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HomeMy WebLinkAbout0461 BAY LANE - Health 461 Bay Lane Centerville P A = 187 003008 ' �I No. 4210 1/3 ORA Pendaflexo ;►off 100/ TOWN OF BARNSTABLE LOCATION SEWAGE # '-VILLAGE tX/� /v�� ASSESSOR'S MAP & LOT IT? '0o3 INSTALLER'S NAME&PHONE NO. Lot= "7 SEPTIC TANK CAPACITY aOM H - a 0 LEACHING FACILITY: (type) Ll�OG� 1�G��� (size) 3 X �+s NO. OF BEDROOMS BUILDER OR OWNER 50 n SM+ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi�8 facility) �+ Feet Furnished by T/►Spt,C1T1 Un t'B!C� �rBAT A 15 A Q a � i 19 h6 a a Aa aa(. 3 O 3 3 ��. 57 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `M a 461 Bay Lane Property Address John Williams Owner Owner's Name information is / required for every Centerville ✓ MA 02632 3/18/2016 page. CityfTown 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 A. General Information filling out forms on the computer, L.]' use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Inspector Name of Ins key. P E: Ford Septic Services, LLC r� Company Name P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 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 (31'0.CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Fu qheEvaluation by the Local Approving Authority 3/21/16 Inspe t 's Sign ur Date The ys m insp ctor shall submit a copy of this inspection report to the Approving Authority(Board of He 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:Subsurface Sewage Disposal System-Page 1 of 17 /°off US f ` Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 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 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page.. Cityfrown 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•3/13 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 wM 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. CitylTown 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•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 f Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. Cityfrown 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 4 4 (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 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 461 Bay Lane Property Address John Williams Owner Owner' information is s Name required for every Centerville MA 02632 3/18/2016 page. Cityfrown 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? El 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 �4 M 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. CitylTown State Zi Code P Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: pumped in 2014 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 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. City/Town State Zi Code P Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet ii 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: 4.5 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: 2000 H-20 Sludge depth: 1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. Cityrrown State Zi Code P Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 40 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 19 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 leakage. The outlet cover was 3" below. 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•3/13 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 `M 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 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 9 El polyethylene El other(explain): N/a 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 Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments s ;M 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. City/Town 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.): * 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 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3'x65' ❑ 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.): The leach was dry. There was no sign of failure A camera was used for the inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•3/13 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 wM 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Date of 6 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.): N/a t5ins•3113 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 °M 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. City/Town State Zip Code Date of inspection- D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I 'I O a. 20 ab 02 3 3 Ga t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I ` i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. City/Town State Zi Code P -date-of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20'+ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `M 461 Bay Lane Property Address John Williams Owner Owner's Name information is required for every Centerville MA 02632 3/18/2016 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed E System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file F t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION JAN 0 5 2004 OF BRNSTABLE TITLE 5 T°WH ALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 461 Bay Lane MAP Centerville, MA 02632 Owner's Name: John Smith PARCEL, Owner's Address: 1 LOT Date of Inspection: December 13, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMII 15.000). The system: ✓ Passes Conditionally Passes Needs r her Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: December 16, 2003 The system inspector shall submi 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 P Y P 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 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 461 Bay Lane Centerville, AM Owner: John Smith Date of Inspection: December 13, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 461 Bay Lane Centerville, MA Owner: John Smith Date of Inspection: December 13, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(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: 461 Bay Lane Centerville, MA Owner: John Smith Date of Inspection: December 13, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS, cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] 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: 461 Bay Lane Centerville, MA Owner: John Smith Date of Inspection: December 13, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bafflesor tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 461 Bay Lane Centerville, MA Owner: John Smith Date of Inspection: December 13, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Qvd 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: Never pumped-per owner 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: Installed Nov. 2188-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 461 Bay Lane Centerville, AM Owner: John Smith Date of Inspection: December 13, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 6' 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: 2000 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 10" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs ofleakage. Recommend pumping A riser was installed The outlet cover is 6"below grade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: . Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 461 Bay Lane Centerville, AM Owner: John Smith Date of Inspection: December 13, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. There did not appear to be any signs of failure from the leach field. 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 f Page 9 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 461 Bay Lane Centerville, MA Owner: John Smith Date of Inspection: December 13, 2003 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: 1 -3'Wx 65'L(per as built card) 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 did not appear to be any sifts of failure. Grass covers the system. 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: 461 Bay Lane Centerville, MA Owner: John Smith Date of Inspection: December 13, 2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1'f0/1T� A B f A Q � i s NO a a� a3 °A 3 3 � L57 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 461 Bay Lane Centerville, MA Owner: John Smith Date of Inspection: December 13, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and water contours map, the maps were showing approximately 20'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is 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. Il TOWN OF BARNSTABLE I OCA'rit -°,. ����� I�/ SEWAGE VILLAGE/-? edur /lam ASSESSOR'S MAP & LOi'["� 00 INSTALLER'S NAME & PHONE NO. l SEPTIC TANK CAPACITY *'9;ogr;P LEACHING FACILITY:(type) (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER/-!,b BUILDER OR OWNER �j�ue,•� %=e•4 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: I "2 -� VARIANCE GRANTED: Yes Te------ "- / c V jo s'7 ,I s a_ y: No..k.12�31.... F.Hs....-.. .�...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �g1��v3- �v8 Tw.