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0211 SHOOTFLYING HILL RD - Health
� •• �, WestBafnstable • Damao Imo . . . 0 I cc $ertified Mail Fee Er /41 U7 Extra Services&Fees(check box,add fee as ate) ❑Return Receipt(hardcopy) $ y ' 0 ❑Return Receipt(electronic) $ -' Postmark O ❑Certified Mail Restricted Delivery $ '' Here r ❑Adult Signature Required $. []Adult Signature Restricted Delivery$ 1 E�- b� � MITCH AMES P Ln 211 SHOOTFL LL'RO '3 CENTERVILLE,%, :�� r �r r�r•,; Certifoed Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate •Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipient's retail associate. f`. signature)that is retained-by the Postal Service- Restricted delivery service,which provides � for a specified period. delivery to the addressee specified by name,or Important Reminders: C y:,i`i w to the addressee's authorized agent t Jra a; Adult signature service,which requires the ■You may purchase Certified Mail seryicewith;, signee to be at least 21 years of age(not First-Class Mail®,First-Class Packs a,*Service®, � \ available at retail). -r or Priority Mail®service. Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be least 21 years of age International mail: , y°'• � and provides delivery to the addressee specified f n Insurance coverage is notavailable fore ri See' •by name,or to the addressee's authorized agent with Certified Mail service.Hoir vk me;;pprchase (not available at retail). l of Certified Mail service does not chaiigii4W' a To ensure that your Certified Mail receipt is insurance coverage automatically includerPwith . accepted as legal proof of mailing,it should bear a i certain Priority Mail items. USPS postmark.it you would like a postmark on rr e For an additional fee,and with.a proper this Certified Mail receipt,please present your _ endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for _ the following services: postmarking.If you don't need a postmark on this Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion j of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece., electronic version.For a hardcopy return receipt, _ complete PS Form 3811,Domestic Return ' Receipt;attach PS Form 3811 to your mailpiece; IMPO6TANT:Save this receipt for your records. PS Form 3800,April 2015(Reverse)PSN 7530-02-000.9047 �.� .. SECTIONSENDER: cOMPLETE THIS •MPLETE THIS SECTION ON DELIVERY I ■ Complete ite� ss1,2 and 3. A Sig atur Agent I ■ Print your namend address on the reverse :. —� ❑ dre `ee so that we can return the card to you. ■ Attach this card to the back of the mailpiece, , B. R eived by(Printed Na,,) C. ivery or on the front if space permits. ddress different from item 1? ❑ s r delivery address below. No - -- MITCHELL, JAMES P `° r 211 SHOOTFLYING HILL ROAD- h. CENTERVILLE, MA02632 ' II"IIIII III ail I III lI II IIII I�II I II I I I I I I)I'lII 3. Service Type ❑Priority Mail Express@ ❑Adult Signature ❑Registered MailTM aiIT"' ?Adult Signature Restricted Delivery O Registered Mail Restricteii 9590 9402 5225 9122 7024 03 Certified Mail® :livery Certified Mail Reestdcted Delivery :turn Receipt for ❑Collect on Delivery foignature erchandise Collect on Delivery Restricted Delivery ConfirmationTm c -:ail ❑Signature Confirmatiorr�. 7 15 17`3 0`'0 0 01 ' 4 9 8 8 0 4 6 'ail Restricted Delivery Restricted Delivery PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return;Receipt M First-Class Mail Postage&Fees Paid USQS Permit No:GAO 9590 9402 5225 9122 7024 03 United States •Sender:Please print your name.,address,and ZIP+4®in this box• Postal Service Town of Barnstable Oa Health Division M 200 Main Street I Hyannis, MA 02601 I r NOV-01-2019 03:52 From: To:15087906304 Pa9e:1/1 To" of Barnstable Replato>ry SelrOces Thomlae P.Geiler,Director a Public I8[ealth D"im rso o�r a� '�'honaae McKean, 200 Main Street,$gannis,MA 02602 Office: 508-8624644 Par. 508-790-6304 installer&IDeenener Certifications®rm� Date: 0 ?0 ( sewage Pe ruaib# g014`��� Assessor's 1VdapTarsel 21 Designer: POOUN CAN&Q19in W61 xrnsta➢ler: 00VOLOM• CAM R Address: 93q MAIN , Address: . 45 IOU Om was issued apermitto install a (date) wstauet) septic system at 211 S 6otE'u•6 v19 �H U M based on a design drawn by (address) De�n1l E1_ h. Q A LA. E57 dated . 20 24- (desigae 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 dist<ibutionbox 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 r but in accordance with State&Local Regulations. Plan-remon or owifi - uilt b signer to follow. j • �,�,``���`Mq sic DANIELA. 