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HomeMy WebLinkAbout0164 ANSEL HOWLAND ROAD - Health '` Ansel Hawland Road Centerville A= 171 - 264 y S M E A D No. 2-153 LOR UPC 12534 smead.com • Made in USA 1 J� CYC4P V I A r Commonwealth of Massachusetts w ip Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V �, /j 164 Ansel Howland Road ` try Pwh Property Address Andy Qayyum Owner Owner's Name/ information is Centerville V Ma 02632 March-11-2021 required for every 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. Inspector Information �1 g aid on the computer, Daniel Hawkins use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S114324 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. 0 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawkins Digitally signed by Dan Hawkins ."-Date:2021.03.1508:15:26-04'00' March-11-2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ----------------- .............. , Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every ate page. City/Town St Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The system was in working order at the time of inspection. 2 System Conditional) Passes: Y Y ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments j 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts n r Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 164 Ansel Howland Road 1� Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4' 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every St page. City/Town ate Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ a Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El 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. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ O The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 l Commonwealth of Massachusetts ------------- �� p Title 5 Official Inspection Form M1i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ❑ El Pumping information was provided by the owner,occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ 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? El ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ 0 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: El ❑ Existing information. For example,a plan at the Board of Health. ❑ O Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. 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): 331.4/GPD Description: 5 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes .❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes El No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑. No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: 2020- 253,000gallons 2019- 145,000gallons Sump pump? ❑ Yes ❑■ No current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �1 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner-date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: New SAS added to existing tank in 2007 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑cast iron ❑■ 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts . ------ - Title 5 Official Inspection Form '- i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t --- 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: 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 1 Dimensions: 000gallons 611 Sludge depth: 3011 Distance from top of sludge to bottom of outlet tee or baffle 411 Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 1311 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t � 164 Ansel Howland Road Property Address Andy Qayyum_ Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. -Grease Trap(locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: — Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts --------.._..------ A - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every St page. City/Town ate Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc,): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts _- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,y 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): NA If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2)500 gallon chambers El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): The SAS was in working order at the time of inspection. Leaching was 3/4 full when viewed. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments note condition of soil signs of hydraulic failure level of ondin condition of vegetation, ( 9 Y � P 9� etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts �.. __ Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t lY n 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town Satet Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: M hand-sketch in the area below ❑ drawing attached separately �► . ♦ ♦ ♦ . r0, sir- � � f.� �.: � � i .s *4 011 I i11 ♦ \ ♦ 1 ♦ % R 1 ♦ ♦ ` ' ♦I %ICI♦er♦I% .e` 4F A',f' A A A .A �►• ,� ,� � i I" A I f ♦ ,.A' � O /' J" r• � f rf ii ,N.,a ♦��� . "�.♦ 1 °► �;�*J �..,I'♦. ,� a . .