✓ OF........ ef,?V.S7754.1 .L. Appliration for Uiipntial Works Toustrnrtion ramit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at - .._.. .............. .1.._ .... ._... - �.7'..C--.....---- Location-Address or Lot No, i ..._ '.Mac.................. ... RY....�/Etsl --•--...------•--------------------- 5..►lv�t ........ 01// Owner --.-Address.• O .............. Installer Address Q Type of Building Size Lot----/--3*_77---------Sq. feet V Dwelling—No. of Bedrooms.............f�U/Z.........________.Expansion Attic (il� Garbage Grinder (�) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures --------------------------------------------•- W Design Flow..................................;95 __gallons per person per day. Total daily flow----...................4 ........gallons. 1:4 Septic Tank—Liquid capacity gallons Length_I_l`-n.`L Width..Lo'7'0"__ Dimv4t@r ............. Depth=7--.4. n_. W Dis osal Trench—No......4....... Width.....a44 Total Len th..&S_.._ Total leaching area..Z.')�.S.......sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (K) Dosing tank ( ) aPercolation Test Results Performed by._ --CIA...sJur-v-.3...C"&ullmois.... Date_._11:._z .- 4.............. Test Pit No.i.._._R_...._.minutes per inch Depth of Test Pit---1'4.4_....... Depth to ground water_____________--------------------- Test Pit No. 2._...:7�.....minutes per inch Depth of Test Pit---- .......... Depth to gro r...&.5.............. ................... O Description of Soil_..Asa" 9"-.-1C1'1,�►um_.sss+uA..l?1.tx .sw � v�el_...._-S4 -L `_�-r--FiS .........- �s`r- p tl V h►� ..... 1-1� �'-�.-0._(0��.��9+ _. i3m j 6v'_ O_�. rmah..�u!�g..Su.6s ca�... Z ...STE j IEN.- , ------•---- f�l �` `� _YL11cc�turr�..San,�I--b+lxx `�� Ylstu2 AL L---------------------•-----------------------••------•----•-' . LYN - �.; ' to WILSON- h V Nature of Repairs or Alterations—Answer when applicable_________________________________________. _____-_ tq 302Y6-_ -----_----__. ......................................DESIGNING ENGINEER MUST SUPERVIS .o '�� rro . INSTALLATION AND CERTIFY IN WRITINU Agreement: T �p The undersigned agrees to installT fe Sa O� i e ��J�pt�3 c� Sewnage 1s osa rdance wi h 14 the provisions of TITLE 5 of the State(S ?1'N9��9JO "1Tfe'�ihdersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. �� -: . ...(�.t. -•--------------------- ���� lo F ...... Application Approved By.................. ---• -- k' ' - ............ Date Application Disapproved for the following reasons------------------------------------•-------------------------------------------•-----•-•------•-----........._ ............................................•------------•--•-•-•----------------•--•--------------------...---------------------------------------------------------------- ............................ Dat Permit No----- 4_---L Z 3 $.. Issued ------------•--------- Date No................_..... FxB.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a ... w-�................_....0F......!?..../4f2/tJr ..•�......----------- s Appliraation for Uiipviia l Worse Tomitrnrtinn Vatnit Application is-hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: ........... _......... - ::_.. - - -.... Location Address' or Lot No. 5.4_11J �....�S-du1A ........... ------- /i!Y_,t!,+StAJ�'................................................ O a Owner T� Address y Installer Address , 175r- d Type of Building Size Lot---..___a______ ___ ........Sq. feet U Dwelling—No. of Bedrooms.............�3�:EJ-/g....._.............Expansion Attic �) Garbage Grinder (K) pal Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ..... W Design Flow.................................V.$._•-_gallons per person per day. Total daily flow.................._ 446-•.._.__ � a WSeptic Tank—Liquid capacit 0.gallons Length/ Width` $rarneer..""....... Depth7_._ _.... x Disposal Trench—No. .....4............. Width...3..f'..... Total Length_G�.`�.-.. ......... Total leaching area._�'"�`''---------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (K ) Dosing tank ( ) a Percolation Test Results Performed _. 1 .0 +5----- Date.. N'"�g_-� ............... .. Test Pit No. _______minutes per inch Depth of Test Pit_A4A__........ Depth to ground water.._____--__ Gz, Test Pit No. 2..._-•----_.....minutes per inch Depth of Test Pit----?6.......... Depth to�gky er........................ C>♦' -T?*l . �C.auln 5artci C►i��' OF O Description of Soil_.30 -&_'_T.Q1?ec0iued__ �ttdZ__1!�il4d_ �.3- 4---l------.A_. '---------------•- �. !, • STEPHEN .� V t�l�+ C-•SttrVQ-o• 'PZ--°-4'!a"4t1cc _1+38t+�1-� �i'---, 1�_ fJ+. 4t $ub8oz 1 •-------------- t t• } �• J.