3 OJALA � CIVII. v I (installeres guature) No.46502 Q• I rS�0 AL eaG esignW Ss i afire (Affix esiper's Stamp Here) gILAS BZTQM TO )BARNSTABLIC FLMUC ]HEALTH CERTMCATE C Mf'7,lfANG'E '@b1DL ®� L N•0T. B'E SUED B TMS WO AND ASIMLEUr ARE ItECE BYT)TS S 7BJU FD_ARNSTALIC MALTA DMSION Z96—N -HOU Q:Eceltb/septidAoaigr cmecatioapo=3-26-04.doc TOWN OF BARNSTABLE I OCATION-.'Wt � i NIA {+t LL l�6 SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL zl4d+ -1� INSTALLER'S NAME&PHONE NO. :TOT, SEPTIC TANK CAPACITY L,%i<( rat A6 1Cz-6!ti LEACHING FACILITY:(type) NO.OF BEDROOMS �- - � OWNER i C tit-1.L_ PERMIT DATE: J Q - -=f COMPLIANCE DATE: U �' Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 4— :�: 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) N Feet FURNISHED BY \0 3 O l T43WN OF BARNSTABLE LOCA' ON07 f l fG -A Y'L �ACrL+s:. pr,55�SMWs."�i LQT .r.�.. 'NSTALL OM 4AM-E tk P I4I+IE N0. j �33p'E'1fC Th. CAPAC.1'I'Y � Lif ACLI wr 1PACII I'l"Y� �S39RC)OMS OWN FBRlElii'TI� 'E. Ct91vI gC..YA c DATE.,,�,._ ....:. Sopa�ration bituna Bstvieeu rho: lp. Maximum;AdWlsd Grau�adwtr�'k�ble W the B�uatn ok lachin�khicili�)+ e Prwi5 U�J'ot��r:;tippiy Vlc t`suid Le iag l�acdtry i y rslls exist boat oyt set�.ae evlt3un:2A0 feat a�1�actiinS f�c�Isy,). ...—. aid U t�let9�4 end L�,bg,PaciLiq�(U MY wnt�tls exist two 3QU f'e pf leacitfng�'us�iliry) :: le-11 e -- B0.ck sty c a 0 3 --3 i No (i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplitatlon for -Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System K'ndividual Components Location Address or Lot No. S '[,� 0 i(( PJ Owner's Name,Address,and Tel.No.,,520 S-?p-136a Assessor's Map/Parcel °d I t/ �� 4 ©/I 1 �1n j •�' Installer's Name,Address,and Tel.No.56`6-1)/~93 9 Designer's Name,Addre ,and Tel.No. 5b S /�®s iota a i;cOns-�ry ,_ZM Po mm c�� 93�rt/til�yi Ito OR6,7S Type of Building: Dwelling No.of Bedrooms Lot Size 3 i 3 & sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) a U gpd Design flow provided 3 VC/ gpd Plan Date p pjfj" gO ?0/9 Number of sheets Revision Date Title 7 6/ � &,16/ Size of Septic Tank 64J J-ir)q /U/�D�b� ype of S.A.S. Description of Soil��&A 4 /moo Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and mainten the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmenta de and n o place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed _ Date '16/ Y!( 9 Application Approved by Date Application Disapproved by Date for the following reasons oe Permit No. Date Issued �0 t 3, No. 0/ Fee THE COMMONWEALTH";dF MASSACHUSETTS Entered in computer: _ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ,r 2pplication for MispoBaf 6pstem Construction Permit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System Wndividual Components Location Address or Lot No. ,I Sr Ki7 IV (' Owner's Name,Address,and Tel.No.,.5�—,�b .?�W-/36:X Assessor's Map/Parcel a( a ig ZVOAX5 M i4 l Installer's Name,Address,and Tel.No. pg-09/.9399 Designer's Name,Address,and Tel.No. f3or-J66tt�-CgonsA ac4ati,,-Zm P-a6,0y rv(-/ .0040w) _�- Type of Building: f Dwelling No.of Bedrooms Lot Size /S 313 } sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 V 9 gpd Plan Date�j0.4,,yt �/)�/9 Number of sheets � Revision Date Title Size of Septic Tank o-,e 4,�/�j/"e,-f ype of S.A.S. Description of Soil-t5,u, Z-T. A& LG � i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: E} 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 Gode and the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 16 y// Application Approved by Date Application Disapproved by Date for the following reasonst Permit No. �� ►'f /-q Date Issued - ----------------------------------------------— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(A Upgraded( ) Abandoned( )by ,��v�v � r� >r,�t�S► I/��' at . _ p has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No /9-3 I dated 1 Installer Designer #bedrooms Approved ddde'siig flow ,---° gpd The issuance of this permit shall of be construed as a guarantee that the system will functi,n as des•n Date l ' � Inspector, Fee 17 ) / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposar 6pstem Construction permit Permission is hereby granted to Construcct�( ) Repair( � Upgrade( ) Abandon( ) System located at QSA L /, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must ompleted within three years of the date of this p" ermit. be Date /� Approved by oFtKE r� Town of Barnstable Barnstable P~ a°: Inspectional Services Department ; ��j BA ABLE, 9�A1639. ,�� Public Health Division T�ONVA�b 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 0046 August 13, 2019 MITCHELL, JAMES P 211 SHOOTFLYING HILL ROAD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 211 Shootflying Hill Road, West Barnstable, MA was inspected on 07/25/2019 by Shawn McElroy, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following; 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEP'FIC\Title V Inspection Report Letters Mai Iing\Failed or Needs Further Evaluation Letters\21 1 Shootflying Hill Road West Barnstable.doc IKE a� ti Town of Barnstable • anxrrsrner.E. NAM 039. ,.