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HomeMy WebLinkAbout0011 BEECH LEAF ISLAND ROAD - Health 11 BEECH LEAF ISLAND ROAD CENTERVILLE A= 187-073 S M E A D KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.RECYCLED INITIATIVE CONTENTIO% certified Fiber Sourcing POST-CONSUMER www.sfiprogram.org SFW12M MADE IN USA GET ORGANIZED AT SMEAD.COM Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name / information is required for every Centerville ✓ Ma 02632 6/21/20 page. City/Town State Zip Code Date of Inspection r3 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information. ��Ocp^' on the computer, Michael DiBuono use only the tab key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Ln Co � Company Address Cotuit Ma 02635 City/Town State Zip Code rem 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/12/20 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described. in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. El Observation of sewage backup or break out or highstatic water leve l in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fall unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Vacant Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 279 Gpd 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 Other(describe below): 3. Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Beech Leaf Island Rd lvwo Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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: 1/17/85 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 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.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure/Data On File Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended if not done in the last 3 years t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level and at normal level 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.): No signs of push back t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. Cityfrown State Zip Code Date of Inspection. D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 40' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pipe was clean and dry. Stain line is of normal flow conditions 12. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 ASSESSOR'S MAP --TARCEL "7 2 LUvATION f SEWAGt PERMIT NO. VILLAGE INSTALLER'S NAIVE & ADDRESS r �$ - �► Ott�¢ & 1 . 144 SS 8UIL0ER' OR OWNER G 1 14 A-(" ST DATE PERMIT ISSUED jzI71 -� DATE COMPLIANCE- ISSUED !Y3 t f Commonwealth of Massachusetts Title 5 Official Inspection Form j ISubsurface Sewage Disposal System Form-Not for Voluntary Assessments . 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 p Y ►Y -" 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11/1/84 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Beech Leaf Island Rd Property Address Mary E Coakley Trust Owner Owner's Name information is required for every Centerville Ma 02632 6/21/20 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate. 4 (Failure Criteria) and 6(Checklist)completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18 3261 Main Street Route 6A Barnstable Village MA 02630 September 17, 1986 Barnstable Health Department 'own Hall 367 Main Street Hyannis , Mass . 02601 RE: Septic System Construction 617 362 8133 Lot 12 Beach Leaf Island Road/Thornberry Circle Centerville 03-1461. 00 Dear Sirs : This letter is to inform you that the septic system at the above referenced site has been constructed . The following minor changes did occur : 1. The top of foundation was raised from a proposed elevation of 23. 75 to elevation 24. 51, and the inverts on the system were also raised slightly. 