Loading...
HomeMy WebLinkAbout1005 OLD STAGE ROAD - Health (4) 1005 Old Stage Road Centerville. P A =. 172 162 f i I R McKean, Thomas From: McKean, Thomas Sent: Friday, February 26, 2021 9:58 AM To: 'Janet Van Orden' Subject: RE: SepticTOB Please submit the required floor plan (or neatly drawn sketch)of the house. Please label each room as to its use and show all doors/doorways., From: Janet Van Orden [mailto:jvanorden@mvres.org] Sent: Friday, February 26, 2021 9:05 AM To: McKean, Thomas Cc: Jaye Van Orden Subject: Fw: SepticTOB Mr. McKean I have attached the Septic Questionnaire in order to move forward for Affordable Housing approval. Mr. Florence has already been to the property. Respectfully Janet M Van Orden 1005 Old Stage Road Centerville 02632 Mobile 508-737-7811 Jaye Van Orden RN CHPN High School Nurse Mystic Valley Regional Charter School 781-388-0222 x 4108 From:Janet Van Orden<Ovanorden@mvres.org> Sent: Friday, February 26, 20219:00 AM To:Janet Van Orden <ivanorden@mvres.orp,> Subject:SepticTOB MVRCS CONFIDENTIALITY NOTICE: This email message (including any attachments) is for the sole use of the intended recipient(s) and may contain confidential information covered under the Family Educational Rights & Privacy Act (FERPA). If you are not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this message (including any attachments) is strictly prohibited. If you have received this message in error, please destroy all copies of the original message (including attachments) and notify the sender(only) by reply email message. i U-N A ............. AT-) Pot fi IOU- ........................... J—i .. ...... 5Q WV poll". n. Mr 0 JAR TA H LE" M1��tfvl Alf ITS 7. _1 Ord". ....... my ju 0 41 ....... ..... lit A 1 cod?F NQ!, 1 .31 FIA J �v 1 "A OSHA A A A 1A i 44 1 (I L4 WA 1 V . i 4N iui Ira F :.-F ! KIM to _ : - 1-� 7—71------- ,r talk of s I r - - _ T' 1 Health Inspector Town of Barnstable- P ~� . 'THE r Office Hours yP� Regulatory Services 8:30-9:30 + + Thomas F. Geiler,Director 1:00—2:00 BMWSrABM MASS. p,�� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508=862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT-SEPTIC QUESTIONNAIRE l. General Information: Size-of Pro e p rty: �35 Address: Map _Parcel kez_ Name: dw0 -Phone #: 2a. How many bedrooms exist at your property now? '7 2b. Are you planning to add any bedrooms? 1�d If yes, how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d. Please include a copy of the,floor plans for the entire property showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label . each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES or NO ���If ttte dwelling is connected to ublic,sewer,�ski `uespons#4 throu #9 below 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to. UBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO .8. Is there an engineered septic system plan on file at the Health Division? YES or NO 2. Has the se tics stem been inspected by a DEP certified inspector within the last two years? YES or NO ------- ---- - --- -------------------------------------=--------------------------- ----------------- �� FOR OFFICE USE ONLY e ublic Healt Division has no objection to bedrooms at t `s property. Special Conditions: Signed: Date: O;1health/wpfiles/amnestyapp t c da �fuvs�) -------------- I � I d 5 oF��ram, The Town of Barnstable BARNSTABLE. 16 9. ��� Growth Management Department �FDNIf►'�p 367 Main Street Hyannis,MA 02601 Office:508-8624678 Fax:508-8624782 September 30,2005 5� Mr.John C.Klimm,Town Manager Gary K Brown,Town Council President Barnstable Town Hall 367 Main Street " Hyannis,MA 02601 Re: Janet Van Orden— 1005 Old Stage Road, Centerville- asingle-family accesso unit Tom Hughes,Safe Harbor Real Estate,LLG 72 Grove Street,Hyannis - a single-family accessory unit Gentlemen: This letter is to inform you that the Accessory Affordable Housing (Amnesto Program has received requests for project eligibility letters under the Community Development Block Grant (C'DBG) Fund and under Article II of Chapter Nine of the Code of the Town of Barnstable and the criteria for the Local Chapter 40B Program. This office is reviewing the requests.If the Town has any comments on the projects,please forward them to me so that they can be addressed in the site approval letter. This letter gives you official notice of our receipt of the above application(s). We will issue a decision as to the acceptability of the sites and the consistency of this development within the guidelines of CDBG. Sincerely, Elizabeth Dillen Special Projects Coordinator Growth Management Department cc: Town Attorney's Office Building Department Public Health Department r. I V 1 ;o - : IL 11 . �. � {. ,. .: I .. I t. � I Lf��l, i i. I >,` �I'- 4�� }� /.` :��.>•t�� � �> � _ )� ; I, I: . I �, i I' I I r J. -^+, .� , �,• r.. ! �_. , ,' �.( IJ�I IY�-;l Im - .I �-I li , ' I I 1 I .@' ..14l� ~\ I , j f : 1 I 1 { ' : . I , ' K ii I i I i l : i i I j ' bi I I ll „ I I � ` I I : I j , i i I t l I ; 1 ' I > I I I 1 - I ..... . ..__ ... ;. _. f I I I I i J .t _ .......... .......... .