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0291 BAY LANE - Health
ol 291 Bay Lane,Centerville f w g0 f i i i I a UPC 12534 No.2153_LOR HASTINGS, MN /Iola- L) Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Xn X. 291 Bay Lane NJ Property Address Jim Pellow Owner Owner's Name 2> information is Centerville MA 02632 3/29/2019 ` required for every page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. L Important:When A. General Information �"� 2 filling out forms � 1 3:7-b-�L— on the computer, use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. Ford Septic Services LLC r� Company Name P.O. Box 49 Company Address Osterville MA 02655 Cityrrown State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further val� ation by the Local Approving Authority 4/1/2019 InsperorsSignature Date Thenspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6116 Title 5 Official Inspection 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 v!% 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;V 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System.will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ?, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): bu{r as- Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . � 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed date- 10/15/2008 per as-built Were sewage odors detected when arriving at the site? - El Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 36"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal. H-20 Sludge depth: 2 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The Tees were present. The liquid level was even with the outlet invert. There was no sign of Ieakage.The tank was pumped after the inspection. The outlet cover was 10" below grade. Grease Trap (locate on site plan): Depth below grade: N/a feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ...........* 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/a Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts �a Title 5 Official Inspection Form ( Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 291 Bay Lane v� Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. CitylTown 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 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 normal. 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.): N/a * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form �n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c !% 291 Bay Lane U Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-leach chambers ❑ 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.): There was no sign of failure from the chambers. A camera was used. C Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/a Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is Centerville MA 02632 3/29/2019 required for every page. Cityrrown 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: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts rd Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments U 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Pr o nfT' 6ArA - I a q 4 a �6 �s 3 3 9a o S S Ito iw` t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information is required for every Centerville MA 02632 3/29/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25' groundwater feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Topo and water contours map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r u Commonwealth of Massachusetts p Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane Property Address Jim Pellow Owner Owner's Name information isequired or every Centerville MA 02632 3/29/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I L/'UI use onlythe tab 1. Inspector: key to move your f r cursor-do not Matthew Gilfo use the return key. Name of Inspector B&B Excavation , IL�I Company Name 14 Teaberry Lane Company Address Sandwich ... Ma. 02644 6, City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-11-14 Inspector's Sig ture Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to,the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•,3/13 Title 5 Official Inspection Form:�ubsDisposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is Centerville MA 02632 9-11-14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,.will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. Cityrrown 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 breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N . ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is.not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is.less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins,3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,..�� 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in.310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary,Assessments 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. CityTTown State Zip Code Date of Inspection D. System Information Description: 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 ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail 2012 = 556 gpd 2013 = 367 gpd Sump pump? ❑ Yes ® No Last date of occupancy: summer 2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 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 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins 3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron Z 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in.good working order. No sign of leakage. Septic Tank (locate on site plan): 2,6„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon H2O 3„ Sludge depth: t5ins•.