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HomeMy WebLinkAbout0146 BAY LANE - Health 146 Bay Lane Centerville P A = 186 028 ti PC 0.H16 . � 3OR HASTINGS. NN TOWN OF BARNSTABLE LOCATION L��L SEWAGE # / VILLAGE ASSESSOR'S MAP & LOT iNSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER_ BUILDER OR OWNER DATE PERMIT ISSUED: c � DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Ir F . : � .. . -_ ,� � r ,. ^%`t 6 � i i � r ;, OW OF BA TABLE OL/-Z/J46§%i LOCATION SEWAGE /� 1EP 6 v� VILLt1L`E CF�— ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ( — SEPTIC TANK CAPACITY Ac� LEACHING FACILITYAtype); (1aD Z-x (size) NO. OF BEDROOMS_-� PRIVATE WEL.I. OR PUBLIC WATER /�4 BUILDER OR OWNER y DATE PERMIT ISSUED: 9,� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r .. 1 s _,. r Rivermoor Engineering,LLC. 781.545.2848 146 Front Street=Suite 211 fax 781.544.7729 Professional Engineers Scituate,MA 02066 www.rivermoorengineering.com R La 00 RI STRUCTURAL ELEMENTS for the SOPHOCLES RESIDENCE RENOVATION Centerville, MA Alan Kearney Architect Hingham, MA . }..a --t RE Project No. 13-264 F� {q? � a^-5n�H OF z �o PAUL D. G SMITHl o STRUCTURAL v No.31227 November 2013 LIMITATIONS This Report includes specific structural elements as required under The International Residential Code for One- and Two-Family Dwellings (IRC 2009) and The Massachusetts Amendments to the IRC (780 CMR 51.00, Eighth Edition). The Report does not include non-structural design requirements, including but not limited to architectural design, and mechanical/electrical/plumbing design. All such non-structural services are provided by others. The structural elements specified in this Report include: • Structural Steel and/or Engineered Lumber Transfer Beams and Posts • Dimension Lumber and/or Engineered Lumber Skylite Framing • Framing Connectors • Foundations (if required) The contractor is responsible for providing all required temporary support, shoring, and/or bracing until all structural work has been completed. The structural elements included in this report are based on the framing arrangement shown in the included sketches. Refer to the Architectural Drawings for controlled dimensions. Where applicable, coordinate all work with existing conditions. The design of spread footings is based on a presumptive allowable soil bearing pressure of 2,000 pounds per square foot, which corresponds to undisturbed sand, silty sand, clayey sand, silty gravel, and/or clayey gravel with no organic material, or better. The subsurface conditions at the site must be verified by others. Rivermoor Engineering assumes no risk with respect to the suitability of the subsurface conditions for the foundation system. The contractor/builder shall refer to the IRC for structural elements and details not included herein. JOB-SITE SAFETY Job-site safety is the contractor's responsibility. Although Rivermoor Engineering may visit the job-site on one or more occasions, such visits are for clarification of specific structural design issues only, and are not for the purposes of identifying potential job site safety issues. The US Department of Labor(OSHA) website provides direction in the form of a job-site safety handbook for residential construction that includes- but is not limited to- requirements for head and eye protection, ladder safety, and fall protection. It is the contractor's responsibility to comply with all applicable requirements. Rivermoor Engineering,LLC Project 13-264 NOTES AND SKETCHES RIVERMOOR ENGINEERING, LLC PROFESSIONAL ENGINEERS STRUCTURAL GENERAL NOTES SOPHOCLES RESIDENCE RENOVATIONS CENTERVILLE, MA GENERAL USE STRUCTURAL SKETCHES IN CONJUNCTION WITH ARCHITECTURAL DRAWINGS. COORDINATE ALL STRUCTURAL WORK WITH THE WORK SHOWN ON ARCHITECTURAL DRAWINGS AND WITH THE WORK OF OTHER TRADES, INCLUDING MECHANICAL, ELECTRICAL, AND PLUMBING. CONSULT THESE DRAWINGS AND COORDINATE WITH OTHER TRADES FOR LOCATIONS AND DIMENSIONS OF PIPES, OPENINGS, CHASES, AND OTHER DETAILS NOT SHOWN ON STRUCTURAL SKETCHES. FASTENERS UTILIZED FOR FRAMING CONNECTORS SHALL BE THE TYPE, SIZE, AND QUANTITY SPECIFIED IN THE FRAMING CONNECTOR MANUFACTURER'S CATALOG. ALL OTHER FASTENERS SHALL BE COMMON NAILS AS INDICATED OR IN ACCORDANCE WITH THE CODE FASTENER SCHEDULES WHERE NOT INDICATED. IF THE CONTRACTOR PROPOSES TO UTILIZE NAIL GUN FASTENERS, IT IS THE CONTRACTOR'S RESPONSIBILITY TO PROVIDE DOCUMENTATION CONCERNING THE SUITABILITY OF THE PROPOSED FASTENERS AS SUBSTITUTES FOR COMMON NAILS. FOR ELEMENTS NOT INCLUDED AS PART OF THIS PACKAGE, ALL WORK SHALL CONFORM TO THE WFCM AND IRC AS AMENDED. DIMENSIONS SHOWN ARE FOR DESIGN PURPOSES ONLY. REFER TO ARCHITECTURAL DRAWINGS FOR LAYOUT DIMENSIONS. WHERE APPLICABLE COORDINATE ALL DIMENSIONS AND ELEVATIONS WITH EXISTING CONDITIONS. THE CONTRACTOR IS RESPONSIBLE FOR ALL TEMPORARY SHORING AND BRACING AND FOR CONSTRUCTION SITE SAFETY. ALL WORK SHALL BE SUPERVISED BY A CONSTRUCTION SUPERVISOR LICENSED IN THE COMMONWEALTH OF MASSACHUSETTS. THE WORK SHALL COMPLY WITH ALL LOCAL PERMIT APPROVAL DOCUMENTS, BYLAWS, ZONING REGULATIONS, AND CONSERVATION COMMISSION ORDER OF CONDITIONS, AS APPLICABLE. EXISTING FRAMING CONDITIONS THE DESIGN OF THE KITCHEN TRANSFER BEAMS PRESUMES THAT NO EXISTING ROOF FRAMING IS POSTED DOWN WITHIN THE EXTERIOR BEARING WALLS. NOTIFY THE ENGINEER IF UNCOVERED CONDITIONS DIFFER FROM THAT ASSUMPTION. CODE THE INTERNATIONAL RESIDENTIAL CODE FOR ONE-AND TWO-FAMILY DWELLINGS (IRC 2009) THE MASSACHUSETTS RESIDENTIAL CODE (780 CMR 51.00) EIGHTH EDITION (MA AMENDMENTS TO THE IRC) PAGE 1 RIVERMOOR.ENGINEERING, LLC PROFESSIONAL ENGINEERS STEEL CONSTRUCTION MANUAL, AISC,THIRTEENTH EDITION LIVE LOADS BASIC WIND SPEED: 110 MPH (MASS AMENDMENTS) GROUND SNOW LOAD: 30 PSF (MASS AMENDMENTS) LIVING AREAS: 40 PSF SLEEPING AREAS: 30 PSF INTERIOR FOUNDATIONS (IF REQUIRED) THE MINIMUM CONCRETE REQUIREMENTS SHALL BE AS FOLLOWS: • FOOTINGS o COMPRESSIVE STRENGTH: 3,000 PSI @ 28 DAYS o AIR ENTRAINMENT: NOT REQUIRED REINFORCING STEEL #3 BARS: ASTM A615 GR 40 (MIN) #4 AND LARGER BARS: ASTM A615 GR 60 WWF: ASTM A185 THE DESIGN OF FOUNDATION ELEMENTS IS BASED ON A PRESUMPTIVE SOIL BEARING PRESSURE OF 2,000 PSF,WHICH CORRESPONDS TO UNDISTURBED SAND, SILTY SAND, CLAYEY SAND, SILTY GRAVEL AND/OR CLAYEY GRAVEL WITH NO ORGANIC MATERIAL, OR BETTER. THE ACTUAL SOIL CONDITIONS SHALL BE VERIFIED BY THE CONTRACTOR. ALL FOUNDATION ELEMENTS SHALL BE PLACED EITHER ON UNDISTURBED MATERIAL OR ON A MAXIMUM OF 12" COMPACTED GRANULAR FILL. NOTIFY THE ENGINEER IF THE PRESUMED SOIL CONDITIONS ARE NOT APPLICABLE. .STRUCTURAL STEEL WIDE FLANGE SHAPES: ASTM A992 GR 50. PIPE COLUMNS: ASTM A53 GRADE B SQUARE COLUMNS: ASTM A500 GRADE B MISC PLATES: ASTM A36 COMMON BOLTS: ASTM A307 