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0081 ANSEL HOWLAND ROAD - Health
81 Ansel Howland Road Centerville A= 172-222 SMEAD No.2-,153LOR UPC 12?34 smead.com • Made In USA cYcl,poo r u��a n�c>�oaucir uw� SFI afn+e � auarm CER77FIED SOURCING �+'+�'.�JSFi�e2aiaiu4l�larTb Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General information When filling out I I forms on the computer,use 1. Inspector: V only the tab key to move your CHRIS NARDONE cursor-do not Name of Inspector use the return key. BRIDGE HOME AND SEPTIC INSPECTION SERVICE Company:Name 27 TIFFANY CIRCLE Company Address WEST BRIDGEWATER MA 02379 'B"0A Cityrrown State Zip Code 508-580-0465 S1571 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 07-17-2012 LIAspectorg 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. t5ins-11110 0 Title 5 Official Inspection Form u rface Sewage Disposal System-Pa 1 of 17 r c i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. Citylrown 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) j 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-11I10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 day flow t5ins•11/10 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 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 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 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: SEPTIC TANK D-BOX AND LEACHING SYSTEM Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage AVER 120GPD 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: UNKNOWN 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-11110 Title 5 Official 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 •'' 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012. every page. Cityrrown 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: NO HISTORY 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ( 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20 feet Comments(on condition of joints, venting, evidence of leakage, etc.): GOOD CONDITION Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal El 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: 8 FT L-5FT W-5FT D Sludge depth: 10 IN t5ins•11/10 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 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owners Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. Cityrrown 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 20 IN Scum thickness 1 IN Distance from top of scum to top of outlet tee or baffle 4 IN Distance from bottom of scum to bottom of outlet tee or baffle 14 IN How were dimensions determined? PROBE 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 SOUND ALL TEES AND BAFFLE IN PLACE 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•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 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 M 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. Citylrown 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 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL AND SOUND NO SOLID CARRYOVERS SCUM LINE AT BOTTOM OF OUTLET PIPE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 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 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owners Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): CHAMBERS DRY NO SIGND OF FAILURE 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•11/10 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. City(rown 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.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 14 of 17 I� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ''< 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owners Name information is required for CENTERVILLE MA 02632 07-17-2012 every 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 t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owner's Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. Cityfrown 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: 10 PLUSfeet 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: TEST PIT RECORD ATTACHED Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 81 ANSEL HOWLAND RD Property Address MARY MCGILL Owner Owners Name information is required for CENTERVILLE MA 02632 07-17-2012 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official fnspection Form:Subsurface Sewage Disposal System•Page 17 of 17 JUL-16-2012 12:57 From:BARNST HEALTH 15087906304 To:915085800465 P.1{2 TOWN OF B ARNSTABLE LOCATION _ A A,/S PL &_q w . A N1J X CZ SEWAGE#J QQ k Z ? VILLAGE �" !