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour 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.): At time of inspection septic tank appeared to be in working order. Tees present with no sign of back- up. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date. t5ins-3/13, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane ,• Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts .Title 5 Official. Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 026K 9-11-14 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.): At time of inspection d-box appears to in working order. No sign of deterioration or carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: t5ins.•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 291 Bay Lane Property Address . Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (4) 500 gal ❑ 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.): At time of inspection leaching appears to be in working order. No sign of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 -Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•.3/13. ... Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 291 Bay Lane Property Address Nancy Leghorn ' Owner.. Owner's Name information ie required for_every ,Centerville MA 02632 9-11-14 page. Cityrrown State Zip Code Date of Inspection D System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage:disposal system, including ties to at east-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 0 drawing attached separately O 2 A A14 S '� „ t5ins•.3/13 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,..°' 291 Bay Lane Property Address Nancy Leghorn Owner Owners Name information is required for every Centerville MA 02632 9-11-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >168" 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: 6/9/08 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: Plan on file Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official nspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 291 Bay Lane Property Address Nancy Leghorn Owner Owner's Name information is required for every Centerville MA 02632 9-11-14 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable P# Department of Regulatory Services Cam" : n„arIrASIX r Public Health Division Date `( - u 16 200 Main Street,Hyannis MA 02601 Date Scheduled 5 Time V Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: p 6 LOCATION& GENERAL INFORMATION Location Address , Owner's:Name f::;/ -at1,t `Z►-� }1�C K. 1h..`'>, Address Assessor's Map/Parcel.: 1(1(A j Engineer's Name NEW CONSTRUCTION REPAIR Telephone# -Z Land Use 1Zt%-::. Slopes a Surface Stones O 6 Distances from: Open Water Body 16 0 ft Possible Wet Area )j 1 tl � ft Drinking Water Well Oft Drainage Way o t ft Property Line l 0 1 ft Other ft ^�J SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity'o holes) `='? Af V 1.16 s 14J _j � /40 m Parent mate al(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Fsce Estimated Seasonal High Groundwater G t 1; DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: O& 5 4`L.- Depth Observed standing in obs.hole: _ — _ In. Depth to soil mottles: Depth to weeping from side of obs.hole: in, Groundwater Adjustment fL Index Well# Reading Date: Index Well level Adj.factor— Adj.droundwater LLevel,,,e PERCOLATION TEST. Date('~ Tlme,._� Observation Hole# Z Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ %0;o O Time End Pre-soak 0;t 7.A tt�l�+l»t,0 Nl s U t;L;" �m Rate Min./Inch Site Suitability Assessment: ite Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\S EPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole.# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell Mottling (Structure,Stones,Boulders. o ' to eve!) 0— (o A4 \o . i2. '� NP[ .� o y of 5 0'(a. 4 Z \ 1-0. 3 t31. t:-►1✓J Lao S i� l DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil ther Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. si • o � its t.► �. . �� d, �s. v DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell Mottling (Structure,Stones,Boulders. consistency. . ' 1 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell Mottling (Structure,Stones',Boulders. • o Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No^ Yes.,_ ,r Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervt us material exist in all areas observed throughout the area proposed for the soil absorption system? 1�� If not,what is the depth of naturally occurring pervious material? ,.. Certification I certify that on Is (date)I have passed the soil evaluator examination approved by the Department of Environmental Pr tecdon and that the above analysis was performed.by me consistent with . the required training,expertise 7experience described in 310 CMR 15.017. Signature Date ©L: 0;�.0 b Q:,SBPn0PERCFORM.DOC TOWN'OF BARNSTABLE LOCATION qi SEWAGE# VILLAGE A SESSOR' MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY u LEACHING FACILITY:(type) ,,M1y y.', (size) NO. OF BEDROOMS OWNER iftUY C . PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Nuximum 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 L-aching Facility(if any wetlands exist within 300 feet of leaching:facility). feet FURNISHED BY o q 711 r f. NJ. goo J(9 Fee 160 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpplicatiou for �Ngo5a[ 4§pgtem Cou0tructiou Permit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon.( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 'Z� "Z�!