLY SOUND-HAD SOME SOLIDS IN IT AT TIME OF INSPECTION.`
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):NOr fiyt
Alarms in working order(yes or no):NO ''" '
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): �4
n/a
iy
rY
r
l -Z�y'
` Page.9 of 11 �== K ;
h
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
J
Property Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384 {
Owner: ESTELLE MACCARON Y '
Date of Inspection: 11/5/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a t ' '
I r r
' �a• ri n
I Type
j 1000 GAL 6'X 6' leaching pits, number: 1 4
leaching chambers, number:. n/a
n/a 9
1 n/a leaching galleries, number: > . nla ��'
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number nla # ' .
n/a ,innovative/alternative system._.-
T e/name of technology:,
gY: n/a
.I Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp.soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT HAS NOT HAD '
1 MORE THAN 2'OF WATER IN IT.BOTTOM AT 8'
i
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) 3
Number and configuration: n/a d
to liquid�
Depth— to inlet invert: n/a P P of uid q
Depth of solids layer: n/a
Depth of scum layer: n/a {
Dimensions of cesspool: n/a majy'
Materials of construction: n/a "t
Indication of groundwater inflow(yes or no):NO �Y
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): ;
n/a
PRIVY: (locate on site plan)
,j
Materials of construction: n/a �
Dimensions: n/a ��
Depth of solids: n/a �
Comments(note condition of soil,signs of hydraulic failure,level of ponding;condition of vegetation,etc.): '
'} M1
a` H�
3
n
Page �,0 of 11
2
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS „
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued) x ' �
Property Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384
Owner: ESTELLE MACCARON
Date of Inspection: 11/5/01
p
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. ' ;.
Waa yVY
W b ti
bes
Wl
j v
x
I
s AA
AC ' �
94
gC 3oi � ry¢
.. Lrft':
tYt �18_� y f I
z
in
Page'l l of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
�4?
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION(continued)
Property Address: 384 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L384
Owner: ESTELLE MACCARON
i. Date of Inspection: 11/5/01
SITE EXAM
_Slope ,
_Surface water '
_Check cellar
y
Shallow wells
r
Estimated depth to ground water 12+feetz' a
Please indicate(check)all methods used to determine the high ground water elevation: `
; z.
ly s
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a 4
i YES Observed site(abutting property/observation hole within 150.feet of SAS) ;
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators; installers-(attach documentation) {'
NO Accessed USGS database-explain: n/a
�SE
i
You must describe how you established the high ground water elevation: „,f
GROUNDWATER DETERMINED ON SITE-12' NO WATER ENCOUNTERED BY AUGER „
x
�a� w
}
tZ r
4 � r
� z
4:r
K
_. TOWN OF BARNSTABLE `
LOCATION �� �S� �lC '`� ���� SEWAGE# ��II���b
VILLA GE ASSESSO 'S MAP&PARCEL
INSTALLERS NA E&PHONE NO. • - �� '--
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) /i. (size) �'[�, ` t
NO.OF BEDROOMS
OWNER rf
PERMIT DATE: _ �.r' S'�C� 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 ��
I
lit o
TOWN OF BARNST LE
.. `�
LXATION ���W� e SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT — S
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation.Distance Between the: .
Maximum Adjusted Groundwater Table to.the Bottom.of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
4YSx
�./ 4
� 1
O� .a
®�, �
.�
os �.
vn �b
w a- a�-�aC,:� o�
a- ot� ,
• � - � `�
m
r
L
1
20,01 JAN
I
I
ld~-
f
f � �
.D
Yll
w 'IT
f
J '
i'
i
f
— 1
tvn'�ci S-��llls Ian s�Iyas r
i
;
i x rb
7n
A �'•
I\ A
�i $1_oli 18'r 3 ii
t 1
3
S
- I
3_a'�x6'-dl r i
r ° e,WStT
s
1
I
I
30 -o
c l—o
*NOTE. ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C.
