HomeMy WebLinkAbout0053 BERNARD CIRCLE - Health 53 Bernard Circle,Centerville
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UPC 12534
No.2_ 153LOR
HASTINGS,MN
No. Fee C
_ THE COMMONWEALTH OF MASSACHUSETTS Entered in co puter:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Rpphration for Disposal *pstem Construction permit
Application for a Permit to Construct( ) Repair* Upgrade( ) Abandon( ) [j Complete System ❑Individual Components
Location Address or Lot No. 58 ]>EVMRID 0 UP_ (E Owner's Name,Address,and Tel.No.
Assessor's MapTarcel 1491 ;2 59$ E Ql CeX gpf L e
Installer's Name,Address,and Te.No. 50S-'t 7 7-09-n Designer's Name,Address,and Tel.No. jb�'-7�'13--03-77
C 09- ETC-AP
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building Q�0gW i J(4,(_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures ''//
Design Flow(min.required) 3,30 gpd Design flow provided 33 T, gpd
Plan Date 3-(S-;L0(q Number of sheets / Revision Date
Title 52 � NRZ7 C.(��C-� �� ✓_!!��
Size of Septic Tank gcmc) C-XArC-- ^ Type of S.A.S.
Description of Soil ( �T - Cp ►.3� l ty �jDu� �CZ� PLK
Nature of Repairs or Alterations(Answer when applicable) UCfC 6_X4S nO Gr 1/Cop dL4"w -st-PliC•
Z �� —Nita) 4-7� D-k>X _rD (W LC [Au c?"L-4 F61aT_
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 ofFeZa1thD--,,
gne �.f
Date
Application Approved by ate
Application Disapproved by Date
for the following reasons
PermitNo ----------------------------------------------- ��.
1�2
No. r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered;nco u r:
».: Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2ppliLatiofl for 33isposar�6pstem Construction Permit
' Application for a Permit to Construct( ) Repair 06, Upgrade( ) Abandon(-) ❑Complete System ❑Individual Components
Location Address or Lot No.5g Oe"R D Q(Jam CZ Owner's Name,Address,and Tel.No.
c atN➢;'�—! iA740CI KA
Assessors Map/Parcel v
Installer's Name,Address,and Tel.No:=5pS-'f`q 7_ZS n Designer's Name,Address,and Tel.No. `V4.'77 03-77
!!tA•A��6 b�T(:'}'LY'R,(g'i�!�o ,?�, �a'M�' 'iQ,l NCT '.
h.
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) -3¢30 gpd Design flow provided gpd
Plan Date ;p Q Number of sheets Revision Date
Title
Size of Septic Tank ! �Exo-c— Type of S.A.S.
Description of Soil k tM &Jh L 0 `S�� �?
Nature of Repairs or Alterations(Answer when applicable) l)CIC C'�,!"/ / 'Cob 6Z Lbbj Sync
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
r ..
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-.,—. „ter
, o
egne, - a e :�-
Application Approved by / ate
Application Disapproved by / Date
for the following reasons �•
Permit No. -� �7 Date Issued ,
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) x Repaired( x) Upgraded
Abandoned( )by 0,*Z—(0)l c aJ7a PA t A A a 'v...m. . .
at M BC-R tj LAC'_(F �J//� has been cons ucted' ac o Pee
with the provisions of Title 5 and the for Disposal System Construction Permit NW �d
Installer -Z7 C..
Designer
#bedrooms Approved design flow and
The issuance of this erm' shall)not be construed as a guarantee that the system wi k€v o as desi ed.
Date ' 1 Inspector //))
------ --- -------- -------------------- ----------- -------------------------------------------------------- -------
No. A0111�—e?" Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction 3permit
Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( )
System located at b cAN C
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must 'e comas ed w'thin three years of the date of this permit.
Date "/ / Approved by
Apr. 5. 2019 2:'19PM No, 3116 P. 1
Town of Barnstable
Regulatory Services
Richard V. Scali,Interim Director
aAtwere>iLe, t
*�►�: 1?ublic Health Division
610 Thomas McKean,Director
200 Main Street,Hyannis, MA 02601
Office' 508-862-4644 Fax: 508.790-6304
Installer & Designer Certification Form /
Date: y -�9 Sewage Permit# A019 —103.Assessor's Map\Parcel P18 12
Designer: SC En tr1 f aI0 c . Installer: Caetwhie- E-,A-crer i Se,S
Address, 7W C-Car►VW4 �iCkhwa7 Address: 133 Comme.{Ciol S4feej
CpSk W4f(,�/1aM, NA 02J�3 Mas41��e.� NPr 02 `/ 9
On cm-te asej was issued a permit to install a
(date) (installer)
septic system at Jr- a d 6ftn ora .C rr(A f, based on a design drawn by
(address)
G EOn qIn ezc in y , :T 0 G, dated
(designer)
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. Strip out (if required) was inspected and the soils
were found satisfactory.
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. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was construc ce with the terns
of the M approval letters (if applicable) o� p Ss�ey
JOHN L.
�4�C�: A ° CHUR ILL dR,
_ Vll
( s a er's igna ) N .41 1►
9�'rRs O
tgn r' Si Lure) (Affix igne s St mp Here)
j
PL E RET TO BARNSTABLE PUBLIC HEA. IElt D S N. CERTIFICATE
OF C MPL ANCE WILL NOT BE ISSUED UNTIL BOTtl IS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBMC HEALTH DIVISION.
THANX YOU.
QASeptic\Designer Certification Form Rev 8-14-13-doe
/ TOWN OF BARNSTABLE
:LOCATION �� 1GRAJAP.J> C1R @.L-- SEWAGE# AO19_ 103
VILLAGE 1,Z1,�T&7,>-V t4J.& .ASSESSOR'S MrrAP&PARCEL 9 A,C.
