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HomeMy WebLinkAbout0008 BLACK VALLEY ROAD - Health 8 BLACK VALLEY RD, CENTERVILLE A= 170 188 IIII QEc'fc goC IN UPC 12548 HASTRIGS, fAN No. � —� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4pliLation for Bisp08al ,pstrm CDnstrurtion permit Application for a Permit to Construct( ) Repair( ) Upgrade(✓jAbandon( ) ❑Complete System 2 Individual Components Location Address or Lot No.8 Z,0 t66 V h\('e�-( Owner's Name,Address.,and Te.No. - l� Assessor'sMap/Parcel e) 1 Installer's Name,Address,and Tel.No. S`Q�- -Cc�3 Designer's Name,Address,and Tel. o.5�`�aC6-_73r1 Type of Building: Dwelling No.of Bedrooms Lot Size �j sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required)(23 gpd Design flow provided ��a , gpd Plan Date 1A�). ` (7, Q !K Number of sheets Revision Date Title Size of Septic Tank `QZ0© Gk x ype of S.A.S.C�,✓.�.i-� Description of Soil Nature of Repairs or Alterations(Answer when applicable)';,Z, � 4\ - O %�Sla bw.CJ1GA ��W Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date of Application Approved by - ' Date Application Disapproved by Date for the following reasons Permit No. 9L 00 (z) Date Issued too . : No. .,�+�. Fee , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plitation for disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade.(Vr/Abandon( ) [:]Complete System ❑individual Components Location Address or Lot No. y' ( QaD t� C$�� �,L�oSG 1/.,ta\�'�'� � Owner's Name,Address,and Tel.No.C. �—� �. ean ��3':\ Address,and Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �` '` ���oS Designer's Name,Address,and Tel. o. 5t24 �c��.\�.��.-fir'�k�y+c�"�.r_„�`- , w�,���E..r-� -�c �o.•�.s���.C' Type of Building: Dwelling No.of Bedrooms Lot Size V7,a? 9 2� sq.ft. Garbage Grinder( ) tk Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33(�D gpd Design flow provided L( ,S gpd , Plan Date ,N i , (`' t Number of sheets Revision Date Title Size of Septic Tank Q7� G-kk it�c hype of S.A.S.�d nc, t•`c C C,� r�,,, ��� c-� aA,,/ Description of Soil Nature of Repairs or Alterations(Answer when applicable) 0 © Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of �. Compliance has been issued by this Board of Health. Signed //�//�J•,►. Date aC Application Approved by Date (/ .)c!`i cj i Application Disapproved by Date for the following reasons , 7 Permit No. + Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that theOn-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(1_ ' Abandoned( )by �c ?c53 c�`nn-\���.J� �A C�At_� t VA-- at �.z.t,�..-Lad ���� .__tlie�/._, ..has been constructed in accordance _ with the provisions of Title 5 and the for Disposal System Construction Permit No. el�` 1 Sg dated Installer k Designer Nj"Y\ \ _1 "Ag .;C�)-A, C #bedrooms Approved design flow/\ � �p gpd The issuance o�this pelprut shall not be construed as a guarantee that the system will fun -on as design c Ins Date � � Inspector p .. No. v 'r&7 + Fee THE COMMONWEALTH OF MASSACHUSETTS i PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ]Disposal �6pstrm Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade((__3 (Abandon(, ) l System located at %'G \ ,� Z.,` � ��.\t l'l' _�ec'.� .c s "��r—1.1 ->,\ 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 be completed within three years of the date of this permit. Date C 1 'J � � Approved by Town of Barnstable Regulatory Services Richard V.Scali,Interim Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form �] Date: �� Sewage Permit#JQ�<::P,.- I Sn Assessor's Map\Parcel Designer: e 9 cy Installer: , 1101, ,-,��� Address: P6 b b Address: On �7' ..A� Q r -z—j j j, was issued a permit to install a (date) (installer) e tic system at c. _ based on a design drawn by (address) `��°dr dated 4 17 desi I � that the s�ftic system referenced above was installed substantial) according to fY eF Y g 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 constructed in compliance with the terms of the IAA approval letters(if applicable) , � N OF DA 1 (Installer's Signature) M R ca 1 (Designers Signature) (Affix) sere) 7 PLEASE RETURN TO BIA STABLE PUBLIC HEALTH D ON: CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTII. BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc I c TOWN�OF BAR�NSTABLE LOCATION� `J�� � l� Qa I �,QSEWAGE#_Da<Ar VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY t©Z10 .r�� LEACHING FACILITY:(type) c�/ S7�ar.�"_ (si NO.OF BEDROOMS C ! OWNER /• PERMIT DATE: Y 1 (9Z COMPLIANCE DATE: t 1hp 4 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet FURNISHED BY g j�,Gk vc, ilt C L 1 Z 'Fey i . 0 i �1 � 3 � Town of B�-�stable. P# Department of Regutatory'Services Public Realih Division Date �r Fie$ 200 Main Street Hyannis MA 02601 Date Scheduled I Time Fee Pct' oil Suitabili Assessment for Sewage Disposal Performed Ey ��� i Witnessed ay�l J�ti i LOCATION& GENE i INFORMATION `p Location Address'�'/ �, '` \��� Owner's Name V Address Assessors Map/P4rrcel: '7,q f Engineer's Name v ' � j6o - 3311 NEW CONSIRU�."EN REPA j Telephone# Land Use �J t � Slopes(%' < ` Surface Stonrs Distances from: ripen Water Body ft Possible Wet Area '7R Drinking Water Well a ft Drainage Way / ft Property Line ft Other ft . i SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) �4 i s j i i i (^ Depth to BedrocIt Parent material(geologic) Depth to Gmoundwaker. Standing Water in Hole;' Weeping from Ptt Face"�"""�' P � Estimated Seasonal Tiigh Groundwater I D TION FOR SEASOJAL HIGH WATIC TADLE Method Used: in, Depth to soil mottles: In. Depth (Ibpery standing m obs.hole -- �. i in. Groundwater AdJusttnetit•" Depth toiwceping from side of obs.hole Adj.factor,,,..«. Adj.Croundwatetl evel,,.,e. index Well# Reading Date: Index Well levdl -- i PERCOLATION TE"�x Dille '�l» Observation > I Time at 9" Hole# M 71me at 6" • Depth of Perc y-= �^- I/ 0 6 lime(91'4')t_, Start Pre-soak Time.@ End Pre-soak irate MinAnch � Additional Testing Needed(Y/N) Site Suitability Asse0sment: Site Passed Site Failed; