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HomeMy WebLinkAbout0004 BEE LANE - Health 4 Bee Lane Centerville A 248 019 I i III�__ff 2J�RECYC(EpCo� UPC 12534 NO2- 153LOR HA$TINGS,MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4.•Y 4 Bee Lane Property Addressti Terri Plifka ` Owner Owner's Name information is ' required for every Centerville I/ MA 02632 05/28/2019 page. City/Town State Zip Code Date of Inspection 711 r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Informationj� �3g on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. Rivers End Road Co � Company Address Teaticket Ma. 02536 Citylrown State Zip Code ,ten 508-280-3356 S13938 Telephone Number License Number B. Certification k I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails I spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,1? Title 5 Official Inspection Form �- 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ 4 Bee Lane Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. City/Town State Zip Code Date of Inspection. C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom house has a H-20 1500 gallon septic tank and a H-20 D-Box feeding into a 55' leaching trench. At the time of inspection the leaching was dry and there were no visible signs of past hydraulic failure. 2) 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): r t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts ►p Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Bee Lane Property Address Terri Plifka Owner Owner's Name information is Centerville MA 02632 05/28/2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The ' system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑. obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form ii; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 Bee Lane Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 ii i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 4 Bee Lane Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h 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. El ® 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 water supply 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 2000 gpd- 10,000 gpd. The system fails. I have determined that one or more of the above failure ❑ ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form + <ii� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Bee Lane Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ 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? El 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ........ 4 Bee Lane Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual). 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: I I Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: occupied i Date i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Bee Lane u- Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: i Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No I If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No t Water meter readings, if available: ; Last date of occupancy/use: Date Other(describe below): { i 3. 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? I Reason for pumping: ,i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �n -, 1p Title 5 Official Inspection Form I l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. /j 4 Bee Lane u— Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: I' R ® Septic tank, distribution box, soil absorption system l ❑ Single cesspool ❑ Overflow cesspool ❑ Privy I ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: I ❑ cast iron ®40 PVC ❑ other(explain): I I i Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Bee Lane u� Property Address Terri Plifka Owner Owner's Name information is Centerville MA 02632 05/28/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 23 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i I I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: standard H-20 1500 gallon Sludge depth: 4 Distance from top of sludge to bottom of outlet tee or baffle 3211I Scum thickness 2" 4" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a miant. plan based on the future use of the home. t5insp;doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i Commonwealth of Massachusetts w Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments j ..............h /j 4 Bee Lane V Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): l Dimensions: I 1 Scum thickness I Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle ; Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: j I - I Material of construction: 1 ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �n ,e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments { �� 4 Bee Lane V� Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) i. is Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No i Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I i' I , i Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0„ Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any ; evidence of leakage into or out of box, etc.): , At the time of the inspection there were no vis$ble signs of past hydraulic failure. i I i ii t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f� r i I Commonwealth of Massachusetts Title 5 Official Inspection Form - .I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . � 4 Bee Lane u Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* ' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I j I, I 1, * If pumps or alarms are not in working order, system is a conditional pass. ,I 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: �i Type. ❑ leaching pits number: ❑ leaching chambers number: ' ❑ leaching galleries number: ® leaching trenches number, length: 1-55' ❑ leaching fields number, dimensions: i f I ' ❑ overflow cesspool number: a ❑ innovative/alternative system j� Type/name of technology: . t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts { Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Bee Lane ! Property Address Terri Plifka Owner Owner's Name information is Centerville MA 02632 05/28/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): � � At the time of the inspection there were no visible signs of past hydraulic failure. - {i t 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert P �I Depth of solids layer I : Depth of scum layer 1 Dimensions of cesspool } I Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, 1` etc.): �l t + 't �1 { ! i j I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 1 � yIf Commonwealth of Massachusetts �� .. Title 5 Official Inspection Form pie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f ', «!% 4 Bee Lane Property Address Terri Plifka Owner Owner's Name information is Centerville MA 02632 05/28/2019 required for every � page. Cityfrown State Zip Code Date of Inspection t D. System Information (cont.) 13. Privy(locate on site plan): i Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, i etc.): 1� i I i .. i �i I�l i i� !la ii i y t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 k I Commonwealth of Massachusetts Title 5 Official Inspection Form 3 F�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 Bee Lane Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference I" 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 i ® drawing attached separately l i t t I ; �L I ,il t I . I � ,l t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I 1UWNUPUA b1ABLls LOCATION SEWAGE# oQs_ �90 VII LAGS �Gs�T' ASSESSOR'S MAP&LOT ` . INSTALLER'S NAME&PHONE N0; [T/J�'7 .e'Cr�OGt�F �9Tm?A7 .SEPTIC TANK CAPACITY 100T4POPO l ''Zo LEACHING FACIIdTY:(type)T�'l�-~ (size),- 'NO.OF BEDROOMS BUILDER OR OWNER �i0 I PERMITDATE `�r1"0. . COMPLIANCE DATE: F I g—03 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 toe 'Ao _ '� i • Commonwealth of Massachusetts } ,/-p Title 5 Official Inspection Form ; 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ��!% 4 Bee Lane V� Property Address Terri Plifka Owner Owner's Name information is required for every Centerville MA 02632 05/28/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: i ® Check Slope j I ® Surface water I ® Check cellar ® Shallow wells i Estimated depth to high ground water: 10 plus feet j feet I I Please indicate all methods used to determine the high ground water elevation: i ❑ Obtained from system design plans on record � rl If checked, date of design plan reviewed: Date t I II ® Observed site (abutting property/observation hole within 150 feet of SAS) I: ❑ Checked with local Board of Health —explain: I in I n ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain.- You must describe how you established the high ground water elevation: augered a hole to 10 feet i I i I . Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r !! 1 11 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I jI u— 4 Bee Lane Property Address Terri Plifka Owner Owner's Name information is Centerville MA 02632 05/28/2019 required for every i page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. � I ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ; ® C. Inspection Summary: i 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached i si For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I fo F I:I i i I i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I '� 13 I TOWN OF BARNSTABLE LOCATION A + SEWAGE# "JII.-LAGS �"�`�✓T° ASSESSOR'S MAP & LOT g;Z"` 9 r INSTALLER'S NAME&PHONE NO. (/ -SEPTIC TANK CAPACITY LEACHING FACIL.=: (size) NO. OF BEDROOMS BUILDER OR OWNER ���� PERMITDATE: COMPLIANCE DATE: S3'�P 03 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 � � � 10 � l 'beck v rA 'No. 3 v ® Fee- THE THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC MEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zfpphratton for Di.5pont 6potem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade�X)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel �v s Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J-IA* L cW19,e`�' ? 7 S 7 07 e.4 via B. ��i!'a��r PYJ .7/,� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 4FeJ' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �3 gallons per day. Calculated daily flow 2'J,C> gallons. Plan Date "9 "o Number of sheets Revision Date Title Size of Septic Tank �So o�9141 -'�'/ao Type of S.A.S. Description of Soil, Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this Board of Health. Si ed Date � v3 Application Approved Oy, Date 6 T9 ) Application Disapproved for the following reasons Permit No. 4NO2 7S Date Issued a14 0 4 r $7 _ 4j No: ^--. t Fee •/ THE COMMONWEALTH OF MASSACHUSETTS ELM in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rpplication for Oigont *p5tem Con!6truction Permit Application for a Permit to Construct( . )Repair( )Upgrade Abandon( ) O Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. l Type of Building: Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( ) Other TI pe of Building OF FJ' No.of Persons Showers( .) Cafeteria( ) Other Fixtures i Design Flow -� gallons per day. Calculated daily flow 2„3;'© gallons. Plan Date 9 " Number of sheets Revision Date Title Size of Septic Tank �S� 94-*' y � Type of S.A.S. 7 Ptt ef--W r .O-69oX Description of Soil r Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued bv=this Board of Health. Date Application Approved by, \ Date 1l`l�� 15 Application Disapproved for the following reasons Permit No. �C�G U Date Issued )14 10 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(x) Abandoned( )by eTi-% Lf257a�C`�ir at �r` Lti . m.