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HomeMy WebLinkAbout0014 BEE LANE - Health 14 Bee Lane Centerville A= 248-018 KSMEAD®® No.2453LOR UPC 12534 sm c oom • Had*In USA s,WbW mmmn=am IOFIGFII*s+ROMM I f T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Iq �� � - of Property Address /� ✓ �491 V1 oin Owner Owner's Name information is r� 9 required for every page, City/Town State Zip Code Date of specti Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1 Inspector key to move your ` cursor-do not MQ�� p use the return - key. Name of Inspector _ Company Name Company Address, 4 S �IM =L 00�4 4Q Crtyrrown State q Zip Code 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 IDEP approved system inspector pursuant to Sectlon is.'an of Title 5 (310 CMR 16.000). The system: µ Passes ❑ Conditionally Passes r_.., Fails❑ ❑ Needs Further Evaluation by the Local Approving Authority Y.> rM E5 M Inspecto 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 is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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 at1the 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. Khis•11/10 J Tine 5 Official Inspection Form:Subsurface Disposal system•page 1 of 1 Commonwealth of Massachusetts Title 5 Official Ilnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /f/f Owner Owner's Name ,�j l C� ,y information is /� ? W4 ct ?a d 6 / required for every ck�,tA �V F O page. CityrTown State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System P saes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 3110 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 Isystem, 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 fiver 20 years old'or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exMtration 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 Q ND (Explain below): t5ins•,v10 Title s Oftel In spection Form:Subsurface Sevyage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official lnspection Form Subsurface Sewage Disposal Syy tem Form - Not for Voluntary Assessments Al /See I-a tt e- Property Address Owner Owners information is / „N Oa required for every ��% Tom'✓� 66GGG — page CityfTo,� State Zip Code Date o Irspedi bn B. Certification (cost.) 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 remloved ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which reouire 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 sysltem 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 (Sins•f of o rrtle s Official i nspedion Form:Subsurface Savage Disposal System•Page 3 0(f 7 I Commonwealth of Massachusetts Title 5 Official Ilnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is r/Ge✓_ D) required for every 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 aseptic 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 aiseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has ajseptic 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 waterisupply 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" ors"No"to each of the following for all inspections: Yes No Backuplof 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 li�uid level in the distribution box above outlet invert due to an overloaded or clog�ed SAS or cesspool ❑ Liquid depth In cesspool is less than 6° below invert or available volume is less than 1/2 day flow t5ins•11/10 Tale 5 Official insp ection Form:Subsurface SeNape Disposal System•Pape 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal SyMem Fonn Not for Voluntary Assessments Property Address a`P1 4 Owner Owner's Name information is required for every page Cit),ffown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ R// =pipe(s). umping more than 4 times in the last year NOT due to clogged or Dumber of times pumped: ❑ []� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ E9/ *"' 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. ❑ L� 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 thje well water analysis, performed at a DEP certifled iaboratgry, 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 tither failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ElThe 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 t� 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 El ❑ 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 b 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 3110 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5im•11110 Tdie 5 Official Inspection Form:subsurface Senage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /q /JP2 LDI t4-e, Property Address '1114 � Owner Owner's Name information is / 4N l /�q C,;?,6 -z� pia required for every l State Zip Code Date of Inspectionpage. City/Town C. Checklist Check if the following have ben 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 ❑ Q/ Were anyof the system components pumped out in the previous two weeks? Q/ ❑ Has the system received normal flows in the previous two week period? ❑ 2 Have large volumes of water been introduced to the system recently or as part of this inspection? lg' ❑ 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? [K�❑ Were all system components, excluding the SAS, located on site? LJ' ❑ Were thel 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 sizeland 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 approxirtiation of distance is unacceptable) (310 CM 15.302(5)] D. System Information! Residential Flow Conditions: / Number of bedrooms (design: — Number of bedrooms (actual): 1/ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): I tsins•t 1/10 Title 5 Official In spection Forth:Subsurface Sewage Disposal system•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Soem Form Not for Voluntary Assessments / Z0 Property Address eo Nt'► q Owner Owners Name / information is required for every l�Ceo ,wvl 1-11,4 VC;? page. CitylTown State Zip Code Date of Im tion D. System Information, ' Description: .