WELDING ELECTRODE: E70XX ALL BEAMS SHALL BE SHOP DRILLED OR PUNCHED TO ACCOMMODATE TOP FLANGE NAILERS AND/OR WEB PADDING AS INDICATED OR REQUIRED. FLUSH BEAM WEB PADDING: UNLESS OTHERWISE INDICATED, WEB PADDING SHALL CONSIST OF LVL, RIPPED TO FIT TIGHT BETWEEN FLANGES,AND SHIMMED TO BE FLUSH WITH THE FLANGES. PADDING SHALL BE FASTENED TO THE BEAM WEB WITH Y2' DIA COMMON BOLTS AT 16" OC(STAGGERED). FRAMING CONNECTIONS NOT DETAILED ON THE SKETCHES SHALL BE DESIGNED BY THE STEEL FABRICATOR FOR ONE-HALF OF THE BEAM CAPACITY BASED ON THE APPLICABLE AISC UNIFORM LOAD TABLES. SUBMIT SHOP DRAWINGS SHOWING MEMBER SIZES, LAYOUT DIMENSIONS, AND CONNECTION DETAILS. THE CONTRACTOR IS RESPONSIBLE FOR REVIEWING SHOP PAGE 2 RIVERMOOR ENGINEERING, LLC PROFESSIONAL ENGINEERS DRAWINGS FOR COMPLIANCE WITH STRUCTURAL SKETCHES, FOR CORRECTNESS OF DIMENSIONS AND ELEVATIONS, AND FOR COORDINATION WITH OTHER WORK. DIMENSION LUMBER ALL INTERIOR OR OTHERWISE PROTECTED DIMENSION LUMBER SHALL BE SPRUCE- PINE-FIR(SPF)GRADE NO. 2 OR BETTER FOR RAFTERS, JOISTS, AND HEADERS, AND STUD GRADE FOR STUDS, UNLESS NOTED OTHERWISE. ALL DIMENSION LUMBER SHALL BE IDENTIFIED BY THE GRADE MARK OF AN APPROVED LUMBER GRADING AGENCY. LUMBER SHALL BE GENERALLY FREE FROM SPLITS &WARPAGE THAT CANNOT BE CORRECTED BY BRIDGING OR NAILING. MOISTURE CONTENT OF LUMBER SHALL NOT EXCEED 19%AT THE TIME OF CONSTRUCTION. LAMINATED VENEER LUMBER(LVL) LAMINATED VENEER LUMBER SHALL BE 1.9E TJ MICROLAM LVL BY TRUS JOIST, OR APPROVED EQUAL, UNLESS OTHERWISE INDICATED. PARALLEL STRAND LUMBER(PSL) PARALLEL STRAND LUMBER SHALL BE 1.8E PARALLAM PSL BY TRUS JOIST, OR APPROVED EQUAL, UNLESS OTHERWISE INDICATED. SHEATHING (IF REQUIRED) ALL ROOF, FLOOR, AND WALL PANELS SHALL BE APA RATED EXPOSURE 1 SHEATHING COMPLYING WITH DOC PS 1 AND PS 2. FULL 4X8 PANELS SHALL BE USED TO THE MAXIMUM EXTENT PRACTICABLE. FLOOR SHEATHING (GENERAL) MINIMUM SPAN RATING: 32/16 MINIMUM THICKNESS: 3% IN GLUED AND NAILED WITH TONGUE AND GROOVE JOINTS FASTENERS: 8d COMMON AT 6" OC ALONG SUPPORTED EDGES AND 12" OC INTERMEDIATE NOTE: USE APA RATED STURD-I-FLOOR OR ADVANTECH IF SPECIFIED ON ARCHITECTURAL DRAWINGS ROOF SHEATHING MINIMUM SPAN RATING: 32/16 MINIMUM THICKNESS: 5/8 IN FASTENERS: 8d COMMON FASTENER SPACING GENERAL: 6" OC ALONG SUPPORTED EDGES AND 6" OC INTERMEDIATE WITHIN 4 FT OF GABLE END WALLS: 4"OC PAGE 3 RIVERMOOR ENGINEERING, LLC PROFESSIONAL ENGINEERS FRAMING CONNECTORS ALL STRUCTURAL FRAMING CONNECTIONS, UNLESS SPECIFICALLY NOTED OTHERWISE, SHALL BE"STRONG TIE"AS MANUFACTURED BY THE SIMPSON CO. IN ACCORDANCE WITH "WOOD CONSTRUCTION CONNECTORS" CATALOG C-2011. ALL FASTENERS (TYPE, SIZE, AND QUANTITY)SPECIFIED IN SIMPSON'S CONNECTOR SCHEDULE SHALL BE INSTALLED. FRAMING INSTALLATION ALL FRAMING SHALL BE ERECTED TRUE TO LINE, PLUMB AND LEVEL, AND SHALL BE FASTENED/HUNG TO DEVELOP THE FULL STRENGTH OF THE ASSEMBLY IN ACCORDANCE WITH MANUFACTURER'S RECOMMENDATIONS. ALL CONTINUOUS WOOD AND/OR STEELPOSTS SHALL BE LATERALLY BRACED IN BOTH DIRECTIONS AT EACH FLOOR LEVEL. ALL ENGINEERED PRODUCTS SHALL BE STORED AND INSTALLED IN ACCORDANCE WITH PRODUCT MANUFACTURERS' SPECIFICATIONS AND INSTALLATION DETAILS. WITH THE EXCEPTION OF MANUFACTURER-PROVIDED KNOCKOUTS, NO HOLES SHALL BE FIELD-DRILLED IN MEMBERS. IF HOLES ARE REQUIRED, NOTIFY THE ENGINEER PRIOR TO ORDERING AFFECTED MEMBERS. FLOOR SHEATHING SHALL BE GLUED AND NAILED. PROVIDE 2X WOOD BLOCKING OR RIM JOIST AT ALL SAWN LUMBER FLOOR JOIST SUPPORT POINTS. PROVIDE 2X SOLID BLOCKING AT ALL UNCOVERED RAFTER TAILS. SIZES OF DIMENSION LUMBER ARE NOMINAL. ALL LUMBER SHALL BE SURFACED FOUR SIDES, UNLESS NOTED OTHERWISE. STRUCTURAL MEMBERS SHALL NOT BE IMPAIRED OR UNDERMINED BY IMPROPER CUTTING OR DRILLING. ALL BUILT-UP LVL BEAMS SHALL BE ASSEMBLED IN ACCORDANCE WITH MANUFACTURER'S INSTRUCTIONS. SCOPE OF STRUCTURAL ENGINEERING SERVICES THE STRUCTURAL ENGINEER HAS PERFORMED THE STRUCTURAL DESIGN AND PREPARED THE STRUCTURAL WORKING SKETCHES FOR SPECIFIC ELEMENTS FOR THIS PROJECT. DESIGN IS LIMITED TO ONLY THOSE STRUCTURAL ELEMENTS IDENTIFIED ON THE ENCLOSED SKETCHES. THE CONSTRUCTION MUST BE PERFORMED IN STRICT ACCORDANCE WITH THE STRUCTURAL DETAILS AND LOCAL CODE REQUIREMENTS. ANY DEVIATION FROM THE SKETCHES MUST BE APPROVED IN WRITING BY THE STRUCTURAL ENGINEER. ANY DISCREPANCY BETWEEN THE STRUCTURAL SKETCHES AND THE ARCHITECTURAL DRAWINGS SHALL BE BROUGHT TO THE STRUCTURAL ENGINEER'S ATTENTION. PAGE 4 WALL CONSTRUCTION TABLE R602.3(1) FASTENER SCHEDULE FOR STRUCTURAL MEMBERS NUMBER AND TYPE OF ITEM DESCRIPTION OF BUILDING ELEMENTS FASTENER",°,° SPACING OF FASTENERS Root 1 Blocking between joists or rafters to top plate,toe nail 3-8d (21/2"x 0.113") — 2 Ceiling joists to plate,toe nail 3-8d(21/"x 0.113") — 3 Ceiling joists not attached to parallel rafter,laps over partitions, 3-10d face nail — 4 Collar tie rafter,face nail or 11/"x 20 gage ridge strap 3-10d(3"x 0.128") — 5 Rafter to plate,toe nail 2-16d(31/"x 0.135") — Roof rafters to ridge,valley or hip rafters: 6 toe nail 4-16d(31/2"x 0.135") — face nail 3-16d 3'/"x 0.135") — wall 7 Built-up comer studs IOd(3"x 0.128") 24"ox, 8 Built-up header,two pieces with 1/"sp acer 16d(31/2"x 0.135") 16"o.c,along each edge 9 Continued header,two pieces 16d(31/"x 0.135") 16"o.c.along each edge 10 Continuous header to stud,toe nail 4-8d(211"x 0.113") — 11 Double studs,face nail 10d(3"x 0.128") 24"O.C. 12 Double top plates,face nail 10d(3"x 0.128") 24"O.C. 13 Double top plates,minimum 48-inch offset of end joints, 8-16d(31/2"x 0.13511) — face.nail in lapped.area 14 Sole plate to joist or blocking,face nail 16d 31/21 x 0.135") 16"o.c. 15 Sole plate to joist or blocking at braced wall panels 3-16d(31/"x 0.135") 16"o.c. 3-8d(21/21'x 0.113") - 16 Stud to sole plate,toe nail or 2-16d 31/2"x 0.135") — 17 Top or sole plate to stud,end nail 2-16d 31/"x 0.13511) — 18 Top plates,laps at corners and intersections,face nail 2-10d(3"x 0.128") — 19 1."brace to each stud and plate,face nail 2-8d(2112"x 0.113") — 2 staples 131" — 20 1"x 6"sheathing to each bearing,face nail 2-8d(21/2"x 0.113") — 2 staples 13/" — 21 1"x 8"sheathing to each bearing,face nail 2-8d(21/2"x 0.113") — 3 staples 13/" — 22 Wider than 1"x 8"sheathing to each bearing,face nail 3-8d(21/2"x 0,113") — 4 staples 13/4" - Floor 23 Joist to sill or girder,toe nail 3-8d(21/2"x 0.113"} 24 1"x 6"subfloor or less to each joist,face nail 2-8d(21/2"x 0.113 1 2 staples 13/4,' - 25 2"subfloor to joist or girder,blind and face nail 2-16d(31/z"x 0.135") — 26 Rim joist to top plate,toe nail(roof applications also) 8d(21/"x 0.113") 6"o.c. 27 2" tanks(plank&beam—floor&roof) 2-16d(31/2"x 0.135") at each bearing Nail each layer as follows: 28 Built-up girders and beams,2-inch lumber layers 1 Od(3"x 0.128") 32"o.c.at top and bottom and . staggered.Two nails at ends and at each splice. 