/�tsL ����✓ Owner's Name,Address,and .No. Assessor's Map/Parcel 2 CANTERBURY LANE Installer's Name Address,a.V Tel No Designer's EMT,l MGL;I A TMA1§SACHUSETTS 02536 7/ 9 508/540-2534 Type of Building: P-elrn No.of Bedrooms i' Lot Size ® sq. ft. Garbage Grinder Type of Building (i& No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min. equired) gpd Design flow provided gpd Plan Date ig Qi Number of sheets '�� Revision Date Title L, �-t ,� � Size of Septic Tank Type of S.A.S. 00 13 mu Description of Soil _ o � � O � Nature of Repairs or Alterations(Answer when applicable) A �.U Q j N Date last inspected: < j Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in �W' U< accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of t— Compliance has been issued by this Board He It _... 1f �W Signed Date Application Approved by _ Date Application Disapproved by: Date for the following reasons p 1 d Permit No. �Ul�p 76 Date Issued 9 •r i t,��"..,s� R .» _. 44 3 OU, ! f . . t y Fee THE.C.OMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OrBARNSTABLE, MASSACHUSETTS Yes F . ZIPPfication for �Mpbo al 4p!Aeln"Conttruction Verluit Application for a Permit to Construct( ) Repair( .Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 'L C✓1` f,�� s Owner's Name,Address;and Te.No. Assessor's Map/Parcel - ' MV Iu' r"' L-Vs. C.,)aO t8 I (1� Installer's Name,,Address,a/n^d,T,el.No. gy—' Desi ner' 2 CAN���j RYILANE I ` �� �O // / W��"/ ��F ��t�A��3ChHUSETTS 02536 /� "`. Type of Building: DWe g No.of Bedrooms �d Lot Size �� sq.ft. Garbage Grinder r , ' �O'fhe—r Type of Building �{.� / No.of Persons Showers( ) Cafeteria( " ) -Other Fixtures Design Flow(mina equired) ` !� gpd Design flow provided �� gpd Plan Date T _ , el Number of sheets •+J _ Revision Date • t 4 " Title S.tie le 6 1 : _ Size of Septic Tank ( a p ! Type of S.A.S. 4,„� t_���;,,`,r, _4- Description of Soil . v \ t.des. / `�,�1� t��e 1- - r Nature of Repairs or Alterations(Answer when applicable) Date last inspected: S , Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on site sewage disposal•systern 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 Health, Sig ned — ••— �� Date Application�Approved by y—�1, � if Date �, olr�1� ' 4 Application Disapproved by:' Date for the'following reasons f Permit No. 4 no -' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS _��-•` � (Certificate of (Compliance > , r THIS IS TO CERTIFY,that the On-site �Sewa/ge�Disposal System Constructed ( ) Repaired (�)�. Upgraded ( ) :• Abandoned( )by /30/ / /7' ( �L�l=S�L at q / / IY t / /�y,,�p has been constructed in accordance d 1 with the provisions of Title/and t7 fo'r'Disposal System Construction Permit No. OD&' 369' dated 9�^1'0 - Installer Designer 1 r >k #bedrooms S Approved design flow � �� I gpd The issuance of this permit shall-not be construed as a guarantee that the system will function as designed. Date / / Inspect r 11/0/4 — ----(L—45:� ,��c !EDL J(/ -------- �,Y^4.......�,.., ys+..,�.;c.;7.��..:t it.—....a.. ,+. ,nsar....z.....'•:A....-.�............... �....�A`. ..R+:._,r�...... .. ....r.—�.r:.S_.�. ..w,+�'...::s^....r`�i..:.gda,'��,, )_..y........e..... .. No. 00 7('! Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS mi!5po.5al '4pgtem congtructioll permit Permission is hereby granted to Construct ( ) Repair ( V J Upgrade ( ) Abandon ( ) System-located at 70Y A-2 I/ Az A9 1 and as described in the above ApplicationXfbr Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following'local provisions or specialconditions. f Provided: Construction be be,completed within three years of the date of this permit. Approved by SEP-03-2013 10:03 From:BORTOLOTTI CONST 52e4289399 To:15087906304 P.1/1 Town of Barnsta' ble Regulatory Services Thomas F. Geller,Director MAR& Public Heatth Division Thomas NICKean,Director 2.06 Main Street,11yantils,MA 02601 Offl= $08-862.4644 Fox. 508-790-6304 installer.&Designer Certillcation Form Date: Ig Ll_=vtt Sewage permit# ;?C;O*- 3`Assessor's MapkParcel A 4o to Designer: 4gtPRENi,i�QIL.��"�tTEsinstaller. <S,>ZC�20dfzt� Ce2p$�-' 42 CAN7ERSURY LANE Address: EAST FALMOUTH,MASSACHuserm o2me Addresk GOV640-2634 on , 2 194 � as issued a permit to instnll a date) (Iffft septic system at based on a design drawn by (add(=) L dated I(dmgnory O?e rtify that the septic System referenced above was installed substantially according to design, which may include minor approved.changes such as lateral relocation of the ribution bok and/or septic tank-- giiipout (if required) was inspected and the soils were found satisfactory, I certify that the septic system referenced above was installed with major changes (i& greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&- Loco]Regulations, Plan revision or certified as-bya est er to follow, Stripout(if.required)was inspected and the soils were f satisfactory A, A F (I . C2 PAIRNIENY 1 mstaller's AfurE) 026 a i b0o'_E a 14 #3'UQ IST ilmature (A—Tix-Ng ere PLEA$E REIVIIN TO '13AANSTABLE PUB4LC 1 DWISIQII M AL;Q CE !QATr W ,H :� ; RT COLIA WU T NCE L NO _K Rg-ISS.U�_-ED UNTIL BQ]M. TH _WILT CARD ARE RECEIVED BY THE J3AANSTABLE-PIUBLICM,ALTH DIVURION- nj�mxou' QA6cp46Dcdignrr Cmificafion Form ftey 03-09-06.doc TOWN OF BARNSTABLE c I 9A AM, SEWAGE # '4IsLAGE__Dy1 M114 ASSESSOR'S MAP & LOT TN.'TALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �2S.iprivv) - LEACHING FACIL=: (type) (size) NO.OF BEDROOMS I BULDER OR OWNER ��t L S CX1 M t•�� PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Tr1 S a e -� For QA`k r dvGc�rowo\ �n:^ coV443 -M O�' P S GfAZL I z McKean, Thomas From: McKean, Thomas Sent: Friday, July 01, 2005 3:42 PM To: Wallace, Amy; Agostinelli, Joan; Daley, Jim; Desmarais, Donald; Kelleher, Maureen; McKean, Thomas; Miorandi, Donna; Saad, Dale; Stanton, David Subject: 291 Bay Lane/Septic Inspection Report The septic inspection recently completed at the above referenced address was marked "Needs Further Evaluation" by James Ford. I determined that is should be"FAILED." The