^ /Sc�a Gr' i/apk_dlC �; A � 1`0 P1 p Number of current residents: Does residence have a garbage grinder? ❑ Yes R"No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes U No Seasonal use? ❑ Yes 94-90 Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Cu��'r" Date CommercialAndustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: isins•11110 Title 5 official Inspection Form:subsurface Savage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 official Ihspe'ction Form Subsurface Sewage Disposal System Forth Not for Voluntary Assessments Property Address -- Owner Owners Name J.> �i� O� J� informations C�vf ✓V/ / ;,� /� required for every State Zip Code Date of nspedio page CityrTown D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: /�� DLL✓ Source of information. Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S stem: 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•i 1/10 Title 5 Otkial Inspection Porte:subsurface sewage Disposal system-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sy4tem Form - Not for Voluntary Assessments Property Address Owner owner's Name (.b« )--I L11 information is required for every State Zip Code Date of I rdpection page_ City/ToAn D. System Information (cont.) Approximate age of all components, date installed (if k n)and source of information: a d o Were sewage odors detected when arriving at the site? ElYes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi�40 ❑ cast iron PVC ❑ other(explain): / Distance from private water supply well or suction line: feet /b Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet / Material of construction: �/GS�/ C / ti ❑ concrete ❑ metal ❑fiberglass olye pthylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-11110 Tdfe 5 officid Inspection Form:subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Forth Not for Voluntary Assessments Property Address I Owner Owners Name 6 'L11 information is i required for every State Zip Code Date of Inspection page City/Town D. System Information (cont.) Septic Tank (cont.) 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 le �.t2.vit^� o �► How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 140 i�oh C/ /i0 GV L�cci Y� Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 I� Commonwealth of Massachusetts Titre 5 official Ihspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address � Owner owner's Name Od 6 information is �QH 4"V tom/ required for every 1111 State Zip Code Date of Inspection Page City/Town D. System Information (cunt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): 'Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Tale 5 Official Inspeaion Forth:subsurface Sem9e Disposal Systern•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form U9 /1� 6ee Subsurface Sewage Disposal System Form -Not f/or Voluntary Assessments , Property Address i��i1�r1�)C3fa Owner Owner's Name /f/ information is �2� l�yl ` ✓`"� D 6required for every State Zip Code Da�� te of I coon Page City/Town D. System Information '(cont.) Distribution Box (if present must be opened) (locate on site plan): Z-_V-ek7 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.): ku Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No etc. chamber, condition of pumps and appurtenances, ) Comments (note condition of pump p p Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sege Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Iq �� G—� ✓1 C Property Address Owner Owner's Name/'9 information is l/.�6;�4 required for every page CityfTo,m State Zip Code Date of Ins lion D. System Information (cont.) Type: `L�1/t 7 �/ l�+4 is ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altdmative system Type/name of technology: Comments (note condition of;soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): gvti D1 AIV 1 ✓I S o7"-'�' C Gtlwe-le , Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration - Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11l10 TAIe 5 Official Inspection Form:Subsurface Severe Disposal System•Page 13 of 17 I Commonwealth of Massachusetts 19 Title 5 official Ihsp6cti'on Form 1 - /�, .-- &W.