INSTALLER'S NAME&PHONE NO. %!'T
SEPTIC TANK CAPACITY OOo tov—L®1iS
LEACHING FACILITY:(type)(4) L size)
NO.OF BEDROOMS 3
OWNER AlU(DPC1 MAZAGIKA
PERMIT DATE: 3—®L 15—,a019 COMPLIANCE DATE: '' S —A 0
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility PJ A Feet
Private Water Supply Well and Leaching Facility(If any wells exist on A
site or within 200 feet of leaching facility) � 4 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within AA
300 feet of leaching facility) AA aa 9 Feet
FURNISHED BY�Vr=uj(D6 Elm' /K F�
Al
A -Z • 23
3 . 31.5 �-3= yo.i
o Z
IA-S: 33.3'
- 3
6
°F.►� Town of Barnstable P
Department of Inspectional Services
* enrwsznsr.e, t `
Public Health Division Date /q I R
16I9•
iOlFp µpt°i 200 Main Street,Hyannis MA 02601 { '
Office: 508-862-4644 NO
rp
Date Scheduled Time // Fee Pd.
Soil SW*tabilitv Assessment fo wage Disposal
Performed By:A-C61 �Piffle&4_'T� _ Witnessed By: �
S�
° ` LO_ CATIONr&�GENERAL��NF$ORIVIATION "
Location Address Owner's Name 'AN OPe f tm A VV(A
59 &Mo Address 519 0AEPJ.&4Ab ejPt C (W
Assessor's Map/Parcel: Engineer's Name 'ZC_ EN6J^4--tje u&,
Engineer's Email:M�i -t��,(���E�,JE�Ne+t ,,Cor�
NEW CONSTRUCTION REPAIR Telephone# _b `
Land Use t f1 n Il/ Slopes(%) Surface Stones
Distances from: Open Water Body �1�ft Possible Wet Area WOO ft Drinking Water Well ft
Drainage Way f ft Property Line ft Other — ft
SKETCH: (Street name,dimensions of lot,exact locations of t;st holes&perc tests,locatewetlands in proximity to holes)
S62e. a4C.C�eQ
Parent material(geologic) Olvi Depth to Bedrock T 4 &7')_
Depth to Groundwater: Standing Water in Hole: �� !( .�j.� Weeping from Pit Face
r' s
Estimated Seasonal High Groundwater
D TERMINA ION FOR SEASONAL HIGHWATER TABLE
Method Used. e p Depth Observed standing�nob hole: in. Depth to soil mottles: >/`r`
V 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 ' , Date �YTime'_ 4Yy1'
Observation
Hole# _ Time at 9" � �M
Depth of Perc Id J - U Time at 6" V_: ¢P/I
Start Pre-soak Time @ f .' Time(9"-67) i'�
End Pre-soak a�eAw1
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\Application Forms\PERCFORM 2018.doc
DEEP':OBSERVATION HOI;E LO'G' Hole
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface in. (USDA) Munsell Mottling (Structure,Stones,Boulders.
O N ) (Munsell) g
`�l L Consistency,%Gravel)
Lam, Y 5
W)" " C, Loa D.S 6 6
IN,
C a Count c f 5®� rave
DEEP:OBSE_RVATION`HOL'E?:I:OG ' �H`ole
Depth from Soil"Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
1) E -'OBSERVAT4iON HOLE°LOG'' Hole'#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) .(USDA) (Munsell) Mottling (Structure,Stones,Boulders.
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.
Consistency,%Gravel)
Flood Insurance Rate Man:
Above 500 year flood boundary No_ Yes"V
Within 500 year boundary Noy. Yes
Within 100 year flood boundary No V Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurrmi .pervious material exist in all areas observed throughout the area
proposed for the soil absorption system? 1
If not,what is the depth of naturally occurr' g pervious material?
Certification �y
I certify that on j0'�7` / (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,
expertise and experience desc .bed' 10 CMR 15.017.
Signature vv Date
Q:Wpplication Forms\PERCFORM 2018.doc
Town of Barnstable Barnstable
Regulatory Services Department o,cac j
BAftNSCABL� r
Public Health Division
200 Main,Street, Hyannis MA 02601 .2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL47015 1730 0001 4987 9255
October 19, 2018
MAZHEIKA, ANDREI V
58 BERNARD CIRCLE
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 58 Bernard Circle, Centerville, MA was inspected on
10/05/2018 by Shawn Mcelroy, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS or cesspool. The SAS is in failure.
You are ordered to repair or replace the septic system within one (1)year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
Fl
PER ORDER OF THE BOARD OF HEALTH
omas cKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\58 Bernard Circle Centerville.doc
�IHF t
Town of Barnstable
9� " a0 Regulatory Services Department
fD MA
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
AE 1 YEAR DEADLINECRITERIA
tic liquid level in the distribution box above outlet invert due to an overloaded or
gged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
I '
Commonwealth of Massachusetts
f,. Title 5 Official Inspection Form
�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
58 Bernard Cir
Property Address
Andrei Mazheika �a
Owner Owner's Name r'
information is
required for every Centerville ✓ MA 02632'� 10-5-18
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.
A. Inspector Information Sly /3 3 S D
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:) am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance'of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
10-5-18
pector's Signature 'Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP.The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev:7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
rai Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. >` 58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
City/Town/Town State Zip Code Date of Inspection
page. Y P p
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or breakout 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 El ❑ ND (Explain below):
❑ obstruction is removed ❑ Y El ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
,w. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Wl
, hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
T.. ` 58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection.
