HomeMy WebLinkAbout0047 AUDUBON CIRCLE - Health 47 Audubon Circle
Centerville F/R
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UPC 12543 o-
No. 53LOR
"+STINGS MN
No.��V�.L.ZD/ a ry FEE
COMMONWEALTH OF MASSACHUSETTS . ' EC
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Board of Health, PRyk S'T,431_E MA. `
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon( ) - ❑Complete System individual Components
Location t Owner's Name
Map/Parcel# Address
Lot# Telephone#
Installer's Name Designer's Name
4 _
LS
Address Address C F' M jc'•
Telephone# (p 1480 310 I Telephone# 2
Type of Building �S�dP1l� d� Lot Size A51 18a sq.ft.
Dwelling-No.of Bedrooms ��_ 3 J Garbage grinder (A41,
Other-Type of Building Q No.of persons T" Showers (7+f Cafeteria
Other Fixtures �.►�1J�A . �' p0 �yS�f1���jV��Q.'P
Design Flow(min.required) .7 3 gpd Calculated design flow 3 3o Design flow provided 3 gpd
Plan: Date �'12�D�J Number of sheets Revision Date ^
N
Title C'
Description of Soil(s)
Soil Evaluator Form No. Name of Soi Date of Evaluation Zl
DESCRIPTION OF REPAIRS OR ALTERATIONS �Rm ek rL)I ,
The undersigned agrees to' e above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees to no o ace the t m in era on until a Certificate of Compliance has been issuedgby oa the;Brd]"of;Health.-
nt r_f ;ON AND CERTIFY IN t°
One Date �3 CYSTf�{1Q WAS INSTAI_L[D I.
IV. - �e-V) �kD."'CE TO PLAN, J .,...
Inspections
No. �IU .►-" <"ca+ : . �( FEE
Board of Health, A(�r1 STt�3t. MA.
APPLICATION FOR DISPOSAL SYSTf '1[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( - ❑Complete System Individual Components
Location q i RC C.F. ,l S? rd% Ny Owner's Name / F f (tic CC''Caoi
v
Map/Parcel# _� � Address
1_` m
Lot# }- �" Telephone#
c Installer's Name -lC Designer's Name
'�� e C.L3
Address -' Address Add -
'
Telephone# ( LI&- 310 1 Telephone# a � sx,
I
Type of Building S\c!.t n C2\ Lot Size /,S; a sq..ft.
Dwelling-No.of Bedrooms '�rnr-ems �� .'r Garbage grinder
Other-Type of Building ` No.of persons 4- Showers (y)Cafeteria (►r
»•Other Fixtures +-hl A A kd nl cky
Design Flow(min.required) gpd Calculated design flow 0 Design flow provided gpd
}Plan: Date `}l�,l p 3 Number of sheefs , Revision Date "4
Title_a �a lrilDdS�'e��' R�'tC4t' r4?M �D�1't^�C `
. _Desc'ription of Soil(s) mod" — '�t r'a(' C� "i?.7 ,r
/�oil Evaluator Form No. Name of Soil Evaluator( , 7 444'r' Date of EvaluationIN CO,
All -A
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to instali,,tthe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further to not-to place the "tem�eratioon until a Certificate of Compliance has been issued by the Board of Health.
Signed 1��wY o,.es r ` Date '
Inspections
No. Uu 3-3o I FEE
C®MMONWEALT14 OF MASSACHUSlt TTS
Board of Health, A Rig-STa-A L.J'- MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑Complete System "k•
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded (�,Abandoned ( )
by: K'06OX4. 5 �JP_t7 i�. ��ite�lsr.rM
at f1-` A.%CA u r)a C t V_r is. C ra TFR_v t U r N1
� r
has been installed in accordance with the provisions of 110 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. UD 3-3 dated -tp-U Approved Design Flow (gpd)
Installer n X
Designer: Inspector: ` h - t 1W• (�3 Date:
The issuance of this permit shall not be construed as a guarantee that the system Affinction as designed.
No. 9-UD 3-301 r FEE
Board of Health, 0 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade X. Abandon( ) an individual sewage disposal system
at 44 P A it 1- An r,r-r t f. as described in the application for
Disposal System Construction Permit No. dated
-_. Provided: Construction shall be completed within three years of the date oft is permit. All to al conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date ?�a//u3 Board of Health
10/05/2013 04:53 FAX 002/002
CARMEN E. SHAY (508)-548-0796
ENVIRONMENTAL SERVICES,INC. P.O. Box 627,East Falmouth, MA 02536
July 9, 2003
RE: Certification of Title V Septic System Installation:
Residential Property 47Audubon Circle, Centerville, NIA
Dear Sir or Madam:
On June 30, 2003, Roger Roberts, Inc. was issued a permit to install_ a Title V Septic System at 47
Audubon Circle, Centerville, MA, based on a design drawn by Shay Environmental Services on July 7,
2003.
XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan
I Certify That the Referenced Above Septic System Was Installed With Changes but in
Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow_
The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is
Required.
If you have any questions,please do not hesitate to call the undersigned at (508)-548-0796.
Sincerely,
CARMEN E. SHAY
ENVIRONMENTAL SERVICES,INC.
CARMEN � ►
E.
Carmen E. Shay,R.S., C.S 1�. 11a1
President QrsTF
a NIT00
JUL-9-2003 WED 04:48PM ID: PAGE:2
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i
TOWN OF BARNSTABLE.
LOCATION (1 t, � SEWAGE # 2WI
VII.LAGE CJ`( ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. ma rts ti
j SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) /#c(� d- !%1 (size)
NO.OF BEDROOMS
BUILDER OR OWNER �F �s
PERMTTDATE: D-7 COMPLIANCE DATE: D
j 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
j Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
y
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Ak ��` Q l��ate
I
�. 0-01 13 : 62 BARNSTABLE HEALTH DEPT 5087906304 �' • OL
• si2s;o�
' :NCOTICE: This Form Is To Be Used For the Repair Of ailed
Septic Systems Only.
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION
FORM
tA2MFn1 eJlX�—t2iq hereby certify that the engineered plan signed by me
cl�(ec nJ 03 concerning the property located at
�JC\V�0o0 ---,c \Q,' C2j� VI meets all of (he
f,I'ow;ng .n(ena
• This failed system is connected to a residential dwelling only. There are , o
_oruntrzia! or business uses associated with the dwelling.
T? e soil is ciass:;:ed as CLASS l and (he percolation rase is less than or eq ai (o 5
-rtnu(es per inch. The applicant may use historical data to conclude this f c: or may
.onduc( :)re!trr.wary tests at the site without a health agent present
• There :s no increase in now and/or change in use proposed
• fhe(e are no variances requested or needed.
• The bo(tom of the proposed leaching facility will not be located less than f urteen
.I,) ;^tc aonve the m3AImum adjusted groundwater table tlevagon. (Adiu ( the
I.. undwa:er table using the Erimptor method when applicable)
Please complete the following:
�. fop a( Grouno S'Jrface Elevation (using GIS informattonl _ ��' O
6; G.W Etcvacor, 12ks_ .i- zd;ustmen( for Thigh G.W. pp .
FT REfvt.E BETWEEN .\ and B
t;'►1E D — DATE:
NOTICE
33set jpon. (,,e above :r.formauon, a rroai( permit wil! be issued for edr^ems
Tex. m-u r. ` � ;c�!(�anil bedrooms ue authorized to future without engi eerec
=sys(e-n plans. a'
�c:un!r,qu )ciccamp
Permit Number: Date:
Completed by:
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: * 0%2GL.E. �lO n i »Q. Lot No.
Owner: L—eb Gs es Address:
Contractor: _9 Ch( "a ACA Address: � 63C
Notes:
STEP 1 Measure depth to water table ZIP
tonearest 1/10 ft. .............................................................................. .Date
mont /day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine: spy
OA Appropriate index well.................................................... oZ
52,
OB Water-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...........................
mo th/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water level adjustment
b
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) ..................................................t......
..........,............,.............
Figure 13.-Reproducible computation form.
15
TOWN OF BARNSTABLE
LOCATIONS SEWAGE #
VILLAGE ASSESSOR'S MAP & LOTI
1NS7,ALLER'S NAME&PHONE NO
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER o� t5
;i'ERMIT DATE: Z 0-7 COMPLIANCE DATE: D
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
t
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL-RRO-
M INSPECTION JUN 17 2003
�b'^ r, INSP � ON TU'vv,`. :!� BAf�NSTABLE
'1.. HEAL"iH DEPT.