- Z� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . Property Address Owner Owners Name information is required for every State Zip Code Date of Intpection Page CityrFown 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.): Title 5 OtficW Form:Subsu face a Disposal System•Page 14 of 17 I'! rs+es•1v10 nspec�on Sevsg i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owners Name information is - V( required for every l State Zip Code Date of I ion Page Fit 770111`n 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 pu Gc water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately P�GS�IL l W S1Q.ere al v,o 3 t � c ST ` C � � 3 � t t5ins•1 trio TAie 5 OHS Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage disposal System Form Not for Voluntary Assessments "i 9& z__6 Property Address Owner Cwner's Name � information is ` �oZ required for every r411 ��� page Cof'rown State Zip Code Date of I pedion D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow welts Estimated depth to high ground water: 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: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database explain: You must describe how you established the high ground water elevation: 0 k✓! C V—cr, Before filing this Inspectioni Report, please see Report Completeness Checklist on next page. 15ins•11110 Tdle 5 Ofrxial Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of'massachusetts s Title 5 official Inspection Form ants v Subsurface Sewage Disposal System Form - Not for Voluntary Assessor f VL-f-- Property Address o ----- Owner Owners Name �y6 WInsction informationis required for every State Zip Code Date of Page, City/Town E. Report Completeness Checklist UT-I'nspection Summary: A, B, C, D, or E checked 0--inspection Summary D (System Failure Criteria Applicable to All Systems) completed �y m Information — Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file f t5im•11/10 Title 5 official Inspection Forth:subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LorATION ef- �h _ _ SEWAGE #, VMLAOE—Ce-4 rV411 e _, ._ ,A,SSESSOWS ASP fir.LOT—_ S NAME&PHONE NO. S13MC TANS CAPACITY -15 t d„ Gca t �a S Ida l r1 k LEACHING P.A,CILITTY: Xti ; 1 rc S 7 X'b Xl' Separation Distance between the: lvls►xi iirn Adjusted Grauiutlwrtter Table to the Bottom of Izaching pueility Private Water Supply Well and Learliing Pacidity (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetdurid and Uactting Facility(Ix suiy wetlands exist within 300 feet ti tcacaun fur''ile ) Furnished by, ` . I A I a-p- a-c- 4/7 � N b a Commonwealth of Massachusetts Vo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services C= Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 �q City/Town State Zip Code p Cw1 1-508-495-0905 S13971 Telephone Number License Number t , , B. Certification E G_r I certify that I have personally inspected the sewage disposal system at this address and that they' information reported below is true, accurate and complete as of the time of the inspection. Tfie inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant ta'Section:15.340 of Title 5 (310 CMR 15.000).The system: ^p ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-13-08 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 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. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: System is in good working order with no sign of failure. B) System Conditionally Passes: jjr----j ❑ One or more system components as described in the "Conditional Pass"section need to replaced or repaired. The system, upon completion of the replacement or repair, as apED ` 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 t5insp•03/08 Title 6 Official Inspection Form:Subsurtace Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. t5insp-03/08 _ . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 ❑ ® 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. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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.] ❑ 0 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 3.10 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. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 t i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town 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 E ❑ ® 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 CM 15.302(5)] t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection D. System Information 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 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 4 08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date ;s Other(describe): t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bee Ln �M Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: r Source of information: N/A 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): Approximate age of all components, date installed (if known) and source of information: 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12 feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ® polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 Gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 22" 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 14 How were dimensions determined? Tape . t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47H 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every 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.): Poly tank in good condition with baffles in place. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: f. 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5-infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrators in good condition with no sign of back up. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4'M 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. i A �rvn'>r n0 A f D 13' ' G -®- 16-, p r I _ [4 t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Bee Ln Property Address Premier Asset Services Owner Owner's Name information is required for Centerville MA 02632 5-13-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' 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: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: You must describe how you established the high ground water elevation: Original design plans show no water at 12'. t5insp•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 I � a oFt�r� Town of Barnstable o Regulatory Services ..� BAMSTABLE ; Thomas F. Geiler,Director 9� 1639. �•� Public Health Division ATED MP'I A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIC\Disclaimer Private Septic Inspections.DOC T // C TOWN OF BAARNSTABLE LOCATION 7 �/ ��Y// SEWAGE#'OZ VILLAGE C �'rY_T]Fy% L0ASSESSO 'S MAP&PARCEL Z"A,?-6kT INSTALLERS NAME&PHONE NO. �P i SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �-� �57�-��` (size) 37 NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Q �rotJ 41 .7 No. gooC� / 1 � Fee ve, THE COMMONWEALTH OF MASSACHUSETTSEntered in computer:PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppricatiou for �Bigo!gar 6ip9tem Cou5truction Vertu Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) X-complete System ❑Individual Components Location Address or Lot No. V 'ffj5� CJ/��—� 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. ,467 F-,4-(, _�&�i �-, 57 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 -3 • F-0 gpd Plan Date W4 Number of sheets Revision Date Title Cis, l._VV0 ot G�� T �� ✓2 Size of Septic Tank / � Ty e of S.A.S. L Description of Soil Nature of Repairs or Alterations(Answer when applicable) r �C 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 o Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by th4 Boar of Healt . Sig ed Date — Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. l9ct?31 co Date Issued �'L No. .C/��. I `I. K Fee ov THE COMMONWEALTH OF MASSACHUSETTS Entered in compute: -- PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes - ZippYtcatton for �Dtgo!goY �§pztem Con.5tructton Permit Application for a Permit to Construct O Repair O Upgrade Abandon O 75"6omplete System ElIndividual Components Location Address or Lot No. C.1/""�_ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Z�{`�'— O d Instal_er's N e,,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures L, Design Flow(min.required) �7) gpd Design flow provided 3 TO gpd Plan Date �A �f�t D(o Number of sheets Revision Date Title Size of Septic Tank CI mot—' Type of S.A.S. r�f � G`- /L!�—rc-r_�> Description of Soil i Nature of Repairs orAlterations(Answer when applicable) 4, �-V\C U ) A I 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 Vitle 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boaro of Health. /� Sig ned Date �T_hV Application Approved by �r Date 9 Application Disapproved by: Date for the following reasons Permit No. [i C9_1 y — —-___Date Issued 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CE FY that t�je On-si e Sewa e Disposal System Constructed ( ) Repaired ( ) Upgraded t' Abandone ( rl 5J�. at G�{�G- +� �/ / C� has been constructed in accordance ' ^^.�� iL�with the pr�visio s of�Ti��tle 5 �xd the for Disposal System Construction Permit No. Cy//y� dated���_. Installer ImbLtm Designer (..I C #bedrooms Approved design flow p gpd The issuance of this permit shall not bb/e1//ccfonstr{ued as a guarantee that the system will function asdes<i�. Date 1.114 )l 0 Inspector --------------------------------------------- No. 1:1•-.� to r� )'—( Fee THE COMMONWEALTH OF MASSACHUSETTS . - PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Miga l *pgtem Con5tructton V'rmtt Permission is hereby granted�t Co( trucct ( ) ) Repair ( ) Uj�gr�ade (./ /) Abandon ( ) System located at 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: ConstruJctionpust be completed within three years of the date of this p rn t> Date �d q/ 6 Approved-by., Town of Barnstable pWE Tqy, Regulatory Services �O Thomas F. Geiler, Director • BARNSTABLE, + 9�A MASS.; � Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Designer: Shay Environmental Services, Inc. Installer: r Address: P.O. Box 627 Address: East Falmouth, MA 02536R$1't.n� T�� On j-Lp -Cato -C was issued a permit to install a (date) (installer)° septic system at t 4 LFw� , l-6;t47t 2.y'r LL,E based on a design drawn by (address) ShU Environmental Services, Inc. dated "5= (o- (designer) VI certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. F I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. � 1�1 OF MgsS,9 _ C CARMEN ( nstaller ) E. S{-IAY No. 1181 0 � GIs e?- SP Designer's Signature (Affix Desi p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM hereby certify that the engineered plan signed by me dated S-4'0C.o concerning the property located at A EE L(4aE meets all of the following criteria: • . This failed.system is connected to a residential dwelling only..There.are no.commercial or business uses.associated with the.dwelling. • The soil is.classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or.may conduct deep test holes and percolation tests.at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) Z . C) B) G.W. Elevation +adjustment for high G.W. DIFFERENCE BETWEEN A and B SIGNFD : 9 q DATE: 5- 4-a(, NOTICE Based upon the above information; a repair permit will be issued for bedrooms maximum.. No additional bedrooms:are authorized in the future without engineered septic system plans. �z C L q ASepdc\perc"emp.doc Zx8 ASPwAtt 30 yR , �sre:S i x g Facsw P,P, PJeE I Nil SoFFbr oC I(o o.c- — STticGo P Tc1�L W►4 L{. W u.S PfrASA1 T 14 ocr, l,ANri GKA/(rvitvbl,t.� (/h fa b tk Block CtJNW4t£ VALL H� coNc�grE G R►� �} g TOWN OF BARNSTABLE LOCATION _I7 �'� (/�/U.- SEWAGE # VIIIAGE CtQj11GfVJ ASSESSOR'S MAP & LOT9YF' DJ!? INSTALLER'S NAME&PHONE NO. L.or,—' _-SEPTIC TANK CAPACITY CQ►S►s(�Gt?L LEACHING FACILn Y: (type) (VA P1 (size) !CW .NO. OF BEDROOMS BUILDER OR OWNER T)/AAII t- tJ Q y r ERMITDATE: 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 g facility) Feet Furnished by �/►�/24(. �dr a {� . Q,,, • ' � � I 3�,5 a`d L3 1�,'"Z P� � �r �T - a w �� 4.. s ulpCOMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED AUG 2 8 Z003 TOWN OF BARNSTABLE TITLES HEALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 14 Bee Lane Centerville, M4 02632 Owner's Name: Dianne Doherty Owner's Address: Date of Inspection: August 12, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map:248 Osterville,MA 02655-0049 Parcel. 018 Telephone Number: (508) 862-9400 Lot: 1 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Co itionally Passes N Further Evaluation by the Local Approving Authority Fa is Inspector's Signature: Date: August 16, 2003 The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I I - Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Bee Lane Centerville, MA Owner: Dianne Doherty Date of Inspection: August 12, 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 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Bee Lane Centerville, kM Owner: Dianne Doherty Date of Inspection: August 12, 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 I 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Bee Lane Centerville, MA Owner: Dianne Doherty Date of Inspection: August 12, 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 '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the 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 I of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes tithe 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: 14 Bee Lane Centerville, MA Owner: Dianne Doherty Date of Inspection: August 12, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 Bee Lane Centerville, MA Owner: Dianne Doherty Date of Inspection: August 12, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 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): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Pumped in 2002-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: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Bee Lane Centerville, MA Owner: Dianne Doherty Date of Inspection: August 12, 2003 BUELDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as septic tank) Depth below grade: Cover to,grade Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: S'W x S'T x 8'bottom to grade Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 4" Distance from top of cum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle: -- How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The liquid level was up to the outlet tee. The cover was to grade. Recommend pumping every year for maintenance. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass __polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Bee Lane Centerville, MA Owner: Dianne Doherty Date of Inspection: August 12, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Bee Lane Centerville, A14 Owner: Dianne Doherty Date of Inspection: August 12, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 - 6'x 6'(1000QaQ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit had 4'of water on the bottom. The scum line was 4'6"up from the bottom. The cover was 1 S"below grade. There were no signs of failure. Laundry is piped to the leach pit and needs to be re-piped to the cesspool. Soap scum should not enter the leach field. 