%t4�° 1�i1!o ASSESSOR'S MAP& LOT /211P`52 .. INSTALLER'S NAME&PHONE NO. ?A C Q AJ eR t . S o N SEPTIC TANK CAPACITY r C>O C ©L p ..LEACHNG FACILITY: (type) x - Ca, y tip PLC_s (size) NO.OF BEDROOMS ' -BUILDER OR OWNER I i 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 i Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furuisbed by r � � i JLL-16-2012 12:57 From:BARNST HEALTH 15087906304 To:915OBS800465 P.2/2 Q C 0 chopQ Q O L 4. TO PREVEt . I`LEVRTton 0 A 40 MIL GI THE LINER C� ooc © 5- SLOPE ALL Op �$ Q Q Q Q o G. THIS SYST -__ 7. LOCAL BO) �a 4.Y SYSTEM I� ! — 4.9' BE BACK F (om'') `� 8. ELEVATIOP -ER ELF - ? 88.87' 12.9 OBTAINED 9- CONTRAC 5'MIN. THROUGH t"��_1 � CHAMBER END VIEW AT 1-888-D ��A BER DETAILS DISCREPA NOT TO SCALE 10- ALL JOINT ll-rml It-In - - -� ��: — -----� _• — �.d T PIT °T'A ! }_. ��0 DE TT . /` - 2-a ZONING R 4w .® offi.-eR v= f t •�. — -Ev v - i , z E 1SES ins a '.. �.� ..:• _@'fl a- ::..L -.�.�" ..:�. .-SA 316„•by..�"'..'•'A S�i`me*"^' -"_-' F PF� , z ti. \TE Y a 1. i c r 'L3�i e'. rri it w lY i - �� ' .7 .! h-� �. '4'7�� � 't r 3:� gK•... gam- -�# -, _ -,.., E a.. �. ""---:.ram—•��.- - - �. -771 EX ` F _ LawfF4 a f£ --.i3df 8 --� _L -trio.-•'',. "�FF� itfi$ 41�. �c law— F i .�•. .t> _ 't[ti t 5 t3 '-�..r:'�' �*� 1� it � � _'- � it sa� rv. r� = r i "- -srF`�.• - e,.,trE s e . X 3 g f as L -3�2....-•r` -.r_ - ESG "T"„duTF+ '; b(- ! i S:- t s - D 4 ..-.: _ -.0 - -.Tm-�- d.. EI iT i•_ 1. - t .- ... k 10%Gravel Coin;Ae5 j LOCUS PLAN t 1 4 26 eL SCALE. 1"=1OM' '*NO GW,WEEPING, MOTTLING ! 2012-67-1612.57 i50Ea9i3b3a4 Yaue 2 � f TOWN OF BARNSTABLE LOCATION A Al .S PL 110W,4 A W D R C>SEWAGE #2 VILLAGE C eA17'eg ilea o ASSESSOR'S MAP & LOT Z INSTALLER'S NAME&PHONE NO. QT/'.M A C ® Al A + . -5 0 Al SEPTIC TANK CAPACITY / 6 6 d ©Z d ,LEACHING FACILITY: (type) 2 d 0,0, cr L u PCt S (size) a.S- 41 — A NO.OF BEDROOMS 'BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r 36 0 3`�`� i TOWN OF11BARNSTAB E 1 LO��ATION • g � WSgA �A w\G Y�1 a l SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 1 Z- INSTALLER'S NAME&"PHONE NO. SEPTIC TANK CAPACITY l 6OC 4 V% LEACHING FACILITY: (type) P t (size) UQ)O 21 Ve-\L— NO.OF BEDROOMS BUILDER OR OWNER 61`2USS PERMIIDATE: `ZS COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and o 2 Feet j Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) i rif Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 et Qf leaching facility) t°' + Feet Furnished by j E4 L r No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for ;h5pont 6petem Conotructfon Vermft Application for a Permit to Construct(-!-I Repair( )Upgrade( )Abandon( ) 0 Complete System ❑Individual Components Location Address or Lot No. $ �$1 �i W f Owner's Name,Address and Tel.No. C_W Assessor's Map/Parcel q 1 Ary� 1 Nw wm 6 Installer's Name,Address,and Tel.N . C5�"° "n S—31'-4tS Designer's Name,Addressand Tel No.. � ,V, toQ) Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building�v-��_No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) OmA Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is by this oar f Health. Signed Date he f 0 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued _ j No. / ,r',, ,. Fee � ~# , - THE COMMONWEALTH OF MASSACHUSETTS` Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE.,-MASSACHUSETTS Application for 30igpozat *pztem Construction Permit Application for a Permit to Construct(It4epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. I Anse 1�-W1_w rA Owner's Name,Address and Tel.No. C qn��i U,, , r1(3 0 tr33, :ry y 14, R1 C6 Assessor's Map/Parcel 72 qi Ary . 1 � A co JA 01& oa x L Installer's Name,Address,and Tel.N44 OCA) 'O S-333s Designer's Name,Address,and Tel.No. e,,o'3 a7I s?, -75.C . CQ11 n C.