` �l I- i ► . I i J , I s I I8a ( i i i I I i i II i iMA I s ..�. �.. _ -- - ..... ...........- .......... 1 _ l _ _ .a. i �.. 1. ._ _ I I I I ..._�........_ .. t _ - ......... i i 1 .. . _........ . _ i 1 ! i 1 ._.._.... - I. I i No. aU� ��� j" ' r Fee Mo 0— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for 30i5pogar *p.5tem (Cougtruction Permit Application for a Permit to Construct( , )Repair( )Upgrade(A Abandon( ) ❑Complete System XIndividual Components Location Address or Lot No.��� ��/ Owner's Name, ddress d Tel.No. �, ` I` ,Tj Name, Gc�l l 1/2i'l Assessor's Map/Parcel Installer's Name9�7 d Tel. o. Designer's Name,Address and Tel.No. ,� G - t Type of Building: Dwelling No.of Bedrooms 5 Lot Size fTsq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets I Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with,the provision 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 by this/Board of Hea /2 Signed Date �5 Application Approved by 'bv_ - Date a Application Disapproved for the following reasons Permit No. -,-7WS ' J1, S Date Issued .� -as No. Fee + Entered in computer:~� THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppricatian for Mgonl *pgtem Cougtruction Fern(it Application for a Permit to Construct )Repair( )Upgrade Oj)Abandon( ) ❑Complete System YIndividual Components Location Address or Lot No/r005 Owner's Name,Address and Tel.No.aq . Assessor's Map/Parcel 17 a.. �i Installer's Name,Address, d Te1,No. G Designer's Name,Address and Tel.No. 11AY Type of Building: Dwelling No.of Bedrooms Lot Size 1 yf Uv-) sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria; ) Other Fixtures 2 2 Q Design Flow 7 gallons per day. Calculated daily flow J , Q gallons. Plan Date Number of sheets Revision Date .: Title Size of Septic Tank FIXI CEO Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ej d_ 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 of Heat . =, Signed Date ulc�3 Le2_2 Application Approved by "`�'• � Date Application Disapproved for the following reasons t ' �� Permit No. -;ZW S S Date Issued �. _-- -==—_— ----=—=------ --- ----------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Coll phaftce THIS IS TO CERTIFY?, that the On- ire Sewage Disposal System Constructed ( )Repaired ( )Upgraded()Q ) Abandoned( )by be.}"f5 /C.. t ,, / at 1 0 ) 01 a E'. &0 M Ille has been constructed in acSprdance with the pro isio 2 J s of Titl,ey.5��and the for 1)4osal System Construction Permit No. �-� S dated a Installer pro Designer �sL The,issuance of this pertnTt shal not be construed as a guarantee that the syste l fun�don as designed. Date Inspector, _' No. �C?S^� .2�Sr --------------------------Fee Uv� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS �Digogal *pgtem Cott$truction Permit Permission is hereby granted to C n tr4 t( T) epair )Ugrade Z` )Abandon(System located at f(.�h [I 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 must be completed within three years of the date of this-permit. Date: / i C'S _ Approved by I �ti• �j f . l ,A F y. 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 F—O,��5iAW ,hereby certify that the engineered plan signed by me dated concerning the property located at SOS enAK�A. 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) B) G.W.Elevation +adjustment for high G.W. DUTERENC ETWEEN A an q IDSIGNED : DATE: La 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. gASeptic\percexemp.doc �1 SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sig item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X ❑Addressee Iso that we can return the card to you. B. Re by rintgd Name) C. Date of Delivery e Attach this card to the back of the mailpiece, , /,D`, � V��l or on the front if space permits. V I/�iv D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No I Mr &Mrs John Sallivan 1.005 Old Stage Road 3. Service Type' Centerville,MA 02632 ❑Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service label) PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SER IE�`°`' '` =•First-Class Mail Fees Paid LISPS..,.. . Permit No G 1.Q. • Sender: Please rint '6df n p y� address,..�r�d-•�IP-�-4�int�i�b®�'•�� PUBLIC HEALTH DIVISION .TOWN OF BARNSTABLE 200 MAIN, STREET HYANNIS, MASSACHUSETTS..02601 . I I , I I � _ E rb c OF F I. � w. -� for l7 t3 Postage $ e 3 L u'1 Certified Fee c13 d+ J �astmark Return Receipt Fee N Here R1 (Endorsement Required) UO Restricted Delivery Fee N N � (Endorsement Required) J J p Total Postage&Fees 1` ,--p Sent o a - -------a-------------- p J h Street,Apt.fo.;or PO x (IO B ^ �J o L U(? Q C3 City ate,ZIP+4 (20 ee e t/% e a.?Gt�oZ ,,, 11 Certified Mail Provides: I o A mailing receipt o A unique identifier for your mailpiece I o A signature upon delivery o A record of delivery kept by the Postal Service for two years Important Reminders: o 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 Mail. For 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. n 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". o 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,May 2000(Reverse) 102595-99-M-2081 CF THE tpw O Town of Barnstable Regulatory Services i639. � � Thomas F. Geiler, Director tFp MA.