E 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 47 Audubon Circle
Centerville, MA 02632
Owner's Name: Leo Coveney
Owner's Address:
Date of Inspection: May 21, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford Map: 191
Mailing Address: P.O. Box 49 Parcel: 183
OsterviUe,MA 026SS-0049 Lot: 17
Telephone Number: (508)862-9400
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
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
✓ Fai
Inspector's Signature: Date: May 24, 2003
The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 47 Audubon Circle
Centerville, MA
Owner: Leo Coveney
Date of Inspection: May 21, 2003
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:
2
0
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 47 Audubon Circle
Centerville, MA
Owner: Leo Coveney
Date of Inspection: May 21, 2003
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(l)(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:
3
i
Page 4 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 47 Audubon Circle
Centerville, MA
Owner: Leo Coveney
Date of Inspection: May 21, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 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.]
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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
I;Pd•
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 47 Audubon Circle
Centerville, AM
Owner: Leo Coveney
Date of Inspection: May 21, 2003
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 47 Audubon Circle
Centerville, MA
Owner: Leo Coveney
Date of Inspection: May 21, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2001- 74,000 gals.;2002-86,000 gals.
Sump Pump(yes-or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): aad
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
Source of information: Unavailable
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
✓ 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:
Jun. 9193-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 47 Audubon Circle
Centerville, MA
Owner: Leo Coveney
Date of Inspection: May 21, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:.
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 20"
Material of construction: ✓ 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: 1000 gal.
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: 10"
Distance from top of sum to top of outlet tee or baffle: 5"
Distance from bottom of scum to bottom of outlet tee or baffle: 9"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Baffles were present. The liquid level was even with the outlet invert. Solids were leaving the tank.
GREASE TRAP: None (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.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 47 Audubon Circle
Centerville, MA
Owner: Leo Coveney
Date of Inspection: May 21, 2003
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/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: None (if present must be opened)(locate on site plan)
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.):
PUMP CHAMBER: None (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.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 47 Audubon Circle
Centerville, MA
Owner: Leo Coveney
Date of Inspection: May 21, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
✓ leaching trenches,number, length: 3 infiltrators
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.):
The liquid in the pit was above the outlet invert. Solids were present in the pit. Liquid was approximately 12"above the top of
the infiltrators and backing up into the pit. Liquid was filling in the hole.
CESSPOOLS: None (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: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 47 Audubon Circle
Centerville, MA
Owner: Leo Coveney
Date of Inspection: May 21, 2003
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.
L/ y
' 1
O �
A Q
50 ay J-33
a
a 57.Y V,6
3 (o S0
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 47 Audubon Circle
Centerville, MA
Owner: Leo Coveney
Date of Inspection: May 21, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
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: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Usm the Barnstable topographic map andthe Cape Cod Commission water contours map,the maps were showing approximately
25'+/-to ground water at this site.
This report has been prepared and the system inspected and failed of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
. � JS3
No.../... ��J 7 Fas..3.o....`......_.
THE COMMONWEALTH OF MASSACHUSETTS
APPROVED BOARD OF HEALTH
BwmtcWO Cwwwvaticn O'MROMTOWN OF BARNSTABLE
ir�fi - rw-Uiri.pwml Workii Ton.itrnrtinn Itermit
Application is hereby made for a Permit to Construct ( ) or Repair ( %,,�*an Individual Sewage Disposal
System at:
........ /. t -u --.o.�xia ........ am.. I .... ..........................................................................
Location-Address or Lot No.
---------------•------------•-------- -•----------------•-••-----•------......._............---.......--
Owner ddress
�----------•.... � 'ts '_ :c�__.� nvz...&-- -...................
ly6dress
Q feet Type of Building Size Lot_______________________ S____ q.
U Dwelling No. of Bedrooms.__._...._._________ .Ex ansio Attic Garbage Grinder
Other—Type of Building ............................ No. of persons.....crC. ......_--..__._... Showers ( ) — Cafeteria ( )
a' Other fixtures _______________________________ _ _
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity_1%Q_.gallons Length---------------- Width---------------- Diameter................ Depth................
x Disposal Trench--No. .................... Width_._ ...... Total Length.................... Total leaching area....................sq. ft.
�s .� Q�.�De th below inlet.................... Total leaching area..............__..s ft.
Seepage Pit No-------------_------ Diameter-__ _....-... p g q.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-----------.............................................................. Date-- ............................
1.4
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
LZ Test Pit No. 2................minutes per inch Depth of Test Pit----_............... Depth to ground water........................
a ....................••--•----------•••--•-..._.._..-----•-••---...•-••••......._......---------•-•-•.........................................................