2. The septic tank and distribution box location were modified slightly. Please refer to the plan for the "as-built" inverts and location of the septic system. If you have any questions or comments , please do not hesitate to ,contact this office . Engineers—Very truly yours , BSC/CAPE COD SURVEY CONSULTANTS Surveyors Scientists St en A. Wilson P.E. Architects Project Engineer Landscape cc : F. Silvia Architects Planners SW:rh Cape Cod Survey Consultants t C--ASSESSOR'S MAP I ARCEL �j U L ! T ION S EW A G f-- PERMIT NO. Lo j i Z 5 cam! (AOJ 0 V I L L A C E 62>1,-Lrev ILL C I,NSTA LLER'S NAME i ADDRESS p, F—'0$cmr 8 OU►2 (.6 /o-Lc, 1,44 SS R UILDER . OR OWNER SrU,tb rLyr k5e,ocIacc . DATE PERMIT ISSUED ..y DATE COMPLIANCE ISSUED i 0 I SUBJE ' No.. .. _mil�o @A! €vSTJ C171i�5 ��.. THE COMMONWEALTH OF MASSACHUSETTSAA1S ,Iv BOAR® OF HEALTH .....TOWN. .....................OF......BARNSTABLE--------------- ApplirFa#ion for Disposal Workii Toustratrtioat Frrutit Application is hereby m e for a Pegmit toConstruct ) or Repair ( ) an Individual Sewage Disposal System at: // Centerville Lot 12 •-- __........ ..... -•-------------•----------•--------------------- .....•---•-•-•••------••••--------••......•-•------------•-----------•----.............---........ Lgcation-Address or I of No. Silvia_& Silvia Associates,__ Inc. Beech Leaf Island Road .. ---• ... .................. .....-----..........----•-----------.................... Owner Address W ThornberrX-Circle ...a Installer Address 21 111 Type of Building Size Lot_-__-_--•-----------------Sq. feet Dwelling—No. of Bedrooms................3....._......._._._--------Expansion Attic ( ) Garbage Grinder ( X) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .----------•--------•---•---•- •. W Design Flow................•..........._.........._._.gallons per person per day. Total daily flow__._................_....0__...__......_.gallons. WSeptic Tank—Liquid capacity_15Ngallons Length---10-'---6��Vidth.`��.-8��.__ Diameter----------:---- De th5._-4" x Disposal Trench—No. ..... ............. Width------ _'_-___-__-- Total Length--- o............ Total leaching area..32 ...........sq. ft. 3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing tank ( ) '-' Percolation Test Results Performed by.__Cape Cod_Survey Consultants Date_....VV9 OFlyq a 2 12' 3 s Test Pit No. 1................minutes per inch Depth of Test Pit___-_____-___....... Depth to ground wate �-+ �,b STEPHEN 'jG fs, Test Pit No. 2................minutes per inch Depth of Test Pit___.._.............. Depth to ground wat X----••-prL'YN.- �^ Tp #1. 0-6-• wood loam; 6 --30" brown sandy subsoil; o n -----WfL-90fi- O Description of Soi1..30 -108 very loose med. sand and fine gravel• 108"- Na_3o216 �i ---------------•------------------------------ ' x 144 fine-mediuIn tan sand. TP #2 0-6", wood loam; V-30" Brown ••-•---•--(-----••--•-•-----••----• •------- -•----•-----•... . .......... ................................................. sandy subsoil; 30"-96" med. sand and.fine gravel; 96"- 4" . U Nature of Repairs or Alterations—Answer when applicable.__fine white Sand. -------------------------------------------------------------- - - TP 43; 0-_•"; Wood_ loam; 6"-30" brn. sandy subsoil; 30-84" median sand �,�,� Agreement: and fine gravel. (Groundwater observed at 78" in TP 43) 1-16 -8S The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T ITI.- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Co p' nce been issued by t board of health. cCa�i y ed Date Application Approved BY......... ��= 1 /7-ZJ' Date Application Disapproved for the,.following reasons----------------------------------------------------------------------•--------------------------••............- .............•------ ----------------••-----•--------------------•---•-----------•--•------•-••-----------•--••-••---•-•-•---•---••••--•-•-••----•---•••••--••-•••-••---------••-•----••--•----......... Date Permit No.