�-10' min. from q 1;
Existing Foundation I house to septic tank g
TOP OF FOUNDATION = ELEV. 100.00 be
Assumed S�� tank cotters must
x arver"mast be SEG'TI01'V A4 'y4
within 6 in. of finished grade within;6 in. of finished ginde
Haade ow Septic Teem-9&00 Grade over D-a«-96.00 Zetiar SAS HIe.DD PROFILE VIEW OF ADDITION TO LEACHING SYSTEM
3" of 1 1 Washed Peaston
�" - �" 1 384 Strawberry H11/ Mir
3/4' to 1 1/2 - Washed Crushed Stan ' Ii S ' -"
S 0.02 3 HOLE H-20 i i . *# ' +t en Iottti IrYt+ ,-
totr
12' EXIST S-0.01 or eater Etox 3' Maximum Cover Top Of SAS-Ehev.=95.75 4 Pvc(cApm)INSPEcnDN Po T TO BE
- INSTALLED AND TO BE WTHN a OF GRADE "t Extsr. PWE 0 1,000 GAL '
FRQI EX[ST. FOl1ND11TTfl1 rn 0 ,n 42 0.01 SEPTIC TANK n Per toot .• " �. :#
1 n rn to
a o.nr rn a 5' i� x- -
CONErE FULL FOUNDA,io►r� o n H-10 toCt �•_.x c. i eb 1 x. :_J
o 0) 0) 1 r EFf DEMN TOTAL
o _ 0 1 O 2' EFF DEIPTH TOTAL = � `�` *15Fas► -
SYSTEM PROFILE 6of3te/d4, 2• °' v o o S , € tY;�;-
tonet
C C m 0 In 1 '" Q +b2iOdtl trria,osra
Not to Scale - - a 0
i .11
n •- 1, 0) .12 ' a25 GENERAL NOTES
6 tn°of 1/2' j
compacttaedd stone
1. s.75
one � 11�� 11 81 1. Contractor is responsible for Digsafe notification, Verification of Utilities
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE 0) Effective %kith Effective Length and protection of all underground utilities and pipes.
W SOIL ABSORPTION SYSTEM (SAS> 2. The septic"tank an4 distri ution box shall be set
+, _, level on 6 of 3/4 -1 1�2 stone.
4CL) W INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN 3. stoneBackf 11 should be clean sand or gravel with no
O E stones over 3" in size.
PERCOLATION TeC� (OR EQUNALENT) Not to Scale 4. This system is subject to inspection during installation
TEST `'- 41 by Carmen E Shay - Environmental Services, Inc.
W Bottom of Test Hole 2 Elev.- 88.00 0 5. The contractor shall install this system in accordance
Date of Percolation Test: NOVEMBER 20, 2006 aoandwater Observed- NONE OBSERVED cn with Title V of the Massachusetts state code, the approved plan
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations.
Results Witnessed By: DON DESMARAIS (BARNSTABLE BOH) 6. If, during installation the contractor encounters any
EXCAVATOR: Shay Env. Svcs. ALL OUTLET Pages FIRM THE soil conditions or site conditions that are different
Percolation Rate: Less Than 2 MPI 0 36" asTRIBu,aN BOA(SHALL BE CONCRETE ODVF from those shown on the soil log or in our design
t
SET LEAL FM AT LEAST 2 FT. 2" - COVER ',.
installation must haft & immediate notification be
-= _> ;.�ti_.,s_, 2 f made to Carmen E. Shay - Environmental Services, Inc.
OUTLETTest Hole Test Hole 3-k-oLET Kitchen
N0. 1 No. 2 K"=O Ts Bedroom Bath Dining 7. No vehicle or heavy machinery shall drive over the
f 5!r 'r ""� septic system unless noted as H-20 septic components.
DEPTH SOILS ELEV. DEPTH SOILS ELEV. outtEr
B. Install Tuf-rite gas baffles or equals on all outlet tee ends.
o 98.00 o saoo
-t: 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
LOOM ndy LoomL andy 'Ss 4' - SCH. 40 T` -�- Bedroom Living Room 10. All solid piping, tees & fittings shall be 4" diameter
10 YR 3/2 10 YR 3/2 PLAN SECTION CROSS-SECTION
o'-s' A, s7.5o o'-s' Ae 7.50 Schedule 40 NSF PVC pipes with water tight joints.
11. Municipal Water is Connected to ALL OF The Residence and Abutting
Loamy Loamy
Sand sand 3 HOLE H-10 DISTRIBUTION BOX 2 BE HOUSE FLOOR SCHEMATIC Properties Within 150 Feet.
10 YR 5/6 to YR 5/6 NOT TO SCALE
Be Bw 95 00 6"- 36" Be95 0o THE PROPERTY LINES ARE APPROXIMATE AND
6"-
COMPILED FROM THE SURVEY PLAN BY ED KELLOGG, INC. ENTITLED
Med.-Coarse Med.-Coarm
Sand sand SUBDIVISION PLAN OF "CRAIG-PORT", WEST HYANNIS, MA
DATED SEPTEMBER, 1961
25 Y 7/4 25 Y 7/4
• AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
36'- 120 G 88.00 36'- 120 G 88.00
- IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
THE SEPTIC SYSTEM INSTALLATION.