0 Description of Soil........... .
U •••--•---•-----••---•••-•-•••-----•-••---•-----•-••••--- ------------------------------------------------------------------------------•---••--•--------------------.....---••............._--•-•••-
W
U Nature of epairs or Al a 'ons—Answer when applicable.- -.1 (� - --. lS " h---_----.•_:.-----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Comp 'ance has bee y the board of health.
Signed ... .. . ... ----------- ..---------_---------..................... ........ 3....:......
Dare
Application Approved By .............a... --...---------------------------.......----_---------_--_------ ..�®.- �.:°`..���......
Dace
Application Disapproved for the following reasons: .... . .... .......................... ........... . ........ ........................ .. ..
. .......... . . ................................................................................................ ................. ..............
q ,,rr•• Dare
Permit No. / ..-... J..... ...................... Issued ..........................
Dare
... 3--�57
1 S3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliraltant for Diri wial lVarltg Ta tuitrur#ion 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( 1„), an Individual Sewage Disposal
System at:
......... ••? _ -aC�cJ. r�/1 C s-C�-P �t,��cr�1���P • --- - .....
-----------• ;.......--
Location-Address ` or Lot No.
owner Address
...
Lrstallerress
Type of Building Size Lot............................Sq. feet
I-, Dwelling—No. of Bedrooms........... ......................._...Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—Type of Building No. of ersons.....
g ..........................•• P -'•-•-•------------ Showers ( ) — Cafeteria ( )
QOther fixtures --------------------------------------------------------------------------------------- ----------------------------------••--------•---.------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity_Ma..gal Ions Length---------------- Width................ Diameter................ Depth................
x Disposal Trench-- No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter---(o tq-.?!NDepth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+ ....••-•••••----------------•-•••--•••--•-•--•••-••----•-•-••--...••---•-•---.......•--•-•------•....................................••........--•---•..--••-
ODescription of Soil............ . ----------•----•--------•---•-----------------•----------......-------•--•----------------•---•----------.................--•---•-•-------
W ......................................................... ---------------------------............--------------------------------------------------•----------•-•------•-••--••-•••--......------••••
W
rr � ... ..-...-• ..................
U Nature of Repairs or Alt at'ons—Answer when applicable...Q=�. r\ .- �(� 1.� .. �.�:............
� ... . . ---..1t..�� ....S . Q. �fi0!`�....C ..S.�n ............................
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has beeqzjss�ted'by the board of health.
Signed , `--........:. w-��.1.. . ....:......
..............................................
Dare
A lication Approved B ,w►�-� �..^.. -......
PP PP Y - .....�� V �.�-w—�-----.-----.- .... ...................... ..... - ... ..�.-- .bare ..
Application Disapproved for the following reasons: ......... . . . ..........................................................................................................
....... ...................................................................... . ............ ........... .................................. .............. ............ .............. .......................
cy Dare
Permit No. ....../...>3.......raZ:S ---- --------------- Issued
Daze
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(felr#ifirate of Compliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by .................. 1'14. r�. ....-.....���-cam - In----- - _------ ----------------------- ---............--------------------...............................................
..-......._........
` ....... staller n
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ....._.q/.. .��.. .. 5_ dated .............. ::...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....................L.....__7. 71. ..........._ ..............__._............ Inspector ........... ..., ...._....;------_......... ...... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.13_;S_7 TOWN OF BARNSTABLE
�io�a1stt^l,, or�o �at�t.�trion �rrmi�
Permission is hereby granted.........lid-1—.....---• -- -------------------------------------------------------------------•---••--••-•-•-•-
to Construct ( ) or Repair (> an Individual Sewagposal System
atNo.............. ! �t� 't2--- ...... p r...--•----------- r«-----------------•-------•-•------..:--------- ------.......----------...........
Street q
as shown on the application for Disposal Vl'orl:s Construction Permit No.l,3:_� Dated...........................................
