Loading...
HomeMy WebLinkAbout0037 BENT TREE DRIVE - Health 37 Bent Tree Drive = 168—045—001 Centerville 1' *Pendaflexr a,Esse/te 4210113 ORA 109/6 K x Commonwealth of Massachusetts N� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 37 Bent Tree Road y f. Property Address 4 Christopher Olson Owner Owner's Name information is Centerville MA 02601 6/2/19 required for every page. City/Town State Zip Code Date of Inspection w r_ Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 67* g 9a-E,p , on the computer, use only the tab 1. Inspector: key to move your cursor-do not Richard T. Johnson use the return Name of Inspector key. The Building Inspector PAW Company Name 10 Mt.Pleasant Street Company Address Plymouth MA 02360 City/Town State Zip Code 508-735-8740 S113545 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/2/19 rector's Si na ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5lns•3/13 Title 5 Official Inspection Form:Subsurface Sev✓age Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form =' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N FIND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 (g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330GPD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 37 Bent Tree Road _ Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder. El Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: House vacant last 2 years Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: unknown Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): 1500 gal. tank, 500 gal. pump chamber t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is Centerville MA 02601 6/2/19 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2008 per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): joints structurally sound, no signs of leakage. Septic Tank locate on site plan): p ( P ) 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: 1" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Field measure/MFG Specs. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet&outlet tees in good condition, no evidence of leakage, tanks are structurally sound. Recommend pumping of system due to non occupancy. This inspection is not a guarantee of future system functionality. 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 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville _MA 02601 6/2/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box level, no evidence of leakage, trace of solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump & alarm tested &appear to be in working order. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 x 24' x 25' ❑ 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.): no signs of hydraulic failure, no damp soil, lot recently regraded. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration J Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville _StMA 02601 6/2/19 page. Citylrown ate Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): Materials of construction: — Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 TOWN OF BARNSTABLE LOCATION �7 Bra T��,� AIM/ SEWAGE VII L.AGE e! lmr0 i&&A ASSESSOR'S MAP&PARCEL /Gg -Vr—d INSTALLERS NAME&PRONE NO.sa V ?IF 4&ays SEPrtc TOM CAPACITY LEAclm d mcmn st:(type) Z';k4 (sire) zf r" NO.OF BEDROOMS 3 OWNER agesc 4 AA,c Cho, PERMIT DATE: 4� COMPLIANCE DATE: 4-S-o8' Sagaration Dunce Between the: Maximum rousted orouadwa w Table to the he Bottom of Leaching Facility Fed Private Water Supply Well and lAwhmg Facility{If arty wells Mist 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) Fed FURNISHED BY T1� ,P f;c* i . .t � Vie•ta. ��"'""���_ ti to � '+ b flaRO®f�Ota•� ' http://issgl2/intranet/propdata/prebuilt.aspx?mappa1=168045001&seq=1 2/28/2017 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 11+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: 2008 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: Obtained from site observation, visual elevation, examined design plans on file at BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 37 Bent Tree Road Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02601 6/2/19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 Bent Tree Road Property Address Wakeby Development V Owner Owner's Name information is required for every Centerville MA 02601 2/28/17 page. City/Town State Zip Code Date of Inspection M1j t� 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 Richard T. Johnson use the return Name of Inspector key. D&J Environmental Services Company Name P.O.Box 764 Company Address Buzzards Bay MA 02532 City/Town State Zip Code 508-735-8740 SI 13545 Telephone Number License Number 1 B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails LEINeeds Further Evaluati by the Local Approving Authority C 2/28/17 n cto s Si ur Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �o� If Commonwealth of Massachusetts u Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 Bent Tree Road Property Address Wakeby Development , Owner Owner's Name information is Centerville MA 02601 2/28/17 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: t ❑ 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 lv 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): 1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of'i7 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is Centerville MA 02601 2/28/17 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled_ or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the.environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.:. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of.Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments M y 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is required for every Centerville MA 02601 2/28/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to'a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has.a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: -4 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is Centerville MA 02601 2/28/17 required for every _ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ; Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: •❑ ® Any portion of the SAS, cesspool or privy is below high ground water el'�vation. ❑ ® 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.- El ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This' system passes if the well water analysis, performed at a DEP certified } laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10;000gpd. The system fails. I have determined that one or more of the above failure El ® criteria exist as described in 310 CMR 15.303, therefore the system fails, The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 1' Yes No 1" ❑ .❑ 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 Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system.owner should contact the appropriate regional office of the Department. . t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is required for every Centerville MA 02601 2/28/17 . 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 Pumping information ❑ ® at on was provided b the own p g p er, occupant, or Board of Health Y � p ❑ ® 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? f ® ❑ 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? Vrl The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in.the field (if any of the failure criteria related to Part C is at issue ` approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is Centerville MA 02601 2/28/17 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: 2015: 95.9 GPD, 2016: 76.7 GPD Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑. Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Bent Tree Road Property Address .. Wakeby Development Owner Owner's Name information is required for every Centerville MA 02601 2/28/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: unknown Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: / ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool. _ J ❑ 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): 1500 gal. tank, 500 gal. pump chamber t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is required for every Centerville MA 02601 2/28/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Approximate age of all components, date installed (if known) and source of information: 2008 per BOH records Were sewage odors detected when arriving at.the site? ❑ Yes ® No. Building Sewer(locate on site plan): .. -. Depth below grade: 2feet 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.): joints structurally sound; no signs of leakage. Septic Tank(locate on site plan): 11 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: 1 t5ins.-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is required for every Centerville MA 02601 2/28/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness , Distance from top of scum to top of outlet tee or baffle 5., Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Field measure/MFG Specs. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Sanitary tee in good condition, tank structurally sound, no evidence of leakage Grease Trap (locate on site plan): Depth below grade: feet d Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is required for every Centerville MA 02601 2/28/17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: t ❑ concrete ❑ metal ❑ fiberglasspolyethylene 9 ❑ ❑ other.(exp..lain):....... :...:. Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No / Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Bent Tree Road Property Address Wakeby Development Owner .Owner's Name information is required for every Centerville MA 02601 2/28/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan):' 0„ Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box level, no evidence of leakage, trace of solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump&alarm tested &appear to be in working order. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Vol u ntary'Assessments 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is required for every Centerville. MA 02601 2/28/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches. - number, length: ® leaching fields number, dimensions: 1 x 24'x 25' ❑ 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.): no signs of hydraulic failure, no damp soil, normal vegetation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert ilk Depth of solids layer Depth of scum layer Dimensions of cesspool — Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is required for every Centerville MA 02601 2/28/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is Centerville MA 02601 2/28/17 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 A.S$Ullt a cav i v. TOWN OF BARNSTABLE. LOCATION .37 go rT Tr,� ROM/ SEWAGE# zwt-/24 vILLAGE ASSESSOR'S MAP&PARCEL 169 INSTALLERS NAME&PHONE NO. fA?