� Inspectional Services Department ArEp hAl►'�A Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS O 1 YEAR DEADLINE CRITERIA tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation`of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts 0�/�-0/� w Title 5 Official Inspection Form i'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ._✓ >" 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centervill � MA 02632 7-,25-19 page. City/Town State Zip Code Date of Inspection f.. t_. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that] am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ® Fails 7-25-19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form II rt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 4'.; 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passses: .. ❑ 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: 2) 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form I;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is recuired for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced El , El ❑ ND (Explain below): ❑ obstruction is removed ❑Y El ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection Form wa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 f c Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form h1 Subsurface sewage Disposal System Form -Not for Voluntary Assessments 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® ❑ 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 'h 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 water supply 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 2000 gpd- 10,000 gpd. ® ❑ 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. 5) 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 CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 . : Commonwealth of Massachusetts . Ir Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate re ional office of the Department. 9 P 6. You must indicate "yes" or"no"for each of the following for all inspections: 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? ® ElWere 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? ® ❑ Wasthe 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)] t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i,l. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is regaired for every Centerville MA 02632 7-25-19 pace. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 7-2019 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form �01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J,Yr 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner----pumped 2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form I;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V�-� 211 Shootflying Hill Rd J' Property Address Jim Mitchell Owner Owner's Name info d for every on is required for Centerville MA 02632 7-25-19 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 48"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5ins�.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form pl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :.; 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 40"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no'sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is Centerville MA 02632 7-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be,opened)(locate on site plan): Depth of liquid level above outlet invert Over 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.): D-box was sumberged below water at inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ! +il�1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts a ' Title 5 Official Inspection Form r ;�Iti Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VI >s` 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was filled to capacity at inspection. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p y ry r S F . 211 Shootflying Hill Rd _ Property Address Jim Mitchell Owner Owner's Name information is Centerville MA 02632 7-25-19 page. p recuired for every a City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form - �rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 4 y r- r � ` �- J4 �2 10 t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form I,61 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name requiratifo is Centerville MA 02632 7-25-19 required for every pace. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5in5p.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' i)l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 211 Shootflying Hill Rd Property Address Jim Mitchell Owner Owner's Name information is required for every Centerville MA 02632 7-25-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 P c ` a j • 1 4I`� RECEIVE® 4 I J U L 2 9 2003 COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE EXECUTIVE OFFICE OF ENVIRONMENTAL AFF RS HEALTH DEPT. z DEPARTMENT OF ENVIRONMENTAL PROTEC N110A? I d ' 4- PAP PARCEL Q1 LOT `7 TITU 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 211 SHOOTFLYING HILL RD.CENTERVILLE, [VIA 02632 rl Owner's Name: ESTATE OF R,OBERT NELSON Owner's Address: 211 SHOOTFLYING HILL RD. CENTERVILLE, MA 02632 Date of Inspection: 7/1/03 Name of Inspector: (please print) JOHN GRAC1, INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address ar.d that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was perfcl coed 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: X Passes _ Conditionally ses _ Needs Furth valuation by the Local Approving Authority Fails Inspector's Signature: t _ bate: 7/2/03 The system inspector shall submit jopy of this inspection report to the Approving Aitithority(Board of Health or DEP)within 30 days of completing this inspectiIf 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 S`_'STEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE S Y.STEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under tk.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. Tillo S Incnrrlinn Form 6'1S"(I(M I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z v DEPARTMENT OF ENVIRONMENTAL PROTECTION r w ti f `t O,M Sao TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 211 SHOOTFLYING HILL RD. CENTERVILLE,MA 02632 Owner's Name: ESTATE OF ROBERT NELSON Owner's Address: 211 SHOOTFLYING HILL RD. CENTERVILLE,MA 02632 Date of Inspection: 7/1/03 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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: X Passes _ Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 7/1/03 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. Titla. 5 lncna.rtinn Fnrm (,/1 S/?000 1 Page 2 of 1 l' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 211 SHOOTFLYING HILL RD. CENTERVILLE,MA 02632 Owner: ESTATE OF ROBERT NELSON Date of Inspection: 7/1/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. n/a 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: 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 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: 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): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 1 f OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 211 SHOOTFLYING HILL RD.CENTERVILLE,MA 02632 Owner: ESTATE OF ROBERT NELSON Date of Inspection: 7/1/03 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 n/a "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: n/a Page 4 of 1 f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 211 SHOOTFLYING HILL RD.CENTERVILLE,MA 02632 Owner: ESTATE OF ROBERT NELSON Date of Inspection: 7/1/03 D. System Failure Criteria applicable to all systems: 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 _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged 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 '/z 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 privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 211 SHOOTFLYING HILL RD. CENTERVILLE,MA 02632 Owner: ESTATE OF ROBERT NELSON Date of Inspection: 7/1/03 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 _ 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? X _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? 