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HomeMy WebLinkAbout0307 AMES WAY - Health 307 Ames Way. Centerville A = 170 - 231 S M E A D U&2.1I&M UPC 12M oewd mm • wa.in USA ftFt- t� Irr` t I M �4 i �r I I i i i F i No. ' Fee `/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes TippYIiAtIOri. for DI8p08aY *pBtPIYI CDtt81TUttIDTY pCCI1lIt Application for a Permit to Construct( ) Repair , Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 30'1 AHES W.44 C1 V tLuF Owner's Name,Address,and Tel.No. M1ct1.4trL_ C,oOmEN Assessor's Map/Parcel 1 rl® �Z3 1 30 Akgg (n f& S:W THY fI.ct5* Installer's Name,Address,and Tel.No.150'$-1—477)--$?`7 7 Designer's Name,Address,and Tel.No.50?—;Z 7 3—637 j GA®Ew tDE WTWkLses u.c- 3c z m c.. IS35 i MAS .42-S4 4W E,W90440A Type of Building: -f Dwelling No.of Bedrooms 13 Lot Size 15,000 sq.ft. Garbage Grinder( ) Other Type of Building QCSI[)C�1 e4 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided q,,q gpd Plan Date Number of sheets j Revision Date Title Atvt 14),mi�� t tlfLL. Size of Septic Tank i,,000 (AiA 1;.9 Type of S.A.S. Description of Soil MEb o a C dt A,$ig7 SAYJ-b G—)� 36 t Nature of Repairs or Alterations(Answer when applicable) C 0­6Old 44 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued is Board of Hea i A6 Date 010 L Application Approved by �w Ell Date Aw Application Disapproved by 41 Date for the following reasons Permit No. 42 Date Issued �. o z ' No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes (}^ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS t Rpplitation for Disposal �&pstrm Construction Permit Application for a Permit to Construct Repair Upgrade Abandon Complete System Individual Components PP ( ) P � Pln' ( ) ( ) ❑ P Y ❑ P Location Address or Lot No. 3o-i Amos wo44 C�V r LkjE Owner's Name,Address,and Tel.No. Mtct44eL_ L_ ONE/ Assessor's Ma /Parcel P !'70 a3 30� .4+k wry ca,,T�v�r.�c.�' Installer's Name,Address,and Tel.No.50%-cf71—92'7 7 Designer's Name,Address,and Tel.No.50?—.Z 7 3—037 7 GgvEc e)tDE S TIC AWE (.c.,c-- 3c r"L l ct�uc sr- c�t�t-sue �8 rev E,w e 4•� Type of Building: Dwelling No.of Bedrooms Lot Size s 0 U�O sq.ft. Garbage Grinder( ) Other Type of Building QC51 OCT 1 r44... No.of Persons Showers( ) Cafeteria( ) Other Fixtures '' ,, Design Flow(min.required) 3 3 gpd 'Design flow provided 3t/j, gpd Plan Date Number of sheets Revision Date Title 3'b i'-A;4 i' LAIA)/ Size of Septic Tank OOCO C.4(j_A&J Type of S.A.S. 901n 6A Description of Soil Me , CA Ak S%� :5A9'b Nature of Repairs or Alterations(Answer when applicable) .�T,L)C I,OCb SqY1C_ rti'4AJ� -TD r1Ft c) O-&oK 'CEO (�Z� G�,4u��a.i C. 4GLE rr J6or c:lfstwsS C,eJ I Ta.! 241 ck ArGGoC�f -Q u1Z&J& tD 4 J r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b� is Board of Hea n Sigtte Date t�. Application Approoved by Date Application Disapproved by / Date for the following reasons / s% / Permit No. Date Issued ( � ` , THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( x) Upgraded (/ ( ) Abandoned( )by t VGw(D 9 EP t 241661 t LC at 3 o,7 A m c3 �/ G'�lJ rZ V/!I i� has been cons u ed'n ac�o�nbe with the provisions of Title 5 and the for Disposal System Construction Permit No� ated r/ Installer �(,�/D� �ryTtP/�rSes f',,( Designer tL jU� #bedrooms 3 Approved design flow n 30 gpd The issuance of this permit shall not be construed as a guarantee that the system will functt to as design 1. Date / (A InspectorIZZI o 4 _-________.________________________________ No. lJ Fee THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS Misposal &pstrm Construction Permit Permission is hereby granted to Construct( ) Repair(A Upgrade( ) Abandon( ) System located at 3wi Am enq W&MTR V(LLA. 7 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:ConstructionAust/be do,m leted within three years of the date of this permit. Date by / ) 840ZO r. UV 1/VU 1 ■:' 1 Town of Barnstable o+ Regulatory Services Thomas F. Geiler, Director ' 8AaN RM ` Public Health Division MA83. �''°�ro,,pr► Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 .Date: (o Sewage Permit#6106-6)31 Assessor's Map/Parcel 17d Z3 Installer& Designer Certification Form Designer: 3-C E05(0e-e'i,nS, TvnC, Installer: 0a(?ewiUe_ CnErrecl'S e 5 L�L Address: 2f,:5y Cian tT�1t�hw 1 Address: t 53, C -mercrGl 5��ee_t -- L�asi w�retnAm � HPr ez53g Hustn�ee., H� DZ(a y On 01 was issued a permit to install a (date) (installer) septic