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
1,3P Title 5 Official Inspection Form
bi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Yt
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 10-2018
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
:-v
9 p Y rY
7 58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow based on 310 CMR 15.203
Gallons per day d
P Y(gP )
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit resent? Yes No
P ❑ ❑
If es discharges to:
Y 9
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner--pumped 2017
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
rl::, Commonwealth of Massachusetts
rill
f;. Title 5 Official Inspection Form
C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1974
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 12"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.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�rM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
h
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
6. Septic Tank(locate on site plan):
Depth below grade: 6"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: 1000 gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
t� 3, Title 5 Official Inspection Form
t �'Cl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir _
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
4N Commonwealth of Massachusetts
p. Title 5 Official Inspection Form
Ii
w.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert N/A
` 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
/ Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or.alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
Ir.
r�1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t-'
? 58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,�condition of
vegetation, etc.):
Leach pit had water level at top of tank.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�Ci Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is Centerville MA 02632 10-5-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) r
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
i.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
0
,r
h4
kr
. .
. r 7
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
i
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
? I;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.) :
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation),
® Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
s Commonwealth of Massachusetts
w Title 5 Official Inspection Form
ibi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Cir
Property Address
Andrei Mazheika
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-18
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16 2008
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information �j) ,L 52Z forms �—
on the
computer, use 1. Inspector:
only the tab key
to move your David D. Coughanowr, R.S.
cursor-do not Name of Inspector
use the return
key. Eco-Tech Environmental
Company Name
lw 43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364 0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Z04 � (�L '` 5 October 16, 2008
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16, 2008
City/Town/Town State Zip Code Date of Inspection
every page. Y P P
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:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
Removal of garbage grinder is recommended.
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
1
-7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is Centerville MA 02632 October 16 2008
required for ,
every page. Cityfrown 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
f
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16 2008
every page. Cityrrown 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-09/08 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
GSM 58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is Centerville MA 02632 October 16 2008
required for ,
every 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•09/08 Title 5 Official Inspection Form: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
9c°M a' 58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16, 2008
every 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): n/a Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a- no plan
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
M 58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16, 2008
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: not
determined
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 190 gpd
9 ( Y 9 (gPd))�
Detail:
2006-2007
Sump pump? ❑ Yes ® No
Last date of occupancy: not determined
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM 58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16 2008
every 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:
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):
Septic Tank Soil Absorption System
P P Y
t5ins-09/08 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
�M 58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age unknown—system is assumed to have been installed at time of dwelling's construction in 1974
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.):
No evidence of leakage or backup into dwelling was observed.
Septic Tank (locate on site plan):
Depth below grade: 1
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: 8.5 ft x 6 ft x 5 ft(1000 gallon)
Sludge depth: 6 in
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16, 2008
every 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 28 in
Scum thickness 2 in
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 13 in
How were dimensions determined? Previous inspection report
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every two years.
Tank and tees/baffles appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M ,•°'r 58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is Centerville MA 02632 October 16 2008
required for ,
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 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
58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. Pit was uncovered and found to
contain 10 inches of effluent. No staining at cover interface or in overlying soils was observed.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-09/08 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
a
M 58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16, 2008
every 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16, 2008
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts '
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owner's Name
information is required for Centerville MA 02632 October 16 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Barnstable GIS Department records
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is 20 feet above groundwater
table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Bernard Circle
Property Address
Thuong Nguyen
Owner Owners Name
information is required for Centerville MA 02632 October 16, 2008
every 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
r
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
£ ;J Sd�01ii c+;a ? a 'a:ls1�3 hs
E-XEC[J"I1 E OFFICE Of< E.\LTvTRv--NwEN- F-m
DEPAR.TMIENT OF Ei1+'Vi�tO��'iEr AL RO�`EC�'ION
s�
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SERFAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: S Q r 1 t/
Owner's Name: l
Owner's Address: jA aj{/Q
va4
Date of Inspection-
Name of Inspector: p print M clkae( 0-
Company Name:
Mailing Address:
F
t/1h1S�-� od6ll -
�.a
Telephone Number-._ -���
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the in on reporters
below is true,accurate and complete as of the time of the inspection.The inspection was performed ased on my
training and experience in the proper function and maintenance of on site sewage disposal systems. am a DEP
approved system inspector pursuant to Section 15-340 of Title 5(310 CMR 15.000). The system:
p Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails V
i1a
Inspector's Signature: Date: ?Z�
The system inspector shall submit a copy of dies inspection report to the Approving Authority(Board of Heath or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****'Phis report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address lkow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/I5/Z000 page I
page 2-of l I
OFFICAI.LNspEenON FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTMCATION(continued)
Property Address: � ,r C`/�Q
� t Li _
der: qsj� r
Bate of Inspection:
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 CNM
15.303 or in 310 CV1R 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass`'section need to be replaced or
repaired_The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statem "not determined"please
eVlain-
The septic tank is metal and over 20 years old*or the septic (whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiitration or tank is imminent.System will pass inspection,if the
existing tank is replaced with a complying septic tank as" ed by the Board of Health_
*A metal septic tank will pass inspection if it is striictuaa sound,not leaking and if a Certificate of Compliance
Micat rig that the tank is Iess than 20 years old is
ND explain:
Observation of sewage backup realc out tw bio staik water level in the distribution box due to broken or
obstructed pipe(s)or due to a brok tiled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)awe d
obsnucfim isnanoved
distrilutkm box is bled of replaced
ND explain:
The m required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pan, if(with approval of the Board of Health):
broken pipes)are replaced
obstruction is removed
ND explain:
2
,.