� Rear of House UM , 35 Q w" M,i Mpw t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts - : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: R Check Slope ❑■ Surface water 0 Check cellar ■❑ Shallow wells Estimated depth to high ground water: No GW @ 132"feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record 9-22-2007 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: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts - - Title 5 Official Inspection Form - <i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 164 Ansel Howland Road Property Address Andy Qayyum Owner Owner's Name information is Centerville Ma 02632 March-11-2021 required for every St page. City/Town ate Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Al A. Inspector Information: Complete all fields in this section. Q■ B. Certification: Signed&Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1,2, 3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed �■ D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w•. 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is required for Centerville MA 02632 April 28, 2011 every page. Citylrown 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 A. General Information forms on the computer,use 1. Inspector: I (n only the tab key \(/ to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA Cityrrown State 02648 Zip Code 508.428.1779 SI 12855 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 April 28, 2011 Job# 11-63 Ins ctor's Signatu 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. 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 117 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is required for Centerville MA 02632 April 28, 2011 every 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: Tank is not in need of pumping at this time. Leaching chambers have 2-Y of standing water with no high stains. 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is required for Centerville MA 02632 April 28, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 16.303(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 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is required for Centerville MA 02632 April 28, 2011 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 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 ❑ n 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-09108 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 w„ 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is required for Centerville MA 02632 April 28, 2011 every page. Citylrown 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-09/08 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 M 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is required for Centerville MA 02632 April 28, 2011 every page. Cltyfrown 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 � 9 c u . 9 p ® ❑ 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 l5ins-09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is required for Centerville MA 02632 April 28, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. 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: 15ins•09108 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 °M 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is required for Centerville MA 02632 April 28, 2011 every page. Cltyrrown 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: None available. 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): 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is Centerville required for MA 02632 April 28, 2011 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Leaching system installed: 10/9/07 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2' 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: 18"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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 3" t5ins-09108 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 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is Centerville required for MA 02632 April 28, 2011 every 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 27 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured Comments (on pumping recomme ndations, inlet and outlet tee or baffle condition, t on, structural Integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact. Recommend pumping in next 12-18 months. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsu rface Sewage _Disposal System Form Not for Voluntary Assessments �M 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is Centerville required for MA 02632 April 28, 2011 every page. Cltyfrown 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 El 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 15ins•09/08 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 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is Centerville required for MA 02632 April 28, 2011 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.): No high stains present, trace of solids observed 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: l5ins•09/08 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 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information.is required for Centerville MA 02632 April 28, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Two 500 galdrywells. ❑ 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.): Interior of leaching chambers had 2-3"of standing water with no high stains 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 15ins•09/08 Title 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 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is Centerville required for MA 02632 April 28, 2011 every page. Cltylrown 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth. of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Ansell Howland Road Property Address ---Anthony Pino Owner ----- ..._.._.. --------- ------- ----- — Owner's Name information is required for Centerville MA 02632 _ April 28, 2011 every page. CitylTown 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 r r r / r r r r ! r r / r\/\ •\r \ ♦ \ \ \ \ 9 2 Rear of House ' 4 35 49 40 Commonwealth of Massachusetts Title 5 Official Inspection Form Subs urface Sewage Disposal System Form Not for Voluntary Assessments 164 Ansell Howland Road Property Address Anthony Pino Owner Owners Name information is required for Centerville MA 02632 April 28, 2011 every page. Cltyrrown 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+ 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: 9/22/07 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: Perc test performed for repair found no water at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Ansell Howland Road Property Address Anthony Pino Owner Owner's Name information is Centerville required for MA 02632 April 28, 2011 every page. Cltyrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARN LE LOCATION nsell #VUA4VST E VILLAGE Mt-er M ASSESSOR'S MAP&PARCEL M6TAUE&S NAME&PHONE NO.�` r,W k®min,,14 SEPTIC TANK CAPACITY /000 qJ LEACHING FACILITY:(type) dhct vA (size) NO.OF BEDROOMS OWNER ' PERMIT 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 h \ \ ♦.\.♦. ♦.\.. . .♦.\. .\.\.h.\.h.\. t J 1 f I t f f 1 f I t J / 1 J f I I J - ♦ 0.- f / F f f J f \ \ \ \ h \ \ f J f J f f f J t f f J f I J f 1 f f f f 9 2 Rear of House 4 35 49 40 No. 20 7ee00.00 THE COMMONWEALTH OF MASSAC-HUS6TTS Entered in computer: �� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for 0igw6af *pgtem Cow6truction Permit Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) ❑Complete System I Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 4 2 8—1 7 9 8 164 Ansel Howland Rd, Ronald Mezzano Assessor's Map/Parcel 171 Centerville 152 Ansel Howland Dr, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco—Tech PO Box 1089 Centerville 43 Triangle Cir, Sandwich Type of Building: 1 n -Z a2/ A,wtvtr or y.„N I ��.�,1 �ln<<f^ 3 �. A`7 cur 04- SR,b,+ Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder (no) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3� gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank xQX;d3, (aa. Type of S.A.S. 2 Stm Description of Soil Nature of Repairs or Alterations(Answer when applicable) We will install a new Title 5 leach system to plans of Eco—Tech, #ETE-2764 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 by this Board of Hea q Signed Date Application Approved by Date Application Disapproved b Date for the following reasons Permit No. .204)7 `f 3 Date Issued 11 y,w. -^ • •"'a+.—r,•.�.,.-+-X+17...�.—. .M... .-�.� - ti -,.--• - .._y...y�,•,-(x.+-rr":....� ,�Y,+.+eti...<`^a'�. ..•.- ,.+h^. - s...,.'r"�r•-.-.. _ �-,r No. . 0) v r f Y -Ieeo 0.0 0 r 1 THE COMMONWEALTH OF MASSAOUS`-H. TTS Entered in computer. •� ` PUBLIC HEALTH DIVISION= TOWN OF BARNSTABLE, MASSACHUSETTS Yes - ZIpprication for Oiooml *patent Construction Permit Application for a Permit to Construct( ) Repair K) Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 4 2 8—1 7 9 8 164 Ansel Howland Rd, Ronald Mezzano Assessor's Map/Parcel 171 Centerville 152 Ansel Howland Dr, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8.7 7 6 Designer's Name,Address and Tel.No.3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco-Tech PO Box 1089 Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder (10) J —ID- { v Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / r Design Flow(min.required) 3 30 gpd Design flow provided 33/_ Y gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank -e r Type of S.A.S. (2) 5Vd �r, Pr, l �X ��•rt k 2 / Description of Soil Nature of*Repairs or Alterations(Answer when applicable) We will install a new Title 5 leach system to plans of Eco-Tech, #ETE-2764- 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 by this Board of Hea Signed Date Application Approved by _ Date Application Disapproved b Date for the following reasons Permit No.2007 Date Issued ------------- (,Vol be 0 �br BPcJru THE COMMONWEALTH OF MASSACHUSETTS 4 BARNSTABLE, MASSACHUSETTS cif� ��4 1 r^^ 7`' l s I d t a•�oG� , 1 t Mezzano (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (X ) Upgraded ( ) Abandoned( )by Wm E Robinson Sr Septic at 164 Ansel Howland Bld, Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ?��^u — tf 1/ dated �J A> Installer Designer tcs1Me #bedrooms Z Approved design fl4- _2 0 gpd The issuance of this permit sha111'not a construed as a guarantee that the system wcrido ill fu as designed. Date _ �C�J -� Inspector No. ?W7- N 3� heel 00.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Nezzano =igpo!9d[*p!5tem Construction Permit Permission is hereby granted to Construct ( ) Repair (X ) Upgrade ( ) Abandon ( ) System located at 164 Ansel Howland Rd,Centerville J 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. 0� Provided: Construction must be completed within three years of the date of thT`77 � Date �1 l (f7Approvedby , 1c,,rr TOWN OF BARNSTABLE LOCATION j(_ /�� �( Y6,1,j(a W Q IZOAP SEWAGE# 0?60 7 J4 3 V. VIjL GE 6B44w-l ASSESSOR'S MAP&PARCEL ! 7)' 940 INSTALLERS NAME&PHONE NO.W^.t �ets� �e�i►c' c� 3D�.'7 7S�'776 +,. SEPTIC TANK CAPACITY aoa LEACHING FACILITY:(type) d-X 9 X a NO.OF BEDROOMS c� a OWNER }��b PERMIT DATE: 7 COMPLIANCE DATE: le��l��`7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility CO¢� 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 360 feet of leaching facility) ll Feet FURNISHED BY 615t�, O a TANK d ,3�= R a 3(f�,�'57cf If ��'� Ar a Town of Barnstable P# —ALA—? Department of Regulatory Services ' Public Health Division ./ I? 2d 07 sesrtsreas ' Dated , 163 200 Main Street,Hyannis MA 02601 41 Date Scheduled Time Fee Pd. �� or - cg . Soil Suitability Assessment for Sewage Disposal Performed By: bew,6l D• � L.S E<Q Do g h GI i o�dl d ' Witnessed By: / LOCATION& GENERAL INFORMATION Location Address 164 d, �]�el, 0 WJgNCJ �q Owner's Name 411,1'pt �P'j�nl1(7 p� ��, (f(i f_�'Re Address (�Z A4 S(41 �Q 141 ci wal N/ coalervl fIP- Assessor's Map/Parceh qt4R [71/ 3 Engineer's Name �t �_ 6v661 1e7 NEWCONMUC71ON REPAIR V Telephone# 15&T 7004 62V4 Land Use re5,J 2ti J t,q Slopes(%) Surface Stones K e Distances from: Open Water BodyC©��5+ ft Possible We Area �O� ft prinking Water Well Drainage Way `y + ft Property Line IUD '- ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) -- -- 140.64 Ft I ®I I ' r I GROUNDWATER ADJUSTMENT I I. EXISTING GROUNDWATER LEVEL BASED ON TOWN OF BARNSTABLE GIS DEPARTMENT RECORDS. IW� INDICATED GW 37.00 Ih INDEX WELL ZONE SDW-252 D READING DATE AUGUST. 2007 I READING 47.4 ADJUSTMENT 3.6 m 1 ! ADJUSTED GW 40.B 0 130.46 Ff- ------ ^�^ ' - Parent material(geologic) r c/el9` ouf�WS 4 Depth to Bedrock 6 Depth to Groundwater. Standing Water in Hole: Ka n e Weeping from Pit Face Ko h e } Estimated Seasonal High Groundwater See qbo✓e k DETERMINATION FOR SEASONAL HIGH WATER TABLE ' b z� Method Used: ee. 4• ®t1 Depth Observed standing in obs.hole: in. Depth to soil mottles: 1 in, Depth to weeping from side of obs.hole: [n. Groundwater Adjustment Index Well# Reading Date: Index Well level--- — Adj.factor— Adj.Groundwater Lev'l --� rrl Observation PERCOLATION TEST Date G 2 o Thne S Hole# Time at 4" Depth of Pere t h Time at 6" '5 Zq �+ i Start Pre-soak Time @ '0 rA t 11 75mc(9"-6") 7 End Pre-soak �'1 Rate MinJlnch p 1 O Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Com leted 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:i.SEPTICIPERCFORM.DOC SOIL TEST LOG DATE OF TEST: SEPTEMBER 21, 2007 SOIL EVALUATOR: DAVID D. COUGHANOWR. L.S.E. u 461 WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. PERC NUMBER: 11968 NO TEST PIT I PAARENOTUMAATERIARL:EPROGLACIRALD OUTWASH PERC AT 72 in - 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 55.75 0-2 E LOAMY SAND 10 YR. 4/2 NONE FRIABLE 2-6 A SANDY LOAM 10 YR 4/4 NONE FRIABLE i 6-32 B LOAMY SAND 10 YR 5/6 NONE FRIABLE 53.08 32-132 C MEDUIM SAND 10 YR 6/4 NONE LOOSE 44.75 NO TEST PIT 2 PAARENOTUNDWATEMAATERI A ENCOUNTERED L OUTWASH 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER I (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 55.85 0-1 O LOAM 10 YR 2/2 NONE FRIABLE t 1-3 E LOAMY SAND 10 YR 4/1 NONE FRIABLE I 3-7 A SANDY LOAM 10 YR 4/4 NONE FRIABLE 7-34 B LOAMY SAND 10 YR 5/6 NONE FRIABLE 53.02 34-126 C MEDUIM SAND 10 YR 6/4 NONE LOOSE 45.35 _ _ _ __ ______•_—.��__�___ _.._.-. - — vvvra.. -- .. __-- l.luuJa:aq .....-. laanuau6'-""'�aaY ubw\G�JWI\W,illlU\4G 5. . Consistencv.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. Consi n draMell— Flood Insurance Rate May: /� Above 500 year flood boundary No_ Yes `!