-VW ff 7-18 c%st9&,iC&afy-S SEPTIC TANK CAPACITY 1-204690 LEACHING FACILITY:(type) NO.OF BEDROOMS 3 OWNER Arm! 5,,w,r4 PERMIT DATE: 9-1-0$ 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 I } :. Ptar'P v { yJ 11 '1 J 13.;r,•T Trc.6 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=168045001&seq=1 2/28/2017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 Bent Tree Road Property Address Wakeby Development - Owner Owner's Name ' information is required for every Centerville MA 02601 2/28/17 . page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 11+ Estimated depth to high ground water: feet Please - 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., 2008 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:. Obtained from site observation, visual elevation, examined design plans on file at BO.H. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Bent Tree Road Property Address Wakeby Development Owner Owner's Name information is required for every Centerville MA 02601 2/28/17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A,;B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 A I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. City/town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not MARK NARDONE use the return Name of Inspector key. BRIDGE HOME AND SEPTIC INSPECTION SERVICE ffi Company Name 40 JACQUELINE LANE Company Address PLYMOUTH MA 02360 Cityrrown State Zip Code 508-747-0611 SI 3895 Telephone Number License Number -� p B. Certification o t t -n 1 certify that I have personally inspected the sewage disposal system at this addresand that f tt�e information reported below is true, accurate and complete as of the time of the inspection. The* spem on was performed based on my training and experience in the proper function and main enance often sl sewage disposal systems. I am a DEP approved system inspector pursuant to S tion 15.40 o c� Title 5(310 CMR 15.000).The system: w M ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority t Q10/13/2010 Insp ctor'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. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is CENTERVILLE MA 02362 10/13/2010 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �Ma 37 BENT TREE DR. a Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. CityrFown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 444 GPD t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ® Yes ❑ No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to,the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s ' 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required fo every CENTERVILLE MA 02362 10/13/2010 r page. City/town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NO PUMPING IN 2 YEARS Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? PUMP TRUCK Reason for pumping: MAINTENANCE Type of System: I ® 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for very CENTERVILLE MA 02362 10/13/2010 e page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2.5 YEARS SOURCE AS- BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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: 18, 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: 14X5X4.5'D(PUMP CHAMBER IS PART OF TANK Sludge depth: 10" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness 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 10" How were dimensions determined? PROBE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GOOD CONDITION,ALL TEES IN PLACE, LIQUID AT PROPER LEVELS, NO SIGNS OF BACKUPS OR LEAKAGE, TANK PUMPED AS PART OF INSPECTION Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM , 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is requi for every CENTERVILLE MA 02362 10/13/2010 red page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 01 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, DISTRIBUTION EQUAL, NO SIGNS OF BACKUPS 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.): GOOD CONDITION, PUMP AND ALARM IN GOOD WORKING ORDER, PUMP CHAMBER IS 500 GALLONS AND PART OF THE SEPTIC TANK, NO SIGNS OF PUMP FAILURE Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s ' 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-25'x24' ❑ 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.): ALL CONDITIONS GOOD, NO SIGNS OF FAILURE Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5Oficial Inspection Form:Subsurface Sewage Disposal System.Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately r t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 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: 11 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: 2008 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: SOIL LOGS AND ELEVATIONS OF LOT Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 BENT TREE DR. Property Address LOUIS LEFTER Owner Owner's Name information is required for every CENTERVILLE MA 02362 10/13/2010 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. / /®C� u � Fee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 3p plication for �Biopo5a[ 6pttem Cou--gtructiou Permit Application for a Permit to Construct Repair( Upgrade( ) Abandon Complete System ❑Individual Components Location Address or Lot No.37 �j h ��=� Ow er's Name,)kddress,and Tel.No. � vI>'/�"✓.!/is e er ! ley �l Assessor's Map/Parcel 147 y5-,®© Installer's Name,Address,and Tel.No..-0g-280-7.78 Designer's Name,Address and Tel.No. sob- 790^ 92 70 Joseph D� 64"-a5 4isj4 Gvorfs, i c l/s 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 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. e Date Application Approved Date �f Application Disapproved by: Date for the following reasons Permit No. D400,9 "— Date Issued �,,3.Y �.-..----�--.'.---.,....,....-...-'-�-' ... -.._ yam,`^ �^:XK-.•..a* ...;+ r.,.. .:.r<e.�, .,r'.+y:.. Fee . :u ra ➢a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEA ' . Yes P U C LTH?DIVIS-ION TOWN OF BARNSTABLE,`MASSACHUSETTS RpItcation for ;Mpo!goY bps�tem Con.5truction Permit Application for a Permit to Construct,�,Y Repair( Upgrade( ) Abandon( ) ®Complete System ❑Individual Components x Location Address or Lot No.,?7 t�/-'s9�' TrY;H" Q Owner's Name,'Address,and Tel.No. 907 Assessor's Map/Parcel rG��ys��( .ram n r I Installer's Name,Address,and Tel.No.l Qz-28v-?7 78 Designer's Name,Address and Tel.No. JasePh D-� 13�•-�'vs G,is�ar L yohs, Type of Building: Dwelling f 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 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) fw � r,Kr,� �,rD /9 / Zr4 Zyx,9S Date last inspected: lj 4 '§ it Agreement: l The undersigned agrees to ensure the construction hint—maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. P ne Date Application Approved/bey_ ' Date _ �/ ` V Application Disapproved by: Date t for the following reasons s hh Permit No. }C.C� —� O Date Issued 0 - ------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired Upgraded ( ) Abandoned( )by at 7 e2 fet/t111: has been constructed in accordance 1 �i with the provisions of Title 5 and the for Disposal System Construction Permit No. 9©G�S' dated 44 ) t d Y Installer J sraz a CC/�rrrf>s Designer Z/. #bedrooms I 3 Approved de ign flow 33� �/ gpd �' /J The issuance of this permit shall'g •onsirued as a guarantee that the system i 'function as designed. D11 /t r"y Date !� _ Inspector , � � ------------------------ --v ---- --/— ---- No. a 06 ,// Fee 00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 'Wi5po5al *p!gtem Cow9truction Permit Permission is hereby granted to Construct Repair Upgrade ( ) 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 S and the following local provisions or special conditions. a Provided: Construction m st a completed within three years of the atd e of this pe P Date `1 , Appro ed by Town of Barnstable Regulatory Services Thomas F.Geiler,Director * BARBE9TABCE, 16 9.M^� 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: 41/ 51CO Sewage Permit# 2 40 8- /29 Assessor's Map\Parcel 68 P-4-5-O 1 Designer: LA 2, 1-�lgsrs Installer: c/a�¢TfiG Address: (02 l.J CICICLiAddress: F/ mA o 2tt o On z/ ,k5e_p4 OG 9,00,�P?Y was issued a permit to install a (date) (installer) septic system at 37 64HT rre.� l) based on a design drawn by (address) G•i S i4 Lu a.4S dated /': 4. 2 3,-®0 (designer) f I 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. 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. 01111 f 1�5�1�� g LISA :n= eo ; LY 0 H S ; _ (Installer's Signature) e L i C #114 g� sell ( esigner' gn' e), (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTEL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU Q:Health/Septic/Designer Certification Form 3-26-04.doc Town of Barns - .table P# Department of Regulatory Services Public Health Division Date "Ji", 3 I a y to ��uo 100 Main Street,Hyannis MA 02601 L � G7, Date Scheduled 1 Time Wiz_'�` Fee Pd. 4 _ Soil Suitabdity Assessment for Sewage Dio osal- _ Performed By:Y Witnessed By: tx� LOCATION& GENERAL INFORMATION Location Address 3- Owner's Name 7 �r-rl�� Address 2,2_A . Assessor's Ma l: �0/4 P��e I � , Engineer's Name �5�' iyouw)S NEW CONSTRUCTION REPAIR 1� Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) -),Pon Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: - _—in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level AdJ,factor Adj.Groundwater Level PERCOLATION TEST bate ` '20 Time 10 Observation Hole# Time at 9" Depth of Pero Time at 6" I Start Pre-soak Time @ � Time(9"-61 i— End Pre-soak Rate Min.&ch ---��� Site SuitabilityAssessment: Site Passed Site Failed: Additional Testis Needed(Y/N) �I g S , l ° 7.J Original: Public Health Division Observation Hole Data To Be Completed on Back----------- �h ***If percolation test is to be conducted within 100'of wetland,you must first notify the. C=' Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICVERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. i tencGravel) _ AJ 4-3 C t DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel) 0 23 54 8A) t M DEEP OBSERVATION HOLE LOG. Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other USDA Munsell Mottling (Structure,Stones,Boulders. Surface(in.) (USDA) (Munsell) g Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nsistency, F i Flood Insurance Rate Man: Above 500 year flood boundary No— Yes Within 500 year boundary No= Yes Within 100 year flood boundary No„ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? _- If not,what is the depth of naturally occurring pervious material? ..� Certification I certify that on A 9 (date)I have passed the soil evaluator examination approved by the . Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training, pertise and a erience described in 310 CMR 15.017. Signature Date d� • Q:\SEpTIC\PERCPORM.DOC TOWN OF BARNSTABLE LOCATION _3 �Fr/T Tr{e- 924 SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. II// 4d Ao-aAe^vS SEPTIC TANK CAPACITY f00 �i GLts�rhbf� LEACHING FACILITY:(type) (size) NO. OF BEDROOMS 3 OWNER r PERMIT DATE: -/—p$ 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 J�^o� � -G . r Oe, _1 v y �o ahce 2y' tit r q }p zv 13 es+t trl�/Zo A Fms............ U............' THE COMMONWEALTH OF MASSACHUSETTS "� lb BOARD OF HEALTH WN-).................OF. ��:.) -------------.%'............_ rr Appliration for Uiipaasal Marko Tonstrurtiaau Prrutit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot .... / ,,II / �...... ___-_. /� a 6 V C. ��� [/' O ft j doss ` ��3i �/ "V�C S-6 S 7 Addr C.*G�U L .......... ... C�_i.............. ... ...� --- -----------------------------....--------•---....._..---I------............._...._ Installer Address Type of Building Size Lot___127-1_0__s3._....Sq. feet U Dwelling—No. of Bedrooms_________________________________________Expansion Attic ( ) Garbage Grinder (V-)0 U aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other �fixtures ___________________________________ _ W Design Flow______________315...............:....gallons per person pe r ay. Total daily flow 3X_'_j._o_-__,cJ___________ a lons. WSeptic Tank—Liquid capacitytWO_g ]ions Length_ _____'"_ __ 4�_ idth�J_ -_1_ ---'Diameter-............... Depth=__!_`� x Disposal Trench—No_ ____________________ Width��_yy_____._.___________ Total Length_____._._....., Total leaching area...............____sq. ft. Seepage Pit No........I------------ Diameter....JA----______ Depth below inlet____+� _. Total leaching area__2.4s ___sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed Date---469/--85 ....... Test Pit No. 1................minutes per inch Depth of Test Pit....8..:�_____ Depth to ground water____.7.__ H OFF f=, Test Pit No. 2-----�_.__._minutes per inch Depth of Test Pit____l__��r__.... Depth to ground water_I1). a' ................................. ----•------•---------------------- ------- ----a0GER PAUL Descri Description of Soil--------••----..__.. ------- _•- Q..... �� fJ`p 'e_ E 1 ri s V �- WC1�MIEWICZ v o a W `F- --•'�------�� -.�•---------------------- --------• c_v �o U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------____________ AL •----..---••_- E --------------------•----------------------------------------------•-------------------------------------------------•------------.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in rdance ith71 the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to pl ce the syst in operation until a Certificate of Compliance has b issued by the boo d of health. igned .....�_j........... .....��. ... ��------------•. --- - DateApplication Approved By -1---•.......................•- � 11 Y�L� Date Application Disapproved for the following reasons--------------------------------------------------------------------------------•-------------•-••••••-----•--••- .....................................•-•..._.._.....••--•-•--•-----••---•-----•••-•---.......•---•-•----•--•---••----••--•--•••-----•-•--•--•----•--•-••••-•-••-•••••••-••••••••••------•--•___...•-••-- Date PermitNo......................................................... Issued....................................................... Date 3261 Main Street Route 6A Barnstable Village MA 02630 B = SC October 15, 1985 � Board of Health Town Hall 617 362 8133 1167 Main Street Hyannis, MA 02601 RE: Septic System Lot 34, Bent Tree Drive Centerville (Our File No. 3-1568.01) Members of the Board: This letter is to inform you that the septic system at the above referenced location has been constructed in substantial compliance with the original design plans. The existing berm in Bent Tree Drive was broken during construction and will have to be rebuilt to direct the gutter flow from the road down to the existing catch basin. Also a paved waterway at the property corner should be removed and replaced with berm. Both of these items are necessary to prevent road drainage from flowing atop the leach pit. If you have any questions or comments please do not hesitate to contact this office. Very truly yours, Engineers BSC/CAPE COD SURVEY CONSULTANTS Surveyors `� Scientists n Ste e A. Wilson, P.E. Architects Project Engineer ® HearhDept, Tom of Barostable Landscape r� D Architects 31 0 Planners OCT 1 6 1985 r Cape Cod Survey Consultants 3 y i FEs- l` THE COMMONWEALTH OF MASSACHUSETTS' _ BOAR® OF HEALTH x 1 y� .............................. Ap iratiou for Dftipaaal Works Tianstrurtiou 1hrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: r Location-Address ' ` �'�f� � or Lot No. ----15/ -Ul �1CSl.. ?._. �y ' ......... ........ ................ a _W. ar/ _Lr.'✓...... .�!_iO.:w__ r r..._�t �f_ t , . = - '. Address ............ . z f,_J Installer ✓v� Address d Type of Building Size Lot...I_�__._0._3._..Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garage Grinder (WO p`3-I Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ...................................................... W Design Flow___.._____._r ___..:_____________gallons per person per dg. Total daily flew_ _ _ �_a. __ 3_�.!_ �Ron �. 9 Septic Tank—Liquid capacitv� Q_gallons Length"` ___ G�jldth _"1 .__ Diameter________________ Depth_ Disposal Trench—No_____________________ Width.................... Total Length_____tt___...... ___Total leaching area___________ ______sq. ft. Seepage Pit No........t........... Diameter----l9_l______ Depth below inlet---!�_6�-• Total leaching area:_ZZ.7-7___sq. ft. Z Other Distribution box ( ) Dosing tank (. ) aPercolation Test Results Performed Date._.q/so!_8 '_____-. Test .Pit No. 1................minutes per inch Depth of Test Pit..... Depth to ground water----- rs, Test Pit No. 2.....?.......minutes per inch Depth of Test Pit....J_Z__ ..... Depth to ground water.11: g41_OF_A4gS yl� ------------------------.................................... �- ------ O Description of Soil- ----• *�p� QIL�---•• d� 'y 7�_ f� jL-------------- o ROGER �A r. G.� No.30420 W ----•--------------------- !-] _.a;[T ---••-----•------•. ---------••- •• .eFWi e U Nature of Repairs or Alterations—Answer when applicable---------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in c o dance th the provisions of'Ti'r" ' p 5 of the State Sanitary Code—The undersigned further agrees not to pl e e system i operation until a Certificate of Compliance has been issued by the board of health. A � �_r--Signed-- w et..__... � 'f ` .............. r t C 7Date Application Approved By................ .................................. p U "bate Application Disapproved for the following reasons:................................................................................................................ --------------•-----..__......---------------------------._...------------------._.......----------....-----------------------------------------------------.-----------------------------------.._..._ Date PermitNo......................................................... Issued ........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J (Irfif irtttr of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ()44 or Repaired ( ) by •--- ..........t: ! i 1,_�_Ti _1,�'ii i c' / .,1.. C r�Y/ Li st I iller t _ ______________________________________ _____________________________ has been installed in accordance with the provisions of �, - r': j of The State Sanitary C Qde as described in the application for Disposai Works Construction Permit No..... ._' ___. dated ' _ �• ==�; THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................... Q.- = ............................... Inspector....-•- .0-•---•- THE COMMONWEALTH OF MASSACHUSETTS �--- BOARD OF HEALTH . : f/ �J�!�r. .:. 0F. . .., ..c�. f.:s- R� `•'=�--------------------- '' Towitrurtion Vanfit Permission is hereby granted............. _ !. ..................._____: to Construct ( ) or Repair ( ) an Indiv't ual Sewage Disposal System _l 1 f Street as shown on the application for Disposal Works Construction Perm�,t_.No �__�^t(2 Dated_._ ` _..., w--. -____..- -•--•-- t r, Board of Health DATE - d' ..�- 1__l -"�• ='--•----•-•---------------•- FORM 1255 H BBS & WARREN° INC., PUBLISHERS • Fermi t Number: Al-L Completed by �0' 11 ��,,•� j.r� k I HIGH GROUND-WATER LEVEL COMPUTATION Site Location: T r Lot No. Owner: �� v Address: Contractor: C,0 Address: Notes: STEP 1 Measure depth to water table c- to nearest 1/10 ft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /✓ �`v date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A) Appropriate index well . . . B) Water-level range zone . . . . . . . . . . -- � II "EP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well . . . . . . / mo yr I • STEP 4 Using Table of Water-level Adjustments for index well STEP 2A , current d&pth to water level for index well (STEP 3) , and water-level zone (STEP 2B) determine water-level adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STEP 5 Estinate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water , level at site (STEP 1) . . . . . . . . . . . . . . . . . Cape Cod Survey Environmental Consultants 76 Enterprise Road Hyannis. Massachusetts 02601 Town of Barnstable Barnstableh� OF THE Tp\ , Regulatory Services Department AlAmMca� I* BARNSTABLE, MASS. Public Health Division O i6gq, ,� m pPTFA MAt p' 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,C140 February 6, 2008 Roger Smith 221 Leland Farm Road Ashland, MA 01721 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 37 Bent Tree Drive, Centerville MA was inspected on January 8, 2008, by Patrick O'Connell, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system FAILED under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to 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. You are ordered to repair or replace the septic system within Sixty.