Pag
e 3 offa
OFFICIAL ENSPECTION FORM-NOT FOR VOLUNTARY ASS ESSM N,,TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address 15r C t��,P
Owner l er
Date of Inspection•
C. Further Evaluation is Required by the Board of Hea&h:
Conditions exist which require further evaluation by the Board of Health in o er to determine if the system
is failing to protect public health,safety or the environment.
i_ System will pass unless Board of Health determines in accords a with 310 CMR 15-303(l)(b)that the
system is not functioning in a manner which will protect pub- 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 v ,etated wetland or a salt marsh
Z. System will fail unless the Board of H (and Public Water Supplier,if any)determines that the
system is functioning in a manner that pr ects the public health,safety and environment:
_ The system has a septic tank soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary a surface water supply.
The system has aseptic and SAS and the SAS is within a Zone 1 of a public water supply.
— The system has a tic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water sup • well".Method used to determine distance
"This syste asses if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and olatile organic compounds indicates that the well is free from pollution from that facility and
the prese of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure c teria are triggered.A copy of the analysis must be attached to this form.
3_ Other_
3
OFFIC.LAL INSPEMON FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL 'SYSTEM INSPECTION FORM
PART-A-
CERTMCA'T1oN(comdmined)
Property Address: jWMj C t fLU'
(/i Ite _
Owner- r
Date of Inspection-
A System Failum Criteria applicable to all systems:
You must indicate`des"or"no"to each of the following for all inspections:
Yes No
J Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Dirge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed p4*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 trn-butary to a surface
water supply-
Any portion of a cesspool or privy is within a Zone I of a public well.
_ Any portion of a cesspool or privy is within So 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-his system passes if the well water analysis,
performed at a DEP certified laboratory,for coMrm bacteria and volatile organic_CORIpMRSKIS
indicates that the well is free from pollution from that facility and the presence of amonia
nitrogen and nitrate nitrogen is eguatto,or less than 5 pprn,provided that no other failure criteria
�j are triggered.A copy of the analysis must be attached to this forms.}
AlV (Yes/No)The system fails.I have determined that one or more of the above fail=criteria exist as
described in 310 CMR 15303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failive.
E. Large Systems:
To be considered a large system the system reset ty with a design now of ltttrt>tt0 gpd to 1
You must indicate either"yes"or"no"to each following
(The following criteria apply to large syste addition to the criteria above)
yes no
the system is within 400 of a surface drinking water supply
— _ the system is 00 feet of a tributary to a surface drinking water supply
the system is ed in a nitrogen sensitive area(Interim Wellhead protection Area—IWPA)or a mapped
2.one II of public water supply well
If you have "yes"to any question in Section E the system is considered a significant threat,or wswered
`yes"in n D above the large system has tailed.The owner or operator of any large system considered a
significan under Section E or failed under Section D shad upgrade the system in accordance with 310 CMR
15304. a system owner should contact the appropriate regional office of the DepartIllent.
4
Page 5 of 1 i
OFFICIAL,INSPEC HON FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Properly Address: — C.rt
plOk4dt
Owner. 6 -
Date of Inspection
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
A' Were any of the system components pumped out in the previous two weeks
_ Has the system received normal flows m the previous two week period?
-41 Have large volumes of water been introduced to the system recently or as part of this inspection?
4 _ Were as built plans of the system obtained and examined?(If they were not available note as N1A)
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
o€the baffies 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
mtenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
T n°
Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is acceptable)(310 CMR 15.302(3)(b)]
5
e6ofll
Or ICIAI,INSP f)N FORM— T FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO FOItM
PART C
SYSTEM "INFORMATION
Property Address: 5-6 /` C t V-r—(P
Owner: I t
Date of Inspection: �3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual):_Z
DESIGN flow based on 310 CUR 15203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: D
Does residence have a garbage gr=ltder(yes or no):
Is laundry on a separate sewage system(yes or no):% [if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use:(yes or no): NO
Water meter readings,if available(last 2 years usage Ggpd)):
Sump pump(yes or no):A
Last date of occupancy: Itt-0s'
C€1lMMERCIAUINDf iS'TRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): apd
Basis of design flow(sea2s/personsJ etc.):
Grease trap present(yes or no):
Industrial waste holding tank nt(yes or no):—
Non-sanitary waste disc to the Title 5 system(yes or no):—
Water meter readings,i vailable:
East date of occup /use:
OTHER(d ):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
1f yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
t7 u m/vr
Were sewage odors detected when arriving at the site(yes or no):
6
t'ag..n
7 04 1 1 .
OFFICIAL INSPECTION V FORM—NOT FOR OL Vg:I $ARY ASSESSMENTS
SUBSURi ACE' -SEWAGE DISPOSALSYSTEM INSPECTION FO
PART C
SYSTEM IfNEORMATION(continued)
Property Address- 3 r1 Gf/
Owner-
Date of Inspection
BUILDING SEVER(locate on site plan) .