---_ Within 500 year boundary No Z Yes Within l00 year flood boundary No Yes Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the in J area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? p Certification f I certify that on N04 5 (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 the requir tramin xpertise experience described in 310 CMR 15.017. N oF,�ss9 _. CSC # � Date SeP� 21 ��7 ° DAVID Signature o D. COUGHANOWIR 4/CENSER ' O QASEPTICAPERCFORM.DOC 'VALUP� K. Town of Barnstable F r Regulatory Services Thomas F. Geiler,Director BnatvseAMr, - MAM Public Health Division 'DrEc ° Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 . Office: 508-862-4644 Fax: 508-790=6304. Installer&Designer Certification Form ..Date: ... Sewage Permit# 7 Assessor's Map\Parcel-171 /2 6 3 Designer: Eco—Tech InstaUer:Wm E Robinson Sr Septic Address: .. 43 Triangle Circle Address: PO Box 10.89 Sandwich -Centerville On.. %A00- '�Wm E Robinson Sr Septiwas.issued a permit to install a (date) (installer) septic system-at 164 _ Ansel ..Howland Rd, Centerwi}likad on.a design drawnby (address) Eco-Tech dated ..09-22-07- (designer) ...I certify that the septic system:.referenced above was installed substantially according to the design, which may include minor.approved-changes.such.as lateral-relocation.of the- distribution box and/or septic tank I certify that the septic-system referenced above was installed with major changes J: greater than..10' lateral relocation of the SAS or any vertical relocation of any component of the system)but in accordance with State &Local Regulations.--Plan-revision or - r certified as-built by designer to follow. tH OF S ` OAVIA - (Instal er's Signatture) -co GHAid R p No. 1093 sgN1TA4�tp� esi er's.Si ature Affix Designer Here PLEASE:.-RETURN TO BARNSTABLE --PUBLIC--:-HEALTH DIVISION. ..CERTMCATE OF .::.COMPLIANCE -WELL--NOT_BE-_ISSUED UNTIL BOTH THIS--FORM AND AS-BUILT CARD ARE RECEIVED.BY.THE BARNSTABLE PUBLIC.HEALTH DIVISION. THANK YOU. ::Q:Health/SepticlDesigner Certification Form l-26-04,doc-- � t COMMONWEALTH OF MASSACHUSETTS t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION WL 5�0 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 164 Ansel]Howland Road r Centerville MA 02632 Owner's Name: Nlargaret Leger Owner's Address: 1135 Curtis Farm Road Middlebury CT 06762 ) I . 2,4 Date of Inspection: June 27,2007 Job#07-131 Name of inspector: 1'?ATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 1189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:,", Passes t G> Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Inspector's Signature: v Date: 6/27/01 4 ryy The system inspector shall submit a copy of this inspection report to the Approving uthority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching pit previously full to top,system is in hydraulic failure. ""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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 164 Ansell Howland Road,Centerville Owner: Margaret Leger Date of Inspection: June 27,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 164 Ansell Howland Road,Centerville Owner: Margaret Leger Date of Inspection: June 27,2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 164 Ansell Howland Road,Centerville Owner: Margaret Leger Date of Inspection: June 27,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 164 Ansell Howland Road,Centerville Owner: Margaret Leger Date of Inspection: June 27,2007 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ Pumping information was provided by the owner,occupant,or Board of Health _ _X_ Were any of the system components pumped out in the previous two weeks? _ _X_ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection'? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)] Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 164 Ansell Howland Road,Centerville Owner: Margaret Leger Date of Inspection: June 27,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): unknown Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Number of current residents:0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): No Last date of occupancy: May 2006 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 11/12/81 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 164 Ansell Howland Road,Centerville Owner: Margaret Leger Date of Inspection: June 27,2007 BUILDING SEWER:XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron X40 PVC_other(explain): Distance from private water supply well—or—suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide—1000 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: STICK WITH HINGE FLAP. 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 has liquid only,Previously full to toP GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 164 Ansell Howland Road,Centerville Owner: Margaret Leger Date of Inspection: June 27,2007 TIGHT or HOLDING TANK: No (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: gal Ions Design Flow: Qallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX 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.): Previously full to too. PUMP CHAMBER: No (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.): r Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSU RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 164 Ansell Howland Road,Centerville Owner: Margaret Leger Date of Inspection: June 27,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X leaching pits,number: One 6x6 pit. 