---- 'S s v Issued ....................................................... Date No.--........ ...... Fmc...........................5 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN ................. ------------...........OF.......PMNST.A.B.LE.................................................. Appliration for Uhipviial Worke Tonstrurtion "amit Application' is hereby made for a Permit to Construct X) or Repair an;,Indlvi'dual ''Sewage Disposal System at: Centerville Lot 12 .... ......................... .................................................................................................. & Sil Lqca1i.n-Add,ess jSLJ N Siltia via Associates, Inc. Beech Leaf and Road ................................................................................................. .................................................................................................. Owner Vd Thornberry Circle ii�(Yle ......... ........ Installer Address 21,111 Type of Building 3 Size Lot............................Sq. feet Dwelling—No. of Bedr6bms............................................Expansion Attic Garbage Grinder X) ' Other—Type of Building ---------------------------- No. of persons...._................_______ Showers Cafeteria Otherfixtures .................................................................................................. -----------------------------*---------------Design Flow.................55 .. .................. ....gallons per person perday. Total daily I flow......................3.......30 ................gallons. 9 Septic Tank—Liquid capacity_;Wgallons Length---;kQ'.7.Kidth578..... Diameter________________ De T-4" W pth5------------- Disposal Trench—No......1............ Width_._...Z1.......... Total Length...+Q 1.......... Total leaching area.-320 Z ................sq. f t, Seepage Pit No--------------------- Diameter.......-_.-----__-_- Depth below inlet......._.-_......... Total leaching area...._............. Z Other Distribution box (X) Dosing tank OFA# 1­4 &� 1/9/85 - I Percolation Test Results Performed by---PPM.. ..SPrVeY.�9;PSUltantS Date.....WPM ........ 9;PSultantS...._. Date...._WPM Pit No. I....... .......minutesperinch Depth of Test Pit--------4%? Depth to ground water I*_I . ...5TF 'HEN ALLYN f3:q Test Pit No. 2................minutes per inch Depth of Test Pit._.._............... Depth.to ground water'. Q TP..#1 0-6 wood lo�m; V-30" brown- � subsoil; .... ........ ......... ...... ......... grave].; subsoil;.. 0 Descrigtion of Soil..30'-108......very---r-v------loose o-s- e.-rned sand..and...fine.-qravel;­108......................... ... co ---------------*-------------------------------------------------------------------------------- - W 144 wood loarn; V-30" Brcm S ----- ......... ........ .----Sand SubSO].I; jqiiz�%w-iid s-a-iid and fine- ............................-14.4 ...Med.............................. U 96" --- -------- .......... ------------- --- ---------------- ----- ----------- - ------ -- ------ ---- Nature of­Repairs--or--Alt'eration,s,--Answe-r--whe'n,appl,i-cable...fine-White...sand........................................... r_---------------------iiia............... ........... TP 03, 0-6"; Wood loam, V-30" brn. scifidy ��il; 30-84" 1 um iii�a........... .................................Ell 11-11-11-11,................................ .- .- I)— ... ........./ Agreement: and ine gravel. iiE 78 -ifi­ --F3) The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by th board of health. ...... .................Signed----z;;;ege 4��74e�e�........... ---/.-../-7 Date ApplicationApproved By...... G = -----•"-----------------•-•-•-•---------"......---•--••...............