Depth below grade:.. -2 p r
Materials of construction:Xcast iron 40 PVC other(explain):
Distance from private water supply well or suction imi e:
Comments(on condition of joints,venting evidence of leakage,etc.):
SEPTIC TANK: _(locate on site plan)
Depth below grade: Q l�
Material of construction:jconcrete—metal fiber lass_polyethylene
iother(explaia)
If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: jej () )Q&/
Stodge depth: t2 "
Distance from top of sludge to bottom of outlet tee or baffle: t�
Scum thickness: �r
11
Distance from top of scum to top of outlet tee or baffle: 1
Distance from bottom of scum to bottom of outlet tee o_r/baffle:/q
How were dimensions determined: Mg
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as reI2t;4 to outlet invert,evidence of l Qe,etc.}G s
sou a de lee, i. to c e a u c
GREASE TRAP:_(locate on site plan)
Depth below grade:—
Material of construction: concrete etas fiberglass___polyethylene,other
(explain): — ____
Dimensions:
Scum thickness:
Distance from top of se top of outlet tee or baffle:
Distance from bottom scum to bottom of outlet tee or baffle:
Date of last pumpin
Comments(on ping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to et invert,evidence of leakage,etc.):
7
Pap 8ofII
OFFUC UL INSPEC ON FORM—NOT FOR V®LTJNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTT®N FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: SS 13,MvlaoylG n�iCp
e 1 _
Owner. � C
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped time of inspection)(locate on site plan)
Depth below grade:
Material of constrwtion: concrete fibertalass____polyethylene other(explain):
Dimensions:
Capacity: 445ilons
Design Flow: lons/day,
Alarm present(yes or no 00,
Alarm level: in working order(yes or no):
Date of last pump'
Comments(con on of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box, ):0- o
PUMP CHAMBER:—_(locate to plan)
Pumps in working order or no)-
Alarms in working (yes or no);
Comments(note c dition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 13
OFFICIAL INSPECTION FORM-- °OT FOR VOLUNTARY ASS SSA =S
SUBSIJItFACE SEWAGE DISPOSAL SYSTEM PiSPECTION FORIM
PART C
SYSTEM INFORMATION N(continued)
Property Address:-.3-0 rj C,i r CA
+n, Vt l e
Owner:
Hate of Inspection:!��
SOIL ABSORPTION SYSTEM(SAS): iY (locate on site plan,excavation not required)
If SAS not located explain why:
Tyge
6P leaching pits,number: /
leaching chambers,number.
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Typeiname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
11 i 6 �`f c5 v n I C. `T_
a Aeek- ap,
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater infl9pTyes or no):
Comments(note condition 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 condi�in of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
e 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Frt,perty Address: 5-0 0.0 VUL
Owner.
Date of Inspection-
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet Locate where public water supply enters the building.
57
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•
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Page 11of1
OFFICIAI-INSPECTION FORM—NOT FOR VOLUNTARY SSIrS-S_ME 1 S
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTI€IN FORT
PART C
SYSTEM INFORMATION(continued)
Property Address-
s�
e
Owner-
Date of Iuspectaon
SFTE EDAM
Slope YP5
Surface water Otb
Check cellar le 4
Shallow wells O-JO
Estimated depth to ground water 4tO feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting propertyiobservation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
6(Accessed USGS database-explain:
You must describe hQw you established the high ground water elev tion: (+
tti -C to yG-hot, D 'f Qom C--Q ex-i
I
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
1
�► A
DEPTH TO GROUNDWATER
Q.n -k depth to groundwater
method of determination or approximation:
T o ,6 ,3 o rl ►'�J�,�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
r
DEPTH TO GROUNDWATER:
Depth to groundwater: Z Z Feet
Method of Determination or Ap ro ' tion: �1 �
u � Q
-7-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Toustrnr#iun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (t,)'an Individual Sewage Disposal
System at:
- i --------------------------------- ................................------------------••---------------------------------....._....--
Location-Address or Lot No.
/<-----•--•---------------------------------- ..........------------------------•----......----...----------•---------•---------------------....
Owner Address
...............•---------....-•--•-----------•-• 0:. ...4 -.. _------ ............�_ �"J. .........--
Installer Address
Type of Building Size Lot----------------------------Sq. feet
1-4 Dwelling—No. of Bedrooms__________________________________......Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
A4 Other fixtures -------------------------------- -
W Design Flow____________________________________________gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area__------------------sq. ft.
Seepage Pit No--------------------- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' ---------------------------
•--------------------------------------------------------------------------
----------
0 Description of Soil............................................................................,---------------------------------------...-----------•-----•---•••-•-•-•---•-•......--_•--•
x
V ----••---•-•••----•--•••--•----------•....--•-•-•-------••••--•••--•••••••-•---•-•••------------•••-•-----------------•------------•-----•.............................................................
UW -------------------------------------------------------------------------------------------------------- ------------------------------.. --_--------------- ---
Nature of Repairs or Alterations—An wer when ap, livable____ ___________________�-P___1 by 0____�-- ___: ._____i_ _._.__.___.
--`6r-------------------------------•--•------------------------------- ------•---------------•
Agreement: v
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State E ironmental Code—Th dersigned further agrees not to place the
system in operation until a Certificate of Complian as been issue by t e board of health.
Signed ......... �.� 5 {
Dare
Application Approved By -----------tF ...... ... '. ....... .................... .......................... V�'Daa ...
te
Application Disapproved for the following reasons- ---------- --------------------------------------------------------------------------------------------- -- --------------------
-- ---------------- ----- ---- ------------------------------ ---- --- ------------------------ ------ ---- ---------------------------- -------------------------.......................... ---------------------------------------
Permit No. --------CI-71.. ......UY....................... Issued ........----------------------------------------------..Dare
Dare
y. .
r
THE COMMONWEALTH OF
�,MASSACHUSETTS '
BOARD OF ':HEALTH t
TOWN OF BARNSTABLE
Xpli iratinn flax-11ispnnttl Works Tnnotrnrtinn 1rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( L..,)-an Individual Sewage Disposal
System at:
.... ..._ E(�J A Q a C I R C�.. GL 1J1"L•�2 v/t..LL�'
... ....--_. ......_..- - - - -- ......
y�� n Location-Address or Lot No.
........f_ Q. _,5��. ....._' l< ......................
Owner Address
----------------------------------------------- ®:_ _.. T.......
?=....4 f z v� _52'rt .......