EXISTING LEACH PIT TO BE-PUMPED OUT AND FILLED IN PLACE
I,OT #73 LOT #75 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
LOT #71 FROM THE EXISTING LEACH PIT TO BE DISPOSED
OF AS PER BOARD OF .HEALTH SPECIFICATIONS.
THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
Perc #1
Depth to Perc: 48" to 66' 99.81E TEST HOLE #1 ,
Perc Rate= 2 MPI , ELEV.= 98.00 SHED ASSESSORS MAP 248, PARCEL 153 °
Groundwater Not Observed f2 5
No Observed ESHWT LEGEND
ADJUSTED H2O Elev. = None 5. o o o- o
D-Box 104X1 DENOTES PROPOSED
- - - SPOT GRADE
Failed
2-18'DIAht ACCESS MANHOLES Leach Pit X DENOTES EXISTING
E 98------ ---------- 0 104.46
SPOT GRADE
----- EXIST. TEST HOLE #2
LIQO-- PL PROPERTY LINE
I
= b Septic
ggal.
H3fc a . L EV.=
Aika
r= 98.09
96P PROPOSED CONTOUR
INLET 1 _ / °6 I - - ---
J \ our'n ET EXISTING �` -97 EXISTING CONTOUR
LOT
,R CN �iEActaN MITIC TAW, z 9EDIMOM
T # i- i 1 LOT #76
SET DEEPER THAN 6 INCHES grow nNISHED SOUSE I , ► ® DEEP TEST HOLE &
GRAM SHALL BE RAISED TO 1MTHIN 6 of PERCOLATION TEST LOCATION
STEEL REINFORCED PRECAST CONCRETE FINISHM GRAM #384 I I i 1
PLAN VIEW INSTALL TUF-nff GAS BAt'RES OR EMALS , I ��
is 6 FOOT STOCKADE FENCE
/-3-24'RFaA01'ABLE COVERS
REV.: 1 1/28/06 per BOH review on 11/28/06
• r: =
_ I � REV • 11/27/06 per BOH review on 11/27 06
3 min deorance tI MET Y 98--- ( v
INLET B' mtn�- 2- min. wet to outlet °.mti = - ----- - ------- �, r
°lnlET --- -----------
JA
PLOT P LAN
5' -r Ll
'5'-T LOT #74 icn ,%ft UWb depth It.150 Square Feet +/-
OF PROPOSED SEPTIC SYSTEM UPGRADE
•_� _ '-_ s ; i I PREPARED FOR
.6;_a� -4''-,a-• 8s.00' � � I � sz.zz' MR. MALCON PINHEIRO
CROSS SECTION END-SECTION = ,
AT
-�- #384 STRAWBERRY HILL ROAD
96--------------------------------------------. \
TYPICAL 1000 GALLON SEPTIC TANK --1_� l NOT TO SCALE ------------------------------------------ ��------------_ __`_96_ C _ � M A
S TRA TYBERR Y 1 yILL .R O.A I�
Design Calculations ``��'�
�y �(F1 OF
PREP RED BY:
`
Number of Bedrooms: 2 Bedroom EXISTING v jJ
Garbage Grinder: No (40 FOOT RIGHT OF WAY) Pal-N RMEJV E. SSffA Y
Leaching Capacity Required: 330 Gal./Doy (MIN. PER TITLE V) z
0
Septic Tank': - 2 x 330 Gal./Day = 660 USE EXIST. 1,000 GAL Septic Tank.
SI-iA
SOIL ABSORPTION AREA: Using percolation rate of Q min./inch N 118 VIRONMENTAL SERVICES, INC.
Bottom Area: 0.74 gal/sq. ft. x 240 sq. fL = 177.60 gallons �F a
Sidewall Area: 0.74 gal./sq. ft. x 212 sq. ft. = 156.88 gallons P.O. BOX 627
Providing: = 334.48 gallons 0 20 40 50 cJ,TAR�PN R EAST FALMOUTH, MA 02536
Use: (7) SEVEN INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE TEL/FAX 508-539-7966
DEPTH, TO BE USED-WITH 1.0' OF WASHED STONE ON THE SIDES, AND 2.125E OF WASHED STONE SCALE: 1"=20' DRAWN BY: CES DATE: -NOV. 21, 2006
ON THE ENDS. (14") Fourteen Inches OF STONE UNDER. SCALE: 1"=20' PROJECT#SD990 FILENAME: SD990PP.DWG SHEET 1 OF 1