--------- Date Application Disapproved for the following reasons:......................................................................................................*-------- ---------------------*-----------------------------------------------*-------------------------------------------------------------------------------------------------------------------------- Date PermitNo..__ .............................. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...... Entifiratr of TV THIS IS TO CP-I?Tl hat the Individual Sewage Disposal System constructed or Repaired by _ , 0 V t_,�- .......... Installer at.......!t........ .......��............./,1' 4 - ------------------------------- ---------- -------------------------------*--------------------------------------- has been installed in acc6'rdance with the provisions 1.of;.'1`.7L T 5 of The State Sanitary Code as described in the 1\T'6 - . .7... ........................... dated............................................... application for Disposal �11V',�_s`Construction Pe­rmitil appi THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTiqN SATISFACTORY. DATE.............................. • ..................... Inspector....----.......................................................................... .......... _e. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF.?­ZHEALTH rb.b.4.1w.................................................. 'Vispollat i4r A.Av Tons trurtion Vautit Permissionis hereby granted................................................................................................................ ............................ to Construct or Repair an Individual Sewage Disposal System r. atNo............ ...._..-----I............... .................... xv"V. Street as showa.,Qn the application f6l� Disposal Worl�s�anstruciWn'4,,,Permit No---- Date�d­­___Zo--- dij ................ .�X .......................... t�t, 4�-�'oard of Health DATE........... ......... ----------f----------------------------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS IL 1'(-..-ASSESSOR'S MAP ARCEL -� LUyl± TION „I SEWAGE^PERMIT NO. Lo j i Z 5A*c (r4�0 90 • 8� -,Sd VILLAGE ^ INSTALLER'S NAME i ADDRESS r IZog ems- a Ca /0,Lc, do 5.< <-� .�v ua P4 SS e I U I L 01 R OR OWNER 7((lLl i a. E 1�1 LV 1 o�. �SoG )gic DATE PERMIT ISSUED + /� � ` —. DATE COMPLIANCE ISSUED 3 t� rr REVISIONS: /7 r .r NO DATE TEST P/T DA TA DA rEsriNc 11��b - - PERC. TEST DATA • SEPT/C TAN/ DETAIL : sIzE- �� GAL. D/ST. BOX DETAIL • LEACHING IAA b. STY DETAIL: - - IF TEST BY: ON DATE OF TESTING: I TANK TO CONFORM TO TITLE 5 REOU/REMENTS TO CONFORM TO TITLE 5 REOU/REMENTS _� �I /�C' ' ZZ-)K/ RCf!/S Fa` Lam/✓ It } T. P. WITNESSED BY: TEST BY, NO OF OU ETS �������� > - -- --- Y REMOVEABLE COVER Vi.'rlAt 7'0*0 &4056 11DUSr_- W/rNESSEO B �' �� •I'' - - ��''- � � f z MANHOL BROUGHT TO _ 3 3 O J �^KOJ •� :. t.o.. . , .......;. •,•;•; ...• . .. a• FINISH GRADE. a .. �,. �, . a �.• 2ttPEASTONf d �, S /•1.� �C'Gu/sc /per -I- I /�tl Z�� •-4 11h_NEU sc h c 1/o/c OIL q I. 3 CLEAR 3 CLEAR ^;r- OUTLET PIPES ' o' ► ' 1 AS REOUIRED --- __. 6'MIN._ 2t M/N. I I _ DEPTH OF TEST• _ 6�M/N i � !ram ill`(; --------- --- , --- -- ----- - - INLET � f \1E1 "A �G -_.-- RA.TE' C f�•3�, �I I - -- INLET TEE /O'M/N. T i '� I��("1 li`, I BOX sCIi 40 Y - , OUTLET TEE _�� — _v sF_ ./. /�a - GAL. t�tG 'Jig ,x �� OUTLET ET TEE DEPTH: \ / \ / : ,I i a - ---- - INLET AND OUTLET 4`' 0 M/N/MUM 2 EPT/C TAN y SA iG TEES TO BE CAST L IOUID DEPTH �� /4' AT L/OU/D DEPTH OF 4' o C 6tt / S K IRON, SCHED. 40 J /9 5' a • / NCRETE WAS He 0 DEPTH OF TEST —— — 24 ' ,. 6' ;.d o . ..,.0 CONSTRUCT/ON IMF _ � PVC. OR CAST/N /0` ? PLACE CONCRETE 29 " 7 r. . 1 MIN. L 'I ,. OW /Q,Q rE: , CONCRETE , 34 9' BO TTOM ON LEVEL STABLE BASE � `�• ' _ - CONSTRUCTION • ' +• � - -- -- I I� I ! (WA TER T/GHT) , — -�-! —.