(60) days from the date of this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF E BOA OF HEALTH i Thomas McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL# 7006 2150 0002 1038 6551 Q:\SEPTIC\Letters Septic Inspection Failures\37 Bent Tree Drive.doc 41S dui r-lo U�. I LOCATIONS �n� � � �Q5EWAGE PERM NO. � 3 � q-7 - VILLAGE C,en-rgZvoff e I___. INSTALLER'S NAME i ADDRESS 311 /f w-{s T ST �'. ®o v yGa S, In A. 0 U I L D E R OR OWNER 12o G--e ms s r»►-�h , �a� w 4 s,c�;�y fo n s �;, DATE PERMIT ISSUED -j-VLY Ion / �Fr- DATE COMPLIANCE ISSUED +•O• i�- �S i To �l -Pao0; ay X q(o I ACME 1500/500 GALLON TANK DISTRIBUTION BOX LEACHING FIELD DETAIL CROSS SECTION LOCUS PLAN NOT TO SCALE LOW PROFILE WITH INLET TEE NOT TO SCALE 99.0 99.0 MIN 2%SLOPE NOT TO SCALE CAST IRON MAN HOLE COVER 98.15 gas WITH COLLAR TO FINISHED GRADS / \ \ ��� ���� ��\��K K� �\��\�6 �\��\��\�� Tt71 ' / , / \ \ � 9 vER Ccbs�/'6^aF dRAnB��� �\��\��\�� °9"COVER INSPECTION PORT TO BE MTHIN 3"OF GRADE r r 4"CAP "Il a^sCH.40 P.v.0 ivexmlaM m1usT Ia ow BACK ro TaNx 4 SCH.w P.v.c MAY USE FILTER FABRIC IN PLACE OF 2"STONE aoxce MAY USE FILTER FABRIC IN PLACE OF 2„STONE / 3N 2 P.E. 200 PSI FORCE MAIN Y - j 97.6 \ / 3' 96.25 /X TING /Z E IS R 4 98.1-_� / •374•'}'}72 DOUBLE•W1tSHEDSTOPII :'. 1 98.5 /\ y D _ _ w H WE1sP O 96.5 F / 97I > tir P 4 5' FILTER CI VAT ALARM ON ELEV.94.55 A,8 98.3 4 y�/ ././.°/. /. ./ ./. ./ . . . . . . . . . . PUMP ON ELEV.94.08 _977 6 4' PUMP OFF ELEV.93.65 ' TANK BOTTOM ELEV.9225 ADJ GROUNDWATER 92.1 AUTUMN >i>: >,:'•:6".bFSfoNEVN[)i31t PdNkcc:a:a i i;;ii i.;i:ji::"::ii:a::;;c;tit. MEYERS SUBMERSIBLE SEWAGE PUMP SMR4 4/10 BP I 12' SITE SPECIFIC NOTES 1 DESIGN CALCULATIONS GENERAL NOTES TANK AND PIT TO BE REMOVED. INSTALL FL 7-�j�l`lj� FLOOR PLAN �T r ALL PIPING TO BE SCHEDULE 40 P.V.G, 1500/500 COMBO TANK. NOT TO SCALE EXISTING BEDROOMS 3 0110 G_P.D. ALL LOCATIONS OF UTILITIES SHOWN ARE AS PUMP AND ALARM TO BE ON SEPARATE I M168 P45-� CIRCUITS. ALARM T PERMIT REQUIRED. 330 G.P.D. MARKED BY DIG-SAFE AND ARE TO BE VERIF CONSTRUCTION TION INSTALLER PRIOR TO BUILDING SEWER PIPE TO BE REDIRECTED I AND SLEEVED. I P# �� 1�� WIDTH BELOW INV. ' THERE ARE NO KNOWN WETLANDS WITHIN 150' OF THE PROPOSED LEACHING FACILITY LENGTH 25' UNLESS SHOWN. INSTALLER TO NOTIFY DESIGNER 24 HOURS PRIOR TO ,/ FIRST FLOOR THERE ARE NO KNOWN POTABLE WELLS WITHIIN BEGINNING OF JOB TO COORDINATE INSPECTIONS 100' OF THE PROPOSED LEACHING FACILITY. THERE ARE NO KNOWN IRRIGATION WELLS 179103 f S.F. TOTAL SQUARE FEET 600 SF WITHIN 50 OF THE PROPOSED LEACHING 1 FACILITY j CAPACITY TOTAL 0.74 444 G.P.D. THIS PROPERTY DOES NOT FALL WITHIN A 4 BATH MIC IEN FLOOD ZONE AS SHOWN ON FIRM MAP BEDROOM 98.36' THIS DESIGN DOES NOT REQUIRE VARIANCES THIS SYSTEM NOT DESIGNED TO SUPPLEMENTAL REGULATIONS.) OR BARNSTABLE ACCOMODATE A GARBAGE ALL CONSTRUCTION SHALL BE IN ACCORDANCE DISPOSAL WITH TITLE 5 AND BARNSTABLE SUPPLEMENTA REGULATIONS. LIVING W-LINE ELEVATIONS PROPOSED AS-BUILT SURVEY INFORMATION BEDROOM BEDROOM STAIRS ROOM INV. 0 HOUSE existing PROPERTY LINE DATA FROM INV INTO TANK 96.5 FRANK WHITING JUNE 1985 INV OUT OF PUMP 96.25 PLAN TO BE USED FOR INSTALLATION } INV INTO D-BOX 98.5 OF SEPTIC SYSTEM ONLY INV OUT OF D-BOX 98.3 INV INTO FIELD 98.1 NOT FOR DETERMINING PROPERTY LINES I BiASEMEI'1T BOTTOM OF FIELD 97.6 BOTTOM OF OBS HOLE 85.8 BE.,Cs v,!v. WATER TABLE 92.1 (ADJ) WATER GATE 100.7 (ASSUMED) DATE: OBSERVED BY: WITNESSED BY: Unim LAUNDRY 'sArx . ROOM SOIL LOGS LISA C. LYONS DONNA MIORANDI TI ULITY FEB 2O, 2008 LISA EVALUATOR BOARD OF HEALTH Roots OBS. HOLE #1 OBS. HOLE ELEV. DEPTH ELEV. #D2 -' FAMILY EPTH 00 ROOM 97.3 0" 97 8 011 - FILL FILL DECK 95.4 23" 95.9 23" ,-- LTVING LOAMY SAND LOAMY SAND tq ROOM 1 OYR 4/4 I OYR 4/4 r 94.8 LOAMY SAND 0" 95.4 LOAMY SAND 29" 93.7 B I OYR 5/6 3„ 94.3 B l OYR 516 211 i #37 C MEDIUM SAND 51" C MEDIUM SAND 2.5Y 6/6 63" 2.5Y 6/6 86.5 1 GROUNDWATER OBSERVED 301' $�a 3O" GROUNDWATER OBSERVED line and 85.8 38" 86.3 38" 97S sleeve wRh "pvc sealed 9 8. � at both ends - - - µ BOUYANCY CALCULATIONS f� ( � 2 $ I 9aS .. PERC RATE<2 MINS./INCH 2 ACME 1500/500 COMBO 1500 SEPTIC TANK/500 PUMP CHAMBER H-10 GROUNDWATER OBSERVED SEPTIC TANK/ DOWNWARD FORCE WEIGHT 22,000 PNDS AT ELEV.87.0 Z. ::.13/ PUMP CHAMBER SOIL OVER TANK 12X6.5X.75= 58.5Cf WELL MIW29,ZONE C 58.5 cf @ 110#/cf=6,435 pnds JAN,2008 ADJ 5.1 TOTAL 22,000+6,435=28,435 pnds -Di f ADJ.GROUNDWATER AT 92.1 m } 9e UPWARD FORCE VOLUME DISPLACED t° !A SAS DIMENSIONS: 24'X 25 11.66 X 6.17(qZ.l-ql,'76)=`ZS9.cf @ r.._.... REMOVE SOIL TO APPROX 2 .z�f s2.4#/�taa .72pnCIS ELEV. 94 FOR V AROUND DO FORCE EXCEEDS UPWARD FORCE BY 1 DOWNWARD XC (Qi,: ® ® 115.46' - )N f-V MASSq fe, �•�'` wdsm sxy �s b°� PLAN SHOWING: F ® - D PROPOSED SEPTIC SYSTEM REPAIR IN BARNSTABLE BENT TREE DRIVE BENCHMARK FOR: DRAWN BY., LISA C. LYONS WATER GATE 100.7(ASSUM) W 0 ROGER&BETTY SMITH DESIGNED & CHECKED BY; A3+ LOCATION: LISA C. LYONS Benchmark set i e �1�+° ` ��� REVISIONS:DESCRIPTION: DATE: o0o e�®� - 37 BENT TREE RD CENTERVILLE Righ tE(, catch (Assumed) `+ f M168 P45-IL FEB 23,2008 LOT#: DATE: I O A C. L S. SCALE 1 20 1 CERTIFY THAT THIS PLAN CONFORMS TO L I S A C . L vi 0 N IS R . S . (508) 790-9270 TITLE 5 AND BARNSTABLE B.O.H. REGULATIONS HYANNIS MASSACHUSETTS (774) 487-1638 (EXCLUDING WAIVERS SPECIFIED) I SOIL TEST PIT DATA: II GATES v OSIEAVEO SEPTIC TANK DETAIL: o o DISTRIBUTION BOAC DETAIL: LEACHING PIT DETAIL: REVISIONS: qq // TEST GROUNDWATER NOT TO SCALE GAL• NOT TO SCALE NOT TO SCALE NO. -- _ ^\ 7 �� r'S`a U;��a GG k'S,71.I..I�i:�ir19 E,8. I.:�,,a`#L�:- ,, TP I TP TP Z TP NOTES: I. SEPTIC TANK SHALL BE STEEL 4. INLET AND OUTLET TEES TO BE CAST IRON TE NO. OF OUTLETS: MANHOLE COVER r- LOAM 8 SEED _:i�._ " /� I�� �..;)C �. 