system at 30-7 AwP,5 LAj ay based on a design drawn by (address) Tc �r19t0eeri(1� ; Sv1C . dated Fe)o. 2 Zo 16 (designer) ' >/ 1 certify thatr the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than I W.lateral relocation of the SAS or any vertical relocation of any,component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if req ' nspected and the soils were found satisfactory. `"OF"�*o yL i0iN L. -- CHUKl.11:L 1 _ JR. staller's Sig ure) No 41601 esigner s Signatur (Affi) esi er s omp Here) PLEASE RETURN O BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILT,, NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. TITANIC 'YOU. q AWl' ('unn.duc J � Town of Barnstable . P# M�6�9 n� Department of Regulatory Services 4/, V/20 t Am&rABu% Public Health Division Date � rA , te1a �d�' 200 Main Street,Hyannis MA 02601 j AlED Mh't� Date Scheduled r 6 Time 111 Fee Pd._N d-o 1•+ j Soil Suitability Assessment for Sew7' e Disposalco Q. Performed By:_ M 1CHgEL P�MENfEI , E'/f e5•E Witnessed By: LOCATION&.GENERAL INFORMATION Location Address Owner's Name M IC14AGC. "00 S4 3OZ knjF�� WA4 dZ?JrgMVIL.L6 c rr /��11 O Address�7 A�� �w� . G V/�� Assessor's Map/Parcel: ` 1-70/ L 3 ( Engineer's Name .TG eoC,(�yeel CigAEWtpZ�E�LLC. NEW CONSTRUCTION REPAIR -- Telephone# 19— - 06-27 3 10377 Land Use 0zS,0ENr14L/L9wN Slopes(%) a-3% Surface Stones 419 Distances from: Open Water Body >t$p ft Possible Wet Area >150 ft Drinking Water Well ft Drainage Way > ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) 1�e.e_ 0_k6,J6& e(Cvl Parent material(geologic) OurOMSH PLgrN Depth to Bedrock > 132' $,C. S' B. > "d. Depth to Groundwater Standing Water in Hole: 132 G.S._ Weeping 1Yom Pit FpCe i32 6.5% Estimated Seasonal High Groundwater > 132" $.G•5. DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: •i fWXr 66SER✓AndnJ Depth Observed standing in obs.hole: 132 In, Depth to soil mottles: 132 In. Depth to weeping from side of obs.hole: � 132 in, 0roundwater Adju#tmeat__A1f,9� Index Well- ReadingDatc: Index Well level Adf,factor— AtU.Groundwater Level , m PERCOLATION TEST We Time Observation TN- Hole# 'Time at 9" ,r— Depth of Perc 3�~48 A- Time at 6" Start Pre-soak Time @ �O CO ch4 — Time(9"•6") End Pre-soak /0:00 UM see— 50l 1 Z-05 daw. I I-`I 6 U Rate Min./Inch . L Z on rewr6 t.-,'60 6 ajacr eerc No, 'j [2 Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Al Original: Public Health Division Observation Hole Data To Be Completed on Back--------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conseirvation Division at least one(1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC �� DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. onsi tency %Gravel) i 0-y" .6. 4. 12" A LOAMY SBNo .b YR 311 tl„- 8 c eAmy .54,vo. /G Yg'sk 3ro"- 132" C. mw.-004ase 59no ?.5 Y 6�� a.K L.M DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% DEEP OBSERV ATION . V ION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (MUOSCII) Mottling (Structure,Stones,Boulders. consistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. ConsistenCY. Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes - r Within 100 year flood boundary No.✓ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorptibn system? Yes _ If not,what is the depth of naturally occurring pervious material? Certification I certify that on �a'27"p (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and a rience described in 10 CMR 15.017. Signature �— Date 2- Q:%$EMCVERCFORM.DOC TOWN OF BARNSTABLE LOCATION 307 A MILS kk-i SEWAGE# VILLAGE CirM'(CW'V IU e ASSESSOR'S MAP&PARCEL I'I0) 013 INSTALLER'S NAME&PHONE NOAP�-4JiD� 1�W�CS SEPTIC TANK CAPACITY li Q60 64"tl LEACHING FACILITY:(type)Ca� 5rOD 66L ! ((size) I,�+S NO.OF BEDROOMS OWNER KMAeL LoQN� PERMIT DATE: 4"D,0 10 COMPLIANCE DATE: a- 4-ao t(p Separation Distance Between the: 006.06 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 6i3,15&WED Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) N/A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �/� Feet FURNISHED BY CAP&WIDE EtJTCZ1 K5. K Gw biEcK 0, 1 . 43o� S A- 4 - �q $}ern e 3 0 4 $-3 = 29 (o 34.3` Postal .. CO 7 CERTIFIED IVIAII-Tm��ECEIPT cc 0F F I C s_� Ljj Im Postage $ o y r=l Certified Fee lie F3 Return Receipt Fee �Q �,z d tmark Q (Endorsement Required) �9 e re Restricted Delivery Fee 0� C3 16, (Endorsement Required) , N $eN Total Postage&Fees rl — --------- -r -- --- - -- Michael Looney 307 Ames Way I e e 32 Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the I endorsement"Restricted Delivery". - --- ? ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry.' PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 11 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3. A. Signature ■ Print your name and address on the reverse ❑Agent so that we can return the card to you. ❑Addressee ■ Attach this card to the back of the mailpiece, B. iv ed by Tinted Name) C. Date of Delivery or on the front if space permits. 4liL 1. Article Addressed to: _ D. Is delive address differEk from item 1? ❑Yes If YES,enter delivery address below: ❑No Michael Looney I 307 Ames-W`ay - Cent II I Il��rilvliHl Ilhi-1.I I I TII II'AII I II0—I III--I II 1- 3.II II I I III Service e PriorityMail _ g❑AdulSgntureRestricted Delivery ❑Registered Mail Restricted 9590 9403 0232 5146 5387 87 ❑Certified Mail® Delivery❑Certified Mail Restricted Delivery ❑Return Receipt for ❑Collect on Delivery Merchandise 2. Article Number(lfansfer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature Confirmation^" 7 014 12 a 0' 01'` 0 3 5 8' 5 8 21 �/ ❑Insured Mail ❑Signature Confirmation ❑Insured Mail Restricted DeliveryRestricted Delivery. , (over$500 �PS Form 3811,April 2015 PSN 7530-02-000-9053 - Domestic Return Receipt UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS; Permit No.G-10 I Sender: Please print your name, address, and ZIP+4®in this box• -Town-ofBan7stable Public Health Division 200 Main Street Hyannis, MA 02601 USPS TRACKING# I . _ ,I:i.F 'i.iii!•i ii:i:i i, 9590 `t403 0232 5146 -538'7 87 .. a �- Town of Barnstable Bpi hstab�e Regulatory Services Department ELUMBrABM °qA & Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO September 22, 2015 CERTIFIED MAIL# 7014 1200 0001 0358 5821 Michael Looney 307 Ames Way Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 307 Ames Way, Centerville,MA was last inspected on 9/12/2015, by Trevor Kellett, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level,<12" below inlet(per Town Code 360-9.1). You are ordered to repair or replace the septic system within Two (2)years 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 ORDE THE BO OF HEALTH I IR liean, R.S., CHO -- Agent of the Board of Health • Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\307 Ames Way Cent Sept 2015.doc Parcel Detail Page 1 of 3 4� �iV, ,tea AR, YAnI W .r a � Logged In As: Parcel Detail Monday,September 21 2015 Parcel Lookup Parcel Info er Parcel ID 1170-231 I DeveloLot LOT 32 I Location 1307 AMES WAY ) Pri Frontage,125 Sec Sec Road; �4 I Frontage villageiCENTERVILLE Fire District C-O-MM I Town sewer exists at this address;No ( Road Index i0027 Asbuilt Septic Scan: Interactive 1702311 Ma Owner Info Owner'LOONEY, MICHAEL P I Co-Owner Streetl •,307 AS WAY ) Street2 ME City'CENTERVILLE _ I State MA Zip 02632 Country Land Info Acres 0.34 I use Single Fam MDL 01 _I Zoning C-I Nghbd 0105 Topography ALevel Road ,Paved Utilities,Public Water,Gas,Septic I Location Construction info Building 1 of 1 Year'----._ Roof�""�`� Ext r"'� ,. Built Struct Gable/Hip wall'Wood Shingle Living--A' 1544 m Cover Asph/� F GIs/Cmp TYpe None_ - — wa u m — _ •. _ ._ _ �. i �t T style;Cape Cod wall]Drywall Roome[3 Bedrooms z t"4t I Model;Residential Int tCar etI Bath 2 Full-0 Half Floor' p Rooms I R TQS, HeatGrade;Average I Type Hot Water I Rooms,6 RoTotal ._�I s ° —71—'"'" Heat Found- stories F9 3/4 Stories ( Oil I oared Conc. Fuel ation Gross 13036 Area Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=l 1452 9/21/2015 Town of Barnstable i + HARN3IABLE, "A , Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 7/6/15 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 ONE (1) YEAR DEADLINE CRITERIA ❑ Static 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) X Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code 360-9.1 OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc 1'7P ,)-3/ Commonwealth of Massachusetts Title 5 Official Inspection Form �) Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _0 307 Ames Way .a Property Address r r� Michael Looney Owner Owner's Name information is rtl a required for every Centerville MA 02632 $/12/15 p� page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form-. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-.donot Trevor Kellett use the return Name of Inspector key. TK Septic Inspections Co � Company Name 38 Vacation Lane Company Address West Yarmouth MA 02673 City/Town State Zip Code 508-579-5502 SI 13744 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage_ disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails Needs Further Evaluation by the Local Approving Authority 8/22/15 Inspector's Signature -- —' �— - Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. -VS t5ins•3113 Title 5 Offidal Inspection Form:Subsurface Sewage�sposa�mage 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 10' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u ' 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): ;r t5ins•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection For n:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts OF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8112/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow Mrs•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w j 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: This is a standard title v with a tank d box and leach pit Number of current residents: 2+ Does residence have a garbage grinder? ❑ Yes ® No 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: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Ofiidal Inspection Form:Subsurface Sewage Disposal System.Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �j 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection D. System information (cont.) Approximate age of all components, date installed (if known)and source of information: 1988 per septic permit Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Septic Tank(locate on site plan): Depth below grade: 1 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: 1500g Sludge depth: 1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments fj w 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection D. System-Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 9 Distance from bottom of scum to bottom of outlet tee or baffle 13" 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.): tank is structurally sound and water tight with liquid at the outlet.invert, both tees are fine,tank does not need to be pumped Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8112/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 1"Above 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 level and water tight with carryover, 1 inlet and 1 outlets, d box is down 20" 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. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: I ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching of this property consists of a,5x5 precast pit, liquid level is past inlet up to pit opening Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 o117 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w. 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or,benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately back of house A B 1 2 A1)16 4 A2)19 3 A3)36.5 A4)30 B1)13 B2)17 B3)32 B4)44 t5ins•3113 Title 5 Otfidal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r5 307 Ames Way Property Address Michael Looney Owner Owner's Name information is required for every Centerville MA 02632 8/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 40 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 Maps show GW at 40 ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f L Commonwealth of Massachusetts Title 5 Official Inspection Form si Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 307 Ames Way Property Address Michael Looney Owner Owner's Name information is Centerville MA 02632 8112/15 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D{System Failure Criteria Applicable to All Systems}completed X System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No.__ Fxs..........1.... ........ THE COMMONWEALTH OF_MASSACHUSETTS BOAR® OF HEALTH sO F.......................................... AVV iraflon for %Voiiai Works Tonlitrurtiun Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Syst at - ------ z�.----- ------ _ _3 Owner Address a ..............�G ... Q--L.IS '�' -----•------------------------------- Installer Address d Type of Building Size Lot.NS-_.�J.O..•....__SQ. feet U Dwelling—No. of Bedrooms___..._.................................Expansion Attic ( Garbage Grinder p, Other Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................ W Design Flow..... ........................... .gallons per person per day. Total dAil how.....�?.> ---.-_-.----- C)_........_ _ Ions. WSeptic Tank—Liquid capacityl=.gallons Length67..G_.. Width._-A.'I..... Diameter__7:7 - ___ Depth.. _7.4__-. x Disposal Trench—No- ------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------L----------- Diameter------lD--------- Dep`t�1 below inlet.._t�........... Total leaching area..��77...sq. ft. Z Other Distribution box NOS Dosin tank (4 ii 11 ~' Percolation Test Results Performed by... ............... Date.A-A.` ............. 0a Test Pit No. 1...# -__._.minutes per inch Depth of Test Pit.... ...... Depth to ground water_.__&.jy �_q Test Pit No. 2---4t....minutes per inch Depth of Test Pit----- K Depth to ground ... v. ! .................................. Z� water_______________________ ....•--•-• ................. -------•.•-•-• .................•-•- 3-- -----.........-- ---••--•-•-•. xDescri tion of C. 2. _ COI z = . W -----------------------------------------------------------------------•-------•-••----•--•••----•-----•---------------------•-------••---•-•--------------•-----------------------••----•-•--•......-- UNature 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 f'l i T i Ti 1E 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 board of health. Signed --—---------------------------- ------------.-..----•-----•-- �t Date Application Approved By.._..... _!�... ._&�h t'. .......... _ / l -fP = Date Application Disapproved for the following reasons---------------•-----••••-•-• -----•------------------------------------------•------------------•-••-•-•.----- ----••••---•-•••••--•-•••.............•••----•-•----•-----••--•--••--•-•-•----•--._.........•---•--•----.-•-•---•••--••••--•-----•••---••••-----•-•-••-••--------------••-••-•••----•-•-•------••••-•--• Date PermitNo.---�0.•. .. ... ...................... Issued....................................................... Date I� 1-70 LOT 2`3 ji No.....= c� Fxs............76....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �C7--.I`------------------OF..... Appliratioat for Dhipati ai Workii Tomitrurtiou rumit Application is hereby made for a Permit to Construct ( k or Repair ( ) an Individual Sewage Disposal Syst ' at - ... l c S W/• `� CE to -V t�L tr ..... ............�`" --..'3�Z_ -• T ..................... 1-V{—� I....O E:E:. �1 hLi' o of N luS 1 ... ........... Q .. �._.1�1 � ..... 1. s Owner Address a RUC k I�YZO 11...G2S Installer Address dType of Building Size Lot..\5- _...._.Sq. feet Dwelling—No. of Bedrooms__._______...............................Expansion Attic ( Garbage Grinder )Q aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) p' Other fixtures ................................. W Design Flow......... 5 ___________________________gallons per personer day. Total daily flow..._..3JJCD.........___..........gallons. WSeptic Tank—Liquid capacity_��gallons Length__ _'__ _. Width___`�.'�... Diameter_._"' Depth....'4... x Disposal Trench—No--- -------------•••- Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.......)_0....... Depth below inlet.....6P.......... Total leaching area..... 2..sq. ft. Z Other Distribution box (11IEVS Dosin ank ( �)O aPercolation Test Results Performed by.._ x ..........A._ Y i.�! _`.............. Date___,-__�.J-._._...._.. ...Test Pit No. 1.... ........minutes per inch Dept of Test Pit...... Depth to ground water_.44_� L©��y G`� fX4 Test Pit No. 2..... Z...minutes per inch Depth of Test Pit------- �.; r.. Depth to ground water........................ •--•------ ------- x Description of '1... ...................AIV" ��t�3SC�!C_. , = e Z- --�� -------- -- c.� ........` . `z r "------------------------------------------------------------------------------------------------------------ ---------------------- 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 I.1T 1 T--� the provisions of 'T t of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed e .1 �.-- ,{A. l _ Date APPlication Approved BY•--••-•-- --------- Date ' Application Disapproved for the following reasons:............................... ------_-------- ---------------••--••••------ ............................ -------•-••-------•-----•-----•---------...•-•-.....••-------------•--......------•-•--------•------...