29 Ledger strip supporting,joists or rafters 3-16d(31/,"x 0.135") At each joist or rafter (continued) 2009 INTERNATIONAL RESIDENTIAL CODE® 147 WALL CONSTRUCTION TABLE R602.3(1)—continued FASTENER SCHEDULE FOR STRUCTURAL MEMBERS SPACING OF FASTENERS Intermediate DESCRIPTION OF BUILDING Edges supports',B ITEM MATERIALS DESCRIPTION OF FASTENER"-° (Inches)1 (Inches) Wood structural panels,subfloor,roof and Interior wall sheathing to framing and particleboard wall sheathing to framing 3 „_ „ 6d common(2"x 0.113")nail(subfloor wally 9 30 /s /z 8d common(21/2"x 0.131")nail(roof) 6 12 5/16" t „ 6d common(2" x 0.113")nail(subfloor,wall) 31 /2 8d common(21/2"x 0.131")nail(roof)f 6 12g 32 19/32"- 1" 8d common nail(21/2"x 0.131") 6 129 1 t 1Od common(3"x 0.148")nail or 33 1 /311 1 /4" 8d(2112"x 0.131")deformed nail b 12 Other wall sheathings' 34 14"structural cellulosic 1/2"galvanized roofing nail,7/16"crown or 1" 3 6 fiberboard sheathing crown staple 16 ga., 11/4"long 35 25/32"structural cellulosic 13/4"galvanized roofing nail,7/l6"crown or 1" 3 6 fiberboard sheathing crown staple 16 ga.,11/2"long 36 1/2"gypsum sheathings 1'/2.galvanized roofing nail;staple galvanized, 7 7 1 /2 long; 1114 screws,Type W or S 37 5/"gypsum sheathings 113/4"glavanized roofing nail;staple galvanized, 7 7 $ 15/8"long; 15/e'screws,Type W or S Wood structural panels,combination subfloor underlayment to framing 6d deformed(2"x 0.120")nail or 3g 3/4"and less 8d common(21/2"x 0.131")nail 6 i2 39 7/811- 1U 8d common(21/2"x 0.131")nail or 6 12 8d deformed(21/2"x 0.120")nail 40 11/,'_ 11/,f 1Od common(3"x 0.148")nail or a 4 8d deformed(21/2"x 0.120")nail 6 l2 For ST; 1 inch=25.4 mm, 1 foot=304.8 mm, I mile per hour=0.447 m/s;lksi=6.895 MPa. a. All nails are smooth-common,box or deformed shanks except where otherwise suited.Nails used for framing and sheathing connections shall have minimum average bending yield strengths m shown:80 ksi for shank dimneter of 0.192 inch(20d common nail),90 ksi for shank diameters larger than 0.142 inch but not larger than 0.177 inch,and 100 ksi for shank diameters of.0.142 inch or less. b. Staples are 16 gage wire and have a minimum'/16-inch on diameter crown width. c. Nails shall be spaced at not more than 6 inches on center at all supports where spans are 48 inches orgreater. d.Four-foot-by-8-foot or 4-foot-by-9-foot panels shall be applied tertically. e. Spacing of fasteners not included in this table shall be based an Table R602.3(2). f. For regions having basic wind speed of 110 mph or greater,8d deformed(2'/,"x 0.120)nails shall be used for attaching plywood and wood structural panel roof sheathing to framing within minimum 48-inch distance from able end walls,if mean roof height is more than 25 feet,up to 35 feet maximum. g. For regions having basic wind speed of 100 mph or less,nails for attaching wood structural panel roof sheathing to gable end wall framing shall be spaced 6 inches on center.When basic wind speed is greater than 100 mph,nails for attaching panel roof sheathing to intermediate supports shall be spaced 6 inches on center for minimum 48-inch distance from ridges,eaves and gable end walls;and 4 inches on center to gable end wall framing. h. Gypsum sheathing shall conform to ASTM C 1396 and shall be installed in accordance with GA 253.Fiberboard sheathing shall conform to ASTM C NE, i. Spacing of fasteners on floor sheathing panel edges applies to panel edges supported by framing members and required blocking and at all floor perimeters only. Spacing of fasteners on roof sheathing panel edges applies to panel edges supported by framing members and required blocking.Blocking of roof or floor sheath- ing panel edges perpendicular to the framing members need not be provided except as required by other provisions of this code.Floor perimeter shall be supported by framing members or solid blocking. 148 2009 INTERNATIONAL RESIDENTIAL CODE® CALCULATIONS ♦ e CALCULATION COVER SHEET Client: Alan Kearney Project: Sophocles Residence-Interior Renovation Job/Calculation Number: 13-264 Title: DESIGN OF SELECTED STRUCTURAL ELEMENTS Purpose, Description and Methodology of Calculation: The purpose of this calculation is to develop the structural design for structural steel and/or engineered lumber transfer beams and posts, and framed openings for new skylites. Structural Elements were designed for loads based on the following design references: Design Basis and References: -1. The International Residential Code, IRC 2009 2. The Massachusetts Residential Code, 780 CMR 51.00, 8th Edition (MA Amendments) 3. Rivermoor Engineering Structural Design Guide 4. Wood Frame Construction Manual for One and Two Family Dwellings, ANSI/AF&PA WFCM-2001 5. WFCM Design Guides as applicable 6. Beamchek—Wood Design '05 NDS 7. AISC ASD 13th Edition 8. Simpson Strong Tie Wood Structural Connectors Catalog C-2011 9. Architectural Drawings by Alan Kearney Load: 1. Live Load Living Areas: 40 psf 2. Live Load Sleeping Rooms: 30 psf 3. Basic Wind Speed: 110 mph 4. Ground Snow Load: 30 psf Conclusions and Summary: Provide member sizes as stated in the calculation and sketches. i BACK-UP CALCULATIONS WILL BE SUBMITTED ON REQUEST • tue r Town of Barnstable Barnstable .�ti Regulatory Services Department `W j ERATtNSfABM 9 MASS. i639. $ Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7012 1010 0000 2850 9088 May 16, 2013 Ellen Burkhardt %Ellen Burkhardt, Estate of 4 Cresent Road Winchester, MA 01890 • ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 146 Bay Lane, Centerville, MA was last inspected on 4/1712013, by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Distribution.box needs to be replaced. You are ordered to repair or replace the septic system components within sixty (60) days from the date you receive this notification. .Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH • Thomas McKean, R.S., CHO Agent-of the Board of Health Q:\SEPTIC\conditionally passed\146 Bay Ln Cent May 2013.doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetaii.aspx?ID=12539 1 8,ll3 i4b'r.Atid ; . Logged In As: Parcel Detail Wednesday, May 15 2013 Parcel Lookup Parcel Info Parcel ID 186-028 I Developer ILOT 3 Lot Location 1146 BAY LANE Pri Frontage 150�� Sec Road m _ Sect I Frontages Village[CENTERVILLE �� Fire District!C-0-mm I r- Town sewer exists at this address j No Road Index 0084 I ASbullt Septic Scan: Interactive a� 186028 1 Map ar� r 11 Owner Info Owner IBURKHARDT, ELLEN � Co-Ownerl%BURKHARDT, ELLEN ESTATE OF Streets 14 CRESENT ROAD Street2 � City WINCHESTER � State IMA Zip i01890 Country Land Info Acres 1.7� Use rSing le Fam MDL-01 Zoning RD-1 �Nghbd 0110 J I Topography(Level Road I 2 d Utilities{Public Water,Gas,Septic Location[Excel View,Rear Location Construction Info Building 1 of 1 Year 1994 �1 Roof IGable/Hip Ext Wood Shingle Built, I Struct._ Wall LivingAC Area Cover over r JAsph/F GIs/Cmp T ype Central - - Style Cape Cod Wall Ill[ Rooms Plastered Bed I4 Bedrooms � Model{Residential Int Carp ( Bath 12 Full+ 1 H � " i,. A � Floor' Rooms l x� * 5 Heat Total�� M •= Grade Luxury Plus Type Hot Air ( Rooms 18 Rooms Heat �� Found t Stories(1 1/2 Stones ( .Fuel(Gas � ation Poured Conc. Gross6516 ' Area • Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=12539 5/15/2013 I I Comfmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 146 Bay Lane Property Address Ellen & Martin Burkhardt Owner Owner's Name information Is required r every Centerville MA 02632 4-17-13 Fo e page. CitylTown State Zip Code Date of inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form- Important, n When A. General Information filling out forms on the computer, OF use onlythe tab 1. inspector p �key to move your l/ � o:' • G; cursor-do not - = JAM E S :;m use the return James .Sears Name of Inspector key. *•: CapewideEnterprises,LLC _ o o Company Name 153 Commercial Street ''w„5 s"'P Company Address Mashpee. MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification 1 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 16.000). The system: ❑ Passes ® Conditionally Passes [} ils R Needs Further Evaluation by the Local Approving Authority -i� 4-18-13 ectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving AlAhoriFf(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. '4w*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. &is•3113 Title 5 Dfficie coon Form:Subsurface Sewage Disposal system Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 146 Bay Lane Property Address Ellen &Martin Burkhardt Owner Owners Name information is required for every Centerville MA 02632 4-11-13. page. GityrFown state Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or'not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y ❑ N ❑ NO(Explain below): [Sins-3M3 Tifie 5 Official Inspection Forth:Subsurface,Sewage Disposal System-Page 2 of 17 Apr l y 1 S "I WZ6a p•3 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 146 Bay Lane Property Address Ellen & Martin Burkhardt Owner Owners Name information is required for every Centerville MA 02632 4-17-13 page_ cityfrDwn State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): Need to replace D Box ❑ 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): J ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is notfunctioning in a mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or'a salt marsh t5ins-3113 True 5 Ofticiai 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 146.Bay lane Property Address Ellen &Martin Burkhardt Owner Owner's Name information is required for every Centerville. MA 02632 4-17-13 Page. CityFrown 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. El 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 w 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: 0) 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 El E 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 minq10 is less than 67 below ni ver or available volume is less -than Y2 day flow ,C Ell C///ic+G - Tilla 5 OrFcial Inspection Form!Subsurface Sewage Disposal System•Page 4 of 17 Apr l y -I3 .1 u:24a p.o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '146 Bay Lane Property Address Ellen & Martin Burkhardt Owner Owner's Name information is Centerville, MA 02632 4-17-13 required for every page. CftyrTovrn . State Zip Code Date cf 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. 0 ® Any portion of cesspool or privy is within 1 DO 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.] E ® 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-3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Amm Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 146 Bay Lane Property Address Ellen & Martin Burkhardt Owner Owners Name requinform r on is Centerville MA 02632 4-17-13 requiredd for every page. City,Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You rnust 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? 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? Were as built plans of the system obtained and examined?(If they were not available note as NIA) ' ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® . ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual). 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 or 17 Commonwealth of Massachusetts lopTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Bay Lane, Property Address Ellen &Martin Burkhardt Owner Owners Name information i e required for every Centerville MA 02632 4-11-13 page- City/rows State Zip Code Date of Inspection D. System Information Description: The System is a 1500 Gal tank D Box and three galleys. Number of current residents: - 0, Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2011-76,000GaIs` 2012-62,000GaI s Detail Sump pump? ❑ Yes ® No Last date of occupancy: NA P cY Date Commerciallindustrial 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 E] No Water meter readings, if available: t5ins•3113 Tile 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 r 146 Bay Lane Property Address Ellen &Martin Burkhardt Owner Owner's Name information is required for every Centerville MA 02632 4-17-13 page. CityRbwn 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: 5/17M 1 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 El Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and Maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3rl3 Title 5 Official Inspection Form:Sthsurfaoe sewage Disposal system•page a of w Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Bay Lane Property Address Ellen & Martin Burkhardt Owner Owner's Name information is required for every Centerville._ MA 02632 4-17-13 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known)and source of information: 1987 Permit # 87-7 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below.grade: ' 20° 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.): _ Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) It tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast Sludge depth: lot 15ins-3/13 Title 5 OffiD al Inspedion Form Subsurface Sewage Disposal System•Page 9 or 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 146 Bay Lane Property Address Ellen &Martin Burkhardt _ Owner Ownefs Name requinform r don is for every Centerville MA 02632 4-17-13 required page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" I 1' Scum thickness - -- Distance from top of scum to top of outlet tee or baffle 1211 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 and covers at 1'below grade, inlet tee oulet baffle. No sign of leakage or over loading. 