(a Public Health Division Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 19, 2005 Mr&Mrs John Sullivan 1005 Old Stage Road Centerville, MA 02632 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 1005 Old Stage Road, Centerville,MA was inspected on May 19h, 2005 by James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: Leaching pit was in hydraulic failure. Liquid was to the top and backing up. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARN'STABLE HEALTH DEPARTMENT I r' COMMONWEALTH OF MASSACHUSETTS ul EXECUTIVE OFFICE OF ENVIRONMENTAL ATFFAIRfS °�'`` TA B LE DEPARTMENT OF ENVIRONMENTAL PROYECtION PM`2.Q j i TITLE 5 OFFICI.AL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1005 Old Stage Road _ Centerville. MA 02632 Owner's Name: Christine&John Sullivan Owner's Address: . Date of Inspection: May 19, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was 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 Needs F her Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: —June 12, 2005 The system inspector shall sub i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I • Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Christine&John Sullivan Date of Inspection: Me 19, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed i distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Christine&John Sullivan Date of Inspection: May 19, 2005 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 2. . System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Christine&John Sullivan Date of Inspection: May 19, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "Wes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1005 Old Stage Road Centerville, MA Owner: Christine&John Sullivan Date of Inspection: May 19, 2005 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 1Grge 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: Yes No ✓ _ Existing.information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 r Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1005 Old Stage Road Centerville, MA Owner: Christine&John Sullivan Date of Inspection: May 19, 2005 FLOW CONDITIONS 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 Number of current residents: 6 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): `Hater meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in 2004-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? F:eason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in May 1991 -per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Christine&John Sullivan Date of Inspection: Ma 19. 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 15" Material of construction: ✓ concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring?stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete ._metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Christine&John Sullivan Date of Inspection: Me 19. 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 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.): The D-box was under water. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1005 Old Staze Road Centerville, MA Owner: Christine&John Sullivan Date of Inspection: May 19, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6'x 6'0000 gal.)w/2'stone-per as built card 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.): The leach nit was in hydraulic failure. Liquid was up to the cover and backing up The bottom to grade was 9 0' The cover was 16"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions. Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Christine&John Sullivan Date of Inspection: Me 19, 2005 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 w"here public water supply enters the building. Q (3ra��C 1 i A B �: 1 1►` 3� 3 3 30 Tr . 10 Page 11 of 11 • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Christine&John Sullivan Date of Inspection: May 19, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours map Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours map, the maps were showing approximately 25'+1-to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection andlor this report. 11 Town of Barnstable �F1HE r Regulatory Services Thomas F. Geiler,Director HARNSTABM 9�AMAS& �0� Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 6/30/05 Designer: _Shay Environmental Services, Inc. Installer: Robert Septic Services. Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street MA 02536 Yarmouth, MA On 6/24/05 Robert Septic Service was issued a permit to install a (date) (installer) septic system at 1005 Old Stage Road, Centerville, MA based on a design drawn by (address) Sha Environmental Servicesti Inc. dated_June 16, 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. y, _J(A OF MAS,C, o� CARMEN yG� aller's Si ure) 0 E. SAY No. 118t � o SAN1TAR\�N (Designer's Signature) (Affix Designe Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE 9- ,/it OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BLILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration fur lliipnstt.1 Works Tonstrnrtiun JIrrmit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: l/6�s• lJ'4D �S Cz�i�J� /V ..........