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.): Pit has previously been full to top CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 164 Ansell Howland Road,Centerville Owner: Margaret Leger Date of Inspection: June 27,2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Ansell Howland Road Water Service 43 25 k 53 37 Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 164 Ansell Howland Road,Centerville Owner: Margaret Leger Date of Inspection: June 27,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: N/A Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet'of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: No....�/..�o_YS�.. F�$...3:..2.---...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® F HEALTH r.............O F...... ... ............ ................................ /lo Appliration for Disposal Works Lnmitrnrtiun Vanat Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........ ._.._.... .. .................... ...................... `...� •.r--•---------------------------- -- Location.Address t No. .. ........... .......... ......•------•-•--...••............................. ,�[� Owner E• Address W ---.....-•-••........................................ .............. ... . ............._........................._... Installer Address � Type of Building Size Lot__.. `i! .Sq. feet U Dwelling—No. of Bedrooms.......2.................................Expansion Attic ( ) Garbage Grinder (��j aOther—Type of Building ............................ No. of persons-----_--_-_----__._..__-__-• Showers ( ) — Cafeteria ( ) a Other fixtures ..t! ------------------- W Design Flow.........(t- . -`�--__.. ......gallons per person per day. Total daily flow...........................v............gallons. WSeptic Tank—Liquid capacityi� glallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—lNo __._ Width.................... Total Length.................... Total leaching area....................sq. ft. 'kP_ Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Seepage Pit No­� Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------- •.......... ---.------------------------------- •................ ---------...----••---•---........ ............. .------- ..... 0 Description of Soil........................................................................................................................................................................ U ------------------------------- _ .....--------- ------------- •------------------------ •...... ....... .----------------------------------------------------------------------------------------------- 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�T LE .5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeno§1jed by tv<oard of health. 4lea.� Sign . -----•-----•--••-•-•------•--•-•---------•------•---------------•------....-- --- ....... Application Approveen - / ••. ••--••------------------•--•••-••-....------......----------••••••-- --1X-4 / Date Application Disap lowing reasons------------------------•--------•------•-----------............................................................ --...---•-----•-----•-•-----...--•-----------------------------------------------•---------•---------•-------•------•--••-••--•---•--•----•--•------••-•-•-•--•-•-•-•---•---••••-------•----•-•........_ Date PermitNo.................•-•-••-••-------••-•---•..........----. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS No..- " s - -- FR$............._..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ... ....................O F.....................-...--------.....-.-.----------......----------......---.------------ Applirttfiou for Dhgp sal Works Tousfrurfiou rrutif Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at,: ................_......__...................................................................... ••••---•-•-------•-•--••............•••-••---•••••---•••--••-•-•-•--•••-•--•-•._...............__. Location-Address or Lot No. .................................................................................................. --•------------------•----•-•••....__......---•-----••....._..._..-•••-•-•••..............._..... Owner Address W ^^ ............. Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '404 Other—T e of Building No. of persons____________________________ Showers — Cafeteria a' Other fixtures _______________________________ __ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ 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......................... (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_____:_________________- ----•----•---------------------•---•----------._....._...._.__.......------•-------..__..._.._.....•......................................................... 0 Description of Soil........................................................................................................................................................................ 