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HomeMy WebLinkAbout0055 AMES WAY - Health 4iV,E,S WA:�7. CFNT VI .I.E A=M-006=001UPC 12543 i Barr � Ulf ® No. 53LOR Jwa HASTINGS. MN � '' x S I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS f d DEPARTMENT OF ENVIRONMENTAL PROTECTION r r d , ti r re TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 55 AMES WAY CENTERVILLE,MA 02632 t RECEIVED Owner's Name: MIKE EDWARDS Owner's Address: 55 AMES WAY CENTERVILLE,MA 02632 FEB 1 6 2001 Date of Inspection: 2/12/01 TOWN OF BARNS iABLE HEALTH DEPT. Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P10.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: 2/12/01 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 '1'^ THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL 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. I: Titlr r T,,,noriinn Fnrm r,,/I si?nno Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 55 AMES WAY CENTERVILLE,MA 02632 Owner: MIKE EDWARDS Date of Inspection: 2/12/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Sectioa 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: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL 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. t 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 _ distributon box is leveled or replaced ND explain: n/a n/a The system required pumping more tt�n.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 11 i. ' I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 AMES WAY,CENTERVILLE,MA 02632 Owner: MIKE EDWARDS Date of Inspection: 2/12/01 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 in a manner which will protect public health safety and the environment: not functioning p p � Y _ 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 1 Z Page 4 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 AMES WAY CENTERVILLE,MA 02632 Owner: MIKE EDWARDS Date of Inspection: 2/12/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: 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 ''/2 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 1999. 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 colifdrm,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 P Y P g g q less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 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 11 of a public water supply well If you have answered"yes"to ariy'giiestion in Section E the system is considered a significant threat,or answered "yeg" in Section D above the large system he*g"fnl[ed,Tile Owner or operator of any large gymem comidered a gignlfieant 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 i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST I i Property Address: 55 AMES WAY'CENTERVILLE,MA 02632 Owner: MIKE EDWARDS j Date of Inspection: 2/12/01 t i 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? i 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 exampe,a plan at the Board of Health. X _ Determined in the field(if any of fb1e failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 55 AMES WAY CENTERVILLE, MA 02632 Owner: MIKE EDWARDS Date of Inspection: 2/12/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 3110 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)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203):,n/agpd Basis of design flow(seats/persons/sqft,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 E OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: 1999 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: 1987 Were sewage odors detected when arriving at`the site(yes or no): NO Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 AMES WAY CENTERVILLE,MA 02632 Owner: MIKE EDWARDS Date of Inspection: 2/12/01 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" 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: 1000G L 8' 6" H 5' 7" W 4' 101t'' Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS. 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.): f n/a Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 AMES WAY CENTERVILLE,MA 02632 Owner: MIKE EDWARDS Date of Inspection: 2/12/01 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(yes or no): NO 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.): THE DISTRIBUTION 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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 AMES WAY CENTERVILLE,MA 02632 Owner: MIKE EDWARDS Date of Inspection: 2/12/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a FLOW DIFFUSERS leaching chambers, number: 3 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 0. Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE FLOW DIFFUSERS APPEAR TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY. 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 AMES WAY CENTERVILLE,MA 02632 Owner: MIKE EDWARDS Date of Inspection: 2/12/01 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. D ° 0 A A.0 I �o 13 in Page I 1 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 AMES WAY CENTERVILLE,MA 02632 Owner: MIKE EDWARDS Date of Inspection: 2/12/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+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 NO Observed site(abutting proMty/observation hole within 150 feet of SAS) NO Checked with local Board of HealtP,-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a. You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET tt t ,a �� Fps.. S�a No..... •--••----..... ..........._............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH P SZ23 Allp iration for Disposal Works Tamitrnrtion ramit . � Application is hereby made for a Permit to Construct ( I<or Repair ( ) an Individual Sewage Disposal ystem at: .......... _�.T..f...... '.. ................' - -e•`� -e ..i/1.. ..-'.....---•---•-••-•---------•-••--•................... Location-Address %`- or Lot No. ......................—.......................................................................... ------------...................................................................................... Owner Address W " ......................................•.. -- --•-••-•-•-'--•-•-----................•.....__....... ......._ ................. a '• Installer Address q dType of Building Size Lot.._ ..4_ _/... q. feet aDwelling—No. of Bedrooms............... ......................Expansion Attic„(' Garbage Grinde>- t( )— p, Other—Type of Building .--_.. No. of persons......_<,................. Showers ( ) — Cafeteria ( ) a Other fixtures .. ............................................ W Design Flow....................... -.gallons per person erg day. Total daily flow__..._..._ _ t._ ..............gallons. Septic Tank—Liquid capacityl�®Pgallons Length--- .__. .Y-Width_ "Diameter _ Depth.'_ .°� -- ----- �{ Disposal Trench—No.--------I-___ _ Width../.a..._...... Total Length... ....�..... Total leaching area___-4'0.T.sq. ft. Seepage Pit No--_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box ( Dosing tank `-' Percolation Test Results Performed b �_ _ .._.. `..i .............. Date_.............. a by................... Test Pit No. 1...A.4.minutes per inch Depth of Test Pit...../.AW" Depth to ground water.... .r_�.v� (i Test Pit No. ._....�..minutesper inch Depth of Test Pit1. _. Depth to ground water_____._ . ,.. ._ a Z)���- ------ -----------------------------------•---------------------------------------- �_---------- ........ ------------------_ O escription of Soil................. `�, `� .. ./``'.::�-x. -- ...--- _ c. �., w ------------------------------------------------•--...-----------------------------'--....---•--------. UNature of Repairs or Alterations—Answer when applicable................................................................................................ ..------•-------------------•---•---------------•--------•------ ................................................. ---------•---•-•-------------•---------------------•------'•............---•..._. Agreement: The undersigned agrees to install xhe aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— e igned further agrees pot to place the system in operation until a Ce e of Compliance has been issued bd�of Aal GVj .. Signed •• --�•-- . ... ....-r. .... . .... . = - ..- ate Applicationpproved By----------•-------•---------- --- ....... ........•--- ''-•--• -'--•---•---•-•-•--- ate D Date Application Disapproved for the following reasons-..........................................------•----------------------------------------------------....._..._ --•---...-•••-•-------------•---...-•--------._....------------------•.......----•---------•---------------•----'-...-----••----...-•----•-'•-----------------•-•-•-----•------•-----•--•----'•--------' Date PermitNo......................................................... Issued.............................................-..--•---- Date No.............. ...... Fps............._..... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............................OF....................................... Appliration for Disposal Works Tonstrurtion Vrrutit 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..........._..y......Sq. feet Dwelling—No. of Bedrooms...................................._Expansion Attic (') Garbage Grinder-(—) �`q Other—Type T e of Building e yp g ._/�_.