---------------------------------------------------------------------------------•-••------------ Date Permit No.....92.. ..�U..... - ----------------•-•-• Issued----------...------------------------------------------. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 41F HEALTH .........Ze.. .... ...........OF..... :.: .�:. . i�... ................................. Trrtifirtt r of Toutpliattrr --- THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( L.,y""or Repaired ( ) by........ Installer = A ... ........ -- has been installed in accordance with the provisa 7---- 'Is of fI 5 of�/T e tate Sanitary Code, as described ' the application for Disposal Works Construction P rmit N'o.._�_ _____lr. �...._.. dated__-.._,l._-:.__l�_'.c l__ ........%. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................ / _. .. . -------------------------- Inspector........-----.. ..................................................... THE COMMONWEALTH OF MASSACHUSETTS BOAR F HEALTH T1� �f� 1................OF....... fr_ !.....1,!!...... .-•-------..........---............ NO.J-J........... ..? I''A_ EE.......7__. �i��ro� � ork� ott�trttrtion �erutit Permission is her ebYg ranted !<_l1? 5! �.;.1/.?=e ', =to Construct ( r Repairr,�( ) an In ividual S �e! Dispos. Sys>kgt}i at No. street �. as shown on the application for Disposal Wor-s Construction Permit Dated..... .......A...I._.... •------•----------------------- — ---------------------•------------------------•--- u y )oard of Health DATE-------_-------------- -< ....---•-------••--- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS s . >EF— `CAA F-t; -21—z, �E;6 t6�Ut��4TA poi?- 7 i4�1 1 I o x.3 s w Gr? PETER �7�6t"'t� �1��T ✓L- UtS NCOO GALL:>V, #"t '`�i�Tf t SULLIVANOrs WALL +!; OF y/?�y'•�:lq-Siff` ti el� RICHAF?D `�'?'�, A. da 8 TER No.24048 9F�►ST Ci Z 12g ►to q eB r S�G US 40 . VJCD r s V 2 Q iOtiJC-x (. 3$.2 3a.e 39.0 . To 39.4Ll 38.(0 tC �' a Ce�>�E� i�►..r t ri�l 1.sx T-VC ;,A4 L-a'r 32 At-A .SWA.'-{ �� f3 UAT Tit -=.F�V40A,710" 6 jojj j `�►�J��t�Y �� �.�J�Fc�..�f C-0wt'PU*i5 `All'% I-RE 6rPCW\s3C. C►�l�c_ �►.�Es1s.��-ram` Tb'4JM OF AXUU d5 t•AC'C /-�3` � C :�.(�(` �05�,' N� � � :_�,*a• XX,A,-'Ct!57 \J teW.c T ���eav�'c..os-+a.�l `Tk �o,t+a �.. r _ L aM a N \46 'WA fax.s-r- rl l �4 P "Ce �.� �.._�r_ .,.. r�-r u67EP �j �J M 170 Lo-c 2 31 A, .4op loop � 2ti 1�to It l lt'Z.3 t J ��1009'e�t�AOJ.S'tQt� AV Z l S000 b F zo, �s' ^ I o-r P;:TER CEI.rTEt��/It1-�. 5�o SULLIVAN�E No. 291„3 r--� " i JTotvN OF BA RNsTABr.r; LO(^ATION f0-40;h, _SEWAGE #- gge-G 7,9 1 V I I AGES Cv/�i / ASSESSOR'S MAP Si I.OT 3� INSTALLER'S NAME PHONE NO. j!i)c-e SEPTIC TANK C'APAC.TY_/OOp oaf LEACHING FACILITY:(type) /'i t_ (size)_ NO. OF BEDROOMS -3 PRIVATE WELL OR PUBLIC WATER���1 � BUILDER OR 0_WNER o 3, �_ // ;�3tee,U DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: .�.�� VARIANCE GRANTED: Yes - !! No �" - -2 �r c_• 1 p,� �_30 APPLICATION FOR PERCOLATIOV TY;b' Kvu VDJAnVral lVLt - LOCATION LOT 32 NoY`71�Zg. VILLAGE C E5t,111Ee Vl l.L S DATE APPLICANT JOB FEE�"ZIS`� (Non-refund 2 .ADDRESS TELEPHONE NO.� g, 3S ENGINEER 'jgkTr_e A,1\. 6 `&t( . TELEPHONE NO. -q-3-b-bC4o DATE SCHEDULED MOV �� �9 & l0'MMpl"` Ac�,GxN- (Applicant' s signature f . . . . . . . . . . . O . . . . O . . . . O . . . . . O'. O . • • . . . . . . . . . • . . . . • . . . . O.. . . . . . • . . . O •'. .i•. . . . ASSESSOR'S biAP & LOT NO: 1-[o� SOIL LOG SUB-DIVISION NAME DATE TIME cOA EXPANSION AREA: YES_NO __TS L��.4_lvp o 4aj'hj k ki c ENGINEER: R TOWN WATER ,PRIVATE WELL JEeQ.q '►.cK-mo Gr- BOARD OF H .. EXCAVATOR I SKETCH: (Street name,etc° ,dimensions of lot, exact location of test holes an percolation tests, locate wetlands in rp vximit, test holes) • ----U I_— -- .. 1 FOUND.. to o� V �1 820 24'k8.. E 24.5.17 g. YV7 ".;oa b lDE .83 .� . ;� DO ,` ; /2 85.31 /05. 57 52 l 49 7 P 32 N o 33 ^ 34 �0 �°9 j).34��000° o /5 384 0� N l5/46'f ° m •3_` ,. d AC AC ` �' 0.35 AC. 8.✓SAC. N '� 0.3. _-,1-- /25 00 125.00 n/76°/5'33"YV �N76°/5'33'`Y N7� �- i2o.00 N7o%3' PERCOLATION RATE: 2N,��ry TEST HOLE NO: ELEVATION: 4,ZOTE5T HOLE NO:7' -2• ELEVATION 1 4.0 6, eSbtiC 1 t`' • . 2 2 Z �c 3 3 4 c '� -5 4 L TO itiSl-� :1�.: � 5 5 , z 7 7 ry•, itA� 8 8 r 9 9 10 i0 10 11 11 `� C.31, r'. 12 12 13 14 14 1515 16 �SE SUITABLE FOR SUB-SURF C �E.