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 TIT1,�, 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. Signedl".................................................................................. ._. Application Approved By_::_ -1��:"__t--------------------------- -•------- ---•------ Date APPlieation Disappr, eV f ollowang reasons---------------------------=---------•--•----------------------•----------------•-----------•-------------.....-------------------------•-••---------._ -------.....-------•-------•---...---•-•--------------------------•---------------------------------------------•=------------------•-----•---•--- Date PermitNo--------------------------------------------------------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... TrrfifirFafr of ft outpliFana TH I T CERTIFY, That the Individual Sewage 'sposal S-stem constructed ( , or Repaired ( ) •--•-••- ----------- ----- -•----•----------•....................................................... .. by.... / F Inst -------------------------------------------------------------------------------- has been installed irf accordance with the provisions of TIT �' 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------V.`-'___________________...... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATIS AC ORY. - DATE.---•--------------------------------- - 1•--------•••. inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ...........................................OF..................................................................................... No... ..... - .._S FEE........................ �: �i��r�r�ttl � ��aat�fra�rrfUaat rrattif Permission is hereby granted ............*.------------------------•-••----------------------..._....-•----------................_._.. to Construct/( ) r Repair ( n In Idu ewage tspo S Street / as shown on the application for Disposal Works Construction Permit No...... _ "i � . . . ................. l -----------------------------••---- -- - ---------- --------------_............... - - f/ Board of- Health ...__. DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - St&L-e= 14 110 G,Atz$oe:� CaRI�.la�-IL �. , bdt.L�f Ft.o ✓ _ !Io 3 + 33o G•P �EPr'IG TASK = 330.r (r70 % • L ci 6.P.D. �L a0V-/LA�'�' hS r-- t 00C, 6AL.. �ISPo�Gs. �:�tT - usE loon (S,I._, U4rrrVAA ,tl. EEA T SO ST-. So S.P D. " Z7 TOTAL,: 'C)r--SIGW a 42S G.•RD. ToTQ L v;dt LY F•c.aw T 330&PD. �fZGDL�TIG++U %F&M �•,u Sm IQ'o¢ l.",.... xf 1-7 A. cJot. �•y^ gym µ Y _ • t. L :: P rioG Tor Put- % -ram- FG-SL o: Y• EL; I1Jb Loawt'' ,�'D.ve 1 000 lug/. Iw. &&L. 53 8 Z -Box 53 4, Sc-vn'C t o map GAa7 t000 tNv �►� '1. GAL. •. [; ! 4'I z LEACH 'A ' t= - = FiT STOW(-- i C.S ZTir-lan pLC)-r PL.43 Ptzo�1 L�• �Lm LoCAT10" �E►JTF�t11Lt,t� IL Stj SAT(= !O'1 LGaTIF TaIAT T64a PO0PXt;ATf014 SN0Wu �-Ar,.! RL-F`R>"�' : •t-iF:Qc_t�►,1 c�r���L�ls WITI•� Tt-1�:, 51�E..LtNE �T �� Hun SETt�.ncK V:c4u1rEAAE:uTS OP TNe -To Va Li Ist CJA'TG -� U � / ,'1 J c�,SL- B�.XTGtiZ �, tJ�(E' tr, c- ' RE6l9;'tT=iZQD LA.wo luevayov-s E T1415 VLAW I'S LAOT E,ASco . via A•J osTEev��.t.c MASS. ,, , 114 LjAA sr� ro l7(aTC�Mrw1�= 1~.o`sc' t_IN�•� i Ao ,Ni4L•L. LO CAT ION SEWAGE PERMIT NO. V►V AGE Centerville. MA. l I N S T A LLER'S NAME i AD_DItESS Robert Our j Harwich, MA. BUILDER OR OWNER Alan E. Small, Inc. 1 Box 536 Centerville, MA. DATE PERMIT ISSUED 10/26/81 DATE COMPLIANCE ISSUED r�.... - .w.��-----' _.�� `, � �e. s ��,A , r . � �. -�.� .�� �� �� � '� .., �,, � .� �; �� �� 1 CONTOURS Q STAGE ROAD BENCH MARK O HEjyRY °• , PAINT SPOT ON MINIMAL GGRADING PROPOSED _ Ro/-oRING BULKHEAD CORNER x z ., GARBAGE GRINDER o o A w ELEVATION = 58.41 O IS NOT ALLOWED y z ozw S WITH THIS DESIGN. BARNSTABLE GIS DATUM J m + J = J B r � /' 2 W c3 z N 0w< m j cD m / '/ 1 e m / L D T 39 I CENTERVILLE. MA w>� 4 ft LOCUS MAP m :s:s:.>;::s: 40 6 AREA = 15.116 s F+— 1 0 0 U Z m+nry:` Z .�/ :,;,,:.,,;,,. m � NOT TO SCALE W J +� :}� ;,�:>:. U7 U) Q 3 / - ® TP-1 3 0 a O 0 :.:::.:.y..••r � W 0 �' —� TP-2 oa Ld z � > o� /''/ 2 1 18.66FLx16.5FLx2Ft }o <uZ� J �-+ w Z �� \ o LEACHING GALLERY Wu �W /z� WII > O �_ o W JW W} U J J LO 0— LEGEND J� O m <z 1 C<7Z � mF �o W < W w ... � / A � 1 W w o m -i C v 0 Z O11 / EXISTING W z I 1 le 2 0 :::. w W 1800 GALLON E3 W Z rY ww cv m O \ w SEPTIC TANK w< m :;: :_: 1 c* W e Jrr \ \ \ �/ 1 EXISTING LEACH O Z Z 0 /' N PIT WW LL LL¢ XLli 561 I o O �X 6 I 1 �li Z 0 e N 1 I �t o w in rn 1 �,`� rn `—' I TEST PIT® D-BOX D) op m w i 1 I 1 wZl w mw °� 1 , � � I 1 LL� v w 0 0 m` I �� HYDRANT U Lu Z I H I �� .. oW W zw m ` �Z c) -z I �� �_ Ld EOM 1 E O Z I 1 cn e o "` O �\ 1 INE iF: + Z 1 Z Z Z W? co U)0� _11 WATERI WATER �W 0- GATE /5 LIB ,a I DISTANCES �0 3 Zz GA ! I TO LEACHING GALLERY lil Z 0 = m I 1 \ ALL DISTANCES ARE IN DECIMAL W O F w 41 7 3 1 C�'/ ` FEET NOT IN FEET AND INCHES. w z.. N m 1 GAS / I (n O 3 +m z m Z` ATE - f ,J A �� > u N �_ Wf\Y \ /' x o �, W s�; D DRIVE ICE \ /'� 2 40.0 4�1 ew W PAVE ���� \ /� 56 W Q 5� 3 56.4 53.6 � J P / 58 H z � O Q � G ,,% ' ®o Te SEWAGE DISPOSAL SYSTEM PLAN 3 Q< z J 58 //� /���30-46 �� day -TO SERVE EXISTING DWELLING 0 "m cn CD v ; // EST. ESTATE OF ANNA HUBER O 0 W I i ro ~ O ` �/' OWNERS OF RECORD ry ~ `"' W � HOFM F 164 ANSEL HOWLAND ROAD o + W \ ti ��y�z gSsgc � cNo ntiassgc �� 1J95 ��- CENTERVILLE. MA Z ti / .