• W b Type of Building: Dwelling- No.of-Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building�v4-ck\n` No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date m, Number of sheets Revision Date Title Size'of Septic Tank Type of S.A.S. Description of Soil: l Nature of Repairs or Alterations(Answer when applicable) pDru�' e x ,h'f'a,A, 1-CAA-1-12' �4,� `.�c- SbO t 7Y�. `�l��rt��,1i� �]d% �1� Moo 1=�.ae. 11,�AA -t�r�C�MI�n►�1� �Q.o,<V1rX1 Lrlt�.,mAy� _t0144, Date last inspected: Agreement: ` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Poard, f Health. Signed F-- = O .� n t�,_ Date &P r 9 0 Ll 9 Application Approved by f�I f', r n tf/1 f��,t, Date Application Disapproved for the following reasons v r �--• .0-1 41 Permit No. Date Issued 1 �-_ r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by n/lawNMAer afj 0(1 r at a 1 r . RowLaa rA has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer S•�. 4 Designer Ir-WALinepr t V1 1. The issuance o this a tt sh 1 not be construed as a guarantee that the syste v✓ ungtio as designe . Date !/t 0 Inspector _,?_ = —" —.—'----------------—------------------------- No. Fee l THE COMMONWEALTH OF MASSACHUSETTS 01 r A,A�( PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lt5po5al *p5tem Construction Permit Permission is hereby granted to Construct( )Repair( ' )Upgrade( )Abandon( ) System located at �Atw 1 1p j f'd . 6(i�at1►'O tl1Q, YA and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ,�' Provided: Cons c Ion 'ust b completed within three yeais of the date of this permif,l f Date:_ / Approved by ! / ��4 , /),s l ' f' f TOWN OF BARNSTABLE ` I LOCATION A A15 eL 110 w L ail Al/6 k.V SEWAGE #2 d®�' �• VILLAGE C eAl reg I✓/,/ -P ASSESSOR'S MAP & LOT /2j9 INSTALLER'S NAME&PHONE NO. eJ-/` 10 A C B M A ed $ tl SEPTIC TANK CAPACITY Z 6 ® ©Z d LEACHING FACILITY: (.type) o CAP y e.0 PLC S (size) A S /_3 — �. NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: COMPLLANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwa e ble 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 36 3q,� � �i CJ m CLon d C r0 O O J ,D JD ��p I V e a. m W o c Si ,aCe OD �g 11) PIN � A w ` 8 00 i3 3 o W O J to c1> J ^ LY d 7- v M fi w Ul �-►� Ila. « y [� dM a.. Q E c I i n. d i COMMONWEALTH OF MASSACHUSETTS Raw EXECUTIVE OFFICE OF ENVIRONMENTAL AF RSOCT 2 2 1998 DEPARTMENT OF ENVIRONMENTAL PROTEC ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 ��lOpF�OL ~! 40 WILLIAM F. WELD $ COXE Secretary Governor ARGEO PAUL CELLUCCI DAVID B. ST UHS Co**+**++ssionsoner � Lt. Governor SYSTEM INSPECTION FORM SLBSL'RFACE SEWAGE DISPOSAL S PART A 1'1 V�AV�Q CERTIFICATION 11 Q�� f�eJS�- �e.r.�c� Property � `�O� t G2v3Z Address of Owner: a�S Date of Inspection: �ss (If di ereny Name of Inspector: i I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) # Company Name: .0 L Mailing Address: r�r it a,�'�,� i, � a Telephone Number: -7 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: I E Passes _ Con3itionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Si Date' Inspec gnature:�Uv QL The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C; or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If'not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Y � (revised 04!'_5l97) Page 1 of 10 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:t(Y V� t'' f i , `-- , Owner:,, 3 ;IIf1S, 1 Date of Inspection: BI SYSTEM-CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with.approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed i distribution box is levelled or replaced The system required pumping more than four 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 Cl 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 the public health. safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETER ELN'ES THAT THE SYSTEM IS NOT FLICTION-r`G IN A . CIA-NNER WI-DCH WILL PROTECT THE PUBLIC HEALTH A:N'D SAFETY AND THE ENVIRON1tENT: _ 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 MILL FAIL UNLESS THE BOARD OF HEALTH (A.N'D PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERAtIr -S THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH ANN'D SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER v � (revised 04125/97) P2ge 2 orlo a 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 10 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clog d SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters ue to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overl aded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volum is less than 1/2 day flow. Required pumping more th4n 4 times in the last year NNOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System. cesspool or privy is, elow the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a su face water supply or tributary to a surface water supply. of a cesspool or privy is within a Zone I of a/public well. Any portionp p Y Any portion of a cesspool or privy is within 50 feet of 4r*ivate water supply well. Any portion of a cesspool or privy is less than 100fee but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has/w1en analyzed to be acceptable. attach copy of well water analysis for coliform bacteria. volatile organic compounds. ammonia nitrogen and nitrate nitrogen. Y E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow f 10.000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 7 Yes No the system is within 400 feet ooFa 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 U of a public water supply well) % The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. y P � t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST r Property Address: Owner: C-�a�S� Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Xes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X — i As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. ; _ The system does not receive non-sanitary or industrial waste flow. i _ The site was inspected for signs of breakout. \ r _ All system components, excluding the Suil Absorption System. have been located on the site. j 1 — t The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or i tees. material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. f The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] J O revised 04/25/97) P� e 4 of 10 ( S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION �"roperty Address: Owner: G)1LOS$ Date of Inspection: FLOW CONDITIONS RESIDENTIAL: � Design flow: . 0 p.d./bedroom for S.A.S. Number of bedrooms: 0-1�i Number of current residents:Q2 Garbage grinder (yes or no):_k_j_ Laundry connected to system (yes or no):� Seasonal use (yes or no): 1-J Water meter readings. if available (last two (2) year usage (gpd): Sump Pump (yes or no): 0 Last date of occupancy: V-J CON LVEERCIAL/MI USI'RIAL: Type of establishment: Design flow: gallons/day vrease trap present: (yes or no)_ industrial Waste Holding Tank present: (yes or no)_ ;`Ion-sanitary waste discharced to the Title 5 system: (yes or no)_ " Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENTERAL INTORMATION PG1fPUtiG RECORDS and source of information: t='X) qacnZ& System pumped as part of inspection: (yes or no)_ If yes, volume pumped: t allons 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: K to 4A Sewage odors detected when arriving at the site: (yes or no) J 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C aa Q SYSTEM INFORMATION (continued) Property Address: Owner: ss Date of Inspection: BUILDING SEWER: (Locate on site plan) i Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints. venting, evidence of leakage, etc.) SEPTIC TAINK: (locate on site plan` h , Depth below grader Material of construction: _Lconcrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list ace _ Is age contirtned by Certificate of Compliance _(Yes/No) Dimensions: ,R Sludge depth: (✓'t ,t Distanct from top of sludf:e to bottom of outlet tee or baffle: L Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet re or baffle: How dimensions were determined: Comments: (recommendation for pumping:. Condit' n of inlet and outlet tees or baffles, depth of liquid level in re la 'o too t vert, ctur I intei_;rit}.