cesspool is located within 25 feet of Bumps River. The real estate agent and potential buyer were notified today. i C K 1 , r /.7C COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL-AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TABLE F '! lQP TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 291 Bay Lane Centerville, MA 02632 Owner's Name: Eric Schmidt Owner's Address: Date of Inspection: June 10, 2005 Name of Inspector: (Please.Print) Janes M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT - ��)(Jog I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes ✓ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 12, 2005 The system inspector shall sub i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing.this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 291 Bay Lane Centerville, MA Owner: Eric Schmidt Date of Inspection: June 10, 2005 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 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) I Property Address: 291 Bay Lane Centerville, MA Owner: Eric Schmidt Date of Inspection: June 10, 2005 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: 291 Bay Lane Centerville, AM Owner: Eric Schmidt Date of Inspection: -June 10, 2005 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: 291 Bay Lane _ Centerville. MA Owner: Eric Schmidt Date of Inspection: June 10, 2005 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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 291 Bay Lane Centerville, MA Owner: Eric Schmidt Date of Inspection: June 10, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n1a Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no):. n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Yes 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: Original-date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 291 Bay Lane Centerville, MA Owner: Eric Schmidt Date of Inspection: June 10, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank) Depth below grade: Cover to grade 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: 5'W x 5'T x 8'bottom to Prade Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle: -- 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: 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.): The cesspool was dry. The steel cover was to grade. The cesspool was within 25' rom the edge of the bank on the salt marsh on Bumps River. Further evaluation by the Board of Health is required 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.): 1 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 291 Bay Lane Centerville, MA Owner: Eric Schmidt Date of Inspection: June 10, 2005 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: Qallons Design Flow: eallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 291 Be Lane Centerville, MA Owner: Eric Schmidt Date of Inspection: June 10, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: ✓ overflow cesspool,number: I Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The cesspool was 5'W x 5'T x 8'bottom to grade and was dry. The steel cover was to grade. Also the cesspool is withi 25' from the edge of the bank ofBumps River. Further evaluation by the Board of Health is required CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 291 Be Lane Centerville, MA Owner: Eric Schmidt Date of Inspection: June 10, 2005 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. NAT , CIA^n sln�,ll Co�trs Tt, � oPcn,�►C GfAZL ) 10 i Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 291 Bay Lane Centerville, MA Owner: Eric Schmidt Date of Inspection: June 10, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: ✓ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The site has a high elevation and Bumps River is approximately 15'lower in elevation than the bottom of the cesspools This report has been prepared and the system inspected and found to be in need of further evaluation as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 A tcs H01111cation Fctin , Sa Asbestos Abatement Description �t�¢ 3rr� 1. Facility location: � � SCI�,-n l d f......... ...................................: :-` ].............. ..�� ...... -__-- --.... -._......_..._._.._......_.._........... INSTRUCTIONS AD"' - - - n n - - . � � . � b3.? 1.Aaseoforvolhis __. .. F .. rrrrlar form rna be completed . h 01d,r to comply with ( Q' / ............._...-........... hDersrlmadtl Wkra.abae balm?keft Am./.oft r—..room Em4eAmeNtl hdscilen na6Tdnn 2. Is the facility occupied? Yee O No rrluienrits e1�tO Csdl 7AS(breavls+pdrys pier Fdrauen is3. Asbestos Conlradot: rsp,:aldaoy5eet NewErl1_GnG�St,rFA('?_.(_Y ! Z.{er�Gn�Q,. tLP ?(1_.t�4lhin� lSfrlrQ+ prrod:and IV -- J ......_.. . ._. DaysrlmerdelWar /6a+ er industries a-l8Q `,l`] 337-?-II nWTdbn emeis -._L.Y.f Afro—):IC..I._...._........_.........!..1..1.!..A......... .:.................. .................1......... ....Y......!... elMCLIRS.12 (I" dty/!am e;"p-lanob betkn b ry [ rip.'ke CIAAr (:> ....0 1v.�. .v ........................................................................................................ ......._. .► ,» . , goffeypv dp-� OUlk*W/ cwtre nr+f/.ee rare or spins 64 4. On-Sfie Project Supervlsor/Foreman: G O Q 2.Srbnl Dleiaal Form t e,' l� .L l._A. . 1.._._... ............................. ...._.:............................_........ ................. .—_�-- T r. war al G lakseon/ Cemseneslth of Usssasaaselts S. .Project Monitor 1135estr+s pro" C ��j n I.CJ.1I00e7 ........................................................................_--__�.-- testes.llAQllti- AWN any 6. Asbestos Analytical S.The lam maybe n ll ��U LG�I�9 n _.. tied br ndByinp .......