•r -�' Ct�•.4-T•- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. -zm3 '390 da-ad 5-- l q"03 Installer fist, Designer 44G1.0 &. The issuance bf permit shall not be construed as a guarantee that the system w IhA�cfj' esig - S Date 1Inspector r •C1 --------------------------------------- No. Qo�� .1 g �� �� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS li5po.5al *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade X Abandon( ) System located at :5;e erez-- and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the dat u of thi pe t. Date: f � lid Approved by OWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP& LOT s "_ 9 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /V"440 LEACHING FACILrrY: (type) (size) NO.OF BEDROOMS_ .' BUILDER OR OWNER �1>. PERMITDATE: COMPLIAN CE DATE: � I03 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 60 3� Eck A 9� - - �... 'tooNJ r 40 V COMMONWEALTH OF MASSACHUSETTS ,; _I ► � EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA 5 ` DEPARTMENT OF ENVIRONMENTAL PROTEC OIL r/ `! ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 1� PtAwrg . 4 � JA N 8 � ... rol%o 1Y4�)DY EXIE �QV, SeoretaFry /• Ofpr�f ,!fir../ ARGEO PAUL CELLUCCI DAVID B��TRUHS Governor °vim Go tttissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART A CERTIFICATION Property Addr : 178 Pine Street,Centerville Name of Owner Virginia & Ken Openshaw Mass Address of owner: 83 Woodstock Ln. Date of Inspection: January 24,2000 Stafford, VA 22554-4721 Name of Inspector:(Please Print) Karl Eklund 1 am a DEP�a ptoved system ins��eecc��oS pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Pruce Scott 5eptic CO. Marring Address: 140 South Street,Unit 11 ,WaItiole,Mass 02081 Telephone Number: 908-668-3134 or 781-784-3644 508-660-8660-Fax CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: XX Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority F811S Inspector's Signature: Date: January 24,2000 The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department offEnvironmental Protection. The original should be sent to ttre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS This system was inspected following the inspection guidelines of Sec. 5 Part A of the Title V Inspection Guidelines. It shows the system is functioning at the present time and has been in the past. This report as defined under sec. 5 part A is not a Warranty or Guarantee of the operation in the future. revised 9/2/98 Pagel of11 i� Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) roWty Address: 178 Pine Street,Centerville Owner: Virginia & Ken Openshaw Date of inspection: January 24,2000 INSPECTION SUMMARY: Check A, A C, or A A. SYSTEM PASSES: XX I have not found any information which indicates that any of the failure conditions described in 310 CMR 1-5.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icoertinued) Property Address: 178 Pine Street,Centerville Owner: Virginia & Ken OPenshaw Date of Inspection: January 24,2000 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less —than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ProWtY Ackkess: 178 Pine Street,Centerville Owner: Virginia & Ken OPenshaw Date of I"sPeC6on` January 24,2000 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facilityor system component-due-to an overloaded or-clogged SAS or-cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. X Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for »coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply -•-•-- the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 178 Pine Street,Centerville Owner: Virginia & Ken Openshaw Date of Inspection` January 24,2000 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No L _ Pumping information was provided by the owner, occupant,or Board of Health. X _ None of the system components have been pumpedifor3at.least two weeks and•the system has been-receiving"armal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n/a As built plans have been obtained and examined. Note if*they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. X _ All system components, excluding the Soil Absorption System, have been located on the site. X _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: /a Existing information. For example, Plan at B.O.H. X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)) X The facility owner(and occupants,if different from owner) were.provided.with infatmatiomon tha.Woper mWntenanr�of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION roperty Address: 178 Pine Street,Centerville Owner: Virginia & Ken OPenshaw Date of Inspection: January 24,2000 FLOW CONDITIONS RESIDENTIAL: Design flow: /-20 g.p.d./bedroom. Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow 220 Number of current residents: 1 Garbage grinder(yes or n�o*n0 Laundry(separate systelnt' (yes n9 0) If yes, separate inspection-required Laundry systEelfh;, acted (yes orl�el' Seasonal useno):ys 1998-100,OOOgallons,1999-74,OOOgallons these amount Water meter lable(last two year's usage(gpd): Sump Pump(Yes o0 were en from a en ervl le/Osterville Water Last date of occupreSently Dept:. COM M ERCIAL/IN DUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: None available System pumped as part of inspection• (yes o no)—yes If yes, volume pumped: 900 ga ftons- Reason for pumping: look for groundwater & Title V requirement for Cesspools TYPE OF SYSTEM Septic tank/distribution box/soil absorption system XX Single cesspool X_ Overflow cesspool —leaCh pit Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and source of information: Unknown Sewage odors detected when arriving at the site: (yes o no) no revised 9/2/98 Page 6ofII i • Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM S PART C SYSTEM INFORMATION(continued) Property Address: 178 Pine street,Centerville Owner: Virginia & Ken Openshaw Dace of Inspection: January 24,2000 BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age.confirmed by Certificate of Compliance_(Yes/No) 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: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structurel-integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 178 Pine Street,Centerville Owner: Virginia & Ken OPenshaw Date of Inspection: January 24 r 2000 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition.of alarm and float switches,etc.) DISTRIBUTION BOX:_ None (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, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 178 Pine Street,Centerville Owner: Virginia & Ken Openshaw Date of Inspection: January 24,2000 SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: One pit 6X6 leaching chambers, number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,.damp soil, condition of vegetation, etc.) Leach pit is empty at time of inspecon Nn Girrns of failure, No signs of pondiM. CESSPOOLS: (locate on site plan) Number and configuration: One Cesspool-2 r X6 r Depth-top of liquid to in1g;invert: 1 Arr Depth of solids layer: 66 Depth of scum layer: Dimensions of cesspool: 2'x6 r Materials of construction: }dock Indication of groundwater: �usc� none Cess wd�p�uuiNe�i��V as part of inspection) No sigm of grumIdwater. No signs of taiiure seen.: system appears at this time. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 112118 Page 9of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) '►operty Address: 178 Pine Street,Centerville Owner: Virginia & Ken Openshaw Date of Inspection: January 24,2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: igclude ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 178 Pine Street,Centerville Owner: Virginia & Ken Openshaw Dace of Inspection: January 24,2000 NRCS Report name Soil Type_ Typical depth to groundwater eater;_than 6-1 2 - it bottom empty. USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater_Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property, observation hole, basement sump etc.) XX Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 LOCATION 1 r L4 SEWAGE PERMIT NO. 1L AGE I N S T A LLEA'S NAME i ADDRESS IUILDEIt OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUEP,��� � 1 �b �� � �,,°� �. a No.....80-J i� Fim... ..5..00........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .......................T..o..wn........OF........Baxnta ble... Appiiration for Uhipaa al Workii Tamitxnrtion ami$ Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: 8..Pie Centerville. � 02632n St...--- .--- ---- .---•------ --•----•--------------------•-•---•-•-----...........------....... Location-Address or Lot No. Walter White Strawberry__Hi],� _R�„__ � t� v ,],��,--NlA_..... 32 ................... - .... ..................................................... Owner Address A & BCesspoolSeryice -- •- -- _. -----------------------------•-•--••••....... isa M Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..........2................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............3.............. Showers — Cafeteria Pa Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter--.--.--.----.-- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water..--.................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...---.................. --------•-------------- ----- -••----------------------•...---------------------------------------------------------------------... .--------------------- 0 Description of Soil.....................................Sand x U -•-----•---•--------•-------•----------•-------------•--------•---•---•--•--•----•------••-...---•---------------------•--•-----•-•-------•--------•....•---------•-----------------•----•-------- W -----•--------------- -----------------------------------•-•--...---------------------------------------------•---------•-•-----...---------------------------•--•---•-------------•----............... U Nature of Repairs or Alterations—Answer when applicable.install.atlon.-of-.a--1-,.0D0--gal lon..I=e-=.east-, .a one--:pa,Qked__1aaah--Bl-t---(cmex:Claw)................•--------•-------------...-------------------------------------------------------------•--...........---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT LE:, y g g p< y of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has n 'sued by e th eal th Sig ......e f . ._.7/18/8-0........... -•-- . ... -- . Date Application Approved BY----- f --- ---- - .. ............................ ------------7/18/8Q.-•-----•--- D ate Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date Permit No..80................................................... Issued_...7M/aQ----------------------------------- Date �1 Fps... ...5..00......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....-•-- _....._..'rows.........OF........Boxastable-...................................................... Appliration for Uiipnlial Works Corm rnrtiun Vanfit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: MA....0262------------ -----••---------•...------.....----•----•--•--•--•-----•----•••--•-•-•----•--•-----•--••••-...