-- evidence of lead etc. '\, C t 1 GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity. evidence of leakage, etc.) v (revised 04125/97) Page 6 of 10 i 1 I ! i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (O Owner: �j�laSS Date of Inspection: TIGHT OR HOLDING TANK: 'W (Tank must be pumped prior to, or at time, of inspection) I (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) i I Dimensions: Capacity: gallons j Design flow: gallons/day Alarm level: Alarm in workine order _ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches. etc.) i iISTRIBLTION BOX: U L, (locate on site plan) T Depth of liquid level above outlet invert: Comments: note if I vel and distribution 1W qual. vidence of solids carryover, evidence of knee into o out o box, e:c.) t. - c u C , PUMP CHAINIBER: a (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) a V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �f, + SYSTEM INFORMATION (continued) Property Address: Owner: C"I ks Date of Inspection:A(���� SOIL ABSORPTIONIII SYSTEM (SAS): 1, ,S (locate on site plan, if possible: excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, numb r._ leaching galleries, number: leaching trenches. number.length: leachin_ fields. number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil. 'gns of hydraulic failure, level of ondin , conditi of_veg o c.) hc CESSPOOLS: (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 (cesspool must be pumped as part of inspection) 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.) v (revised 04/25/97) Page 8 of 10 ir • i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C G SYSTEM INFORMATION (continued) Property ddress: f� Owner: � $� . Date of Inspection: ShZETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 ' L 7 -A r1A 'Q^)_ Pace 9 of 10 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection:�+ Depth to Groundwater to Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole. basement sump etc.) i Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers r Use USGS Data Describe in your own words how you established the High Groundwater Elevation. `tust be completed) S. 5-ao�0-it C-, wy� ct IC1cw 5 (revised 04125197) y Page 10 of 10 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH C" ...............0 F... 6r ------................................ Appl r atiun for Ditivas al Works Toutitrurtiun permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systteemj at: _ --•!=•= .......................................rt —.� r� �' f ..................................................// / L_.-�tiortldr qr Lot ..... :'..✓ ... ............................................... .................. o. ....---........... Owner Address Installer Address d Type of Building Size Lot---- Sq. feet Dwelling—No. of Bedrooms...........�..............................................Expansion Attic ( ) Garbage Grinder (,A)j a p., Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ----""-""---"-----•-•-----••-•......-••••••... - - r - � J, W Design Flow.........°� �.................."..gallons per person per day. Total daily flow........`".__._"_-..-._.____-___.._-____--gallons. WSeptic Tank—Liquid capacity-/�-P-.tl.gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...l .'r ... Diameter............... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) • Dosing tank ( ) '-i Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..................... Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ "--•-""-""------------------"---""""----.....---.....--".............---..........-----------.---.--......................................................... 0 Description of Soil........................................................................................................................................................................ x -----"-"-"- ...;r........................ V Nature of Repairs or Alterations—,Answer when applicable............................................................................................... ................•-•....•...............••••-•••••••----••---------•----••------•--..._..___.._...._....•-•-----•--•••---••--•-•-----...----...........••••-••------•----•-••----•••-......