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 baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum? X _ 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 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 unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 211 SHOOTFLYING HILL RD.CENTERVILLE,MA 02632 Owner: ESTATE OF ROBERT NELSON Date of Inspection: 7/1/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 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)): q;�x Q� _ LVp00 Sump pump(yes or no): NO Last date of occupancy: 2/1/03 ��1 i 00 6 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a 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 OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a Approximate age of all components, date installed(if known)and source of information: 1989 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO F f Page 7ofIi OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 211 SHOOTFLYING HILL RD. CENTERVILLE,MA 02632 Owner: ESTATE OF ROBERT NELSON Date of Inspection: 7/1/03 BUILDING SEWER(locate on site plan) Depth below grade: 60" 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: 54" 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) Dimensions: 1000 GALLONS" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: 0" 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: 18" 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.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: —(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): n/a Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 211 SHOOTFLYING HILL RD.CENTERVILLE,MA 02632 Owner: ESTATE OF ROBERT NELSON Date of Inspection: 7/1/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a 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 r n : N 0 ode es o o O g (Y ) Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) 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.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 211 SHOOTFLYING HILL RD. CENTERVILLE,MA 02632 Owner: ESTATE OF ROBERT NELSON Date of Inspection: 7/1/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. PIT WAS EMPTY AT TIME OF INSPECTION. STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN 6" OF LIQUID IN IT. BOTTOM IS AT 12 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) 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.): n/a 4 Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 211 SHOOTFLYING HILL RD. CENTERVILLE, MA 02632 Owner: ESTATE OF ROBERT NELSON Date of Inspection: 7/1/03 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. o A O ° AA `0 AP �4� Ace IFA n 6D y� in Page I I of i I C i OFFICIAL INSPIJCTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DIP c'. 'C DISPOSAL SYSTEM IN�,PCC TION I'OIZM PART C SYSTEM INFORMATION(continued) Property Address: 211 SHOOTFLYING HILL RD. CENTERVILLE,MA 02632 Owner: ESTATE OF ROBERT NELSON Date of Inspection: 7/1/03 SITE EXAM _Slope _Surface water _check cellar Shallow wells Estimated depth to ground water 14 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-if checked, date of design plan reviewed: n/a 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 You must describe how you established the high ground water elevation: HAND AUGER- 14 FT. t � TOWN OF BARNSTABLE LOCATION 5��0/ llI Pj SEWAGE VILLAGE, ASSESSOR'S MAP & LOT I e INSTALLER'S NAME & PHONE NO. �WqZV--" ��14 a G/�( v SEPTIC TANK CAPACITY /000 Q LEACHING FACILITY:(type) L eAJA IPA (sue) 6-x 6 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILD EROR OWNER �L� , DATE PERMIT ISSUED: �- - DATE COMPLIANCE ISSUED: �� VARIANCE GRANTED: Yes No --� r n Y r Z6 AJ w. No..... .. � Fxs THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -..._.. _ .W ....... OF.O /Q .S _t . lirFation for Utz .anal Works Tomitrurtivat Prrutit OApplicationis hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: dj�ress �j �" [7 Il!e Y rz+fa ( 1 c_ C�1® �4 _0r d o. �n �1=--- - -=------,-----------.•...-------------------------------_..... E--?..........• . ---- ���!�� r 1 Kam, s O ner � A r w . ..�:.....A. �.�`� ...................................•---- ....s-.---- -�_.:��._. .'1�. ,.a Installer +.. Address U Type of Building Size Lot/jam 5�_..___Sq. feet ., Dwelling—No. of Bedrooms..........................�._.......__....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -•----------------------------------------------------.-•-----------------•--------------•---.._...--------------•--------...---•-----............---- W Design Flow................................ __gallons per person per day. Total daily flow.._.._Z.__Z1_........ ................__gallons. f� Septic Tank—Liquid capacityW !?..gallons Length._A " Width..... �`p Diameter................ DepthS_' Disposal Trench—No..................... Width.................... Total Length................... Total leaching area-•__-.•-----__------sq. ft. Seepage Pit No---------/-------- Diameter....../,0........ Depth below inlet.... Total leaching area_2 ----- ft. Z Other Distribution box Dosing,;ank ( ) ,,� qq aPercolation Test Results Performed by._ .__�i�....C l ...5.4.� �-�---------- Date--- -S"-- f 1.4 Test Pit No. 1.......;Z-...minutes per inch Depth of Test Pit.....1.Z....... Depth to ground water------ fs. Test Pit No. 2........Z...minutes per inch Depth of Test Pit..__...... Depth to ground water___..�~.... O Description of Soil � ,�!�!e ...._� x •--- , °V ± �� 1 4--4-------------------------- w UNature of Repairs or Alterations—Answer when applicable..__________________________•-----•--_______-.------______--__-________-__---_---•---_-------_-. ------------------------------------------------------------------------•--•-•----------.........-•---------------------------------•------------------------------------------------.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ('1T+-1�-•• the provisions of 1� .LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the oard f 1 alth. Si ned � K. ........ ®._ ..� _- ------------- Date Application Approved BY--------•-•----------�---•--•-----------------------------•------------...._••. t Z Date Application Disapproved for the following reasons---------------------•-••-•-----•----•--•----•---•-------------------------------•-------------------•-----...--- ..............•------------...---..........--•--••-----------...--...-•••-------.....-- 11_,�_ PermitNo.----- ........ _ Issued--•--•----------------------------•---•-•-•--•-•--•---. No..S ( . FEB THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. ! OF.,.�•�3i�i1.�, �:_._ Appliration for Diipoiial Works Tmitrnrtion P.erntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_............................................................................... •---•-••--......-•-•••---•---------•------..... --------•--•--••--....----••----••......•. Location-Address or Lot No. ......................_.......................................................................... .......•.........................._.......•---•.............................•......---•-•-------- Owner Address W Installer Address Type of Building Size Lot:'::_. 4_ ------Sq. feet ►-� Dwelling—No. of Bedrooms...................................-_-__---_Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a Other—Type g -------------------•----•--• P ( )--- Cafeteria ( ) dOther fixtures - ----•--- -------------------------------••----------------------------------------------------------------- ---------- W Design Flow............................... _....gallons per person per day. Total daily flow____ .=_e..........................gallons. WSeptic Tank—Liquid capacity/Z,}.__gallons Length..==_..:.�'='.:.. Width.... Diameter................ Depth.:'.-_ x Disposal Trench—No..................... Vidth.................... Total Length.............. .... Total leaching area--__----••--_------Sq. ft. Seepage Pit No_________ _________ Diameter---.._.jam._.... Depth below inlet... °..... Total leaching area. :c'�_....sq. ft. Z Other Distribution box Dosing.tank ( ) aPercolation Test Results Performed by f✓�_..__ Gt:_.._:_...: .......j .a........... Date........................................ Test Pit No. l........ _._.minutes per inch Depth of Test Pit------'.:='_. ... Depth to ground water_.__-:`_.............. 44 Test Pit No. 2._.._..,�_._._minutes per inch Depth of Test Pit----1.2_.'!y... Depth to ground water--------_'.�"_____. ......................................... f- -•---•------------•------ O Description of Soil.... - '= =='V/ ...... �/" 3 /%�� x � - U ---•---••••••--•-••---•••••----••-••--------------•--••-----•---••••---•-•.._..-•••--•--••---------•---••-••-----------------•---•-•-••...--------••---••-------------••--------•-•-••-•-----•--------- w ----------------------------------------------------------------------------------- --------------------------------------------•-------------------------------------------------------------------••- M. 