�...................... ......... US.EmOra r" at ?pore a►amaanon/ hobr0onApsxyFt"W ( Ib��enddale�J�7epecHleworkhoure(Mon.frl.) C�uU-LU(Sat.Sun.) laimbdosdemol1w 7. Project staddaleJJ_ "m4cn apaatbro xlled b NESttAPS(t0 9. What type of project Is this? (circle one): eemoeron nwk qem oeM1 f"�i°'1 CFR Sul&1q. 9. Describe the asbestos abatement procedures to be used (circle): obrrdp edxw lcecodaf—r dwop •rpahfbs atrpadavy oerr(upbNl 10. Is the job being conducted 1�,Indoors O culdoors? ix If. Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear ft.) or olh�r � surf (square ft.) to be removed,enclosed or encapsulated: G s linear/spuarefeet bads;br'6&V,clxt IV*xrfla'eafirps..1�_ Owmsl,solMcaepbeImulalion...... mvpalda6leedpapspbeWstlon....iNU/_ hwfalh11comed.................. spot`W&WOO&V....................._/ rovilrr'ayercoafings.............. —J dolts.eme,Wics.....................—J ►a s/k bard,wan bawd............._J oft(ph=cesarrb)................... !2. Describe the decontamination system(s)to be used: ........... -V.C.-rd- ._........._..._..................... -----........................._......._................:................................................................................................... 13. Describe the eontalnerlrallon/dispout methods to comply with 310 CMR 7.15 and 453 CMR 6A4(2)(g): -. •.: •; .»...6...m�.a_._..1.cab.IkJ.e�__..bn�.S.__.___..._._._� .......__............................................................................................._..........................................__.............. 14. For Emergency Asbestos Abatement operations,the DEP and DLI officials who evaluated the emergency: .... .................................... .............................................................................................._..........__._...._......__.. lrenr d q/dHf ?prredtr!(Xkrel lap :............................ ............................................................._..._...._................................... _ de dAdMealbs Wa'rer/ 45: Do prevailing wage rates apply as per M.G.L.e.149,§26,27.or 27A-Flo this project? O Yes No Facility Description 'l 1. Current or prior use of facility: .. . . ..._.........................._....................... _.....-.__.._.. 2. Is the facility owner-occupled residential with 4 units or less? J%es ❑ No 3. Facility Owner. tidt...... ..................................................._................................................._....... ........._............................;:.._....._...........__..__.,_ 4. Facility's Owner's On--SSlto Manager nage ......_......_...............,�,1.t-T........................................ ��................................................................................................._..._...._._._. ..........................._.._..................................................................--._...._— -- 5. General Contractor. _.. _...._._ __.. ............................................... _..........._._....__ Nan. Address py/rorm Zb . conmrf"Worbrs comp.fnsunr r��KK Polq/ Esp.O.n SV� 6. What Is the rise of the the lacllily7 (sq (f of Iloort) Asbestos Transportation and Disposal 1. Transporter of asbestos-containing waste material from she to temporary,storage site(fl necessary)to final disposal she: ..._N ._..m....0......un.P................. 5a.....WG f x)....., firee�. _ ...v11..e .na.cV.:I ...........,m/�. ..a' -�.. ......:..... ►er4ftm .-.. 3.........-°�......7...._ 2.- Transporter of asbestos-containing waste material Irom removal/temporary storage silo to final disposal site: r inch_ Stf �.....-....... 9........e��4.1 ....__..__. _....._.. ......Po t1 a.n. ..................0 1. ..........Q..b y...�.Q............ 3..'.3 N.�..-0 6 b7 Note:Transfer �011 �700�r rd Stations must 3. Refuse transfer station and owner(II applicable): comply wrih the sord Waste - Dnislon►egvls —.---.—.—__. Afto Bons 310 CAfq 18.00 ..... ................._................................ ................................................_.........................__._................ _._.__�._ Cy/Tore 10mar refe0m. 4. Mal Disposal Site: h oral e-i Lf�f1d� or S tom. A i l e r ----- W =--S1.._.._....................._...._. : \ (A(el view Dave, Cl.1.Zab.C: ............P .......16037............................ ............:.............._t-�01SG p� t P� 5q3� pyAaw Itomd, rNepdorr - Certlficallon The undersigned hereby states,under the penafliss of perjury,that he/she has read the Commonwealth of Massachusetts Regulations for the Removal.Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15.and that the information contained in this notification Is true and correct to the bell of his/her knowledge d bellef. _..__.._._j �nn.................:� .............A........ .rd nsfurt RrY.. . ... ...._......................._........._call.!.....:......'.: f1MMmn Note:Contractor must spn this form for DLI natrTialion �1 r • purposes Wo WQShr"Tii� C1k�')...:.��tZW ._. W .... 0)Cv-+�h. .rn� -dalaq ........ y ___... _ _ Fee exempt(City.Town,district,municipal housing authority•owner-occupied residential of lour units or less) yes O no Sticker f(from front of form): CENTERVUE-OSTERY&LE-MARSTONS MILLS FIRE DISTRICT 1875 ROUTE 28 CENTI=_R# ILLE, MA 02632 (500)790-2380/ AX*(5 ) 790-2385 OILIHAZA15 DOUS MATERIAL. RELEASE FORM F,A.# EA-0,86 F LOCATION: DATE(IF RELEASE T?1fe mm PRT?I'.'UC,T RfLEASEU' f) iTdYFI— InTT. ES T I-I ATED QUAW ITY: T1s Im-InwK. CORRECTIVE ACTION TAKEN IRY R'ESPONSHKE PAKY: TgnTTv'rvT% PRCIErR AGF'.','LY NOTIFICATIONS: FIRE DEPARTMENT. YES(,, NO( DATE- a 1 /29/QS TIME: 17 L,P-0 NATIONAL REvP+ SE CENTER YES( NO(,C! MATE: TIME: DEPT..OF Elfi/1i21'.1Nt"IENT AL PROTECT ION YES 1 NO( s_� GATE _____�i iNiE OIL_PILL COORDINATOR: `/EE;i F10 DATE: TIFIE:.