Installer AddrAs
Type of Building Size Lot----------------------------Sq. feet
U Dwelling No. of Bedrooms._ _hh Expansion Attic Garbage Grinder
p, Other—Type of Building .............................No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -------------------------------- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid ca.pacity.�...........gallons Length................ Width................ Diameter________.-_._... Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area•___-----__-.•--__-_sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
` Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water.......................
f=t Test Pit No. 2................minutes per inch Depth of Test Pit____._...--•-_------ Depth to ground water........................
pG •............................................................................................................................................................
xDescription of Soil.................................................................................-••••-...
-----•--•••--•.•-••--•--•---•••••-•---------------••-•-••----.........•••--•••-•------.....•----------•------•••-••••--•-••••-•-•-----•--•---•••-••••----•-----------••-•--•••----•---••-••......••••.
W ............................................. --------------------------•--------------------------•---- --------------- ---...---
-----------------------
V Nature of Repairs or Alterations—Answer when--a''p�,,�linAcable __________________4-�...t Q_____1-.26-_•_ : ___I __________.
ic -
Agreement:
`+ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code The undersigned further agrees not to place the
system`in operation until a Certificate of Comp iancl a has been issued by t e board of health.
Signed .-.�../ -� .. ------.. --.................................. --�-��:.'9 -----
Application -
«} ..,..Y.. Date
Approved B ' �,
PP Y CF 4<h r.......
Application Disapproved for the following reasons: ` ------------------------------------- ----------------------- ---...e- --------------
r
PermitNo. .........1 l 1../..�- ----------------- .r Issued ....................................... .................Date-----
------ ------
e
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH ,
TOWN OF BARNSTABLE
C'Iex#titrtt#E of C amplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by .......... ----------------------------------------------------------`------- ------....------...------------------•.------------------ .
Installer
at '15....... �a<'�2.►,�A.2.' ..........C.t.RG 4., �.t�Y •V.l...c,l-.�� ............................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ......... J---..../..-.9.- f......... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION:SATISF ,CTORY. j , C' 4
DATE................................. � ... Ins ector .... /(f :��. `� .....- � t. ------
r P , .
-aHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
p TOWN OF BARNSTABLE
No.....��"...,�1.y FEE... „
Disposal Works (Innutrnrtinn Prrntit
Permission is hereby granted..--- .......C..FI P.C®..--•---•-----••----•-•............................................................
to Construct ( ) or Repair ( an Individual Sewage Disposal System
at No.......5 ----_ -A_ :!;;k...... ........ - l' NYts 2Y_.(. -...................................
Street
as shown on the application for Disposal Works Construction Permit No-��.���Dated....................................:.....
!/� �j ..................................... -.'�._r... ..,.._.................................................
._
DATE. �;" s/ 5 '/� V Board of Health
...........•.r --•-•-•---•-....---•••••... _
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
E C TOWN OF BARNSTABLE
LOCATION /s✓�4!-� ( � CC�SEWAGE # ��
VILLAGE ASSESSOR'S MAP & LOT 6
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) /` 100 d (size)
NO.OF BEDROOMS PRIVATE WELL OR BLIC TER
BUILDER OR OWNER 7
DATE PERMIT ISSUED: S ,5
/q /
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ��
r
i
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57
��9C;L-
FINISH GRADE OVER D-BOX= 43.0'± FINISH GRADE OVER CHAMBERS = 42.50' - 43.33' PROP. VENT WITH CHARCOAL FILTER TO ABOVE GRADE GENERAL NOTES
FT.O.F. EL.= 46.5 �' -
PROVIDE EXTENSION RISER REMOVABLE WATER-TIGHT COVER OVER SLOPE @ 2% MIN.OVER SYSTEM 3/4"TO 1-1/2" DOUBLE WASHED 1- UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION
WITH COVER OVER INLET& RISER TO WITHIN 6"OF FINISHED GRADE o STONE TO CROWN OF PIPE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
FINISH GRADE OUTLET TO WITHIN 6 OF F.G. 4 SCHEDULE 40 PVC MIN SLOPE 1 /o INSPECTION PORT WCOVER TO GRADE
' F.G. OVER TANK EL. = 43•7'± 5" DIA. OUTLET(S) (SEE NOTE#21) 2" OF 1/8"TO 1/2" DOUBLE WASHED STONE CODE AND ANY APPLICABLE LOCAL RULES.
r
@ FND. EL.= 4 ± I 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
tDESIGN ENGINEER.
4.10' MAX. 5.00' MAX. TOP OF SAS = 38.33' PLACE RISERS ON
EXISTING 4" PROPOSED 4" SEE NOTE 23 CHAMBERS w/PIPED 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
SEWER PIPE SCH. 40 PVC 4" PVC TEE SEE NOTE 23 137.501
BREAKOUT EL - 3$.00'- INLETS TO 6"OF SYSTEM UNLESS OTHERWISE NOTED.
SEWER PIPE FINISHED GRADE 1
4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
6" 3" 3 DROP MAX 3„ 9 i 1 00
2" DROP MIN MIN.SLOPE @ 1% L-$'± PROVIDE WATERTIGHT 00 ELEVATION = 38.00' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A
71 „ ��JOINTS (TYP.) ��� j 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF
LI +I� 14" *41 .8'± SEPT C TANKOM 4" PVC OUT TO O OF
0 0 0 0 THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
CONTRACTOR TO PROVIDE LEACHING FACILITY o0 0 0 0 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
SPECIFIED DROP BETWEEN 12 6 + o 00
00 0 0 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
INLET AND OUTLET CONTRACTOR CONTRACTOR SHALL ' 37.73' o0 SHALL VERIFY SIZE 48" VERIFY CONDITION OF OUTLET TEE 37.90 MIN. � o 0 0 0 0 0 0 o 0 0 0 007. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
1' �C:> 0 00 0 0 0 00 00 0 00 0 00 o 0 000 00 00AND CONDITION OF EXISTING TEES GAS BAFFLE � o0 0 0 o0 0o FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
6" CRUSHED STONE � _ �
EXISTING SEPTIC AND REPLACE AS OVER MECHANICALLY NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
TANK NECESSARY COMPACTED BASE 4'0 ( 6 0' ) 4.0 3.0' (3Yo_) 3.0' AND DESIGN ENGINEER.