�-----••--_.._.. - .... .._._..... .....-----•-----•--••--•---•---•-•--•--- ---•.................••••--....._••-•-... Location-Address or 14t No. ......................... _ Owner Address a �«� -anRs"T � / ------ !�% �J�� -----•-----....................... Installer Address f Type of Building Size Lott ---Sq. feet Dwelling=No. of Bedrooms................�._........._•_._.__..Expansion Attic ( ) Garbage Grinder ( ) a p•, Other—Type of Building ........................... No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------- . Design Flow.............. -.__:_.._._._..gallons per person per day. Total daily flow__..:....__... _.... gal W � d Ions. WSeptic Tank—Liquid capacity/1 Length_..)-,5. . Width__l. Diameter________________ Depth_..------ x Disposal Trench—No. .............:.......Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No........ ------ Diameter......./®.I.,.... Depth below inlet..... Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing-tank ( ) Percolation Test Results Performed by.....................................•-------- ------.------- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.......................... G14 Test Pit No: 2................minutes.per inch Depth of Test-Pit.................... Depth to ground water........................ W ---------------------------------=-----= -•---------------------•-•-=.................................................................................. 0 Description of Soil----------L � " G� r s L - ..../f!1 ...........................Z: '..��c_,c+LtJl----------------------------•...----•--- W x • ----------•------------------------ ----------- y� U Nature of Repairs or ter ations—Answer when applicable_:_. ....,./l� .._[.�_...= � ..%vim`:__..__. ......................... 1�• .....................•---------••--- . 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 Compliant as eejiss d by e board of health. Signed:-'- -------------------------- ---- .. ---------- ------------------ ......� Dare Application Approved BY � _. .. .,---- Application Disapproved for the following reasons- ---------------------------------------- ----------------------------- -------------------------------------------------------- ............................................ ................ Permit No. =.t.-..- ..--'--'--'---.:_---'�---...---•..:.------ �. .. Issued ---------------- �� --- -- n Fps.......... -�.. . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iration for Disposal Works Toustrnr#ion rumi# Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: Location-Address or Lot No. %._ ........_ a yam.............. /DDS" .......... 1 ��•- ' ..._....................................................... ..:�?.....--•--��,�fTf'�i/ •-----_..... ..............................e ................... Owner �• Address Installer Address d Type of Building ;t Size ...Sq. feet U Dwelling—No. of Bedrooms______ _________.....___._._______._Expansion Attic ( ) Garbage Grinder ( ) Other—T e of BuildingNo. of persons............................ Showers — Cafeteria f-4 Other fixtures -----•----------•------------------------•--•-•_..._._.. W Design Flow............... -._______._______gallons per person per da . Total daily flow._____..____ } ................gallons. WSeptic Tank—Liquid capacity!��__gallons Length---J=�Width._./-:.......... Diameter________________ Depth.,` ./_____- x Disposal Trench—No..................... Width.............. Total Length.................... Total leaching area...................sq. ft. Seepage Pit No._____..=�------•• Diameter____..�i... Depth below inlet..... ......... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i. Test Pit No. 2......... .......minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•-----------••---..--••--•-••----------------•---------•--------•----•••-••-••••--•------•---------•---•--,------_...._.......-----...---------•----------- O Description of Soil..........Z:!- -3----...__��?47!1 .................... --�-/`-'--z...._._/-r!J......-•--•.... •---• x --------------------------- SaCL+-.:1�-------------------------------------------------------W --••----•---•---------------••-•••••--•••-----------•-•-•--•-•--•••----•----•--•-------•---••-•••-•----•-•-••-•---------•-----•--•••-•••••---•---•-- UNature of Repairs or lterations—Answer when applicable_.__�'__✓4.____./lJG2"J•� 11��Ez�.............-----•.. --------------------•----- C— _/-••-= i7J_'Sj�------------•--•-•-----....----•-•--•-------------------------•-------------.....__.._......................................... 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 een iss ed byte board of health. Signed ....:-�; .... G' - " .................' i .. --------------- -------- 7.p.