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: 14 Bee Lane Centerville, MA Owner: Dianne Doherty Date of Inspection: Augmt 12, 2003 Map:248 Parcel: 018 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 1 Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A � 3aS ao 6 1� a w i • Page I 1 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Bee Lane Centerville, MA Owner: Dianne Doherty Date of Inspection: August 12, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +1- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: 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 most describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately 25'+/-to groundwater 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. li TOWN OF BARNSTABLE LOCATION 4 N SEWAGE # VILLAGE C �N T ASSESSOR'S MAP & LOT 0 !F IIQ*!a5 NAME&PHONE NO. �� �� r SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) No. OF BEDROOMS .. . BUILDER OR OWNER • j N5p£c �sr ©„®� =PERMIT DATE: DATE: 4st d Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . ;, - ��. i3-s , . _ 3��3., � � f.� O ���. �N MEN] .._.... ;._,. .,._._;. _...,. �.�-�9:.ah�.5vs�o — l- 5 I - - - - -- - -a- --- -- Li I � m 0 4 11 ks n ,- 1 . ., T o t����,�"tt���.{.•�• :fin r ~�`ar�Y.ss � �'( ' :. ... ..::�_. '_�.___-E-._�.....h:.,,.c t;;rs,.a�aw.r. _,'h,�si€.4r,,.n ,wi r.�.•>:..•.,d:.:. ._,. __ — - — — — _ „t � ���� t�ro��, ��•-51 r a �P T T T T MOT.�tYJa,.T __.. �e 1TIT � _ ... ....:... _.: ...- _. .-.:.:...__,''Uhl gum ' I I 4'S' r I yFf°7 :4v ,G + T _ , I . 4 I I I I I I— I I 1 I S 4S% 1Y j 1 } 5A 4 - t t- : i _ .... t'' `k�i't":•:. :q Fyn.�y� ; k : ' _ I I — 1 i I ( t 1 _ : 1 s�L`9�'s•a I_ _ T- f y � x _1 z. t2 JJ --- - --- T � 1- . as '. .� t ��rJ try .c w����t��7+�p x�•} : r t -f T � � I I is r _ I f € � ;I — ,I ., ,tx• '2 "t',t;�,.a 9�Y��'`{ �' ,�.. �� I I � I I I I I r�. J� i 1 0 3 k { 1 • • ! y k Y rt1 i Z i � f ` i f { l� F t - t i 4 - tt . S 4' 9 a i�i d r � � I f H c O o z � - I i s i ' - - i i ,. 3 i 1 f _.. _. _. _ i - :. i 1 .6 e � ii� ` S � � `{t (}jk 1 J � � a A 8 g� FF F 1 1' � 0 a � IR _ Z � � P''� I t9 i �I E 1 i �c�aNntn 1 � a 13 So7'/ i N,nred� JSJ71N��rJ� r43t4 O - /fills\ 72 13so1� 5�lnirvdMYlW O 'Tl 0 o. s c �j �q to�� IZZ G7 3 SECTION A -A ALL OUILET PIPES f110N TlE 'NOTE. ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C. DMTRWTM BOX SHALL BE 10' min. from t2' f :. Existing Foundation �hou se to septic tank o-eox .r met e. PROFILE VIEW OF ADDITION TO LEACHING SYSTEM SET taxi FOR AT►�sr 2 caHcaEiE covet �1 �,.: 0o h sch�el s SaPtic tank coven must be 6 in. of finished grade ?r-- z within 8 in. of finished grade 3" of 1/8" - 1/2' Wool Peostort K�ou1lET '" T.O.F. elev. 100.00 ••°t• y�� ` TS Cnnde ovr Septic Tonk- 00.007 //-Qads over D-[!m,-99.00 / vde over SAS- 99.00 3/4" to 1 1/2 ' Noshed Crushed Stone //N ZSS• OUIIET 12• WIET dyiew r = t I} r w // /! 4•P1C(CAPPED)MSPEC110N PORT TO BE 4•* ;`� a S= 0.02 3 HOLE Top OF Syetarrr Elay.-96.TS FIST/LIFD AND TO BE 11111W r OF GRADE s' (H-20) DIST. BOX 3' LAaxeraan Cover I - \\ EXIST. rmE 14' NEW 1,500 GA 01 or greater 0.0/0' toot 0"EffectM Depth 155• I.7s' FROM F°u"BAATER /1 m SEPTIC TANK N o 2s 0.83' (10 inches) PLAN SECTION CROSS-SECTION c AiF°" ; t L„ CONCRETE SLAB FOIIlIa4Tigr-r > N a.er.. m ro �p 5 Units 8 6 25' = 30' _ '¢ s ' O , M 3' 3' // n P daAPS 011 �; ai.2s' 3 HOLE H-20 DISTRIBUTION BOX x SYSTEM PROFILE o o e ' °' 37.25' NOT To SCALE ;yv �.�„„, �;~• �� 9 5 0 3.5' 3.5' p Bxarttkteralyac ,yemo�wnrtee Not to Scale o 3'� > `Effective Length c c K0. o SOIL ABSDRPTIDN SYSTEM (SAS) Effective Yldth GENERAL NOTES 6 In.of 3/4'-I 1/2' o INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE compacted stone o m 1. Contractor is responsible for Digsafe notification, Verification of Utilities w Bottom of Test Hole 1 ov.-e90o (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. Groundwater Observed- NONE OBSERVED NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10' 2. The septic tank on j distribution box shall be set level on 6" of 3/4 -1 1/2' stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. P E R C 0 LATE 0 N TEST 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance Date of Percolation Test: MAY 1, 2006 with Title V of the Massachusetts state code, the approved plan Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations. Results Witnessed By. WAIVER (Per Barnstable B.O.H.) EXCAVATOR: Shay Env. Svcs. PROJECT BENCH MARK 6. If, during installation the contractor encounters any soil conditions or site conditions that are different Percolation Rate: Less Than 2 MPI 0 36" TOP OF FOUNDATION - from those shown on the soil log or in our design ELEV. = 100.00 (Assumed) installation must halt & immediate notification be Test Hole Test Hole made to Carmen E. Shay - Environmental Services, Inc. No. 1 No. 2 DEPTH SOILS ELEV. 7. No vehicle or heavy machinery shall drive over the DEPTH SOILS may septic system unless noted as H-20 septic components. 0 99.00 0 99.00 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. Gavel/Hordpo k Sandy I o4 +l 9. All Distribution Lines shall be 4' diameter Schedule 40 NSF PVC pipes. 10 YR 3/2 10 YR 3/2 10. All solid piping, tees & fittings shall be 4" diameter 0"-6' Ae 98.50 0'-6- Ae 8.50 Schedule 40 NSF PVC pipes with water tight joints. ndy Sandy 100•'25 11. Municipal Water is Connected to ALL OF The Residence and Abutting m Loom Properties Within 150 Feet. 10 YR 5/6 10 YR 5/6 6'- 36" Be 96.00 6-- 36- Be 96.00 THE PROPERTY LINES ARE APPROXIMATE AND Medium/Coarse Medium/Coaree #14 COMPILED FROM THE SURVEY PLAN GENERATED BY Sand Sand BENCHMARK SURVEYING OF MASHPEE, MA 15 Y 7/4 2.5 Y 7/4 NEW 1,500 GAL 1 EXISTING SHED ENTITLED "CERTIFIED PLOT PLAN OF LOT #1, 14 BEE LANE 3s - 132 SEPTIC TANK S BEDROOM PATIO CENTERVILLE, MA, DATED NOVEMBER 11, 1988 C, 36'- 132 C, HOUSE AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Failed Cesspool I O IT SHOULD BE USED FOR NO PURPOSE OTHER THAN CONCRETE SLAB THE SEPTIC SYSTEM INSTALLATION. 