3 OUTLET DISTRIBUTION BOX 32.0' 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF 45.00,
TO BE INSTALLED ON A LEVEL STABLE , GROUND WATER ELEV.- < 30.501 9.0' ESTABLISHED ON TOP A HYDRANT TAG BOLT AS SHOWN ON PLAN.
BASE. FIRST TWO FEET OF OUTLET 35.50 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
PIPES TO BE LAID LEVEL. 5' MIN. THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
CROSS
SECTION VIEW LC-6 CHAMBERS TO THE DESIGN ENGINEER.
*CONTELEEVATIONPRIORTOAACTOR TO IFY EXISTING NYWORK & SEPTIC TANK PROFILE H-20 DIb I KIbUTION BOX DETAIL TYPICAL CHAMBER PROFILE CHAMBER DETAILS CHAMBER END VIEW
10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT.
NOT TO SCALE 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE
/ U.P/ Benchmark ��1 .-` .J
TP ST PIT R ATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
/ �29/1 -; Hydrant Tag Bolt SWING-TIES '� • \ • � . . f � *'' • ,£;.:� I APPROPRIATE AUTHORITY.
PERC NO.
15910
Elevation =45.00' DESCRIPTION HC-1 HC-2 •`; �,Z _ ' l `, ` 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
Approx. M.S.L. - INSPECTOR: Donald Desmarais, RS
-- M--- - - i'{" • �; LOCATED UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT,
/ CORNER OF STONE (1) 40.5' 27.8' • � !I . •tr* r1 EVALUATOR: Michael Pimentel, EIT, CSE DRIVES, OR TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING.
0 • • • • • . ; C.S.E. APPROVAL DATE: Oct. 27, 1999
CORNER OF STONE (2) 29.5' 48.2' 1 �'I ,•t ,�`_ • t 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
�P` O�� / OIL .r1 �o �� : . . •� DATE: February 27, 2019
�0� p �� CORNER OF STONE (3) 38.5' 43.7' I, ' ' • ; Q ,' 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
�� / / �� ' o0 00, \\ . • • • • ;' fr TEST PIT#: 1 MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
O
14 CORNER OF STONE (4) 47.4' 36.5' -� �; ' �;C,. ,•: • ." � ELEV TOP 42.5G' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
=
FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
FPP I� >k�/ 8" OAK II . •+ .� I ' ELEV WATER = < 30.50'
• 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
PROPOSED 4 LC-6 LEACHING OG j0/ j ply ' - / '// " . SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
c`i CHAMBERS w/AGGREGATE PERC RATE _ <2 min./inch
o /
lam) ,\ LOCUS DEPTH OF PERC - 60" -78" 16. PROPOSED PROJECT IS LOCATED WITHIN:
o_ BIT. DRIVEWAY
N PROPOSED H-20 DISTRIBUTION BOX / /' � £ ���" � f \\ • ASSESSOR'S MAP 148 PARCEL 26
LO / 4Z / `<� } • TEXTURAL CLASS: 1
`q ' / / 2� f8 erry \\ ,' OWNER OF RECORD: ANDREI V. MAZHEIKA
m 4" CHERRY '
B •
IL C3 PROPOSED INSPECTION PORT , ADDRESS: 58 BERNARD CIRCLE
/ / \/ �._. `r ,�r' i' 0" 42.50' CENTERVILLE, MA 02632
PROPOSED 4" PVC VENT PIPE; (4/ L.P / •'" ---" �� Fill FEMA FLOOD ZONE X
EXACT LOCATION PER OWNER .. , I COMMUNITY PANEL# 25001CO561J
24" 40.50'
_ Sandy Loam
\
OI TP 2 c9 r rt rr ' A 10Yr 3/2 17. DEED REFERENCE: DEED BOOK: 23341 PAGE: 5.a -s.' i f .... y • 26" 40.33'
1 1 f F. ^, '0 //r B Sandy Loam 18. PLAN REFERENCE: PLAN BOOK: 252 PAGE: 32
•� 42x5 1) / 1 ZONE 2 ' Jj! 10Yr 5/6
/ a MAP 148 1 �II ,- 42" 39.00' 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
LOT 24 3 I,� '- Sandy Loam
-v �P TP £ �/ x 23 /� • J C-1 20. A 4" PERFORATED SCH. 40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A
f ,��� � 2.5Y 6/6
/ (3 0 h' \ .1 { {' I >i±' +• J j 60" 37.50' DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3" OF FINISH GRADE. A
i 0��� / 42x \ C7.�` r 7I - Perc REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS.
4j, j
cgs 32 `�� ��O / `�, 'ti. _ . . • ��/ ` 78" 21. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY
GRAVEL y , �; FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
4" CHER Y \ \ C-2 DRIVEWAY _ -_ ._ _ _ �_ ` • _ c_ FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE.
Med.-Coarse Sand
\ C-2 2.5Y 6/4 22. OWNER/APPLICANT/CONTRACTOR SHALL BE RESPONSIBLE TO OBTAIN ANY AND ALL
(2 LECTRIC METER 5/o Gravel REQUIRED PERMITS AND APPROVALS FOR THIS PROJECT.