__�._�._.._.. No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures.;:...........................................................-----•-•••••-•--••--•••-----••-••--•-••............••---- W Design Flow...................... ...`'.._..._..gallons per person per. day. Total daily flow__-_-•-•--- .—.... gallons.„ WSeptic Tank—Liquid capacity/ �agallons Length............... Width.`�.... Diameter................ Depth.' x Disposal Trench—No.........s.......... Width_.�.o._........ Total Length....:..`........ Total leaching area_._....t......�....sq. ft. Seepage Pit No-_------------------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing..tank("" ) f Percolation Test Results Performed by._._`'..-`�..�D t :� _._.: ...? ` '�.. ._.-:-_._.•... Date...___•` . ----.......-••-----....... .a Test Pit No. 1...........2--minutes per inch Depth of Test Pit.....l ..., Depth to ground water..... . Li, Test Pit No.21,...... ...minutes per inch Depth of Test Pit-----hA....... Depth to ground water--__-_. Gd31' C&3 L •-•••--•-••.••-• -•---•-••••-•--••-••--•---•-••--•••----•-•••--•---•-------------------------------•--------•....••... / O ( � V P Y /- / t C tea. . .... x Descr><phon of Soil �;:�j ' =�-----------•----------------------------------:.: ' r/ > `' 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a CergM� of Compliance has been issued by the board of health. _ t/v Signed. .. . ... ....... ...........•-•--•---••----------........__ ........----••......••••••- A lication roved Bj1°'�� lt_ a _ PP PP Y - -••••----------------- - ------------- ----------------------• •-• ------ Date Application Disapproved for the following reasons:--------•-----••-------------------------------------------------•--------------••--•---•-•-••••--...•••••- .........••••••••-••••-••..........•-••-...•---•----••-•---•••-•----------•--•--••------•••...---••----....•----•--------•------•----•••--•----.....•••••-•--••......................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF............................................................................ L.� Trrtif irFa#r of ToutpliFanrr , THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by............................................................................................................................................................................................ •.... __. Installer has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION PATI,$FACTORY. G DATE.............................t .................. Inspector..........................f....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ( ,« S4. ...........................................OF...........:-..... ..........................................._...................... S OS- No. -•.................... FEE........................ Disposal Works Tons#r tion rtnti# Permissionis hereby granted............................-............................................................................................ ....... ...to Construct or Repair ( ) an Individual Sewage Disposal(System at No. -- - �- � S "1/—: �j C_ .-7 -.... -----------------•------ --•------------.--••-•............•-•. e�� _..... Street L_ 5 q 1 fir.y as shown on the ap lication for Disposal Works Construction Permit No...................._ ateyd�. ..4_�....__......53 !1 Board ealth a DATE....-•----- .... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS W rci ni t ►:unber:- —Uatc: Completed by ,!jZ �S ff v�Ott. IT`-- HIGH GROUND-WATER LEVEL COMPUTATIOId Site Location: 07— e_T C (2nter-V,l/� Lot No. Owner: Address: /3 1 a/ot Contractor: i, Address: Notes:_ T h e s es TZ e s IJ/.t s s h o v✓-- a_4 , i/,A a- C! �-o ter- o,;3 1417 - t h a Da. c . &.�r Te s C - `2 �'e S a CL s l y a- March nOf Z Et OL ✓/ 0l ) OL43J STEP 1 Measure depth to water table g ' to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: . / VV 230 A) Appropriate index well . . . . . . . . . . . . B) Water-level range zone . . .. ©/V I� STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to 2 3, 9 water level for index well . . . . . 