� T,,i N BOARD OF HEALTH:: 'as.(14 NO( ; D ATE: TIME: TOWN H ARBORM ASTER,: YES( Nam) DATE T la`•`IE:� OTHER AGENCIES: TxAMID "I AWTVi7A R��g' f�FAFig �r ('f53.?' {Ad"�f3ii s.;srare !lI^t' a 3f°3dB 9m TDip(aT3T"ef T wojaM fife Bn'#'Tf9A' f9& d'Oa PE6 I MT FD AVAY Tap.13s`g T YlTf' �fl il?T4k-K4 'V nV C61'TT. YV`AyrA?J f_?A'8"'j0K-- WHINE AT- TOWN FAtTH�W"s TETF_FOR FURTHER FVA.T..T3lR°d IO _ REPORTED Isi` � �,/ ✓ !�r �I�"C� ra#TE: WHITE 0jPY-FIRE DEPARTMENT YELLOW COPY-DIP. PINK COPY-BOARD OF HEALTH C-0-14M FORM *FA TOWN OF BARNSTABLE I LCI'ATION 9A y L SEWAGE# P, e R 1 /G L 'S MAP&LOTAGF INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by J- M A OC '- 5 0/1J 1 \ 0 3 1 � 9 G� `! v v DATE:_ 9J;91.95 PROPERTY ADDRESS: '::291'-Bay. .Lane`. _._ ..Cente' rville,Mass . ' 02632®. ;... On the above date, I Inspected the septic system at the above address. This system .consists of the following: 1 2 8 'x5 ' - block cesspools . (SE Ei�.°EO �► 2. with cast iron rings & covers to grade . 8 1935 Based bn my Ins.naction, I certify the following conditions:1 . This is nota title five- septc' system. Th,.Fp. is• a" sewage_.system that is in proper �io�king Orde9 at the present time. 3•. The cesspools arB less than 1601 frombumps-: river�.;. Approximat�oly '501 Must r'ef(fr to Guides of,reVisions Of title 5 Dated 8W95 105.303 section S. The 'cesspools are not in ground water. At least 61 off the groundw ter. 5IGNATUR!-: Name:_J P Macomber Jr,.. Company:_J•P,Macomber— &_Son-_Inc ; Address: Cente,rvi11e Mass : 02.632 Phone:---548-7-7-S-3338------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY RMown- au nose ,JOSEPN P. MACO�RBER & SON, INC. Tanks-Ce"Pools-Leachfleid= !Jumped & Installed To►an Sewer Connections P.O. Box 66' Centerville MA 02632-0066 773-3338 775-6412 r - r 7 SE A.CE DISPOSAL SYSTEM edt<:or. �Odress Of Property, 291 Bay Lane Centerville ,Mass . owner ' s name 9/8/95 Date of Inspection Margaret Trejiton PART A CV?'CKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. V/ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 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 site was inspected for signs of breakout.. All system components, Zcluding the SAS , have been located on the site. C�eSb�Do�s�. The manholes were uncovered, opened, and the interior of the •sQpt-iQ-=�: 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance '.of SSDS.• SUBSURFACE SEWAGE DISPOSAL BYBTEM 1NBPECT.ION FORM PART B SYSTEM INFORMATION FLAW CONDITIONS*. ' v If residential ,_.:J number of .bedrooms number of current residents garbage grinder, yes or no YeeS- laundry connected to system, yes or no _Yt,A seasonal use, yes or no If nonresidential , calculated flow: Water meter readings, : if available: i9g3��►�;��'i�SS'= �`�PD Last date of occupancy AV GENERAL INFORMATION Pumping record and source of information: Iv MAC6"4 rAV _A& System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: r?uy4 eEz,Oeo.� R� , Type of system _A Septic tank/distribution box/soil-absorption system Single cesspool _L Overflow cesspool _A&_ Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components . Date installed, if known. Source of information: _ __. ...._. h�•P�4�P,� D Sewage odors detected when arriving at the site, yes or no i 9 SUBSURFACE SEWAGE DISPO¢AL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: material o construction: sconcrete metal FRP other(explain) JV dimensions: sludge depth distance from top of-sludge to bottom of outlet tee or baffle 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 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, - recommendations for repairs, etc. ) NONE DISTRIBUTION BOX:_AkAX (locate on site plan) depth of liquid level above outlet invert Comments: .(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into= or out of box, recommendation for repairs, etc.) PUMP CHAMBER: /lgeE (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, • recommendations for maintenance or repairs,etc. ) 1j/t2&L f 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ) PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : '(locate on site plan, if possible; excavation not required, .but may be approximated by non-intrusive methods) If not determined to be present, explain: Type f leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields; number, dimensions overflow cesspool, number 1- ` Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) 9j2 i purrlj4 �VAOI� �. ,. CESSPOOLS (locate on site plan) : number and configuration jaaot g 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) All 14, k"l<✓9ZO- ;,0 Xo k Comments: I (note condition of soil, signs of hydraulic failure, level of ponding, condi io of vegetation, r commendations for main penance or repairs,el p r� �15-414 L0,49. s� I PRI Y: d�{/ji�J1�,. I (locat on site plan) j -materials of construction dimensions depth of solids �( . Comments: (note condition of soil;. signs of. hydraulic failure, level of 'ponding, f condition of vegetation;• recommendations for maintenance or repairs,ete. ) . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION CONTINUED Sketch of sewage disposal system; Includes ties to at least two permanent references landmarks or benchmark i Locate all wells within 100 i f _� ---- 7-- 1 - Depth to grounyl �e ,O 1--- depth groundwater Method of determination or approximation Ii_41 _ G�_--------------- ------------------------------------------------------------------------ ------------------------------------------------------------------- --- ------------------------------------------------------------------------ 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C �) FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of ' determination in all instances. If "not determinedif, explain why not) _AAD, Backup of sewage into f5acility? _ _ Discharge or ponding of effluent to the surface. of the ground or • surface waters? i :_dCQ Static liquid level-' in the distribution box above outlet invert? { 1 Liquid depth in cesspool <6" below invert or available volume< 1 2 day flow? . .1l1fZ. Required pumping 4 times -.or more in the last year? number of times pumped 0 _ V . ' -Mq ? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure• imminent? 1 Is any portion of the SAS, cesspool or privy: . ld below the high groundwater elevation? y Ie 7 within 50 feet of a surface water? -&-d. within 100 feet of a' surface water supply or tributary to a surface water supply? . , 0* within a zone I of a° public well? i within 50 feet of a •bordering vegetated wetland or salt mars4- (cesspools and .privies only, not the SAS) ? within 50 feet of a private water supply well? i j I ::1Lrr1 less than 100 feet but greater than 50 feet from a r supply well with no .acce table water private water has 'been' analyzed to be acce table attachtanalysis? If the well acceptable, copy of well water anal; ,for coliform bacteria, .volatile organic compqunds, ammonia nitrogen- and nitrate nitrogen.; rert:RTnrrfr�rfte: . rs��.r.::r...•.Teer... TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D•- CERTIFICATION �•••T}9�T•:^::fTT.its•:�TTiRtf!HT.:T7(4RtP.TEA'if.T.... •IT.•s1T�T�TPJtT�R�T.3i'T.S�TIRTi'ST7TL77 Rflt :TSI'•I!T'T•1.... .� ,� -TYPE OR PRINT CLEARLY- _ i PROPERTY INSPECTED STREET ADDRESS 291 Bay Lane Centerville .Mass . 026 2 • _ i ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s .NAME . Margaret Trenton j PART D - CERTIFICATION NAME OF INSPECTOR Joseph' P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville ,Mass ,02632 . Street Tort, or City Stat• ZIP COMPANY TELEPHONE ( �nR ) 77�i ���� FAX ( 508 790 1578 rm r e�R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true,. accurate, and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems. Check one: { XXXXX, System PASSED The inspection which 'I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment. as. defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection .which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector Signature Date A_ One copy of this certification must 'be provided to the OWNER, the BUYER (where applicable) and the BOARD OF HEALTH. * If .the inspection FAILED, the owner or"" erator shall u within one year of the date. of the inspection, unless allowed dortrequired, otherwise as provided in 310 CMR 15 . 305 . partd.doc. C:t ,mcnwea^r, cr Mass=%:,.ers Executive Gtfic-m cr Envirc , ,.entc, Department of Environmental Protection ' Water Pollution Ccntrol Tecnnccl Assrstence and Training Sections WlUUuu F.Weld Goy.mar Trudy Cox* Soawry.EOEA Thomas &Powers • k"cortrrroivr 06/12/95 ATTN: Joseph P. Macomber, Jr. Joseph Macomber and San PO Box 66 Centerville, MA 02632- Dear Joseph P. Macomber, Jr. , I am pleased to inform you than you have attended training, met the experience qualifications,, and have passed the Title 5 System Inspector exam, pursuant to 310 CMR 15.340 . The passing grade for the exam was 39/52 or 75% . This is an official notification that you area Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15.340. You will receive a System Inspector certificate at a later date. If you have any futher questions, please write to me at the following address: Kimball Simpson D.E.P. Training Center 150 Route. 2.0 Millbury, MA 01527 Thank you very much for your time and consideration in this matter. .a Sincerely, Kimball T. Simpson, DEP Training C=:-:.-..er Director (2405) Rouu :`n • Millbury, MA c• • FAX 508-755.9253 • f.-,n„n• 508-756-77QI 1 Water . Conservation SAVE Tips . . . ME! I CHEeK FOR LEAKS . Water Loss in Gallons Due to Leaks Leak this Loss Per Day . Loss Per Month Size 120 3,600 360 10,800 • 693 20,790 • 1,200 36,000 1,920 57,600 3,096 92,880 ® .4,296 128,980 ® 6,640 199,200, 6,984 200,520 8;424 252 ,720 .9,888 296,640 1 11,324 339,720 12,720 381,600 14,952 448,560 .3 i 1 r , i l f F, t � � ' �� _-�°-- 66 ��G �. :J,'�._ GENERAL N(1TES: 1 SEPTIC TANK IS PROPOSED 104' FROM TOP OF COASTAL BANK CENTERVILLE S.A.S. IS PROPOSED 110' FROM TOP OF COASTAL BANK -''----- ANY ON—SITE ACTIVITY (PUMP AND/OR FILL) RELATING TO � EXISTING CESSPOOLS SHALL NOT BE DONE WITHOUT BARNSTABLE IL AL AL AL 'L CONSERVATION DEPARTMENT APPROVAL i _ _ SYSTEM COMT ONENTS SHALL BE CAPABLE OF H2O LOADING. scuvDER AL , BREAK OUT EL. 23.07/HORZ. DIST — >50' ear LOCUS AIL, b AL — ` _ - 4 ---24 _ LOC' LJ,S MAC AL ALCID tl o Ak Ill / / /, ASSESSORS MAP 166 PARCEL :59 : _ _._ AL j1 I I1 / / COASTAL —� - OCUS LANE, • CE ' / ° ' AL I 291 BAY NTE'RVILLE , �` ,� �I 11 /1 ' �►III : I �. _ i °s�: _ Extstl Are, , � �` r D�..-- '- � PLAN REF.- 150-143 r k! kl�l ill patty — 3 hi n_ II A c NCERDDEED' PROPOSED !,'Aj�Yy,7 , 2g1 , 150o GALLON O0VERLAY DISTRICT.• 1 / r. ! �". \ p. G # SEPTIC TANK_ _ G pWE�LIN r4 // / 4.5% 'GRADE ExisTlNc AP AND RPOD 4 / / XISTIN PAVED CB / r/ / / I = �` - 1� 1.�` ,, DRIVE N BM: HYD/sPlr�. FND FEMA DATA: ZONE A10 (BFE 11:0) r W } f c EL. 32.06 FIRM PANEL 250001 0016 D TRAM I A l04• ; s �o ; w rn:: 4, DATUM: NGVOf MAP REVISED. -• JULY ,2, 1992 Q SECT ' '�q � �. _ :r i ti� ONE G - 9:4 �` �. J 11 11 T ®. _ 10 p Ifv / � 0• $ COASTAL / _ _ �, 1 a/ ll OF BUFFER Q SHEET 1. OF 2 AL _DGE 01 L� - Se e � S stem lie alr° Plan 1-1 I.NIO 24. II �.::.� / NO-:. �' _j�� .... IP . b ✓ 1" Prepared For.- I D/8 I 1 LOT . A» N �> �, 'PROPOSED . 75,11 Of SF i „ 14' S.A.S. 11 EB 4 PVC CHAMBERS In N88'41'40"W. l: CLEANOUT. , �. k .. 