4.5' _r"3.759 FOUNDATION EXISTING CESSPOOL & LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE ® NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE t9 I 1 5, EACH PIT TO TEST HOLE #2 OFO P AS PER BOARD OF HOL THE EXIST. CESSOEALTH LSPECIFICATIONS.E DISPOSED C . ` Leach Pit oRed Perc #1 ---_ I ..-18• THERE ARE -NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY Depth to Perc: 36" to 54" Perc Rate= 2 MPI �,_ SHED ____/ ,• � \ •?- LOT #2 ASSESSORS MAP 248 PARCEL 018 Groundwater Not Observed No Observed ESHWT / `. E ' :T �O LEGEND ADJUSTED H2O Elev. = None DENOTES PROPOSED 3-24 DIAM. ACCESS MANHOLES / `�� \ • x T 17104X11 SPOT GRADE TEST f jt EXIST. ��� E Ev.H�99.o0 X DENOTES EXISTING t�r• - - 104.46 -r` •=�; DRIVEWAY � F, SPOT GRADE 3' LOT #1 I`x I PL PROPERTY LINE 7 10,400 Square F�et t/- CUT ET �96 PROPOSED CONTOUR p THE ACCESS COVERS FOR THE SEPTIC TANK. r-` DISTRIBUTION Box AND LEACHING COMPONENT I I I 100.00' `.�-- I �` ---- - SHALL BE RAISED TO THIN 6" of i WI \\ 97 EXISTING CONTOUR FINISHED GRADE. ` STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITE GAS BAFFLES OR EQUALS �� DEEP T PLAN VIEW ON ALL OUTLET TEE ENDS - -� �1 o I -� I,- EST HOLE & L - PERCOLATION TEST' LOCATION J ��24'REMOVABLE COVERS - • 6 FOOT STOCKADE FENCE mfnrdavanw NET� a OLrR.ET it mT Y min Hat to outlet e. >< (40 FOOT RIGHT OF WAY) P LOT P LAN 5-r S'b 5--7- a E - 4'-0'min. b a j a nnnn. Llgidd dopy, SEWER LINE TO BE DOUBLE SLEEVED OF PROPOSED SEPTIC SYSTEM UPGRADE ' ` "`''` -• ?- " '` `"- -� ' 10 FEET EITHER SIDE OF WATER LINE PREPARED FOR CROSS SECTION END-SECTION WITH 6" SCH 40 PVC PIPE AND PLUGGED AT ENDS OF SLEEVE MR. MARCOS CASTILHO TYPICAL (H-10 LOADING) 1500 GALLON SEPTIC TANK - AT NOT TO SCALE # 14 B E E LA N E Bedroom Kitchen n r CENTERVI LLE, MA 9 j ° w Design Calculations Number of Bedrooms: 3 Bedroom EXISTING , o ���ZN OF Mgss9c PREPARED BY: Garbage Grinder. No 0 3 °� R yG� gIl ' RM�'N E. �l.J ff l Leaching Capacity Required: 330 Gal./Day (MIN. PER TITLE V) � m E. �=,Septic Tank - 2 x 330 Gal./Day = 660 USE NEW 1,500 GAL. Septic Tank. ONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of G2 min./inch Bedroom Bedroom 0• �� Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons 10 P.O. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. = 58 gallons Providing: = 331.80 gallons 0 20 40 50 s a EAST FALMOUTH, MA 02536 ANITAR\P Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, TEL/FAX : 508-539-7966 TO BE USED WITH 4.0. OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE 3 BR HOUSE FLOOR SCHEMATIC SCALE: 1"=20' DRAWN BY: CES DATE: MAY 4, 2006 ON THE ENDS. No STONE UNDER. SCALE: 1"=20' (Description Provided By Owner) PROJECT#SD914 FILENAME: SD914PP.DWG SHEET 1 OF 1 I y Qee �.anQ CeA Ire I v;Jl�, Z �B -- oIS ///L M E A D KEEPING YOU ORGANIZED No. 12534 2-153LOR nsusrwn 'A FORESTRY MIN.RECYCLED 111 INITIATIVE CONTENT707 ecru gII flbe1Sourcia, POST CONSUMER wwwsfiprogremarg SFl01290 MADE W USA GET ORGANIZED AT SMW40Y TOW OF"BARNSTABLE LCATION,,(' SEWAGE # (3 VILLAGE AV 1ASSESSOR'S MAP 6z LOT � M'®19 INSTALLER'S NAME & PHONE NO.jah& SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (sue) NO. OF BEDROOMS , _P IVATE ELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: ' DATE >COMPLIANCE ISSUED: - -� VARIANCE GRANTED: Yes No t(f nj qt C) a 1 pxo t�Z i c �n �v<1(e, m� �12C� 3� �� �� &" � 018 � � C o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ppliration for Disposal Works Tonstrwtinn Prruti# Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal Systm Lq__�.-...5.r. L AA J ic.....__ .................. ....... z. ........-------.--....._.._..._.. L ion-Address .-or Lot No. . .. ;k ......... --------------------------- ----------••.......5"4--•--• ....----•-........-----------------------._........ Owner 4ddress a ..---•-•---4%� ..... .....�� , r --::.---•----- ------------------------�"- ll.L�.�;A.C ............................................... Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms....��...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 0 Other fixtures -------•••_.....---•----••••-•••---••••-•-•-•.............•-•----•-••-•--....--•-••-•••.--•-••. WW Design Flow......... _�.....................gallons per person per day. Total daily flow..... .....................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_............. Depth................ x Disposal Trench—No.....................3 Width.................... Total Length............ Total leaching area....................sq. ft. Seepage Pit No..._._._pag t._.--__-__-. Diameter.....,.O......... Depth below inlet................ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ....--•------•---••••••--•••...._...•••....•-•-•.............•-..........-•-..................--...•......................................................... Descriptionof Soil..................................................................................................