� Cn o DAVID G o AVID G PROPERTY O .� � N� � D J� �®N(I�A� E ADDRESS D) D. N ASSESSORS MAP 171 PARCEL 2 6 to Z F N FLAN COU . 1093�R C o 43 TRIANGLE CIRCLE O o 11 „ COUGHANOWR � ? No. 1093 SANDWICH MA 02563 PLAN BOOK 343 PAGE 8 5 (L m x x �( FciSTER� SO, "CENSE �p� 506 364-OE394 DATE. SEPTEMBER 22. 2007 w w w SCALE: 1 in = 20 f t # SAN q a E VA u P JOB #E T E—2 7 6 4 IPAGE I OF 2 VERSION: A 20 0 20 40 THIS PLAN IS BASED ON AN INSTRUMENT SURVEY AND IS INTENDED SOLELY FOR INSTALLATION OF THE PROPOSED SEPTIC SYSTEM �er 2� �7 DEPICTED HEREON. FOR ANY OTHER CHANGES TO PROPERTY INCLUDING 0 la 20 .�C�N `- PLACEMENT OF ADDITIONS. SHEDS. FENCES OR SWIMMING POOLS. OWNER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. SOIL TEST LOG DESIGN CALCULATIONS DATE OF TEST: SEPTEMBER 21. 2007 DESIGN FLOW: 2 BEDROOMS X :10-GPO = 220 GPD SOIL EVALUATOR: DAVID D. COUGHANOWR. L.S.E. # 461 SEPTIC TANK: 220 GPD X 2 DAYS = 440 GALLONS WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL PERC NUMBER: 11968 CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) NO GROUNDWATER ENCOUNTERED DISTRIBUTION BOX: USE 3 OUTLET D-BOX. TEST PIT 1 PARENT MATERIAL: PROGLACI_AL OUTWASH SOIL ABSORBTION SYSTEM: A 16.66 ft x 16.5 f E x 2 ft LEACHING GALLERY CAN LEACH PERC AT 72 in - 2 MIN%INCH IN C SOILS AboL = ( 18.66 x 16.5 ) = 307.69 sf ELEVATION Asdw = ( 18.66 + 18.66 + 16.5 + 16.5 ) x 2 = 14 0.6 4 sf DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER Atot = 448.53 sf 55.75 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING Vt 0.74 x 446.53 = 331.91 GPD 0-2 E LOAMY SAND 10 YR 4/2 NONE FRIABLE USE A 18.66 FL x 16.5 ft x 2 Ft. GALLERY. VL = 331.91 GPD > 220 GPD REOUIRED 2-6 A SANDY LOAM 10 YR 4/4 NONE FRIABLE 6-32 B LOAMY SAND 10 YR 5/6 NONE FRIABLE 53.OB 32-132 C MEDUIM SAND 10 YR 6/4 NONE LOOSE 44.75 L EA CHILI G GA L L ER Y NO GROUNDWATER ENCOUNTERED USE SHOREY PRECAST 500 GALLON NOT TO 1000 GALLON SEPTIC TAW LEACHING DRYWELL (H-10 LOADING) SCALE DIMENSIONS AND DETAIL NOT TO TEST PIT 2 PARENT MATERIAL: PROGLACIAL OUTWASH 2 MIN/INCH IN C SOILS USE EXISTING H-10 UNIT SCALE CONSTRUCTION DETAIL ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DRYWELL STON SEPTIC TANK IS TO BE PUMPED DRY (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING UNIT7 AT TIME OF INSTALLATION AND IS TO BE EXAMINED FOR STRUCTURAL 55.85 16.5 f t 0-1 O LOAM 10 YR 2/2 NONE FRIABLE INTEGRITY. INSTALL NEW PVC OUTLET m,, TEE EQUIPPED WITH A GAS BAFFLE. 1-3 E LOAMY SAND 10 YR 4/1 NONE FRIABLE P 3-7 A SANDY LOAM 10 YR 4/4 NONE FRIABLE 4 m 4 TAPER 7-34 B LOAMY SAND 10 YR 5/6 NONE FRIABLE LD m� co 53.02 34-126 C MEDUIM SAND 10 YR 6/4 NONE LOOSE m m m C 45.35 m� 0 m 0 � GROUNDWATER ADJUSTMENT 4.0 Ft 8.5 ft q.0Ln EXISTING GROUNDWATER LEVEL 16.5 ft BASED ON TOWN OF BARNSTABLE GIS DEPARTMENT RECORDS. 6 f£_6 1 A n INDICATED GW 37.00 500 GALLON DRYWELL INDEX WELL S D W-2 5 2 DIMENSIONS AND DETAIL INLET OUTLET ' ZONE D INSTALL ONE INSPECTION COVER COVER READING DATE AUGUST. 2007 RISER TO WITHIN THREE USE H-10 UNIT ,.,.,..,.,:,a,: READING 47.4 INCHES OF FINAL GRADE 3 IN DROP ADJUSTMENT 3.6 AND INDICATE LOCATION -� FLOW LINE ADJUSTED GW 40.6 ON AS-BUILT PLAN FROM 10 in = ]q TO BUILDING .: in D-BOX NOTES LJOU LIQUID GAS � 33 LEVEL BAFFLE 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. pppp Opp In 2) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED oaoopapoppp FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. pppppooppo o� �� CROSS `SECTION" VIEW 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS Gj0 OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). 101- In 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. CROSS SECTION VIEW SEWAGE DISPOSAL SYSTEM PLAN 5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED. 2 to PEASTONE 2 to PEASTONE r 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES- AND YDUST IN-, PLACE. -TD SERVE EXISTING DWELLING ' =".." Z) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES 24," ESTATE OF ANNA Hl_JBER AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. 2B EFFECTIVE 3/4inr2InDEPTH 1-]/2 i"GRAVEL !nB) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOTI64 ANSEL HOWLAND ROAD CENTERVILLE. MA PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. 46 In 58 in 46 in ECO-TECH ENVIRONMENTAL 9) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL 150 In ,STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH 43 TRIANGLE CIRCLE SANDWICH MA 02563 SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. FABRICLINR APPROVED MAY SUBSTITUTE AN PLACE OF THE 2 PEASTONE LAYER SPECIFIED. ETE-27641 SEPTEMBER 22, 2007 2/2