------ALL:YN--------- dK-%p,-ri111�c9�u,+a..S �aQ __.ull'ir il------------------------------------- ,; - VV-;-t-sON----- y U Nature of Repairs or Alterations—Answer when applicable_-__----_---_-.--... :� ND_30216. .... ................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage isp accordance with the provisions of"L"L T iE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. !' .f <_--m _Sign =r�c�' .-sl- ......(L........................ •-- ` - ---•-- PP PP y---------- Application Approved B ...l_i 1.. i.....,:� ..�_!a_`_Date �---•- `- ate Application Disapproved for the following reasons:--------•-•---•---•------•---------•---••-------•-•------•---•-•--•-------------.............................. ..................•--•----------•--•---......._.....--------------•-------•------._..._......------....-------------•-•-•----••-•-•----•-•--••-•----••--•-------•-•-------------------------•----------- / Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HE4LT // ..........................................OF..................................................................................... Tprtifirtttr of TuntpfiFanrr THIS IS TO CEf27� Y, That he Inu:vtdual Sewage Disposal System constructed ( ) or Repaired ( ) by -----_- f - __...-------•--------------------------------•-----•------•-••---•-----•--•--- r-r nsttall f,/ !/_C-. at------...= --------------------- 3----------- has been installed in accordance with the provisions of T 1 T 1r,( � - The;,State Sanitary Co�//cue/•--bg�i in the application for Disposal Works Construction Permit No----------------------------------------- dated---..------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................Y.-.k.- ...................................... Inspector.............. ,!L--•-----------------------•---•---.........---•-•-•-•----- THE._COMMONWEALTH OF MASSACHUSETTS BOARD--_OF HELTH f u l ...tom.F......................... No........................ FEE........................ Im topaoFai Worse %Tnnitrnrtion Prrutit Permissionis hereby granted-------- ------------•---••••-••....•. ...•.---••---•-••-••--------•--•-----•••----•••------•---••-•-•-••••---.............•--------------- to Construct ) 9,Re it ( a�n�In�jvidual �P��age gis�posal Sysi�md at No. ----- --- -- ----- / Street ' �! 3 f�+ S�7 t} j (/ as shown on the application r Disposal Works Construction Permit No..................... Dated.._....___.-:....... __ __ ✓.. Board of Health DATE--------- -. . ........................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - ' BAXTER & NYE INC. • Y Registered Lana Surveyors and Civil Engineers 7 Parker Road / Osterville, Massachusetts 02655 / Tel. (617) 428-9131 WILLIAM C.NYE,R.L.S.-President RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering October 3 , 1988 Town of Barnstable Board of Health Town Hall 367 Main ST Hyannis , MA 02601 PE: Septic System Inspection Lot E (86-1238) Bay Lane, Centerville Members of the Board : This letter is to inform you that the septic system was installed at the above noted lot and completed on September 30 , 1988 in substantial compliance with the plans . If you have any questions or _comments , please do not hesitate to call this office. Very truly yours , St phen A. _Wilson , P. E . Baxter & Nye, Inc . SAW/fmj CC : Silva & Silvia-#81143 Vince Bros . I I MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS II SOIL TEST PIT DATA: SEPTIC TANK DETAIL: 2000 Gallons DISTRIBUTION BOX DETAIL: END SECTION REVISIONS INDICATES INDICATES PERC. V_— oesERVEo NOT TO SCALE NOT TO SCALE _'.�\�I 11J No tATE OP,I, TEST GROUNDWATER _ _ S ►�At NOTES: I. SEPTIC TANK SHALL BE STEEL 4. INLET AND OUTLET TEES TO BE CAST IRON, NO. OF OUTLETS: r I!1 .. - f nS I Au1,vSt�v�ie.�t t: t�1 \n/ TP L c7T E TP 4-or TP TP REINFORCED CONCRETE. SCHED. 40 PVC OR CAST-IN-PLACE CONCRETE. TEES I NOTES! GRD. EL. 2 Z GIRD. I. DIST. BOX WITHSTAND D. EL. /,��-` UNLESS UNDER PAVEMENT,, DRIVES OR 16 GRD. EL. GRD. EL. _-. 2. SEPTIC TANK TO WITHSTAND H-10 LOADING TO BE CENTERED UNDER MANHOLE COVER r- -� ---, I GW. EL. � GW. EL. 8 GW. EL. GW. EL. UNLESS UNDER PAVEMENT, DRIVES OR I I in WAYS,WHEREIN H-20 LOADING I I D LOADING I 3' E,ccgGrrvE WOipt7 L D.4 r� ,S' --- "- SHALL APPLY. PRECAST I TRAVELED WAYS WHEREIN H-20 LOADING 11 )S _ I I DIST. I I SHALL APPLY. _ 1 Der�rw BRoI'fN 3. ALL PIPE CONNECTIONS AND CONCRETE MANHOLE COVER —I I-III-II mill-+I - 13RO y SA�l:J y CONSTRUCTION TO BE WATERTIGHT. BROUGHT TO FINISH GRADE j BOX 2. PROVIDE INLET TEE OR BAFFLE WHERE SLOPE OF �3 SANIOV ' SU S SvR `1G)'G INLET PIPE EXCEEDS 0.08 FT./FT. OR IN PUMPED SYSTEM. GENERAL NOTES. - /71 12"PO MIN. L---r�---J 3 OUT OF DIST FT)ED/U/►% - _ __ rovEr+ — _ FIRST TWO FEET OF PIPE SIDE VIEW BOX TO BE LAID LEVEL. I. THIS PLAN IS FOR DESIGN AND + =i1 CONSTRUCTION OF THE SEWAGE PLAN VIEW _ Ifi 5.4N.D PPIP`( SANS r= FILL b LOAM -- 12" MIN. - DISPOSAL FACILITY ONLY. r»/ x a NORMAL WATER LEVEL E ABLE I( n 2. ALL CONSTRUC FION METHODS AND w�GRAvEL w/C,,eAve4 - 1 4• PERF. PVC � � �--2' O F PEASTONE MATERIALS SHALL CONFORM TO MASS. —�` D.E.Q.E. TITLE 5 AND LOCAL BOARD :. PROVIDE —� . , . .