��-Z)APPlication Approved BY ----- �' .. � Dace Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------ ----------------------- ------ Permit No. �' /��...................... Issued ` .... `f ..-. ------------------------------ Dare `------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' TOWN OF BARNSTABLE TErtifirate of Compliance THIS IS TO CERTIFY, ThA a the Individual Sew Me Disposal System constructed ( ) or Repaired by........................ �o�D�o7r7 �� ro� Installer -- ---- ------------------ has been installed in accordance with the provisions of TITLE 5 of The St at Environmental Code as described in the application for Disposal Works Construction Permit No. .. �-- .��------..-- dated ...�� '..- -ter'.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION-SATISFACTORY. DATE.-.. --------------------------- Inspector ------------...---------------l/�... .......... G THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE. ..-.-... Disposal Works Tunstrnr#ion 11nmit Permission is hereby granted............... 0�a�'>11 --------••.................••--------•-------•-----•---...-•_... ._...._..--_....._........._.............---._.... to Construct ( ) or Repair (/JC) an Individual Sewage Di osal Syst at No............ ... %-�---.s..._... C)l6 `5� � �, ..........--__---•--•••••--••--••------_•-•_............................... ......jn/�� as shown on the application for Disposal Works Construction Permit No___ _ Dated.... .__..`_�........._`.�: Board of health DATE........... ......................................................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS ";97e, No........�Y .... - Fwic.. �`.��.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFn HEALTH Gam' �. ..................OF......18I�melk: _................. =-- Appliratiun -fur li,ipuuttl Works Tonstrnrttun Vrrmft Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: V03 �Locatio Add re _ —' Lot No -------------------------------- ----------------------------- --- W ,//.J�/-_J�j/�/�� �, /7/j Address !.....—X_......... ......... .........V-...--------..-.•-.-------_.---.--------. --.--. -------- -------------------...i.... --------------•----------------------. � Installer Address Q Type of Building Size LotA__/_ ---Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (/LYQ aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 44 er fixtures d Desi n Flo ___._.� '' W g �-�--`—_____ ________gallons per person per day: Total daily flow._..._.___.---------------------------gallons. WSeptic T-,.nk Liquid capacitvyl'PQ""-O-gallons Length_............. Width------.......... Diameter---------....... Depth.___-----_.-.--. x Disposal Trench—No_ ____________________ Width___-_-_ _--------- Total Length...................- Total leaching area------- ___..sq. ft. Seepage Pit No--------------------- Diameter.. �. Depth below i*tlet_________ __-___- T tal 1 aching area_2_0 ----sq. it. Z Other Distribution box ( ) Dosing t '-' Percolation Test Results Performed by..... �_____ _ /►?4d_-__-_._-_ -2 W Date ---------------­--- Test,� Pit No. 1________________minutes per inch Dept of Test Pit._.-.._..........._. Depth to ground water-------------.--__..__.- LT, Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ 9 ................... . -- -------- O Description of Soil------- --LpdLw 2 U -------------------------------------------------------------------------------------------------------------------------------------------------------------------•- ------------------- W U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------- -------------------------------------------- ---------.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned fu ier agrees not t ce the system in operation until a Certificate of Compliance has been i u d by the b of he h. gne ....... ......... ...............'---- --------------•--------------•------- -••-•-_---•- ..--•-- ` ate Application Approved By.... = ..-_7_ Date Application Disapproved for the following reasons:. --------------- -----------------------------------•----------------------------••......---- Date PermitNo......................................................... Issued... 44......................... Date No....... FEE...�.J......a""......... THE COMMONWEALTH OF MASSACHUSETTS - -. BOARD OF HEALTH . Appliratiutt -for M!iVaiittl Works Towitrurtiott Pun it Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No- ......................................................--- �.. ................................ .•........===—....------.........-=... ------......--................---• i O*'w.wn r%/ s...l✓ / / + Address � Installer Address -... Q Type of Building Size Lot.Z5_,-_..'0...Sq. feet Dwelling—No. of Bedrooms............. -•-----------------------Expansion Attic ( ) Garbage Grinder (/LYC) Other—Type of Building ____________________________ No. of persons------------------------- Showers ( ) — Cafeteria ( ) ierfixtures ---------------------------------------------------------------------------------------------------- Design �-- d Flo -___ '' ' r`� T Mons er erson er da Total dail flow--_____�_�_ W = = g P P P Y Y ---------------------gallons. USeptic Tank I-Liquid capacity f-_`'-`'_ _gallons Length_-____--____--- Width__.