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'T' LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue bUth bard of health. C� Signed.... ---------------------•••......---------• Q a� D -------- �r Ji C � � — D Application Approved By-----===` -----�---- ... `� f Date Application Disapproved for the following reasons:----•...........................•••---------•---.._............_..-•-------.............._...................-- ..............................................-----------•............----------.....-•----------•...-•-•-•--•----•-••---•••••......---•---•----------•-••--•......................................... Date PermitNo.------`_='.............................................. Issued....................................................... THE COMMONWEALTH-OF MASSACHUSETTS BOARD OF HEALTH . .............OF......(�7�.................................................................... TWrtif irttte of Tontplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby ( ) •------------------------•------•--...--•--- ........---••-•---• -----•--------e-•-••-----•..........................................................-------------------- I .. ! S statl/1�` e (7 r C L .✓� ri �r S has been installed in accordance with the provisions of-TT 1 }5 of The,Sjate Sanitary C de as described in the application for Disposal Works Construction Permit No -- ------------------ dated_. .. l._ � .__._..._.._....._._._.._. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A UARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.-•••............. ..__.. Inspector............. .......................................................COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................... -•-•-- .... - NoC.::................... FEE— = ........... Disposal Works Tono#r ion rrntit Permission-is hereby granted............................................................................................................................................... to Construct( ) or Repair ( )--an Indivi ual•-Sewage Disposal System at No.---------- = .........................-=_===f' ).:a.:. f (------- . �_r*..�;•_r !..� 4 I. `� //1 _ -----••------------------ street as shown on the application for Disposal Works Co`nstructton Permit N& Dated.._.�I--t'.'�'.I.��7............ --- .................... _"I ' =%ry_r / - ----•--• .. -- lt�2 Iffy Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS zot 56 1-6 30 r000 it •eot 8 r� I I i I I l'1/2 4.torce; -rPz SIerAJo o. ' I lit r?'g62 S �o ................................ . � '�• a I so At C �? I , 9 '•lydrecnt rlS6.S f..aq. boat 60.D i S�fiic ��.ic No. bedAwO1N�: ,I.tt Ca.,0e ?0 ►. . . £�,tin+ated w _ j - 2 cap 14 9 �rc,tbo t 1'oacl Jae u-rg g' .C'euchrrta. a�ieiz ; jI i 2b a : } Idyanr,�, /�la. 02601 20 a I i Cacap .. 4 ,t ; Sketch I)t an of Xand in (Ueda gcr t &,b&, p boa• l�obett /Ve,t .ort !)e iaut tot 7 ate. dhovm on Xand Court 122SS6 Rev atiLo ad. aJl c on ail` awned d atur t• ' ) 1 + date: --fllc 2n, • a2ri .t ze �c� o a i..i -173 -5-89 I I ; •, Alo wa tch encov�ztehed j'etc. 2 nr�i.n. p eat SIP 2 53.1 S6•o !.i r L.. 5/•3 '�� 54•s' ) j r . � 4 rrrtac.l i `CUB E J. D. c K NEY, H 2 06 Au o.4 N '� o: 49Q oq. �o FOIST � s 4i.3 43.5 I t 56 :?' 1 1-6\JW 01000 / l .eot $ / a�.t i •1-h P''t UI/2. I b 1 _I b,43 f i- �Ib�u VO l i i i i i dot 6 SGrA'o ZG' o 17: 862 S nAto I 0 1 f �� ;. 56.4i: I ' W 1 � 9� i. I I I 1�.i I A:�z� catch a j i�t II: . . i i i � � 0 s - I �hoo�g�-G.i•i-n� l�.i,LC load . ..I � i . . _ {. i: _ . 60 ' Se�tcc No., bed400lild., ;.; ; is ' t t Ca.00 %u�i�e�r the Scr�Le 1 "-30 £� o'�°w j' ��� cep ' 49 IIc✓cbot, 1?oad Jrfe B-IS-89' .l' - ,J a,w;- pia., 02601 I�e�cvtue : �' ` ;_� i �0 i qP i� I i ' slutch Plan o Xand ,in 6Vedt ga b.te. Aa:.i �.:; . .�._ ;_1 53o t /\26ie t t Neh.ort ' �: lie i.0 tot 7 a� w�t: on Xand Court t 722556 R"�" e atiLoIti ante on MW a iuw," da ttem. i 9e t n%t P-7273 11 o wa..erz enco top r, top 1 S4-S, 1 r yu n ,CAA If. '. —� � tiN 01 OF' I Ile, .rculc•1 �cu�l E v�ARO —4 c K NEY, 2 06 q �49Q Q' .e q4' �� O Ao GIST `� �J'J� $1EA` c 1AO 43.5 i I •1 SYSTEM PROFILE NOTLS (NOT TO SCALE) ALL SYSTEM COMPONENTS SHALL BE 1. DATUM IS NAVD 88 t MARKED WITH MAGNETIC TAPE OR ee Exit COMPARABLE MEANS FOR FUTURE LOCATION. cn 5�t 2' CAST IRON COVERS TO GRADE OR 2. MUNICIPAL WATER IS EXISTING o� -::-6 CONCRETE COVERS TO WITHIN 6" GRADE, 'Rote 6 �oG� COORDINATE W/ OWNER VENT 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. d• TOP FOUND. EL. 59.2' 2" PEASTONE OR GEOTEXTILE Serviae R �� \ 4. DESIGN LOADING FOR ALL PROPOSED PRECAST / Locus MINIMUM .75' OF COVER OVER PRECAST FILTER FABRIC OVER STONE 2%, SLOPE REQUIRED OVER SYSTEM 55.9' UNITS TO BE AASHO H-29- NOTE: 2" MIN. WALL BLOCKS OR 5. PIPE JOINTS TO BE MADE WATERTIGHT. THICKNESS REQUIRED PRECAST RISERS / �\\ Lakeview i 55.96' 4"OSCH40 PVC MORTAR ALL H-20 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE / � + 6" MIN. SUMP PIPES LEVEL 1ST 2' COMPONENTS W! , 12" MIN. INT. DIM. 4' (TYP,) INV'S EL. 51.9 4' , WITH 310 CMR 15.000 (TITLE 5.)ENDS SIDES 52.9_ M.