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 15ins•3113 Tltle 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts v; Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 146 Bay Lane Property Address Ellen &Martin Burkhardt Owner Owner's Name information is required for every Centerville MA 02632 4-17A 3 page. CityfTown 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 0 fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No ISils•3113 Tntle 5 Vidal 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 146 Bay Lane Property Address Ellen& Martin Burkhardt Owner information is Owner's Name req ui red for every Centerville MA 02632 4-W-13 page. Cityrrown 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.): D Box is 16"x16"-22" below grade Wone line out. No sign of over loading or solid carry over. Wall's are gone. Need to replace D Box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc_): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i5ins•3113 Title 5 Offdal Inspection Form:Subsurface Sewage Disposal System-?age 12 of 17 Commonwealth of Massachusetts _ -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 146 Bay Lane Property Address Ellen &Martin Burkhardt Owner Owner's Name information is required for every Centerville, MA 02632 4-17-13 page. cityfrown. State Zip Code Date of Inspection D. System Infor'lmation (cont.) Type: ❑ leaching pits number: El leaching chambers number: ® leaching galleries number: 3 ❑ 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.). Leaching is three galley's w14'stone. Galley's are 27" below grade,clean and dry. Wall's are like new. No sign of over loading solid carry over or stain line 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-3113 Title 5 Official Inspoaon Form:Subsurface Sewage Disposal System.Page 13 of 17 nNi v iv iv.� u Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments W�W�. 146 Bay Lane Property Address Ellen &Martin Burkhardt Owner Owner's Name information is required for every Centerville MA 02632 4-17-13. page. CitylTown 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-W 13 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 146 Bay Lane Property Address Ellen & Martin Burkhardt Owner Owner's Name information is required for every Centerville MA 02632 4-17-1,3 page. City/Town State Zip Code Date of Inspection D. System Information (corn.) 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 3.7 3- 3 . 3 :� B 3 - y= I� � G t a ❑ o 3 t5ihs-3113 Tick 5 Official Inspection Form:Subsurface Sewage Disomal Syslern•Page 15 of 1T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 146 Bay Lane Property Address Ellen 8r Martin Burkhardt Owner Owner's Name information is required for every Centerville MA 02632 4-17-13 page. City/Tcwn State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells N Estimated depth tofigh 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: 1987 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: T.H. on Plan 1987 no G.W.at 10'. Bottom of leaching at 6'. Bottom of leaching at 4' above T.H. Depth.. ... .. .-_ Before filing this Inspection Report,please see Report Completeness Checklist on next page. 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 ar 17 Commonwealth of Massachusetts lot Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 146 Bay Lane Property Address Ellen & Martin Burkhardt Owner Owner's Name information is required for every Centerville MA 02632 4-17-13 page. Cftyfrown 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 Ohs•3113 Tille 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17 No. 10`I 3 /q Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitation for Disposal *pStem Construction Permit Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System individual Components Location Address or Lot No. / 0�( Owner's�N)i e,Ad ess,and Tel.Noo.. 5 09— 5 7'SS(+5 Assessor's Map/Parcel r g�o ©� ��„�`p �� 4. ®��q Installer's Name,Address and Tel.No. 11 G fl 7 a Designer's Name,Address,and Tel.No. ^ Type of Building: Q Dwelling No.of Bedrooms Lot Size /,7 7 o l► sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Healt [� Date Application Approved b Date '� 3 Application Disapproved by Date for the following reasons Permit No. Q0 —�4�3 Date Issued l No. �G 13 J t t Fee �Q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS YA Application for 13I8posal �6pstrm Construction j3ermit Application for a Permit to Construct( ) Repair N4 Upgrade( ) Abandon( ) ❑Complete System 9ndividual Components Location Address or Lot No. & QVOW Owner's Name,Address,and Tel.Noo.. 5 0g- '5 7'5S(V* Assessor's Map/Parcel g�o/O J�O L)C rT K ` 01� Rot Installer's Name,Address and Tel.No.�F o y 7 8 8 77 Designer's Name,Address,and Tel.No. CCke, ,J., Type of Building: A Dwelling No.of Bedrooms Lot Size /,77 � `, sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 1 Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A:S. r Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Healt �S Date Application Approved by ed Date- I <( l 3 Application Disapproved by Date for the following reasons d4 Permit No. °��G/ 3 .. fr-3 Date Issued - - ------ - ^-- ---.! -- _ -=--- --;----- ------------------------.-- ---- THE COMMONWEALTH OF MASSACHUSETTS # BARNSTABLE,MASSACHUSETTS Ceftificate of Compliance ` +� THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Rep aire ) '�Upjraded( k Abandoned( )by2W f. at �y�Y - CQwTe��li has been constructed in,/accordance with the provisions of Title 5 and the for Disposal System Construction Permit No- 3 /7� 3 dated L)� Z/h !y Installer�d W t ae 1 �fiI r' K s i LLC_ Designer #bedrooms Approved design flow gpd I The issuance of this permit shall not bjd construed as a guarantee that the system will f cti n as designed. Date _ f Inspector -------------------------------------------------------------------------- --------------------------------------------------------------------- No. � J Fee 1496) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS disposal 6pstetn Construction permit Permission is hereby granted to Construct( ) Repair(✓� r Upgrade( ) Abandon( ) System located at If and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date L J Approv`d�b� TO OF BARNSTABLE p ,�-� - L0,1 A- ON /�� JJ ��- SEWAGE # JILLL C¢/IT ryi`LC ASSESSOR'S MAP & LOT l �o INSTALLER'S NAME&PHONE NO. LGT- 3 SEPTIC TANK CAPACITY r CO LEACHING FACILITY: (type) 3� YX 7 (size) NO.OF BEDROOMS L BUILDER OR OWNERC' PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ' g facility)_� _ /� Feet Furnished by 8AL� 0 3 ia.