-•-------._-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITI LEE 5 of the State Sanitary Code— The unders' ned further agrees not to plax the system in operation until a Certificate of Compliance has:been iss ed by theboI rd ofhealth. Signed.. .. ............!•• ----- ................................................. .�1 Date Application Approved By.............. .................-OIL,_....._.. Date Application Disapproved for the following reasons:................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date ' /Va No...... ............. '` FE.S................ . ...._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F.........................---............------------......---------........-......------•. Applirntiun for Disposal Works Tonstrnrtion rrnti# 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 QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) 44 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_-_____-------..__-_- -------------------------------- ---•......... --.......... ----------------------------- ....-.•-.-------------------------- .--.--------------- -----......... ..... . 0 Description of Soil..............•------------.....----••---------....................-•--•-....--•--------------------....--------•---------------......-----------------•--------•------- U W -•----------------••------------------------•----------•••---•---------•-------•••-•--•-------•--•-------••-•••••--------••----•-------•-----•-•----•---•-••-----•...._..................-•-----•---••-- VNature 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 TIT1,1, 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.................................... ------------------------------- Application Approved By....................................................... ...................................... --------------------•- -----•-------••-- Date Application Disapproved for the following reasons:................................................... ............................................................ .................................•------------------------------------------•-----------•---------.......•-----••...._...-•---•-----•-----••----•--------------•-••-----••-----•----•......--•-•---•---. Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF................. ....................I..........I................................... Trrtif iratr of TOmplianrr THIS IS TO C�- That gibe Individual Sewage Disposal System constructed ( ) or Repaired ( ) at---•---------•----------------------•---....----•--•-•--------......-------- --•----•----................•----.-w-.-•----�..--- --f-----------------•--------•-----------.......--------------- has been installed in accordance with the provisions of TI.T , 5 f The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-- -µ__�_� ......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL U)ICTION SATISFACTORY. ...................................................... Inspector-.. .-._A......_.. ............................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH JOF.......................... d No......................... FEE........................ Dispou�tagrksfoustrurtion antic PermissioLis hereby granted........................ to Constrt:> 'er� Rep ' ) an ndivi �ewa .e Di osal Systern,1�'�C.__ atNo _--_---------- ----------------------------------------------------------------....................................... Street as shown on the application for Disposal Works Construction Pelyi No.................!__ ated................................:......... w .. ................... ✓�IToard of Health DATE.!. " ^-- -�--------•---------------•----. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS pE.sIGN UA _ , SING�G- FAM{LY - � BEORoc�k `' . DAILY F%.OW : IIo x 3 = a3oG.Po SEPTIC, TANK 330x15o'/• =-4956.P. 0 ' y5E l000 GAS.. ! f O15Po5AL PIT usE l000 GAL.. 5�D��A�u A2F.�► _ ►5c s.� _ 150 5.F x 2.5 a 375 G.Ro 50TTOM AQAr .. �� aF•_ PAP to E• So 5.I= x I-o A 5•0 &P o r '� N b -roTAL DAII-�( FLov,! = 33oG,Po 14 r PE�LCOLAT{O�l RATEi I''IN 2MIN o�.�C�55 ° N I lot +TN. P� l. VA pF M4z \ G ` .