*"EXISTING 14" EE °°°°°°°° °°°°°°° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND TEE SEPTIC TANK TEE ; ° ° ° 0®�® ®®®� �® -mmm� o°o°o°o° NOT TO BE USED FOR LOT LINE STAKING OR ANY *54.66 0,0,00000;oa WATERTEST D'BOX o°o°o°o° 0®�I0®0®®E3� ®CC�]]r=== En ° ° ° ° '°°°°°°°° ®®D�O�®®®®® ®hJ ;°°°°°°°° OTHER PURPOSE. Wequaquet GAS BAFFLE::: °o�������o° FOR LEVELNESS c� ;°o°o°o°o °o Lake 52.17' S2.0' ° ° ° ° °°°°° 49.9 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. `:�,.. 't,.. ..•e ` • . 9. COMPONENTS NOT TO BE BACKFILLED OR o0o�o�a° o°o°o°o°o°o°o°o°o°o°o°o°o°o°o°o°o �o000 0 0o0o0-,,o00000000000o�o�o�o�o�o�00000. 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. H-20 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. CONCEALED WITHOUT INSPECTION BY BOARD OF (2) UNITS REQU,RED HEALTH AND PERMISSION OBTAINED FROM BOARD ALL AROUND PRECAST STRUCTURES 6" CRUSHED STONE OR MECHANICAL OF HEALTH. OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X •12.83' COMPACTION. (15.221 [2]) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP ( 10 % SLOPE) ( 1 7. SLOPE) VERIFYING THE LOCATION OF ALL UNDERGROUND & H-20 H-20 OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF SCALE 1"=2000'f FOUNDATION EXIST. SEPTIC TANK 25' D' BOX 12' LEACHING 44.2' BOTTOM TH-1 WORK. FACILITY NO GROUNDWATER FOUND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL ASSESSORS MAP 214 PARCEL 19 *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC BE REMOVED BENEATH AND 5' AROUND THE PROPOSED LEACHING FACILITY. SITE IS LOCATED WITHIN A ZONE II UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS TANK' SIZE AT 1000 GALLONS AND ITS SUITABILITY PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM FOR`: RE-USE. REPLACE WITH 1500 GALLON 12. EXISTING LEACHING FACILITY SHALL BE PUMPED TWO 'BEDROOM DEED RESTRICTION REQUIRED SEPTIC TANK APPROPRIATE TO SITE CONDITIONS IF AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND- NOT SUITABLE SAND. 99_ EXISTING CONTOUR SYSTEM DESIGN. X 99 1 EXIST. SPOT ELEV. -[99] PROPOSED CONTOUR ( GARBAGE DISPOSER IS NOT ALLOWED 198.4] PROPOSED SPOT EL. BENCHMARK: DESIGN FLOW: 2 BEDROOMS @ 110 GPD = 220 GPD TH1 CEMENT BOUND E USE A 220 GPD DESIGN FLOW TEST HOLE =52.4 NAVD88 6 0 59 46 .- 2/ SLOPE OF GROUND f o �1 ,_--�\ SEPTIC TANK: 220 GPD (2) = 440 UTILITY POLE �� h **RE-USE EXISTING 1000 GAL SEPTIC TANK h� �� LOT '7 FIRE HYDRANT. > \�\` LEACHING: � / HE 15,313± S.F. 3 t 1 NOTE: NOT ALL SYMBOLS MAY APPEAR IN'DRAWINQ __. - .. x�_ w,..�...._-_ SIDES:_.,2 (25 + 12.8 ) 2 .74 = �12 GPD BOTTOM 25 x 12.83 (.74) = 237- GPD PROP. VE WITH ARCOAL FILTER D BUGSCR N 5 TOTAL: 472 S.F. 349 GPD TEST HOLE LOGS �n" PLACEMEN Y 12'2'ACTOR GARAGE USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) HOMEOWNE ULTA N) 56 I SLAB • WITH 4' STONE ALL AROUND ENGINEER: DANIEL E. GONSALVES, SE #13587 19 9, (WALK OUT) -P rn l- d l DAVID STANTON, RS 1 WITNESS: GRAVEL EXISTING DATE: 9/5/2019 DRIVE ,i DWELLING PERC. RATE _ < 5 MIN/INCH I I �� TOF= 59.2 APPROVED DATE BOARD OF HEALTH MA s CLASS I SOILS P# 19-129 51 I C� ELEV. 2 ELEV. 011 4 55.2' 0" 55.5' _ I DECK oI I / 14„ ALL 12 FILL I 3 41 TITLE 5 SITE PLAN PAVED OF LS LS I / IVE \10YR 3/2 20" 10YR 4/2 , I I � � #211 SHOOTFLYING HILL ROAD 18„ 53.7 53 8 WEST BARN TABLE B B I I S BARNS TABLE, MA I LS LS PREPARED FOR 40" 10YR 5/6 51.9' 42" 10YR 5/6 52' o , BORTOLOTTI CONSTRUCTION/ 59 '-- a439 ON JAMES MITCHELL PERC C C DATE: SEPTEMBER 20, 2019 0 �DANIEL NIEL of MAS o DANIEL� F MAS - off 508-362-4541 MS MS S ��� sgcy � sq� fax 508-362-9880 �Jgo A. ��m R� G��� n o OJALA jo A. I downcape.com 4 CIVIL N (!� oJ _A 2.5Y 7/4 2 / E No.46502 !c 40:980� d 5Y 7own cope engineering, //1C. �'01STE Al ��oF �P S civil engineers 132" 44.2' 132" 44.5' �r s&. taNAL NG R\JE .: land surveyors NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' �-Z t�- �� 939 Main Street ( Rte 6A) YARMOUTHPORT MA 02675 DCE # ' 9-250 o 10 20 30 40 50 FEET DATE 'DANIEL A. OJALA, P.E., P.L.S. 19-280