-:. ..:.: r•.', INLET TEE `: ( , CAP ENDS OF HEALTH REGULATIONS. WATERTIGHT `• _ _ JOINTS(typ) 1: DOUBLE WASHED k, 3. ALL PIPES LOCATED UNDER PAVEMENT 6L' .I PRECAST I• I 4•-0" MIN. OUTLET f -1 SEE I .. 1 I''. — I SEPTIC I� LIGUIU DEPTH TEE 4" INLET ANOTE 2 ' ,� , I ' STONE, 3/4 A '� - If OR TRAVELED SHALL BE SCHEDULE _ TANK — I 1 �`' - 40 OR EQUAL. I =}Li1 � 1 4r•OUTLET i �� r TO 1- 1/2 � F/art `-Solf4t"' OF Fir I I ' 'L------�� ------- -� W.41774;'" - - - - - - - - - - - - - - - - --� , Tit/5 T6'S T t aft' � o.. ,' . ' ,. . >. '-'�. �� o �; ° �� o.o -BOTTOM ON TY:I=JICAL LEACHING TRENCH 41- � BOTTOM ON LEVEL STABLE BASE O _409. 5A/Vj� il�_ u LEVEL STABLE Fcr k' (IPnuiv D- � ovQ. NOT T O SCALE �I3 i4� s������L „�✓r//v CROSS-SECTION '%�-//- BASE PLAN VIEW CROSS-SECTION VIEW 12 C? DATE: DATE: DATE: DATE: INVERT ELEVATIONS. CONSTRUCTION NOTES: ?e nro V. / tr 2 R M4 V '' `l E4- TEST BY: TEST BY: TEST BY: TEST BY: 4" INVERT AT BUILDING S- R- by/e- �.C/y S. A. W/G Sc%N WITNESSED BY: WITNESSED BY: WITNESSED BY: WITNESSED BY: 4" INVERT AT SEPTIC TANK(in) ?"� ��-- E G I r F0fii,p R GIFi'ode4) N4" INVERT AT SEPTIC TANK(out) - PERC. RATE: PERC. RATE: PERC. RATE: PERC. RATE: 4" INVERT AT DIST. BOX(in) 1L- � Z MIN./INCH 2 MIN./INCH MIN./INCH MIN./INCH 4" INVERT AT DIST. BOX(out) �- MAaC/n� .,,r, /-- � <�R� R��c` Gfio:-siv�-• w.9r�A' E�6v ,Basso oNuSG c',Qcc �'ct�"� �. <: DATUM: R_4s ,E� �-c %`" � � vEy y �,4X j` " ' INVERTS AT LEACHING FACILITY: NyE' , /V INVERT AT BEGINNING VERTICAL DATUM: OF LEACHING TRENCH ?6 .00 INVERT AT END BENCH MARK USED: OF LEACHING TRENCH S7.6 ELEVATION AT BOTTOM OF LEACHING TRENCH CONSTRUCTION NOTES 2 .� ADJUSTED GROUNDWATER ELEV. Z4- OBSERVED GROUNDWATER ELEV. J ,,--`r• 5• Ea 1) Septic system leaching facility setback from wetlands 150 ' Z minimum. (See attached site plan) 2) Septic tanks to be located a minimum of 10 ' from house �r / foundations or retaining walls. OD , 3) Leaching facilities to be located a minimum of 10 ' from «t �• � ,� �' -p property lines and 20 ' from house foundations or retaining ,� -- - �'" P _ walls . �r /� - ' �. � Tn.`S � n DE'ICN CRITERIA: .. 4) Topographic information shown was taken from a plan by _ DESIGN FLOW: Inc . and does not represent an actual survey f _ _ �`-_ - - _ - Baxter and Nye, - �E 9 �'-,` I _T__ BEDROOMS AT G.P.B./D G.P.D. Un the ground by Capp Cod Survey. ` ---- -- - - -- — --- 5) Perimeter compiled From Open Space Subdivision Plan records =+ i ----- - ^-- d ti; in plan book 402 , page 78 at Barnstable County Registry of �; 1r i \y ' r<o �xz�s- ,� � '�` ` (� The BSC Group Deeds. gy G> J �rr7 �..✓tt�-Z r VG1 ���/ \; ..v, \ 7.P, `�-.� ��, REQUIRED SEPTIC TANK: 6) Driveway easement recorded in plan book 420, page 36 . .�, :;3 �, 4'�s ,/ "e;, �' �,• w10 3 4 vv .L .'�`' `. �1v _ -- -- — 'R'n GAL. t. 1 C L� c TNK. , V " 'c ,;9 O/ SEPTIC TANK PROVIDED: GAL. N. Cape Cod Survey Consultants F T ' , S?' SIZE OF LEACHING FACILITY REQUIRED: nj DESIGN PERC. RATE: _ __ MINJINCH 3261 Main Street Route 6A - - _ 71 G E 14z.- = �.�-� I z PI BBarnstableVillageMA -- �(� ace T T ►rn 'p l 02630 S1 t 617 ' j. _ _. '`'' "''� �f �� � PROJECT TITLE: SIZE OF LEACHING FACILITY PROVIDED: -- - F SEWAGE DISPOSAL , r t _ _ �, K 2, SYSTEM DESIGN T p l� SHa:I I N /� Comte/CEO fRo,» A PLAN _ _-3 --- 117 ,� ---- 4Jcy C'fi� t <� � .•' � �• PER/i»ETE" r -- - r P!. AN O r �AN© /N BA JQh/5 TABCE• ------ -_-- - C7 (C'E/✓ TE"�QV/LLE} ,qr.g P2EP.9RF-!� FCR 5/GV/A A T S/C v`/A ASSot.', /r�/C'. OA T�"!.� 3/s�6 3, S c,v�E 5 C•L1QQG�.R L�,� y ,BY C.4i'�"COO ,541h'►i6-Y G'GivSLrL T.ONTS. LOCUS PLAN: L5,41 , , 7WA54., PROFESSIONAL LAND SURVEYOR DATE k `�'/TEr2V14 Z d"� "' WA55. r � 3 Z PREPARED FOR: P �( S/L VIA f S/L V/A 4550c, DF 4, h ;,TEPHr v aE AL i VN si V,"LSOPd SAY r .s DATE. 8 /98 c(v COMP/DESIGN 5_ 19, fa/. PROFESSIONAL ENGINEER-CIVIL DATE CHECK: 5, .0, PRO CENT"�RVI �.4E PLAN VIEW DRAWN: J. ,V C, SCALE: 1 " _ FIELD: FILE NO - ---- DWG. NO. / 1776 SHEET 0 -> FEET JOB NO.3-/29�0". 1 2 / OF /