2/ 86 mo yr STEP 4 Using Table of Water-level Adjustments for index well STEP 2A , current d&pth_ to water level for index well (STEP 3) , and water-level _ zone (STEP 26) determine water-level adjustment . . . . . . . . . . . . . . . STEP 5 Estinate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water 4' S level at site (STEP 1 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L, 2 7. o �J, . J,P: 4,S y jv December 19, 1986 John Kelly Health Department Director Barnstable Town Hall Hyannis, MA 02601 Re: Lot One Ames Way, Centerville File 1-51 D.E.Q.E. File #SE 3-1445 Dear John: This is to certify that I have inspected the installation of the septic system.at the above site For the record the top layer of hardening was removed for 10 feet around the prime leaching area as I had designed. . The septic system does meet Title V, the Barnstable Health regulations and the order of conditions imposed by the .Conservation Commission even though the hardening around the future reserve area. was not removed as planned. If you have any questions, you may contact me at 362-9411. Sincerely, �� �ZN OF Mgssgc L�/J cRAi� ti SHORT Crai ort CIVIL y g too. 27483 Professional Engineer cat/CS FSS�aNAI cc: Barnstable Conservation Commission i C VSESSOR'S MAP NO.�---- -�- R� RCEL_ �, LOCATION Sy SEWAGE PERMIT NO. VILLAGE i ;INSTA LLER'S NAME i ADDRESS S U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ��� _1 - L ok�1� ��a�� T :� aG,��� � �. 3� y ' ��� �; �� TOWN GP- 'IZ STABLE 9 ` G 0 LOCATION SEWAGE # VILLAGE 02-nAeN AJZ�—. ASSESSOR'S MAP & A—"Mc-CA INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS CT al) BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by e3 Ale R A g 1s AC 11 A � 5� �A alG o QC a' D -� UP ———————————— -- c I I I I I v IIIII ------------1 Z 1 I I I I I I A D 1JJ I � I c Z I I NU O� OA �WOIq A uU I I n ca x g mZ g g D ig D� 1 i� pmE� aE D I Z x im i3 y �DN �a I i� �R Z. j< I m I Mwa No MATCH EXIST. I m uu up I ..: I I M Ifl <O < m z 1�I p I$e I O I I 'n AF < u o IMs l i Im �m m I i 4v >� - �p i I _ u I� �'nI z i r r lL t� i N I I Iz Iz � I :. 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I I I I I I I I �a� I IQ rr j l I I-ai I I I I I M I I W I I I N IL N 1- -_ to _ _ - a O ------ z z � d I • '71 I I nn I V I Li_—_jpry—(�J E f�tp LJ W II i O -10 I 3 jl D z - r ((� IQ 1 w g tU I I 1 I I z e+A �u11s N I 4'-�• o F o I p I z o 7°7 o I II N I 14• 6'-9 I/2• 4'-6• 17'-6 I/4• I — L TW2446 13-24" N '-o•L 20'-I1 1/4' 7'-10 9/4• SOUTH CAPE DESIGN SERVICES CONSULTANT z m �� r 16 Briar Patch Lane ADDITIONS&ALTERATIONS 3:0v is-.1 :y,.', N �� Mashpee,Massachusetts 02649 Gleason Residence V TEL: 508 539 8642 55 Ames Way c '� e-mail: jerry_thiboutot@hotmail.com Centerville,Massachusetts N H t.ti SIGNATURE 9 ,7 \1 Z, 12G SOI L L O G �, "� 1:5 2 r-r FR ✓ '.v w a O u 7-E 29. S H�I2 T' 28 3 __ __,.� IS\ ` �..}' � T 31S/8 G DA T E-' 2 Cc _ -- -`"' WI7-1VCSS4D ay : WITNESSED 'BY 4' ___W_____. - �,*q i✓7 .x ? 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MIN. 2 LASER Y p PITCH PEA STONE l L- O� / EL29.5.�/ o; 1141FT ,, Ar"{:..�;...� y"`' r8 !_ . < G',SuMP �7.83; D r • INVERT -'� — GALLON INVERT DIST. INVERT' , p �y �• INVERT A• ca BOX � � 4r < Q' . 3/4 - 1 112 D I A j SE PTIC TAN K - - ! INVERT 7�.��s �, d V 4Zj•" - WASHED STONE INVERT U� nap w3 . ALL AROUND I O GARBAGE --/ (L k �., -- -_ —� E L E V. 8 O T T 0 M I MIN . GRINDER ^1 OF P IT -• L " Cr1 ?_ G KA N i. /Dta S ELEv _ 22 ,5 ' PROFILE OF t GROUND WATER TABLE -) DJ"(JST, S A N NARY DISPOSAL SYSTEM NOT TO SCALE DESIGN DATA \ BEDROOMS CONSTR UCTI ON OF SAN ( TAR Y DISPOSAL :� DESIGN FLOW --, •=- `�. GAL ;'DAY SYSTEM SHALL CONFORM TO MASS . / - LEACH RATE 4 _ MIN./INCH E NVI RONME NTAL CODE TITLE V (REVISED 7- 1 - 77) AND THE TOWN OF PROPOSED LEACH CAPACITY i HEALTH R E G U LAT 1 QN S . 2 , 0 y sip ` ; 'x R4- ; i' 9 °�-/c. ! /c 3 'L; • SEPTIC TANK, DISTRIBUTION BOX AND LEACHING DITTO BE OF REINFORCED CONCRCTE � 4 33 GAL. DAY MIN. CONCRETE STRENGTH .3000 PSI ,{ J'V07-,T TO C_ OtV7_1', - -r- .� ft P/Ec�J�C� �'J> F'4U�IUyT/ Cahl LCaG�7?"IC1rat MIN . STEEL. STRENGTH 20004PS1 \ © '? •� . S /--/ C7 v 2-,U 43 ,- / /V 7-/-t 4S7 Ay�O L �' }' .S V/� V E* >,'O T� H 10% DESIGN LOADING o DRIVEWAYS N OITTO BE LOCATED OVER SYSTEM ,N 0 7—�' �'"�? L L + T R �/ti'� ��/� .� /-f i��� '/ ty` F-1 L. 4) /S UNLESS H - 20 DES IGN LOADING IS USED , _ 7"0 4ff .N1.5 p a >/ Z:)J5_,,.; / c:- /Y �',1V49 /N,=- A'� � CTzS) o ALL PIPES AND FITT I NGS TO BE WATERTIGH AND G ' "= C 3 EO, E PLAN SHOWING PROPOSED CONSTRUCTION SH . % OF sHs LEGEND A T 1 b N : 43 �i?/y c ni ___._2-- E- x-� &I- o f 4-�O Z�) E"V" C © jZ p. A P P R O V E D 19 - - SCALE: L": 301 _ DATE : JZ2. o 3/7/eG BOAR D OF HE A L T H BUILDING SETBACK REGULATIONS PER EXISTING CONTOUR - --16--- REFERENCE : -7-. 1 19 ,5 v'vA/ /n/ ` BUILDING INSPECTOR OR BUILDhNG COMMISSIONER . �-• "3 ,; � _ i-�' � PROPOSED CONTOUR 16 ---- IQL�N a""- 30� "'' 3 DATE AGENT r\ I N FRONT SETBACK � (:D EX STING SPOT ELEVATION 17. 6 MIN . SIDE SETBACK cz:) PROPOSED WATER SERVICE W_ OFIG MIN REAR SETBACK ` TEST HOLE LOCATION CIVIL27483 v' C . R . SHORT, INC . a,.. FCtSTE �o PROFESSIONAL LAND SURVEYORS L ENGINEERS 1586 MAIN STREET (RTE. 6A) EAST DE NN IS, MASS. 02641