-' �LEAZNNFIELD LEACHING PITS i LEACHING TRENICHEN ICUNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED -ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P . E. AN RETURNED TO BOARD OF HEALTH i COPY: RETAINED BY APPLICANT t FINISH GRADE OVER D-BOX = 42.8'± T.O.F. EL.= 44.6 ± FINISH GRADE OVER CHAMBERS = 42.4' - 42.8' 2% MIN. OVER SYSTEM 3/4" TO 1-1/2" DOUBLE WASHED SLOPE PROVIDE EXTENSION RISER REMOVABLE WATER-TIGHT COVER OVER @ STONE TO CROWN OF PIPE 1 WITH COVER OVER INLET& RISER TO WITHIN 6" OF FINISHED GRADE UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION OUTLET TO WITHIN 6" OF F.G. 4" SCHEDULE 40 PVC INSPECTION PORT WITH ACCESS METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL FINISH GRADE , ' 5" DIA. OUTLET(S) MIN SLOPE 1% BOX TO F.G. (SEE NOTE 21) 2" OF 1/8"TO 1/2" DOUBLE WASHED CODE AND ANY APPLICABLE LOCAL RULES. @ FIND EL.= 43.5 ± F.G. OVER TANK EL. = 43.1 ± STONE OR GEOTEXTILE FILTER FABRIC 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE TOP OF SAS- 40.0$' PLACE RISERS ON ALL DESIGN ENGINEER. PROPOSED 4" 9" MIN. 9"MIN - CHAMBERS WITH 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL SCH. 40 PVC 36" MAX. 39.25' 36"MAX. INLET PIPES TO 6" OF SEWER PIPE ( BREAKOUT EL= 39.75 FINISHED GRADE-f SYSTEM UNLESS OTHERWISE NOTED. 6" 3" 3" DROP MAX ' + 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN 2" DROP MIN 3., L=17 ± PROVIDE WATERTIGHT ELEVATION = 39.75' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A r\ r LOPE @ 1q o 13" 4" PVC IN FROM JOINTS (TYP.) ��� o 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF 14" SEPTIC TANK 4" PVC OUT TO O 0 0 0 0 0 0 0 0 o THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. CONTRACTOR TO PROVIDE LEACHING FACILITY0- o0 0 0 0 o oo 0 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. SPECIFIED DROP BETWEEN o INLET AND OUTLET CONTRACTOR CONTRACTOR SHALLUTLET TEE 39.67' M N. 6 39.50' 2' oo o 0 0 �1 00 00 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. SHALL VERIFY SIZE 48 VERIFY CONDITION O \ o 0 0 1 , 0 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK EXISTING CONDITION SEPTIC AND ING TEES LACE AS GAS BAFFLE 6" CRUSHED STONE o o 0 00 o FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS OVER MECHANICALLY o _ NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH TANK NECESSARY COMPACTED BASE AND DESIGN ENGINEER. 4.0 8.5' (TYP) - 4 0 4.0 4.0' 5 OUTLET DISTRIBUTION BOX TYP 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF 43.00, ` TO BE INSTALLED ON A LEVEL STABLE 25.0' ( } ESTABLISHED ON A NAIL SET IN AN OAK TREE, AS SHOWN ON PLAN. BASE. FIRST TWO FEET . OUTLET 37 25, GROUND WATER ELEV.= 31 .SOS 12.83' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION PIPES TO BE LAID LEVEL. j 2 - 500 GALLON CHAiVIitRS 5' MIN. �,HA�vIts�K �iVU V iCVil THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK CROSS SECTION VIEW 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES n TYPICAL CHAMBER PROFILE . �- - -TAILS -- TO THE DESIGN ENGINEER. ELEEVATION PRIOR TO ANY WORK & 'N ° �E D I S ! "IOU 1 1`�114 O�JA LJ� C � T I LS 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. NOTIFY ENGINFFR IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE 1 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING ij REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM ^� _ + 4 --�•-- ' ✓� PERC NO. 14939 APPROPRIATE AUTHORITY. r INSPECTOR: David W. Stanton, R.S. � 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED EpGE O P (5° Wjp Cq AY :ra' EVALUATOR: Michael Pimentel, EIT, CSE UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT, DRIVES, OR \ `P T E YOVT -4, y '•'�j 'I Oct. 1999 TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING. Z . EN ) $ J'� ,+ +r�• C.S.E. APPROVAL DATE: \ \- errs f � �+ "�;�. DATE: January 28, 2016 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE j __ c1;N„ . � -•-�, .� ,•` l; •,r'� TEST PIT#: 1 r' MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. 40\ ZONE C ELEV TOP= 42.50' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, " -- ��,V E FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). ELEV WATER = < 31.50 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN :� Il PERC RATE _ < 2 min./inch \ _`'`�-.^, � ti: �'-- �_ � � `.� `• „ SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. s76 \ -- �.. ti. ran rr a�+'i - a 15'33,E 40- �'+Q s rs 1`' �-'- +. •� f" "' DEPTH OF PERC = 36" -48 16 PROPOSED PROJECT IS LOCATED W THIN \ 125 00, „; �!