__...------ Diameter..............:. Depth---------------- x Disposal Trench—No..................... Width-----------_-------- Total Length--_-__-__-___--___. Total leaching area .._.....____.. sq. ft. Seepage Pit No--------------------- Diameter.f!1.�__�__ Depth below ' let.._..........._...- T al]caching<trea_.��/___.sq. ft. Z Other Distribution box ( ) Dosing Percolation Test Results Performed by----~' �. --- a _ _. ...-----'�!•.. -•---- -...-•------------- Date----._.....----•---------------•-•---- " Test Pit No. 1________________minutes per inch Depth of "Pest Pit__.______._.____.... Depth to ground water.._......____..______... f3:q Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-...- __.____-___.... W11-------------- I j - > O Description of Soil-------....... =��-._� 2.�_�._.._ �. '� z - l . r Y` '-— V ....--------------------•-••----••----•••......------------------.----------------------------.........................................................------ - ------------------------------------- W V Nature of Repairs or Alterations—Answer when applicable--------------------------------- .... -----------------------------------------------------------•------" Agreement The undersigned agrees to install the aforedescribed Individual Sewage'Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to'place the system in operation until a Certificate of Compliance has been issued by the board of hearth. r gne _- G -- r - � ZL�ff` . •.. ----••......•--•--- i...... -to Application Approved BY-----. ---- - E:,� ----- ------------------ I -Ae .7 Date Application Disapproved for the following reasons:-------•----------------------------------- .........-----------•----••-----•---------------•------------------- ---.......-•------------•-••-------•--------•-------•--.. Date Permit No........................ -••-••----•...... Issued = Date THE COMMONWEALTH OF MASSACHUSETTS 'IB,OO'ARD OF EALTH ...... Tatifiratr of'(9butliliattrr THIS IS,T RT x'YZat.,-..6(�'Individual Sewage Disposal System constructed ( �or Repairedby.....:...C / a ...._.A. r ,. ,/ -f�•"--- sta1=r.... # �j '. r�► ...;_4 has been installed in accordance with the provisions of Ar I T 1 State Sanitary Conde as described it-t the application for Disposal Works Construction Permit No.' . �Gi ------ ------------•-_. dated----- ' .��/_`--7.r------. THE-;ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ' ems• DATE-------fit'- 2 `-------------------- -----=............... Inspector._.................................. Zt..t... ---------------- - THE COMMONWEALTH OF MASSACHUSETTS ., BOARD 01FHEALTH 3 7S ....OF...:...... ...... '� ..' --...---------------------------------- No......................... FEE---'a- ���i��>or,�tt1 or r Permission reby gr� ted - •--------------- ._.........--•...-••-•--•-..----- to Constru ( ) or Rep r ) an d id an Sewage D' po41 at No..... i_ Street / as shown on the application for Disposal Works Construction Per No.-.. ..._ a ed...... ---................... -------------------_ / �� Board o Health ; .._ - DATE----------------- - 2/--7 0 FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS T:;&(1,� FLAW = tto -4 3 - 33o G•P-ram too o0 5eP-ric TjN+-:EK = -SSov {SG % = A-95 6.R0. tJSi--- l oc>c, 6AL.. !! ISPpSAL PIT- - EJSE I000 GAL_ BVI-rOAA A1ZEA- EvO ST- c> TC7TAL 425 G.P.D.' .. ToT4t_ tJrdtL}f �LDW = 330csi?T�. !3t (�7� � � /3F 10? PEf1GDLdTI0Q tZ&TE OR LP-%. �Q TA+ w t� �c rX R A. t hoc E- 2/?8 F _ •S tPL- ....�. 4:. E: ..�.....,, ql S�T�OtL looc� IIN. 's� f 'Sox `tG sepnc I o i►JV. T-A rt K l 000 R59 iNy. t►N , t>eUi1 GAL. qG•u u.-L Pi-r U'x.1�oa WITi1 Of WASHED ' S/TONS ' 'Q Ao C ZTtFICD PL.CGT F'L A,1�iT Ptzo�t L..� uo 1 c_t3Ez rEr=�{ -r�1Ar THE � +-IDAi'1U+� Suow►.3 P�= v.E-j 6,.;c�_ -1 t_t?t�t�e.a . Gr �t`�!S W i Tt-Z Tt� 5 t� .trt►-tE= LDr i c� ,&Wr-> ACT LIACV— V:C-QUICENtc WTS OP T"Cz 'Tow>~ off' F.,A�tJ�T �3t. PL. &L 30Ca �6, L.t,r Cr.. ! j g A-ATC Q- <-� W C t2L-GIS t-Lzilt> '1../a"b lU2vGYuiz�S Tt-115 n trt.A+.1 ► W OT ZA,;GV 04•4 -W 11J;C1� �'✓tl-t.l i �Ui -r?f4b 1LD A.NP1 1 C_/a.!` i j C',C:. t,j-;C-C> rC., 1�r 1 t=r_M �!t, oT t_i W �> __ -- 1� t OA A t_. f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED SEP 3 2002 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1005 Old Stage Road Centerville, MA 02632 Owner's Name: Edward Dilorenzo Owner's Address: Same Date of Inspection: August 9, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 172 Osterville,MA 02655-0049 Parcel: 162 Telephone Number: (508) 862-9400 Lot. 107 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was 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 Needs Further Evaluation by the Local Approving Authority Fails - Inspector's Signature: Date: August 15, 2002 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Edward Dilorenzo Date of Inspection: August 9, 2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain- 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1005 Old Stage Road Centerville, AM Owner: Edward Dilorenzo Date of Inspection: _ Au--ust 9, 2002 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 ?age 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Edward Dilorenzo Date of Inspection: August 9, 2002 D. System Failure Criteria applicable to all systems: You must indicate either`yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1005 Old Stage Road Centerville, MA Owner: Edward Dilorenzo Date of Inspection: August 9, 2002 Check if the following hove 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 ? I✓ _ Was the_-facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1005 Old Stage Road Centerville, MA Owner: Edward Dilorenzo Date of Inspection: August 9, 2002 FLOW CONDITIONS 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 Number of current residents: 2 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)): 2001 -52,000 gals.; 2000-53,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pamping Records Source of information: Never pumped-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: May 3191 -per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1005 Old Stage Road Centerville, AM Owner: Edward Dilorenzo Date of Inspection: August 9, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 15" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 12" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 2" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 f Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Edward Dilorenzo Date of Inspection: August 9, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) D-.pth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): 7-he D-box was level. There were no signs of solids. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Edward Dilorenzo Date of Inspection: August 9, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'w/2'stone-per as built card 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.): The pit had approximately T ofwater on the bottom. The scum line was at the same level. There were no signs offailure. The bottom to grade was approximately 9'. The cover was approximately 16"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1005 Old Stage Road Centerville, AM Owner: Edward Dilorenzo Date of Inspection: August 9, 2002 Map: 172 Parcel: 162 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot. 107 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. II At- 11-u 3 I � I - A3- 30 3 10 V Page 11 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1005 Old Stage Road Centerville, MA Owner: Edward Dilorenzo Date of Inspection: August 9, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25' +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 7"ae bottom of the leach pit to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod Commission water contours maps, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection andlor this report. 11 r v i z C n - i sr i - i� —77 c� r 0' C. rylc -- - - 77mq i t iA- V r � . •� II mm 1 �f I' r _ x , .' T- lk ..r I _. _ 31 , 01 3 - ..: ._-....,�'..,,_„•<�,...,_ .yell W r w' + �5 .�...,.. :.u:.. ..:r.u.w.. a.._....-:, r..._......_...<_ ..,.-___ ...... .........._ _, 'NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. VENT PIPE ® Least 24 inches tail SECTION A -A QAA\Tyi(GAILY 10' min. from- ( ) ALL OUTLET PIPES FROM THE Schedule 40 PVC w/Charcoal Odor Filter DISTRIBUTION Box SHALL BE Existing Foundation i house to septic tank PROFILE VIEW OF ADDITION TO LEACHING SYSTEM SET LEVEL FOR AT LEAST 2 FT. t2 r CONCRETE COVER D-BOX cover must be Septic took covers must be I TOP OF FOUNDATION = ELEV. 100.00 Assumed within 6 m. of finished rode _' -- � •-»�:. _ (Assumed) within 6 In. of finished grade 9 . Grade over Septic Tank - 99.00 Grade over D-Box - 99.00 A\ over SAS - 96.50 3•.of 1/8" - 1/2" Washed Peastone 3 - 5"OUTLET -. .•g(j ; o' 3/4- to 1 1/2 Washed Crushed Stone /' KNoacouTs Qe C _,` A c Ju � -15 5' 12" INLET .,T'.- S - 0.02 3 HOLE H-10 �, pU 1LET s' `' 4" PVC (CAPPED) INSPECTION PORT TO BE ST. BOX 3' Maximum Cover INSTALLED AND TO BE WTHIN S' OF GRADE 1805 01d St>t !14d O 10' EXIST. S-0.01 or Greater Top OF System- Elev. -93.40 I •-. / Y �. -"q,,. 9 �. FXIST. PIPE N 1,000 OAL. O 13• 0.01" per foot A 10"Effective Depth 155'- 4 - SCH. 40 Te 1J5" FROM EXIST. FUUNDATIt;r1 rn SEPTIC TANK o - ;` 4 Q PLAN SECTION CROSS-SECTION =' ~ h CONCRETE FULL FOUNLM y H-10 II - tV rn 0.83' (10 inches) I 5 Units e 6.25' = 30' 0 5 m 111 SYSTEM PROFILE 6 k,.°f 3/4"-„/2" " u 3 s1.25' 3' 3 HOLE H-10 DISTRIBUTION BOX ! r` compacted stone ; y o A 37,25' NOT TO SCALE Sao>t Not to Scale - u N ® Na►{E., ,nyO setNA�rEo > 4' �� 4' II Effective Length .S u 3 0 S❑IL ABS❑RPTION SYSTEM (SAS) GENERAL NOTES 6 in-of 3/4--1 1/2- p 11' y compacted atone a m EFFective vth 0 INFILTATROR HIGH CAPACITY (H-20 L❑ADING)/ GEORGE ❑'BRIEN NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE m 1. Contractor is responsible for Digsafe notification, Verification of Utilities_ o (OR EQUIVALLNT) Not to Scale and protection of all underground utilities and pipes. w Bottom of Test Hole 1 Elev-85.50 NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" 2. The septic tank and distribution box shall be set Groundwater Observed - NONE OBSERVED- - IeVe1 on 6" of 3/4"-1 1/2" stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation PERCOLATION TEST by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance with Title V of the Massachusetts state code, the approved plan Date of Percolation Test: JUNE 13, 2005 Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations. 