� �'3 a �a 3-7 _3iy3a I � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION G0 4 2002 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY IF SSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION l 59 Property Address: 146 Bay Lane _Centerville.MA 02655 Owner's Name: Robert Bownes Owner's Address: Same Date of Inspection: November 18, 2002 MAP r Name of Inspector:(Please Print) James M. Ford PARCEL COT Company Name: James M. Ford 13 _ Mailing Address: P.O. Box 49 y `\ Osterville,MA 02655-0049 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 her Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: November 21, 2002 The system inspector shall subm 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 r Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 146 Bay Lane Centerville, MA Owner: Robert Bownes Date of Inspection: November 18, 2002 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 i Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 146 Bay Lane Centerville, MA Owner: Robert Bownes Date of Inspection: November 18, 2002 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 146 Bay Lane Centerville, AM Owner: Robert Bownes Date of Inspection: November 18, 2002 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.] No (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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 146 Bay Lane Centerville, AM Owner: Robert Bownes Date of Inspection: November 18, 2002 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: 146 Bay Lane Centerville, M4 Owner: Robert Bownes Date of Inspection: November 18, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a 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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown 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 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: 1993-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r ~ Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFAC E SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 146 Bay Lane Centerville, MA Owner: Robert Bownes Date of Inspection: November 18, 2002 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: Town water Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 12" 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: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: S" Distance from top of scum to top of outlet tee or baffle: 10" 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.): Tees were present The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping 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 V Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 146 Bay Lane Centerville, MA Owner: Robert Bownes Date of Inspection: November 18, 2002 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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 level and clean. No solids were present 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 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 146 Bay Lane Centerville, M4 Owner: Robert Bownes Date of Inspection: November 18, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: c Type leaching pits,number: ✓ leaching chambers,number: 3- 4'x 4'Galleys-per as built card 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.): I dug down in the stone beside the galleys and the stone was clean. There were no signs of failure. The bottom to grade was approximately 5'6" 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 F., Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 146 Bay Lane Centerville, M4 Owner: Robert Bownes Date of Inspection: November 18, 2002 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. � a 3 13 ia.b 413 a /a 3-7 3 �y3a 10 f 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: 146 Bay Lane Centerville, AM Owner: Robert Bownes Date of Inspection: November 18, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 16 +1- 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: 11197 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: The bottom of the leach field to grade was approximately S 5' Using the Barnstable topographic map and water contours man, the maps were showing approximately 16'+/-to ground water at this site This report has been prepared and the system inspected and passed as of the date of inspection. This report is 4 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 t`kv 4 s s A l .,'>.� ..:r t t [[ (`CAT`\ Kff y6 •®\ ' s S F SSS i T"i`A ` - COTIMMONAVEALTH OF ivWA ACHUSETTS `g 9 EXECUTIVE OFFICE OF ENVIRONMENTAL DEPARTMENT OF ENVIItONMENTAL PRO ON 1� ONE WINTER STREET, BOSTON MA 02108 (617)292-5 cc / ✓ J(IL O to of 1 19,9gI'R CO ttaary ARGEO PA UL CELLUCCI A TRUHS Governor ioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A y CERTIFICATION Property Address: j'1(q p,T 7 ( Al, CQO'ERUILL&'r Name of Owner/M 8/AJ&2L/_4 /� `/ Address of Owner: ..� Date of Inspection: ( '�/q f fp 99 Name of Inspector:(Please Print) E7,0iV q p BOUSF/EGp I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: WgRD 3 inn0 161— Mailing Address: 62 Lijono Ay6 /(! WIC O.Z$6 3 Telephone Number: S08888��?3 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails 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 thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS Soo G&LOAI SEPric yWd e 1"ED 16HT Sot+/OS G4= Com&7`104) D-BOX 3 Xy� LEAcH/4) 611Ll6"V revised 9/2/98 Pagel of11 1/1 Printed on Recycled Paper µ(� r ��ryk'�•y� V5 SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM =a PART A CERTIFICATION(continued) Property Address: l yb SAY ( A), Owner: M, 81881604 Date of Inspection:/_19 INSPECTION SUMMARY: Check 6) B, C, Or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances._If"not determined";explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:l y 6 BPvY-LA W Owner: m. 01R616tin Date of Inspection:6, ,_Nqq 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 the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply.well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER . t revised 9/2/98 Page 3ofII � .. ... _ ., v. vy d ui 'e �sk. r .. .. .sue-�fiw . � .# � ♦ "1+n.r e i.'d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM '-OART'A CERTIFICATION(continued) Property Address: 14 BR y ( Al Owner: /)'►, gf el G L)A Date of Inspection: D. SYSTEM FAILS: You must indicate either"Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 :l rf. uiy'^a ti .La f ,� may. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM N1 ' PART B CHECKLIST Property Address: N 6 611 V LA Owner: 01, 13w616019 Date of Inspection:6_�9-1999 Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes No .