�FLAG O / \ LOCUS PLAN 23. IN ACCORDANCE WITH 310 CMR 15.401 -15.405, THE FOLLOWING LOCAL UPGRADE
'41 \ �, POLE LSA \ / 12" OAK SCALE: 1"= 1000' APPROVALS ARE REQUESTED FROM 310 CMR 15.221(7):
v� #58 144" 30.50' (1.) A 2.00'WAIVER (3.00' -5.00') FOR THE MAX. COVER OVER THE DISTRIBUTION BOX.
EXISTING (2.) A 1.10'WAIVER (3.00' -4.10') FOR THE MAX. COVER OVER THE LEACHING SYSTEM.
No Mottling, Standing or Weeping Observed
EXISTING LEACHING PIT TO � \ � / 3-BEDROOM DESIGN DATA TES I PI i �. I A
BE PUMPED, REMOVED / DWELLING
OFFSITE, AND REPLACED \18"/18" OAKS I FFE = 47.5'± PERC NO. 15910 -- - - --- ----- -------- ------
WITH CLEAN COARSE SAND c� INSPECTOR: Donald Desmarais, RS
/ TOF = 46.5'± NUMBER OF BEDROOMS (DESIGN) 3 EVALUATOR: Michael Pimentel, EIT, CSE
. LEGEND
HC-
\ j DESIGN FLOW 110 GAL/DAY/BEDROOM C.S.E. APPROVAL DATE: Oct. 27, 1999 50x0' EXISTING SPOT GRADE
l / LSA I TOTAL DESIGN FLOW 330 GAUDAY DATE: February 27, 2019 - 50 --- - EXISTING CONTOUR
EXISTING 1,000 GALLON \ c DESIGN FLOW x 200 % = 660 GAL/DAY TEST PIT#: 2 50 PROPOSED CONTOUR
SEPTIC TANK TO BE N / ELEV TOP - 42.50'
UTILIZED IN THIS DESIGN rr USE EXISTING 1,000 GALLON SEPTIIC TANK
J/H/W EXISTING OVERHEAD UTILITIES
( '4" CHERRI� ELEV WATER = < 30.50'
GAS EXISTING GAS SERVICE LINE
IPERC RATE =
DEPTH OF PERC -_ W V, EXISTING WATER LINE
INSTALL FOUR (4) LC-6 LEACHING CHAMBERS
TEXTURAL CLASS: 1 TEST PIT LOCATION
MAP 14$ SIDEWALL CAPACITY
LOT 28 (LENGTH + WIDTH) (2 SIDES) (2' HIGH) (0.74 GPD/S.F.) = GAL/DAY O O EXISTING 1,000 GALLON SEPTIC TANK
(32.0' + 9.0') (2 ) (2' ) ( 0.74 GPD/S.F.) = 121.4 GAUDAY 0" 42.50'
PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE
MAP 148 Fill
BOTTOM CAPACITY
�o LOT 26 ❑ PROPOSED H-20 DISTRIBUTION BOX
o �o 15,400 S.F. (LENGTH x WIDTH) (0.74 GPD/S.F.) = GAL/DAY 24" Sandy Loam 40.50'
(32.0'x 9.0') (0.74 GPD/S.F.) = 213.1 GAL/DAY A
QQ 26" 10Yr 3/2 40.33' PROPOSED LC-6 LEACHING CHAMBER
O � \ / B Sandy Loam
TOTALS: 1OYr 5/6
O 4'- TOTAL NUMBER OF CHAMBERS
42" 39.00' REV. DATE _ BY APP'D. DESCRIPTION�
o p6 TOTAL LEACHING AREA 452.0 SQ.FT. C-1 S 2 5Y 6/6m PROPOSED SEPTIC SYSTEM UPGRADE
O
NOTES: \ 1,�p� TOTAL LEACHING CAPACITY 334.5 GAL./DAY 60" 37.50' PREPARED FOR:
1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE \ / CAPEWIDE ENTERPRISES
TOP EDGE OF EACH SEPTIC SYSTEM COMPONENT. �. MAP 148
2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE �, / LOT 25 Med.-Coarse Sand LOCATED AT
LOCATION OF THE PROPOSED LEACHING SYSTEM TO
ENSURE CONSISTENCY WITH TEST PIT DATA SHOWN ON THIS Q
/ / C 2 52% Gravel 58 BERNARD CIRCLE
PLAN. REPORT TO ENGINEER AND LOCAL BOARD OF HEALTH O / CENTERVILLE, MA
IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA.
SCALE: 1 INCH = 10 FT. DATE: MARCH 15, 2019
3.) PROPERTY IS LOCATED WITHIN A DEP APPROVED ZONE 2, . MAP LOT 2 4$ 144" 30.50'
�tN of ass o s io 20 ao FEET
THE GROUNDWATER PROTECTION OVERLAY DISTRICT, AND No Mottling, Standing or Weeping Observed
�� PREPARED BY:
RESERVED FOR BOARD OF HEALTH USE CHURCHILL JR.
THE ESTUARINE WATERSHEDS. Q \ �HN L.
CIVIL N JC ENGINEERING, INC.
4.) SWING TIES SHOWN ON THIS PLAN ARE PROVIDED ONLY \ NO. 41807 2854 CRANBERRY HIGHWAY
AS A COURTESY FOR THE INSTALLER. INSTALLER SHALL /
VERIFY SWING TIE MEASUREMENTS IN THE FIELD PRIOR TO EAST WAREHAM, MA 02538
INSTALLING THE SYSTEM. CONTRACTOR SHALL NOTIFY 0. SITE PLAN 508.273.0377
ENGINEER IF MEASUREMENTS APPEAR TO BE INCORRECT.
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� SCALE: 1" = 10' Drawn By: SJI Designed By: SJI Checked By: MCP JOB No. 4566
�04- /® 3