•--•••---- ---------•-------�-v ---------------•-
I� . _3............................... Board of Health
DATE.................-�--•-------•-----------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
y � TOWN OF BARNSTABLE
LOCATION, SEWAGE #-lrJ-A-1-
VILLAGE CR®VrUL ASSESSOR'S MAP &'LOT
77.5�$ow
INSTALLER'S NAME PHONE NO. �
" EPTIC TANK CAPACITY iODO GrA -
LEACHING FACILITY:(type) �c�L :Pek (size) 3n�
NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER '?,,
BUILDER OR OWNER, COy�i��L
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
r
VARIANCE GRANTED: Yes s No l
r
r ,
�f
�P
s _
2 s
r
v
SECTION A -A �`t` V. = 2000'
TO' min. from *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. PROFILE VIER OF ADDITION TO LEACHING SYSTEM 0retaiuRON ammo m L THE `l��
Existing Foundation house to septic tank XT UMM FOR AT(FAST 7 FT. 1Y OONCREW OD" 4
TOP OF FOUNDATION ELEV. 100.00 (Assumed) �c tame caw' mist be 3- of I1W - 1/2- Washed Peo•ton
vlMin 6 In. of Ifd Nnd 9rode
prey over Septic Taal - 95.50 41
/ Q�aver D-4Tox - %.00 ow SAS -%.00 to 95.00 3/4' t0 1 1/2 Washed Crushed Stop -, 3 - 5'OUTLET _r_ :�, q O
/ wrOdcOUTS J 94 Qr
-eel A\
a
15' --, tY sari C
S - 0.02 3 HOLE H-10
ouTLET _ r - °y 3 °'
S-O.Ot or Greats DIST. Box S �'ns'n COW Tap of SAS - EAv. -9175 _ /- _;• f ~ T � �v
rx"T. PPE t J' n 1,000 AL.
22. S- 0.01• per toot . 156- L ~ ti
FRM EXIST. FOICIATIIII w ri SEPTIC TANK
Effeethe Depth 4" - SCH. 40 T 1.7Y V
CA H-t0 o N 7 Units 6' = 4e' PLAN SECTION CROSS-SECTION a'' s4 JQ'f'
CONCRETE FULL Fouts► o 1 04 01 q 1' 3' 3'
0 0 > to h .9
6 in of 3/4--1 1Ir � � o is 8' 3 HOLE H-10 DISTRIBUTION BOX �° °Y_
SYSTEM PROFILE compacted stone a o�
c b Effective Length L❑CUS MAP'"
� II � NOT TO SCALE V
30
Not to Scab _ 0 4 4 '
S
�-2.5� _o
10• • S❑IL ABS❑RPTI❑N SYSTEM (SAS)
6 N.ot 3/4•-, 1/2• �C GENERAL NOTES
OA
compacted ste ` Effective Vknt, ° CULTEC MODEL 125 (H-20 L❑ADING)/ SHOREY PRECASTE CD1. Contractor is responsible for Digsafe notification
Mtnm_vt I:itgl o 1 L7""'-es'L------ OR EQUIVALENT Not Cale J
( ) � and protection of all underground utilities and pipes.
• (�� 2. The septic tank anq, distribution box shall be set
NOTE HEIGHT OF IJFIL CT1VE HEIGHT IS 10 \ y� level on 6" of 3/4'-1 1/2` stone.
2' OF'STOW (, 3. Backfill should be clean sand or grovel with no
- stones over 3" in size.
4. This system is subject to inspection during installation
\ by Carmen E. Shay - Environmental Services, Inc.
c \ 5- The contractor shall install this system in accordance
PERCOLATION TEST LOT #21 with Title V of the Massachusetts state code, the approved plan
LOT #22 co LOT #20 and Local Regulations.
Date of Percolation Test: JULY 2, 2003 Nt Cb 6. If, during installation the contractor encounters any
Test Performed By. CARMEN E. SHAY, R.S., C.S.E.
soil conditions or site conditions that are different
Results Witnessed By. WAIVER ( per BARNSTABLE B.O.H.) �� from those shown on the soil to or in our design
' S 10d 48' 33" E ' g g
Excavator: ROBERTS SEPTIC SERVICE 1 / installation must halt do immediate notification be
, made to Carmen E. Shay - Environmental Services, Inc.
T
-- � - - 124. 15 ,
Percolation Rate: Less Than 2 MPt r / 7. No vehicle or heavy machinery shall drive over the
1
i septic system unless noted as H-20 septic components.
Test Hole n i 8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
NO. 1 �t I j 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
i
- oEPiTi- SOILS_ ELEv i 3 10. AN solid piping, tees do fittings sholl be 4" diameter
0 96.00 i TEST HOLE #1 j Schedule 40 NSF PVC pipes with water tight joints.
Sandy .� t ELEV.= 96.00 i To 11. Municipal Water is Connected to ALL OF The Residence and Abutting
Loan I I 36' L- Properties Within 150 Feet.