� Pumping information was provided by the owner,occupant,or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normaf flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow.. _ The site was inspected for signs of breakout. _ All system components, ,have been located on the site. _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)) x _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page sorll ' ef`� .. a . -, - ,vtZ+�ae-�.3�k�ri�ti .!y �sr�r' 1.nF. r�r•h.S ,wr z^'�� },i rp� Ab�''�..i i�„ .s.`�� a.T+... a sue`.' SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM _. - PART C ' + SYSTEM INFORMATION Property Address:/ Owner: ) MI 6 RB1Gt.ln Date of Inspection:;-ri-1M v FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedro m. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow yyo Number of current residents: 3 Garbage grinder Oor no):,Y-65 Laundry(separate system) (yes or(9):N0; If yes,separate inspection required Laundry system inspected ( es or no) Seasonal use(yes or "1:WV ` Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or ): II JD Last date of occupancy: S-rf C"UP/E 0 COM M ERCIALANDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes orfiQ IVO If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: I�STA�C ED /`f Q3 Sewage odors detected when arriving at the site: (yes or O revised 9/2/98 Page 6of11 .G A ri � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '' SYSTEM INFORMATION(continued) Property Address: 1 y 6 31$Y L Nr Owner: M I R d l6 01 Date of Inspection:6-11415 BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK (locate on site�1 n) Depth below grade:AfA4NS Material of construction:,cconcrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_yIs age confirmed by Certificate of Compliance_(Yes/No) Dimensions: /O'6"(.)"S X'W)6 14 Sludge depth: 7?IIUC 5 Distance from top of sludge to bottom of outlet tee or baffle: o23INCHS Scum thickness: me !> Distance from top of scum to top of outlet tee or baffle: Q i RICH S Distance from bottom of scum to bottom of outlet tee or baffle: "VCf/S How dimensions were determined:-::rAPF I► g-19Svr2E Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) CONCRE F G OU7 ET' TANK IS 1rV 60C)nco/to/ze212 LI©UIO f r_,.v To 66170A o ouTC GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) a4 revised 9/2/98 Page 7oftt �_.. X 4 : •.�;.i g l C, 4'� �"i,{w 5 �S+*I �.i':i#1 d-t ..F i.y rst..'v4)..? `J' � �?a ,Ts �'zjl f SUBSURFACE SEWAGE DISPOSAL SYSTEM BYSPECTIok FORM '-PART 2n SYSTEM INFORMATION(continued) Property Address: I yb Y CN r Owner: A B I R61609 Date of Inspection:6-j,-jqq Q TIGHT OR HOLDING TANK: �1 (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: X (locate on site plan) !� Depth of liquid level above outlet invert: W� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) DRJe PIPE 110 OVE P/PE OuT NO SOLIDS PUMP CHAMBER:_ (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.) revised 9/2/98 Page 8ofII ni v ix 'p : .. n �,5� �h• - ...Y. ,. ^tr t.sw +.-.. .r.iw., r• .-tn R`. k # -ems` `xdd"'t'"v � r ' t E h i « `° ° the gt r$ nNWtaa�r -4' t t# a. '* .u'• U far: Y'T�r. ..rT ..,.,, .,.e ,• `.{x .�i+'-�` t .47. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 3% PART C SYSTEM INFORMATION(continued) Property Address: I y6 LN, Owner: h1 i R Q16 04 Date of Inspection:6-11-IC�!.� SOIL ABSORPTION SYSTEM(SAS)_ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number:_ leaching chambers,number: c1t LFHU/fN6 �iA«�y leaching galleries,number: x leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) ONLY S•Ir /NCHS OF Ut2olD 11I2.51Df CdUey< UIERY jCLEA/U, CESSPOOLS•_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 it4p tr"z,.; ?"'A"�T+ arRad 4srY�. rr� f 1$$ 1 t r;ft `:'k 4a 4 w�.:1 r y ss.,. _ �'� E k ��'` .k r�'����r d �+� C' S4 'S J - a h^e �+ `�"'". f a '`+:7rt. �•i s — �� �' 1 � 4 �`�xr a.r.. 'k$,... k <.w � rY,�r w...t"f' �-�.. k .. fr y �; �t.ii �,,d+'7��+•�3��}"r'r`pf".s�.y.,.�a "1 r`s Y... dry !a: L7 t'Yei-t+r: � `z t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C '. SYSTEM INFORMATION(continued) Property Address: /y 6 BAV CND Owner: rn, QtRQi�CI!} Date of Inspection:6_(q-jq q SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) GIs --------------- 1 1 t is O revised 9/2/98 Page ioorii V. £ r dFe a k a N i� � - • r4i g ,_r4,i z Ott sx s3 r; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(eordhwed) Property Address:l y 6 PA e IV, LAI Owner: m, (3iR 616A Date of Inspection:` NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole,basement sump etc.): Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) G ieowD tu.4-�rf- t1�1 r9�?a PO Al A P revised 9/2/98 Page 11of11 J s � I....--, �• �l.�(� �18.E No. .�. .. LOT 8 Fps���J J THE COMMONWEALTH OF MASSACHUSETTS BOAR® F H EA T 12-. � ..OF..... ... ApplirFa#ion for Biipno al Workii Toustrnrtinn Prrutit Application is hereby made for a Permit to Construct ( or Repair ( } an Individual Sewage Disposal System at l' (l 7 •.... ... ..... ..... -•-----•-•-• --- - 1 NGL —...Loc i . ess._� i '� --• y�— �fl�.orCs� ®a��......: `— ...._ Owner Ads s a --........CC. .._...__... /--------------------------------- � �r�_._ c...,�.�,../. Installer ` Expansion Attic Address Garbage Grinder U Type of Building C(� Size Lot-----.f�!•1��_-S feet �. Dwelling—No. of Bedrooms.............. p ( g Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------••-----........-••---•-------•---•...._.........---•- . . W Design Flow......5S+.SQ.e..............gallons per person per day. Total daily flow---- 6d_..__.....__......._..._gallons. WSeptic Tank—Liquid capacity.I.�Q.gallons Length.lp� 5.. Width.6.:l.... Diameter---—^------- De th-.`�._.�_. x Disposal Trench—No.......I............. Width....l�........... Total Length___....S.�..... Total leaching area---6o-�--.--sq. ft. Seepage Pit No--_----------------- Diameter...._............... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box �/a Dosing tank 40 1 n '-' Percolation Test Results Performed .............................. Date..A.U.Z�t.: 4........._.. aTest Pit No. 1_L:Z____.minutes per inch Depth of Test Pit*!o........... Depth to ground water..�_?_5_. f_, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... ----------•.....-•-•------....--••-- .. .................. ...----- _ D Description of SoiL0.—••Z--�':�? c . -QS�'� `A -----1M. (2A�Vtz V DESIGNING ENGINEER MUSY SUf�ENIVI�� W .: 'NSTALLATION AND__ CE;RTIF'Y' ir,......................H ---- ------------------------------------------------------------------------ r�, -�-ll< SYSYEM WAS � S7pL EIL)'iI 0 j'rii:t U Nature of Repairs or Alterations—Answer when applicable.......__ ----__________..._ ____--...__. . ••• --•--•-•---•--•------•----------------•-----------•----•-----••......