— INLET TEE PROVIDED WHERE SLOPE Z ... /j'% �J/ JN)... :''•►',•►.•T•.;�.' .�',:.'�':;4o.:r. .,.�. .., •.-.►t••,'.P.•0, FOUNDATION {��_n1E�1iJltl " • ' CIE TANK TO BE ABLE TO W/THSTAND OF A ET PIPE EXCEEDS O OB % OR /'► BOTTOM OF TANK ON LEVEL STABLE BASE H-/0 LOADING UNLESS UNDER /N A PUMPED SYSTEM. lei2Ut M/N. TAN �'f}1JU L•Ji/r PAVEMENT OR/N DRIVE.h1- 20 L 04 D I NG UNDER PAVEMEN T OR DRIVE. c1 rJi!ER NO TES : P L A N VIE W : IN VER T EL E VA TONS: /. THIS PLAN IS FOR THE DESIGN AND CONSTRUCT/ON OF THE SEWAGE T DISPOSAL FAC/L/T Y ONL Y. SCALE / c'O r `�; �p OFF c — INV AT BUILDING _ I fir, ,KEN 2. A L L CONSTRUCT/ON METHODS AND MA rER/AL S SHALL CONFORM TO ° INV. AT SEPT(C TANK ON) �' STEVHErJ ���' ��,+ of r� r MASS. D.E.Q.E. T/rL E 5 A ND THE t; � 7 2Ei8 BOARD OF =� /NV. AT ,SEPT/C TANK(GYJT) ;? ,4 r �nLLVN� /�! !J' I � 4W�LS�ON i%- vlydTi+ ,, HEALTH REGULATIONS. r'O w-,/ Cc' 3'Y:err:' /S .�1 c.<i�!c C!G�E- 7n 7711, .� ., \�a ,y�.5 %��k• �- ! -/NV. AT DIST. BOX(INr�� `''_,•,, ---INV. ATDIST. BOX(OUT) ?27 6 INI OTI��/�� MASS. WORCESTER, MASS. BOSTON, j_} '~ ,,` r3r f'iI C.Nl�1'v TF'�r,re /►/ .- ��-- HALIFAX, MASS. NORWELL, MASS. 1"V y rr E,A✓Z OF BEDFORD, MASS. LEXINGTON, MASS. `. ..., • '`--�, HYANNIS, MASS. MANSFIELD, MASS. ..�� ,E,�Ch'/r�✓G 7X�tENChol — CRANSTON, R.I. DERRY, N.H. / C ,:j, v�✓ �`"'`'-• _ c. ./�� .4�'Ja►G N/NCB 7?c'Q'i411ti,./�r' •->�.•T G- I � ..-� c.- ��, ��� ��/� .,G�,. �` �' i h, tirfA'7''•t�'�. �t.,�Vf-1T`i�-?�'' �'L_ Ca.1l� FFi totjT t`#AL> �� ' 4D ��,�c.,yf v'G rR�Nc� �- � � '� d !(� 1 _�, .` �-•"`— B C 'uIi,c� - 51{/ PKAZZ) I o I � l � � o -•- a r c.r•ram�-r /�t,. r ` 1 DESIGN DA TA i f I wd IO f I {gip /� �c y4. -Is '~ - - DES/GA/FLOW { Silvia & Silvia f RO PO. )F-? I � 8,4gff C:>E , q..'' �` �I fC - �C r• 9� � _ "l3• 6 >itocx•^ ��� ,•T_:..� �- r,I_-� _ - SSOCInc. r ! ''� � b; tr 3 '.."---- � �=,ft lc, ii��_ �.�," III ..:: .-;••�•, A at�S, !(1 Ae, o5 r-- -_ P t4 L_ f a --- — - - -— --- - �ullden Deveieown De+ignen v ;• n f�N � ' I A` e — �y9aE�syY _ '8✓dl1.�fi�aEc --- --- 3.S - 619 a n Street 775-1442 G�TG17� ► t ,^ �, REQUIRED SEPTIC TANK Centerville. MA o b �� = 6 c1 GAL. SEPTIC TANK PROVIDED = 1�non GAL'_. N CAPE COD SURVEY REOUIRED SIZE LEACHING FACILITY CONSULTANTS / st • - � ��' `' � � �� � ���-�C 3 © 3261 MAIN ST ROUTE 6A __ w ^r -- — -- _--_—_- _-_-- BARNSTABLE VILLAGE, MA 02630 �" �/�.,��.:.�.•� \ � J! .-�•_ y f � � I � }v, 1 362 813 -•... ! I C'[ -� o - --- --- --- DIVISION OF ti { f D BOSTON SURVEY CONSULTANTS INC. p7-0p FEZC� c �` h, w I S/ZE OF LEACH/NG FAC/CITYPROV/DED ENGINEERING • SURVEYING • PLANNING ra / TYPE OF SYSTEM: TITLE: As _ f'6o.l-f plate, f y r. . ; _ _ - SEWAGE DISPOSAL SYSTEM i� f1RC) 'F_RTY L--►Nr= INFoRMA-rioN SHOkJN `.AIRS i c� I/� /� �1 ��t CL �� 1 � X c'1' {aPI,� t"� - ��Jc,FL7 CnNIPItEJ� FRvi,n LRN� COI�RT CONF1R ►V\A 10!V CC Llc1T*t'7it'I a, ,- - ` , 1 ' 1 X a 1 .X, II o pr_�-!s �t� �• DESIGN f�' � 1.c� .,., it/c�a-- ,�'k'Fr:�� .rT .�In/ �-v [- i c7,r�9; � ` cX O nJ 3 1 Y I - f IZ TC r n�:F +'}P,4/Y' T/aX'ti 71!' /° 't>r<"i /� Dt%4/i<✓ G� C - - S 8 7 - Q g - t �E--' I/ 'e�c c" l,�r;F L.�tic:�•v G-s>✓ i3.� r�,� tt ' >=tir,. J2. I� /ty f (04 ,N; c�q. - — - - - -- (�EE C�-► Lt=AF 1SLANO RO►; D fr`..� l r 'Fr ./G. M• i'r "� /!.s••� LOCUS PLAN: T I�S� R R� R C�.. 4 Q c n;;u )A/ 1�t -i .e r' .CEG �1,�1� / tI ' — _ _ 1 �c.� ;or, .:c�ra sv* . r' c � � �: .�., rs a� � r. _r r 1.L M-r L0-r' +� _ ' �, _ �t�.� ((,.E N TE R�1 �- � , ���/ ;�RE PARES FOR '. /4/;a !✓/?GP I TOP Z_ LOCUS SIL\){ p VI • �• 0C,) INC , I WRT&-R �� ell/ � a SCALE: AS SHOWN METERS FEET 0 DATE: NU V. , NoRTht --.� Por,►t> ,-. .�� tzlv�r� COMP./DESIGN: CHECK: fl\P IVN DA TUM : DRAWN: E3 v,yxr h y` , Yl�' FIELD: FILE NO: DWG. NO: 1 0 JOB NO: SHEET: I OF: r ( t I