10 YR 3/2 i 34.5'-
0--6- A, 95.50, I THE PROPERTY LINES ARE APPROXIMATE AND
COMPILED FROM THE SURVEY PLAN GENERATED BY
Loamy f P10 • • • CHARLES N. SAVAREY., R.L.S., OF HYANNIS. MA
Cc
10 VR 5/e i ►.` s" M�y; t±• -•�� ENTITLED " SUBDIVSION OF ALAN E. SMALL IN CENTERVILLE, MA"
6-- 47• Be 92.50, 1 D-Box I ,
DATED FEBRUARY 12, 1973
r Failed i � AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
Mod
S r Leach Pit�_-_' IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
z5 Y 7/4 �I / THE SEPTIC SYSTEM INSTALLATION.
42•- 96• C
sand LOT #16 r EXIST 1000 gal. �' ,' EXISTING LEACH PIT TO BE PUMPED dt FILLED IN PLACE.
r Septic Tank _-
2-5 Y 6/4
C. 55.00r - NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
r FROM THE EXISTING LEACH PIT TO BE DISPOSED
i LOT #18 OF AS PER BOARD OF HEALTH SPECIFICATIONS.
DECK
Perc #1
Depth to Perc: 42" to 60" PROJECT BENCH MARK -- -LEGEND
Perc Rate= Less Tho 2 MPI TOP OF FOUNDATION
Groundwater Not Observed ELEV. = 100.00 (Assumed) '
No Observed ESHWT
ADJUSTED H2O Elev. None e; %/ ggISrING 104X 1
fi DENOTES PROPOSED
3 BNDROOM SPOT GRADE
r eously "' DENOTES EXISTING
X 104.46
�47 SPOT GRADE
r
PL PROPERTY LINE
I /
i I 9r� PROPOSED CONTOUR
C I
r LOT #17 ; ; - - - - - -97 EXISTING CONTOUR
\ I
\\\ 15,782 Square Feet +/- I ASPHALT
0'
z-,e• crud. Amass MANHOLES \ DRIVEWAY DEEP TEST HOLE &
e \\\ L = 99.19 % i PERCOLATION TEST LOCATION
• ` ` -`�`.1 `" `-` "�= `\\ R _ 333.40'
o 6 FOOT STOCKADE FENCE
THE ACCESS COVERS FOR THE SEPTIC TANK. \ /
MIST DISTRIBUTION BOX ADD LEACHING COMPONENT \
OUTET SET DEEPER THAN 6 INCHES BELOW FINISHED \
GRADE s BE RAISED �,TN.N t3• OF I PLOT PLAN
FINISHED GRADE.
INSTALL
TUf-ATE GAS BAFFLES OR EQUALS I CAR CL E'
UD UB 0 OF PROPOSED SEPTIC SYSTEM UPGRADE
A
STEEL REINFORCED PRECAST CONCRETE OD
FLAN VIEW (40 FOOT RIGHT OF WAY)
PREPARED FOR
3-24• REMOVABLE COVERS L E 0 8c M A R G A R E T C O V E N E Y
AT
, #47 A U D U B O N CIRCLE
, r BEET
INLET � 2 min. InIet to aaUet OUTLET
Id CENTERVILLE, MA
TII�u
5' -r ' cs L 5' -r Design Calculations
b$ •my` Y UqL" dWO mim
Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) �N�M y PREPARED BY:
�s Garbage Grinder: No °? ARAMY E SHA Y
J +_ Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) � E.
• �• _ septic Tonle : - 3 x 330 Gol./Day - 660 USE 1.500 GAL. Septic Tank. 0 20 40 50 f» ENVIRONMENTAL SERVICES, INC.
4' -10- SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch 11
Bottom Area: 0.74 gal/sq. ft. x 360 sq. ft. = 266.4 gallons '� P.O. BOX 627
CROSS SECTION END-SECTION Sidewall Area: 0.74 gal./sq. ft. x 92 sq. ft. >= 68.08 gallons `c°jstE�`� EAST FALMOUTH, MA 02536
Providing: = 334.48 gallons ANITAa1!'�
USE EXISTING 1000 GALLON H- 10 SEPTIC TANK Use: (5) CULTEC MODEL 135 UNITS. HAVING A 1' EFFECnVE DEPTH, SCALE: 1"=20' " TEL/FAX : 508-548-0796
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3' OF WASHED STONE SCALE: 1 =20' DRAWN BY: CES DATE: JULY 3, 2003
NOT TO SCALE ON THE ENDS, NO gMW {NM. PROJECT#SD442 FILENAME: SD442PP.DWG SHEET 1 OF 1