---- Location-Address or Lot No. 632 Walter White _ _____________ -Strawberry_--Hi11-.Rd�--C@ntery Ile,...................2 . Owner Address a A & B Cesgpool.Service 128 Bishops-.Terrace-,-._Hy_annis1--M�'-- 02601-- Install er Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.........2................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons........... .............. Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- - - WDesign Flow............................................gallons per person per day. Total daily flow--------------:.............................gallons. WSeptic Tank—Liquid*capacity............gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width------------------_ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No________________•.... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by_________________________________________________________________________ Date..................... :................ Test Pit No. I________:_______minutes per inch Depth of Test Pit____________________ Depth to ground water_______________________. tT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Sand Description of Soil ----------------------------------------------------- x W -----•-•-•-•--- ------------------------------------------------------------- ---------------------------------- ----------------------------------------------------------------------------------•--- UNature of Repairs or Alterations—Answer when applicableinstallatIon...of'__a..l+QO0.'gallari_pre.-Cask. (O erflo?.)_x_______________________________________________________________________________________________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T T p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha en slued by the o oteal h. f Si e _r-.-1!......64. . .... ............. ....MV84-------•-••- D to Application Approved By..... -. -.�'...............•••••-••-- -----••--•-7118�80............ Date Application Disapproved for the following reasons___________________:._ -_.._..-----•-•---••---•-•----•----------•-•-•---• ........................................ -------------------------------------•--••---------•------------------=---------------...._..••----------. \ Date Permit No.807------------------•. ... Issued_..7/..18/80 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................TOM.........OF....... zistable..............................._........•--..._.... Murrfifiratr of Tompliana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired .... -6z X A & B CeSsoolService 128_Bishow Terrace, Hynn 261 - 75by D •_ ,__ - _- S , 0 7 - --- .--- ..)._ Installer at___.._178 -Pine St., Centerville ---- -•----- - --------------------------------- ---------------•----------------- ------ has been installed in accordance with the provisions of TIT r. j of e tate Sanitar odg as described in the application for Disposal Works Construction Permit No_____________"__ ___ dated ..l$1.�___________-___________________ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F1' T105�1TISFACTORY. PC DATE __........ ......... - ..._..... Inspector..... . ... ------••-•--•-•----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................T own.OF..........Barnstable No. $�: : :� FEE........:....00..•-....... Uinpn,oaal Vorkv Tnnitrt ion Vanfit A & � Cess ool Service Permission > hereby granted----•------------- ------�-----•--•----...-------------------------------------------------------------------•----•--------••-•--••-------- to Construct ( ) or Repair � ) an Individual Sewage Disposal System at No....... Pine St., Centerville,- MA 02632 -- Walter White ---------------------------------------------------------•------.......-- Street as shown on the application for Disposal Works Construction Permit':e� o__80.'..: _____ D d_._.71181$Q..................... !f' ------------- ------------- Board of ealth r�T ' --•-• DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS i T_ ASSESSORS MAP : V ,k TEST HOLE L A G S PARCEL : SO I L EVALU�TOR doh FLOOD ZONE: Ir- :` ► I , ► Gh/ > WITNESS : � l.-'1 NOTES: REFERENCE: , DATE: C7 - It --- � PERCOLAT ION RATE: lMl , i 1) The installation shall comply with Title V and Town of Barnstable Board of I Health Regulations. b� TH- I TH-2 2) The installer shall verify the location of utilities, sewer inverts and septic components prior to installation. {1l� 3) All septic piping to be 4 inch Sch 40 PVC at /8"per foot. 4) Existing cesspools to be pumped and backfilled per Title V abandonment procedures. L O C A T I ON M A P L�- ��I �5' 5) This plan is not to be utilized for property line determination nor any other 5 ,# purpose other than the proposed system installation. 5 Y6 . O — 6) All septic components must meet Title V specifications. r ll7o �y 7) All septic components to meet H2O loading. v 8) The property is bounded by property corners and property lines as depicted. 9) The property owner shall review design considerations to approve of total number �5 of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the number of bedrooms. Y SEPTIC SYSTEM DESIGN 3 ;a FLOW tJ 1 1 MATE ✓ BEDROOMS AT ID GAL/DAY/B DROOM GAL/DAY SEPTIC TANK ;GAL/DAY x 2 DAYS - GAL USE I GALLON SEPTIC TANKQ� 0 I L A'BS01�P 1 oN SYSTEM sa vv, *Z io' �►n1, SIDE AREA: Z�c �i5 '4 X Z X Oil __ _ - * BOTTOM AREA: . .. ,.,�, OUT T I .0 SYSTEM S T E! .� rr - M SECTION I N - __ J r 9, , 3 L _ P flo()ec,c, w q OU GALIQ e (n� _�1 W--SEPT I C TANK I .�6 !_ � 6 I ,�. . � S I TE AND SEWAGE PLAN ' LOCATION : . PREPARED FOR : �l 001411 '6� 6 SCALE: ' DAV I D B . MASON, DATE: z DBC ENVIRONMENTAL DESIGNS z EAST SANDWICH . MA DATE HEALTH AGENT ( SOS ) 833- 2 177 W Z I