�V RICHARD ag �G Q ALAN ., v,xY F n QT'1 -6 BAXTER i.;'4 JONCS Na 2"048 u. 251 13 ti �' - ovc iL,��1D aA TRST RL32 �(,' SS To P FWD= �� NoLC- 611zIBI - GL% 54. FG`� °' Imo•53. a Ioov INV. e SI�BSO,Ir G>r DIST INV. G°iL rj2$ BOA S C �jZ.,(. PTIG Z {000 I NY, TAN K Fax- 57- �4 4' Mev. PIT INK INV. j` S}a�. wlTu 52.2. 5Z•4 WAsuco 'f 8 6TaN6 i to Meb, - I+— & �1•� !I Spate CE2TIr-IGD PLOT PI-A.W PR.oFILE l 42 12 NO SGALeF �jGp•LE "_ 1�' AT I2-82 o ATE1Z. P 1_p►►.� RE F 6IZEN CC- 1 GEaTIwY THAT 'I NE 1-Duu10ATI014 5"0wtj gr,.R60 Al COMPU. !S of ITN Z HIr S I oR LIN E �0-r A►JP Sf-T'aAGK R.6QvIR.EMEN'f� gQF'iNE- 'joWN- of T AQW5TABLGC►NV IS IJdr P� . '{3►L. 3d� `PG ��+ LOCATED -WITNI TN FLOOD PLAIN DATE BAxTEze WYE; INC. R.EG 1 S•T EQ6•D IuAN D S u MY 'Tull PLQN 1�; NCrr ca AW os•rEPtVILLrr MASS• IuSTRuM6NT Su2VGY �- THE OFF5ET5 'SWOUO - n-rtft r1r•Tr. to MI►.1G. I r>1- %—It C-,' APPLIr-A.Wr A( AL1 L 9 CATION SEWAGE PEAMIT NO. Jeri,j- 4-a(S6 '7 73 VILLAGE INS A LLER'S N A N I i ADDRESS 6U1LDER OR 4 NER �� it.�,4 Cr tr dc,/I Lo&Z L�fT�ry2r/iLC � DATE PERMIT ISSUED DAT E COMPLI A_ NCE ISSUED r r b � �- �� ,� � � -� , TOP OF FOUNDATION ELEV. = 101 .63' PROVIDE PRECAST CONCRETE 5" DIA. OUTLET(S) FINISH GRADE OVER CHAMBERS= 9$.90'-99.83' EXTENSION RISER WITH CONCRETE COVER TO WITHIN 6" REMOVABLE COVER SLOPE @ 2% MIN. OVER SYSTEM GENERAL NOTE S OF FINISHED GRADE ABOVE FINISH GRADE OVER D-BOX= 99.95' 4"SCHEDULE 40 PVC MIN SLOPE 1% 3/4"TO 1-1/2" DOUBLE WASHED STONE TO CROWN OF PIPE FINISH GRADE 100.96- FINISH GRADE � ' OUTLET COVER '� __ F @ FND. EL.= OVER TANK EL.= 100.00 -100.40 2"OF 1/8"TO 1/2" DOUBLE WASHED STONE '1 =20" MIN.ACCESS COVER TOP OF SAS= 96.83' PLACE RISERS ON ALL CHAMBERS 1. UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION EXISTING 4" (TYPICAL FOR 2) 36"MAX. 9"MIN. TO 6"OF FINISHED GRADE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE PVC PIPE 96.00' 36"MAX. BREAKOUT EL - 96.50' ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES. - 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD 6" 3" PROVIDE WATERTIGHT OF HEALTH AND THE DESIGN ENGINEER. 2"DROP MIN. 3" 9" JOINTS (TYP.) 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL 0 3" DROP MAX. 4" PVC IN FROM O 0 oo �`b� O o0 p BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED. 14" SEPTIC TANK 4"PVC OUT TO To 4. TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE LESS THAN 98.80't- LEACHING FACILITY o00 o ELEVATION =96.50' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS 98.65'± 98.20 ± 12" oo A 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF *CONTRACTOR TO 97.60' MIN. 97.43' 2, 0 0 0 0 0 00 0 oo THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. CONTRACTOR TO CONTRACTOR SHALL VERIFY SIZE 48�� VERIFY o o O 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. VERIFY AND CONDITION OF TANK AND TEES o 0 0 o OUTLET TEE WITH 22" 6" CRUSHED STONE o 0 0 0 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. AND REPLACE AS NECESSARY ZABEL FILTER MODEL OVER MECHANICALLY o 15.1' COMPACTED BASE 4' _ 7. LOCAL BOARD OF HEALTH TO BE NOTIFIED PRIOR TO BACK FILLING WHEN #A1801 HIP(GAS 8 5 4.0' 4.0' SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS NOT TO BAFFLE ON BOTTOM) 5 OUTLET DISTRIBUTION BOX 25.0' 4'9 BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH. _- TO BE INSTALLED ON A LEVEL STABLE (NP ) � GROUND WATER ELEV- > 88.87 12.9' 8. ELEVATIONS BASED ON ASSUMED N.G.V.D. DATUM OF 100.00 MSL EXISTING 1000 GALLON CONCRETE SEPTIC TANK BASE. FIRST TWO FEET OF OUTLET 94.00 OBTAINED FROM A NAIL IN FENCE AS SHOWN ON PLAN. LENGTH 8'-6" WIDTH 4,_10„ DEPTH PIPES TO BE LAID LEVEL. 2- 500 GAL. CHAMBERS MIN. 9• CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION �.� 5' CROSS SECTION VIEW THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE TYPICAL CHAMBER PROFILE CHAMBER END VIEW AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL CHAMBER DETAILS DISCREPANCIES TO THE DESIGN ENGINEER. NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE STRUCTURES SHALL BE MADE WATERTIGHT. TEST PIT DATA 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR `�^ �'`` -- -✓ -- ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH -� INSPECTOR: DETERMINATION FROM APPROPRIATE AUTHORITY. --�- � SOIL EVALUATOR: Samuel Philos Jensen _ • 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS > ~� _ a- DATE: June 13, 2003 LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE TEST PIT#: 1 THEY SHALL WITHSTAND H-20 LOADING. ELEV TOP 99�.3T 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND =ELEV WATER= >88.87' FINES. 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF PERC RATE = LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN ♦ - DEPTH OF PERC= N.A. COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN MAP 172 �-- `�� r ., 6 , ACCORDANCE WITH 310 CMR 15.255(3). 1f f TEXTURAL CLASS: 1 � PARCEL 022 r8n berry � � •,,,.- + * « �' � Y�-- ,✓ 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN Co N/F TOVET �i O!- Q ` • « « « SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. 0 99.37' /�_ i i� • `' , �•` '�; o G 16. PROPOSED PROJECT IS LOCATED WITHIN: / r, _ - . • ASSESSORS MAP 172 PARCEL 222 _�-_M._.w• �• + �`'��' « 1 Fill . ! •' 17. OWNER OF RECORD: MARY K. MCGILL • '' " • 18" 97.87' ADDRESS: 81 ANSEL HOWLAND ROAD MAP 172 / �* ' «• �•• •; •f�' �a CENTERVILLE, MA 02632 PARCEL 221 4 • 4 x B Sandy Loam �l • y� r _.._ ,� ', , • . 1 OYR 5/8 18. PLAN REFERENCE: N/F DRAKE + • •,r ` `• • 1. BOOK 343 PAGE 84-86 AS RECORDED AT BARNSTABLE COUNTY REGISTRY OF DEEDS / • • • i • ,• -.``f ". • ` ' 38" 96.20' 19 DEED REFERENCE: «'« • • rt " 40 ` ( • 1. BOOK 306 PAGE 17-24 AS RECORDED AT BARNSTABLE COUNTY REGISTRY OF DEEDS «a • « •• M-C Sand • «r� �t 'A i� ' �• : C-1 2.5Y 7/6 20. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. } ` •�f,� • * ` 15% Gravel Cobbles T ` « • 21. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY MAP 172 / ~ ,� • *�4 FOR SEPTIC SYSTEM UPGF 4DE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY }/ 99.3T \ INTERIOR WALL ` • +„ . , : j ' "` •'► • 64" 94.04' �p PARCEL 222 �,,�/} DIVIDING FULL .4 I,° , �y . R •�Q� , I FOR USES OF THIS PLAN 01,1ER THAN ITS INTENDED PURPOSE. 17,166 S.F.t /J \ BASEMENT AND g`� ►.p 100) CRAWL SPACE �r_aL o `tea -""` "._` ; • • M-C Sand - - - - CB t - C-2 2.5Y 6/4 MAP 172 }/} (FND) 10% Gravel Cobbles PARCEL 023 EXISTING LEACH `99 / N6023/, LOCUS PLAN l / PIT TO BE 7s 3jy / 126" 88.87' N/F PERRY PUMPED AND HE ? E/T/C/ r23• / SCALE: 1"= 1000' FILLED WITH '`NO GW, WEEPING, MOTTLING CLEAN SAND ` d` / SLAB GARAGE NNI o / ( CB LEGEND /' PATIO (FND) DESIGN DATA -:: 5.0 0 AS \ l / j�� EXISTING CONTOUR 0 O 40 0`S \ NUMBER OF BEDROOMS (ASSESSORS) 3 50 PROPOSED SPOT GRADES O •- CONCRETE \ \ �Q I NUMBER OF BEDROOMS(DESIGN) 3 �� PROPOSED CONTOUR 0 ? Q . DRIVE DESIGN FLOW 110 GAUDAY/BEDROOM E j I /L EXISTING OVERHEAD UTILITIES / '== =_'_- h 262• �,� ��I-,- / /L.0 ' TOTAL DESIGN FLOW 330 GAUDAY 2-500 GALLON 'c .9- = `�' �<v OJ^p �C ' LEACHING �✓ „ ^ �'� �� CHAMBERS `-1�� Cj '©s 0���; ,� of W EXISTING WATERLINE o' Q 4( GAS EXISTING GASLINE �� 0 0� / h� DESIGN FLOW X 200 % = 660 GAUDAY USE EXISTING 1000 GALLON SEPTIC TANK TEST PIT LOCATION Nail in Fence O O EXISTING 1000 GALLON SEPTIC TANK INSTALL 2- 500 GAL. CHAMBERS N.G.V.D. 7 - 0-1 PROPOSED500 GAL. LEACHING CHAMBER , i SIDEWALL CAPACITY DISTRIBUTION BOX 2�•3)F � � V (L+W)(2 SIDES)(2' HIGH)(.74 GPD/S.F.) = GAUDAY 4"SOLID SCHEDULE 40 PVC PIPE �� EXISTING (25' + 12.9')(2 ) (2' ) ( .74 GPD/S.F.) = 112.2 GAUDAY 1000 GALLON O DISTRIBUTION BOX "J SEPTIC TANK BOTTOM CAPACITY (LENGTH x WIDTH) (.74 GPD/S.F.) = GAUDAY MAP 172 (25 x 12.9) (.74 GPD/S.F.) = 238.7 GAUDAY REV. DATE BY APP'D. DESCRIPTION PARCEL223 TOTALS: PROPOSED SEPTIC SYSTEM UPGRADE N/F J&J REALTY TRUST TOTAL NUMBER OF CHAMBERS 2 PREPARED FOR: TOTAL LEACHING AREA 474.2 SQ. FT. MARY K. MCGILL TOTAL LEACHING CAPACITY 350.9 GAL./DAY LOCATED AT 81 ANSEL HOWLAND ROAD RESERVED FOR BOARD OF HEALTH USE CENTERVILLE, MA 02632 SCALE: 1 INCH = 20 FT. DATE: JULY 7, 2003 0 10 20 40 80 FEET 1H OF JOHN L. CHURCHfLL. m, PREPARED BY: CIVIL JC ENGINEERING, INC. M No 41807 7 2854 CRANBERRY HIGHWAY WAREHAM, MA 02538 SITE PLAN 508.273.0377 SCALE: 1"=20' _ Drawn By: SJZ Designed By:SJZ Checked By:JLC 473