1 Results Witnessed By. WAIVER (Per Barnstable B.O.H.) 6. If, during installation the contractor encounters any EXCAVATOR: -Shay Env. Svcs. soil conditions or site conditions that are different Percolation Rate: Less Than 2 MPI ® 36" from those shown on the soil log or in our design installation must halt & immediate notification be Test Hole Test Hole made to Carmen E. Shay - Environmental Services, Inc. NO. 1 No. 1 98 7. No vehicle or heavy machinery shall drive over the - SOILS ELEV_ septic system unless noted as H-20 septic components. DEPTH SOILS ELEV. DEPTH B. Install Tuf-Tite gas baffles or equals on all outlet tee ends. 0 96.50 0 96.75' ___ - - - ------- 98 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Sandy Loam Sandy Loam ~ 10. All solid piping, tees & fittings shall be 4" diameter 10 YR 3/2 10 YR 3/2 100.00 --97 Schedule 40 NSF PVC pipes with water tight joints. 0'-12" A, 95.50 MIS TEST HOLE #1 p'-g" Ae 96.00 TEST HOLE #2 11. Municipal Water is Connected to ALL OF The Residence and Abutting Sandy Sandy ELEV.= 96.50 Loom Loam ELEV.= 96.75 Properties Within 150 Feet. 57.25' 10 YR 5/6 10 YR 5/6 Failed THE PROPERTY LINES ARE APPROXIMATE AND 12 42" 83, 93.00 g-_ 36• BW 93.75 Leach Pit D-Box ` '* ` ' ;: ; COMPILED FROM THE SURVEY PLAN GENERATED BY Medium Medium +' • • -5 0• BAXTER & NYE OF OSTERVILLE, MA � • • Sand Sand >�_,� �,j _.t•, ENTITLED "SITE PLAN OF LOT #107 OLD STAGE RD. CENTERVILLE, MA- 96 , + DATED DATED MAY 31, 1978 2.5 Y 7/4 2.5 Y 7/4 - 4" PVCAND IS NOT INTENDED TO BE A SURVEY PLOT PLAN 42'- 132 G 36"- 132 G ---_ _ Vent IT SHOULD BE USED FOR NO PURPOSE OTHER THAN -------^ ------- ----------------- --- 96 THE SEPTIC SYSTEM INSTALLATION. i O> EXIST. 1000 GAL. O .� ' EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE SEPTIC TANK v, NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE !' EXIST. Deck I FROM THE EXISTING LEACH PIT TO BE DISPOSED EXIST. PROJECT BENCH MARK ! OF AS PER BOARD OF HEALTH SPECIFICATIONS. _ Cement Petio THERE ARE NO WETLANDS ARE PRESENT-W!TH!I 200' OF THE PROPERTY . Perc #t TOP OF FOUNDATION --- -- Depth to Perc: 42" to 60" ELEV. = 100.00 (Assumed) " ASSESSORS MAP 172 PARCEL 162 Perc Rate= 2 MPI �\ I Groundwater Not Observed EXISTINC LEGEND No Observed ESHWT LOT #108 EXIST. \\\ 11 ADJUSTED H2O Elev. = None ----- 3 .3EDRO:�M ` LOT #f 06 96 -- - xoasE GARAGE \\l `� 104X 1 DENOTES PROPOSED 2-187 DIAM. ACCESS MANHOLES 97--- ------ #1005 \\ SPOT GRADE s 98 x 104.46 DENOTES EXISTING SPOT GRADE �/ •. ; 1 i i PL PROPERTY LINE INLET - \ ET < ' \� ---_.._ -� i � i i 11 96P PROPOSED CONTOUR OUTTHE ACCESS COVERS FOR THE SEPTIC TANK, \ I I \ - EXISTING CONTOUR 97 DISTRIBUTION BOX AND LEACHING COMPONENT \ it / I I I \ � ::• --n--•" .-.*-- ----:�:: SET DEEPER THAN 6 INCHES BELOW FINISHED GRADE SHALL BE RAISED TO WITHIN 6. OF _----\ __-- I ( \ FINISHED GRADE STEEL REINFORCED PRECAST CONCRETE I_ ___ /__________ `1---�� c- � 1 1 `\ \ � DEEP TEST HOLE c�C INSTALL TUF-TI'TE GAS BAFFLES OR EQUALS 99----- - - -'� PLAN VIEW I / �' �\ EXIST. ; ; `\ c9a� PERCOLATION TEST LOCATION �\ r'- • DRIVEWAY 1 \ 6 FOOT STOCKADE FENCE 3-24' REMOVABLE COVERS I \ -'\ _ I 1 e • 4• 3" min. clearance I 13 INLET- I LOT 1 O7 INLET 8" rr .T12- min. Inlet to outlet 6.m_ l ugTd le�ei OUTLET I I 15,000 Square Feet I I I P LOT P LA EQ I '_ 4-0" min. I I 1, I ` --t ----- 99 v e".•"nl. Liquid depth L I 100.00 I I Yo OF PROPOSED SEPTIC SYSTEM UPGRADE PL 100 -----------j-----1----------------------1-41-------- 1� ------ ---100 PREPARED FOR CROSS SECTION END-SECTION ----------------' --------------'-- -_ ------- J O H N �c C H R I STI N E SULLIVAN AT TYPICAL 1000 GALLON SEPTIC TANK # 1005 OLD STAGE ROAD NOT TO SALE O�L_,0 s' 7_7 4 GE ®A -Z:) CENTERVILLE, MA Design Calculations F PREPARED BY: Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) AR /j/f E. SHAY Garbage Grinder: No E1l1T 1 1�T Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) Septic Tank : - 2 x 330 Cal./Day = 660 USE EXIST. 1,000 GAL. Septic Tank. " S ENVIRONMENTAL SERVICES, INC. . 81 SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch P.O. BOX 627 Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons O 20 40 50 Sidewoll Area: 0.74 gal./sq- ft. x 78 sq. ft. = 58 gallons cfsTE�a EAST FALMOUTH, MA 02536 -Providing: = 331.80 gallons SgNITAR P \ TEL/FAX : 508-539-7966 Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, MOM SCALE: 1 "=20' DRAWN BY: CES DATE: JUNE 16, 2005 TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE SCALE: 1 "=20' PROJECT#SD762 FILENAME: SD762PP.DWG SHEET 1 OF 1 ON THE ENDS. NO STONE UNDER.