-----•---••----------..............---............--••---•------:..... W U Nature of Repairs or Alterations—Answer when applicable...___&Vv....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITI2 5 of the State Sanitary Code— The undersigned further agrees not to place the system in p p issued by of hN th. Si ned....._.._.__ operation until a Certificate of Compliance has been Date Application Approved By•--..._..... 4.4---r ..:..... ----•-----•----•-- ----------•- Date Application Disapproved for the following reasons---------------------------------••-•----•---...................--------------•---------......_........-------- ......................................................................................................................................................................................................... Date PermitNo..----- . ..._..a.6_1.................. Issued....................................................... Date No._�9 _ _ F$s.. ` J . r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , ..... .... -.. .................................. Appl ration for Disposal Murky Tonstrur#inn Prrmi# Application is herebyl made for a Permit to Construct ( ) or Repair (k.-)an Individual Sewage Disposal System at• i ko .. 'Location•Addres� .............. or Lot No. --__--__..........-•-•••..-••• __ - .. --------------------- --------•-- --- . .............••-------- r Owner Address y Installer Address Type of Building Size Lot...........................Sq. feet i Dwelling—No. of Bedrooms........................... Attic ( ) Garbage Grinder ( ) Ga4 Other—Type of Building ............................. No. of persons............:________.._.__ Showers ( ) — Cafeteria ( ) d Other fixtures ...•••••••...•..............•-•------------_---------••---=-------•------------------------••------------------ •---------•-•---•--••---------- WW 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. 3 -Seepage Pit No........It...... ...... Diameter.... . ......... Depth below inlet....a..__.______. Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------=------••-__-_-_________-_....._____-___...._____..__...______-___. Date........................................ Test Pit No. l________________minutes per inch Depth'.of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ------------•---------------------- ••-•-•-•...-•••-••--••--•-...............------......._.......................................................... 0 Description of Soil.................................................................................................................................................................... .__. ............................................................. ......-•-•---•-•_-•-•-----...._____.-_•---._____.. ----_•......--••-•--•--___-__-...............................-_____._........... _..- U Nature of Repairs or Alterations—Answer when applicable._... 1� ___.__!I.1!! ____..�� l<t_- l i .-_( � -�.•••.. ••--_-..._�'�'�r1,r.Q.........A eG.fit �------1 S`t (.\ �Z_"S C,T _-___ Agreement: The -undersigned, agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary.'Code,—:The undersigned further agrees nof:to place the system"in operation until a Certificate of Compliance has been issued by the-board of Health ." �, ' -�S1g Dae ApplicationApproved By .A. ... ... r_............... ..........--------------------- -- -....:..... ' I................ Date { 'F r, Application Disapproved for the following reasons:.............................................................................................................. --•----•-•--•-•••••-•-•-•.....••••----••...---....--••--•••-•--•--••••••---•---••-••-•----••••-•-.._._._.....--•-...................................................................................... �� _ Date Permit No........ - --••--•••-__._.. Issued---------------- -•••---•--......_...------..._.._... .._. ._... •Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrtifirate of Tomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (jj_ow" by..................... .r 1,4. -.--••---••-----r..•----•-••---------.........-----••-------............._.......---•----•-- Installer at......................V4....... ........ ... - -e w>--"-------•••-••-••-•--•••-•..-_______-.._...... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------6` ....... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............: l,� ................................ Inspector............. ....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No..RC1-•; 5) ....OF.......a`�. t 'I ,S > •••............ FEE. 2N/2 L Disposal Works Tonstrudion Permit Permission is hereby granted........... b -� - + ? •... ................... _ ..._ _ice'--- . ...._....._...._......---.-.-.....,..._-........................... to Construct ( ) or Repair ( ),an Individual Sewage Disposal System - street Q' as shown on the application for Disposal Works Construction Permit No.. d-�_ &._ Dated.......................................... _ Board of Health DATE................................-...............................................