5.� 1Z� GRD. EL. "12• � GRD. EL. _ GRD. EL. GRD. EL. _,_______ � � BROUGHT TO FINISH GRADE OR PAVEMENT ,q (, , � REINFORCED CONCRETE. SCHEQ 40 PVC OR CAST-IN-PLACE CONCRETE. TEES 2. SEPTIC TANK TO WITHSTAND N-10 LOADNG TO BE CENTERED UNDER MANHOLE COVER. NOTES• �� . .. I j1 GW. EL. _8 — GW. EL. GW. EL. 84. 7 GIN• EL• UNLESS UNDER PAVEMENT, DRIVES OR r -�--- L OAT. BOX TO WITHSTAND N-10 LOADING 2"MIN OF I/8" ` iyl 4 ?'OPSOIL. 4 TOPSOIL TRAVELED WAYS,WHEREIN H-20 LOADING UNLESS UNDER PAVEMENT, 12'MINFILL DRIVES OR TO 1/2" SHALL APPLY. j i TRAVELED WAYS W14EREINH-20 LOADING WASHED S V f3 t1 1 I.. 7 L I PRECAST E- SHALL APPLY. STONE 1 q4•1 3. ALL PIPE CONNECTIONS AND CONCRETE MANHOLE COVER 1 _; DIST. t �►`' `$ ` RROVVN CONSTRUCTION TO BE WATERTIGHT. sRouGHT TO FINISH GRADE BOX 2. PROVIDE INLET TEE OR BAFFLE WHERE SLOPE OF PVC INLET PIPE ° r� o o a =� �� c ti INLET PIPE EXCEEDS 0.08 FT./FT. OR IN . SILTY i --- 1 PUMPED SYSTEM. L_-- J ~ ❑ r1 c� c� :_� n a ❑ a J NOTE ! r-. COVER d 3. FIRST TWO FEET OF PIPE OUT OF DIST. Z C r ' r . --A--- -- �— LEVEL. P LEACHING PIT TO F i ►J E BOX TO BE LAID L a Dp� p WITHSTAND H-10 LOADING GENERAL NOTES: r '.. ! a c c� ra r� c� c u � �. UNLESS UNDER PLAN VIEW PRECAST{_ NORMAL WATER LEVEL RE MOVE AeL_E , I PAVEMENT,DRIVE OR �• THIS PLAN IS FOR DESIGN AND - - - - - - - - - L _ ____�_��--- f -- COVER `•� N > 1. 3/4"TO 1-1/2' ❑ o co " C7 C1 co 0 ❑ TRAVELED JVAI' WHEREIN r " - - - - - - - - r DOUBLE LEACHING PIT v� H-20 LOADING SHALL CONSTRUCTION OF THE SEWAGE ?: CO A R5t' - i a �►' WASHED rN °' APPLY. - .. INLET TEE I y WATERTIGHT ►1 w I STONE C7 �, (� � DISPOSAL FACILITY ONLY. l ° ° S Y � I .._L_ ��7' WATERTIGHT LL � (no f ine � ti '-AN CJ _ ►R[cAST I - --- -- - JOINTS(typ) .1 i' +I ► ❑ r� _ a �+ ��y� r-O"MIN. OUTLET �� ,; rr Y =; 2. ALL CONSTRUCTION METHODS AND 911►�� .-.. lG s_aF FI_T__. 84,2 SEPTIC ¢e�:: Y - r-,�lEE 1 LIQUID DEPTH TEE I NOTE z - _ o c o r-� ".--� _� o n n e D MATERIALS SHALL CONFORM TO TANK q'/1" �4" INLET z =}L1� 1 4 OUTLET I --- i •' --=`-- ._,1 ;-- \° -2 MASS. D.E.O.E. TITLE 5 AND LOCAL _ ' �__-- - 'L�___ �_1�" L_----__- -, BOARD OF HEALTH REGULATIONS. PI A p w t-- �� BOTTOM ON LEVEL STABLE BASE o ° AB� 3. ALL PIPES LOCATED UNDER PAVEMENT �. - ��E�r� BASE r - - �rx � f�, ,, CROSS-SECTION :,� _-___- - _. t35.Z PLAN VIEW CROSS-SECTION VIEW OR TRAVELED WAY SHALL BE i44 BOT OF PIT 84. --- W CR_Q-5_S--SECT10N SCHEDULE 40 OR EQUAL. DATE: GATE: DATE: DATE: - -� -= - --- --_- - _ --- ��= � ' UNDERGROUNDUTILITIES MIERE COMPILED FROM AVAILABLE INVERT ELEVATIONS: TEST BY: TEST BY: TEST BY: TEST BY: RECORD PLANS OF ll�TIL.ITY COMFOMES AND PUBM ASE�ICIES R�MICNuIEWICZ ____ __ R. mIcI4I4IEWIGZ _ _ AND ARE APPROXIMATE ONLY. BEFORE DESIGN Ak0CC1'STRUC 4" INVERT AT BUILDING WITNESSED BY: WITNESSED BY: WITNESSED BY: WITNESSED BY. TION CALL * 016 SAFE* 1 - 000- 322-4444 . 4" INVERT AT SEPTIC TANK(in) 95;55 A - ---------- -- — -- - T-- 4" INVERT AT SEPTIC TANK(out) $� PERC. RATE: PERC. RATE: PERC. RATE: PERC. RATE: _.___..MIN./INCH MIN./INCH Z—_ MIN-/INCH —___.__ MIN./INCH 4" INVERT AT DIST. BOX(in) 4" INVERT AT DIST. BOX(out) - CONSTRUCTION NOTES: OBSERVED GROUNDWATER ELEV. ._Z5-Z0 DATUM: 1�I t�° � . C, INVERTS AT LEACHING FACILITY: -7 VERTICAL DATUM: ,� �J I-� E , ,� -Tenn '�F= L., -,AGE-)1►. C­ vP rT BENCH MARK USED: N // l3'00" w _ _ I - R = 937. 5/ L = 98.36 �162' � N_� ! FRAN TIN ! z5T A / `! .•' L.-� - 7 .••' ,', , ) 0.' 7, �. ¢ 5 f c 1 °'' DESIGN OPITFRIA: ' � -3. /.• .. .�••- � DESIGN FLOW: BEDROOMS AT LIO __G.P.B./D �G.P.D. *dam . REQUIRED SEPTIC TANK: CAPE COD SURVEY 1 1 Rf�l'•-` x - �, 33© X ISt�je = _4 `�5 CONSULTANTS _ , I - r-� -------_-------__------- - _ GAL. mot' f 1 Q uu�ltiL' ING 1 cP � SEPTIC TANK PROVIDED: _ �o GAL. 3261 MAIN ST./ROUTE 6A -+ BARNSTABLE VILLAGE MA 02630 �+. 1� 7 SIZE OF LEACHING FACILITY REQUIRED: (617) 362-8133 Q ~ '\� 3. `{ 7 DESIGN PERC. RATE: _.-____ - . _ �- DIVISION OF MMJ./INCH - ------ BOSTON SURVEY CONSULTANTS INC. t !_ _ 3 �� O �` Y / a;' ,Av�lc ENGINEERING • SURVEYING • PLANNING tZ TArK p � ► M TITLE: RIM _ �. ;it SEWAGE DISPOSAL F K I M U.P. '� � � ° < �I. w r- SIZE OF LEACHING FACILITY PROVIDED: r,. � '" ; �' I� SYSTEM DESIEL GN w.... 3 " • IB►T. P 6 . _ rR /065. L = /l5. 46 � • o,G� k� DRIVE Q � - -- is T -- ;u f\L bET Its i ' „ F,IN M. , J /o l LOCUS PLAN: 1 3 i ! D � PREPARED FOR: 4 W Ur. Hl �"'9j")fir;.(/ •v...._•�,'S'J S•j/ DATE M A.`� `z`) 1` 5 ' COMP./DESIGN: F',PX1 CHECK: : . DRAWN: `" - T->, PLAN VIEW FIELD- SCALE: 1 "= Z a' - FILE NO: DWG. NO: JOB NO: 1 5 C .C-) I 0 10' Z o° 40, (PO' F E E T SHEET: OF: I