1283' 88u p1 0 t.; FND: AT BEND 28 �� r� 14of- �2� , s Cen ter'V.ill e, Massa ch use t is ` 0 TOP. DEP COASTAL BANK Scale: 1' = 40' Da te: June 9, 2008 W �02% ¢� o TOP T.O.B. COASTAL.BANK Jy �, �� �0. LU I¢ ;� �®00 Prepared By. p�:N J w 15.1% o Df g�� e�' N��� ®® �r,.7 s®®� Stephen J.. Doyle and Associates v qs y Falmouth, ' MA 02536- o�� w , 20.9%.0 4 N c �� Canterbury Lane O 6 w O. N CHRISTI E y SCR rl �; �� �! N. - J g N B 2 C{�is ���� Telephone: 5081540-2534 O 00 .J w I O N ., w 0. J W N w o` FAIRNENY. :. S tiFN : w i r _. i �, FND s STEP, - It J w i i I i �. J . i I No 926 vo _ � o J. ® � �' 'VT.z .1' .Z � �g .�_Z � C w I I I I i i w I i �F <y® - I GOYLE i I I i i i GIST�� Sad I 39.8' ' i i i i SANITAR14� ti G�'C� 9.55 i 13.21 9.76 1 - y ' E^ �A,� o TRANSECT LINE AA SCALE: 1" 20' ®�v NO. DATE DESCRIPTION F/FIN.FLR EL. 29.5' of YS JL E111/JL �PH O 1 ' 1L LJ VI ly IX _ \ o To S. FINISHED GRADE EL. 28.8'f 6 S,, 1/81) TO 1/2" DOUBLE WASHED STONE ® 3" THICK OR GEOTEXTILE. FABRIC 1 Charccohal.Vent 20" RISER 20" FINISHED GRADE EL. 28.5'f 1 FINISHED GRADE EL. 28.4't .: ss' ova Crade I V.EL _Dia. Dia. 24.84 RISER f 8.5' xrsEn 12.83' _ 1 f_ _-'1 (Twv). El. 03.07 OOO OHO - . 10" Min. 14" Min. INV EL a a o m e e e e 20.24 �,.. . INV EL INV EL m o 0 34" ., f — INV EL Min. s. INV EL 22.24 —48" 3 4" 1 1/2"- Below —48" •d o o p• . 24 23. 79 Flow.Line 23.54 Sum .. — 48 48- !4. Liquid Level 48". 23 04 . 02.84 DOUBLE :WASHED STONE 58 6" Stone 42' _ F TR N HES E DISTRIBUTION BOX NUMBER o E c = ON PROPOSED CHAMBER TRENCH NUMBER of UNITS = FOUR PROPOSED 1500 GALLON TANK H2O LOADING - PROPOSED LEACH TRENCH-END VIEW P Tees shall be constructed of.Schedule 40 PVC and shall extend a Bottom of Dee Observation Hole El. 14.5 INSTALL FOUR 500 GALLON UNITS.: minimum' of .8 . above the flow.line of the septic, tank and be on. . . NO GROUND. WATER OR WITH FOUR FEET OF DOUBLE WASHED STONE the :centerline of.the septic tank located directly under the REDOXIMORPHIC FEATURES. OBSERVED AT SIDES AND.ENDS PRECAST REINFORCED CONCRETE DISTR,IBUTION BOX clean out manhole. Install on a level:base The inlet:pipe elevation shall be no less than 2 nor more than 3" a bo ve the::invert: elevation :of.the .outlet pipe,::, Minimum: wall thickness =: 2 . . Septic tank shall be installed.level and true to.grade on a level, Minimum inside dimension . 12" stable base that has .been mechanically compacted and on which Outlet inverts shall be equal to each: other and at 2" minimum below:inlet invert. 6":of crushed stone has been placed to ensure stability and � P�tH OFd9,q The distribution fines from__the distribution box shall all ha ve. SU+ to prevent se ttlinB equal inverts as determined by flooding the: distribution box to ®� �� o y Septic tank: shall have a minimum cover of 9: the height of the distribution line' invert after all lines have ®� or .� ss a� :: cHRIsrINE Two 20 manholes with readily removable impermeable covers been sealed in lace. �L�� ��h; o FAIRNENY of durable material.shall.be rovided with .accessports. �° a'~ .G�sT.E>aFc P Invert adjustments shall be made 10 filling wdth durable and F v Na: 926 fl, The .outlet tee shall be .equipped with gas baffle. �� FN _ _ nondeformable material permanently fastened. to. the line or c gCEPH- � reconstructinghe lines verts al elevation. - ST t until all � are of equal Y1 E GENERAL. CONSTRUCTION NOTES SANITR� 1. A11 the workmanshi and ma aerials shall conform to L?E.P Title 5 Design Da ta: and the Town of Barnstable rules and regulations for the subsurface Five Bedroom. = 5 X 110 gpd = 550 gpd Required Flo w ®v disposal of se wage. n p 2. Access ports over. tank tees shall be accessible No: Garbage Disposal Allowed g Use: Chambe Trench 42L x 12 83 W x 2 Eff/Depth within 6" of finish grade.... ' SHEET 2 OF 2 3 All components of the sanitary system. shall be capa ble of f 42' + 12.83 + 12.83 x 2.0 = 219 sf withstanding H--10 loading unless they are under or within 10 ft l I sewage : Sys tet Re pa Plan of:.drives or parking H-,20 loading shall be used under or. vdthan 42' x 12 Et3 = 538 sf Prepared For. 10 ft of drives or parkin unless noted. Plastic a uals_ may be 757 x 0, r4 560 GPD Total Design Flow used in lieu of all recast units. P '& 01 13� � L�.�T_ 4. . The excavator/contractor shall call dig safe and verify the location of all site utilities prior to any excavation, and shall be responsible SOIL DATA: In for all matters relating::to electric easements. TEST DATE: 06-05-08 SOIL EVALUATOR: S. DOYLE Cen t er v ll e, Massa ch use t is 5. Sewer pipes shall be : 4 Schedule 40 PVC laid at a min. 0.02 slope. WITNESSED BY: DONNA MIORANDI F 6. Any masonry units used to bring covers to grade shall be mortared in place: TP#1/ TP#2 . June PERC <2, M INCH PERC <2 M/INCH a 9, .20 Scale: As Shown Date: n 08 7 Finish grade shall have a minimum :slope of 0.02 ft per foot. EL. 2a;5' „ EL. 28.5 „ _ a O Prepared By.. 8 Existing. :system components -if an shall be abandoned g 3's P y- "A" 1ovRI13/2 "A" 1orR 3/2 „ Stephen J Doyle and Associates p q P s Ls s 42 Canterbury Lane, E. Falmouth, MA 02536 IOYR!5/S "BW" 10YR 5/8 9.e The t excavator/contractor shall be res onsible to contact L�„ 28" EL.26.17 28" Telephone: 5081540-2534 BW tOYR Doyle Associates 24 hours prior to any required inspections $ ® �� 10. All components shall be marked with magnetic tape or "c" FINE "C" FiyE = PERC comparable means in order to locate them once buried. SAND sAn10 48" 11. Should water service :lines be located closer than:. ten feet from 2.5Y's/4 2.sY s/4 EL. 14.5'I_168„ EL. 14.5' 166" sewage components, service lines shal be set in ,PVC and pressure tested NO GA/ ATER OR NO %/ ATER OR NO. DATE DESCRIPTION REDOXIMOf�PNIC FEATURES REQOXIMORPHIC FEATURES