`ilri L°1' = '� •,=' ASSESSOR'S MAP L170 ELOTI 231 t P N TEXTURAL CLASS: 1 m OWNER OF RECORD: MICHAEL P. LOONEY _.._ .E a �q \ �r *,rxs' a r, LOCUS k� 011 Fill ADDRESS: 307 AMES WAY ? -41 " ' ..; r "� • ';, 4" 42.17' \ 3 #� Loamy Sand CENTERVILLE, MA 02632 \ s A \ \ / �r• � �'� * .• 1( FiSt1 12" 41.50' FEMA FLOOD ZONE X MAP 170 ; ,� ., • _ Hatchery:.; GOMMUNITY PANEL# 25001C0561J PARCEL 231 �- -- ,>� •��:* �" + ,+ . Loamy 10Yr 5/6 d ; B \ 15,000 S.F.± �' 17. A DEED REFERENCE: DEED BOOK 20142, PAGE 50 MAP 170 / \ 42, q `"�� t 36" 39.50' 18. PLAN REFERENCE: PLAN BOOK 324, PAGE 73 PARCEL 230 -43 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY i' �3 \ , ..� cif ax'. "•� '$ :a FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY FOR USE OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. Med.-Coarse Sand 21. A 4" PERFORATED SCH. 40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A C 2.5Y 6/6 DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3" OF FINISH GRADE. A REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS. N #307 _ Q LOCUS PLAN R EXISTING 3-BEDROOM \ m SCALE: 1" = 1000' 132" DWELLING 31.50' TOF - 44.6'± \ No Mottling, Standing or Weeping Observed �-HC-1 - - ---- DESIGN DATA ' PER SOIL LOGS DATED NOV. 11, 1988 EX. TANK TO BE UTiLiZEL, WALK (PERC No. P7128) IN THIS DESIGN - \ 3" MAPLE 3 MAPLE BH HC-2 / - EXISTING SPOT GRADE j EX. DISTRIBUTION BOX ' NUMBER OF BEDROOMS (DESIGN) 3 TO BE ABANDONED ' '' '� BUSH , �,- EXISTING CONTOUR DESIGN FLOW 110 GAL/DAY/BEDROOM EX. LEACHING PIT TO BE PROPOSED CONTOUR z r r TOTAL DESIGN FLOW 330 GAL/DAY -L- PUMPED AND FILLED WITH "�...� PLANTER � �h, BUSH l' CLEAN, COARSE SAND AND BUSH / +'�r'�i� j DESIGN FLOW x 200 % = 660 GAL/DAY 50 PROPOSED SPOT GRADE ABANDC11 PERC NO. 14939 \ BUSH J a USE EXISTING 1,000 GALLON SEPTIC TANK INSPECTOR: David W. Stanton, R.S. L` 4 EXISTING GAS LINE £ ,6"OAK \ '\✓�� 3" MAP E s_ 4 EVALUATOR: Michael Pimentel, EIT, CSE EXISTING OVERHEAD WIRES ` o v Oct. 1999 EXISTING WATER LINE C.S.E. APPROVAL DATE: j \ ` INSTALL 2 - 500 GALLON CHAMBERS DATE: January 28, 2016441 fI - x42.6 ) .a ^ w/ AGGREGATE TEST PIT#: 2 �� TEST PIT LOCATION 42 PROPOSED D-BOX 5 PUSH SIDEWALL CAPACITY ELEV TOP = 42.60' x42.8 `PROPOSED 2-500 GALLON LEACHING ' (LENGTH + WIDTH) (2 SIDES) (2' HIGH) (0.74 GPD/S.F.) = GAL/DAY EXISTING 1,000 GALLON SEPTIC TANK 42. .- CHAMBERS WITH AGGREGATE -x42.7 (25.0' + 12.83') ( 2 ) (2' ) ( 0.74 GPD/S.F.) = 112.0 GAL/DAY ELEV WATER = < 31.60' (1) (4) MAP 170 PERC RATE - PROPOSED 4" SOLID SCHEDULE 40 PVC PIPE PARCEL 232 BOTTOM CAPACITY DEPTH OF PERC= PROPOSED DISTRIBUTION BOX Benchmark (LENGTH x WIDTH) (0.74 GPD/S.F.) = GAUDAY Nail in Pavement (2) O TP 2 42 7 FIRE I (25.0' x 12.83') (0.74 GPD/S.F.) = 237.4 GAUDAY TEXTURAL CLASS: 1 PROPOSED 500 GALLON LEACHING CHAMBER Elev. =43.00' x 4 Co 42.6' PIT Approx. M.S.L. N I �., TOTALS: 0il Fill 42.60, REV. DATE BY APP'D. DESCRIPTION 25°, 2 4" 42.27 12" OAK TOTAL NUMBER OF CHAMBERS MAP 170 A 3 SH x42.3 PR. INSPECTION PnPT TOTAL LEACHING AREA 472.2 SQ.FT. A 12" Lo10Yr3/1amy nd 41.60' PROPOSED SEPTIC SYSTEM UPGRADE PARCEL 240 � 42 5 (3) TOTAL LEACHING CAPACITY 349.4 GAL./DAY PREPARED FOR: 3H Buses B Loamy sand CAPEWIDE ENTERPRISES •� x 42.8 10Yr 5/6 a 36" 39.60' ��. N7g `'Uses LOCATED AT �ryrivcm,; 307 AMES WAY CENTERVILLE, MA 02632 NOTES: ��Q W MAP 170 U 1. MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF PAR EL 241 tW SWING-TIES SCALE: 1 INCH = 10 FT, DATE: FEBRUARY 2, 2016 � �� C7 �Z ��. 0 5 10 20 40 FEET EACH SEPTIC SYSTEM COMPONENT ®. O DESCRIPTION HC-1 HC-2 �f O Med.-Coarse Sand -.-- 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF 5' -" C 2.5Y 6/6 '`' • * PREPARED BY: L. THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST I CORNER OF STONE (1} 38.8' 28.2' RESERVED FOR BOARD OF HEALTH USE "_' CHURCiNLL JR 1 JC ENGINEERING, INC. PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL - CORNER OF STONE (2) 48.6' 40.6' � IL 2854 CRANBERRY HIGHWAY BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. A N 41807 MAP 170 CORNER OF STONE (3) 66.2' 43.0' EAST WAREHAM, MA 02538 3.) ENTIRE PROPERTY IS LOCATED WITHIN A DEP APPROVED ZONE 2, THE SITE PLAN PARCEL 242 132" 31.60' "+ - 508.273.0377 GROUNDWATER PROTECTION OVERLAY DISTRICT AND THE ESTUARINE [CORNER OF STONE (4) 59.4' 31.6' ►►~y� - - WATERSHEDS. SCALE: 1" = 10' No Mottling, Standing or Weeping Observed I� Drawn By BSM Designed By:BSM Checked By: JLC JOB No. 3380