•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTT�_ p 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 t e b rrc1�W1111 d -•-- . ApplicationApproved By................................................................................................. ------------.1-. .... .....e. - Date Application Disapproved for-'the following reasons:----•---------••------------•---•---------------------------------------------------••--••..Da•_.......------- ..................... ••-•-----•-----•---- .... =......-•--------------.....-----••--•---------•--•------------------------------------------------------------------------------------------- Date PermitNo............. .......�--------- Issued....................................................... ?^I— Daze THEICOMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ....... ..... ...... OF............ .... 41t............. Trrtif r, ab of ToutpliFanrr THIS IS TO C RTIFY, at the Inu vtdual Sevczge Disposal System constructed ( ) or Repaired ( ) by �...ta._14 d= ...................................................... = -•---•------•----••---------••-- r Installer at•----........... ---- -------=- ........ ... -•-•---------------- -- has been installed in accordance t' the provisions of TiT;T of The State Sanitary C`� as described in the application for Disposal Works Construction h it No.__.. 7_—_�--. dated-...,.- --------------- `- --� u�7--------------- :,c t TIME ISSUANCE OF„THIS CERTIFICATEI SHALL NOT BE CONSTRUED AS A GU RANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector..................................................................................-- 73 THE COMMONWEALTH OF MASSACHSs �IS.ING ENGINEER MUST SUF, BOARD OF HEALTWIN� TLATION AND CERTIFY 1°' 1 iNG _ .............OF.....� `r'� . TEM WAS T S I NS�'rr+��' ��f RIG NO._.. C FEE........................ Disposal Vvr � (9t*sposal rudivit "rrrutit _____ _ _______. . Permission is hereby granted.................. _� • to Construct ( ) or Repair ) an In 'vidual Sewage ?;P at i�To. �*- L ----------•-- as shown on the application for Disposal Works Construction Permit No�.77Dated.._.._ r� � 7........ Board of Hea -04 DATE................................................................................ I Y4 -- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS L C)i 28 Fi$ ` ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH r , _................OF........ .........---------.......--------;��.......................... App irafinn for Dispog al darks Tnnstrar tiun rr*mit Application is hereby made for a Permit to Construct (--,--Or Repair ( ) an Individual Sewage Disposal System at: C........................... ................................................................................................ Lo ai Address or Lot Now Owner Add ess Installer Address Type of Building ; Size Lot----0-----------Sq. feet Dwelling—No. of Bedrooms.......... ..............................Expansion Attic �Ao) Garbage Grinder ((_- Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) Q' Other fixtures ................ ................. W Design Flow____. _______________gallons per person per day. Total daily flow----- -- ......gallons. WSeptic Tank—Liquid*capacity ..gallons Lengthb -._5_._ Width:?`.It..... Diameter.:=........ De ths:_(__- x Disposal Trench—No. .....I.............. Width...).6............ Total Length----- _.._._. Total leaching area-4 ------sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box lb5 Dosing,tank (30) Percolation Test Results Performed by. akT>r?. ..dV-`�-��¢�.'! C.................... Date_ �.' .�.......__. a T minutes per inch Depth of Test PAO._. .._.. Depth to ground water_!S.............Test Pit ;�o. 1 L�-_..... ®__.___. rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ _ _..... .................... D Description of Soil.D -�•......�. :`... ------3 sq---..... � �� x ----------------------------------------------------------------------------------- ---------------------------- --- W Nature of Repairs or Alterations—Answer when applicable__...__..'��CIr�l�dr F�I���I�E4�-����-�iJPERVIS� - U P PP 0STAi:� ATIQt�l--�1ND CERTIFY IN IVRITIN( iE SYSTEM WAS INSTALLED 1+' :rV --------------.........................................................................................................--............................................................................... ..4�^ `I .Agreement TO PLPI The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance.with the provisions of TiTiE, 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 Pofealth. Application Approved By--•-------•------------•-•----•-------'-= ...---r r..... -......- -----. .... •.----- .. Date Application Disapproved for the following reasons------------------------•-------•----•-----------------------•--------------------------------------------......_ -----------------=---------------•---------------......--------•-•-.....------------.........--•-•---•--------------------------------•---•-----...----------•---•------------------------------------- Date PermitNo........... - - ---- �----------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �f• �G ... .............•••- ... j .........OF............�rr�if�ctt#� ,af f�u�t��i�nr�e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by--------- 4, ------ ------- -------------------------- --------------------- y� Installertn / / 6 � at---•--� -- - f-a,..,.d ------- --- ,,+ has been installed in accordance w' h the provisions of Ti i 7 of The State Sanita�y 'C�SdF as described in the application for Disposal Works Construction Permit N'o.___ 77__- .77•... dated_._.._.�_r._ 'I)................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. . DATE................................................................................. Inspector.................................................................................... DESIGN!NG ENGINEER MUST SUPERVISf THE COMMONWEALTH OF MASSACHUSvETjTs�_ATION AND CERTIFY IrJ 1 'RITIN- = Si EU�WAS INn\S T�ALL FrTBOARD, :OF HEAL ............_OF.... �........... ......� .�VO �.._. .... � �. FEE.......:: ........... Billpos al Workii Tonotrnr#inn permit Permission is hereby granted.................�___ ,�(,t,r��,_. to Construct ( ) or Repair ( ) an Individual Sewage isposal System at No----- ----- �i' . f - �j as shown on the application for Di osal Works Construction Permit No`�'�_._ _._ Dated...__ --....•-_. Board of Health DATE---------------------------.................................................... FORM 1255 HOBBS & WARREN., INC.. PUBLISHERS o N aC W8 Icj oR FmJN 9 z/ I I ►� �� Vr DAUL I IGays W 7Ner SMITH Z Z cn o 00 \. o STRUCTURAL ;; W No.31227 � Z � L � � z . LO W cn 00 V f C E e i tv ._ 7 f � 4> PAUL D. 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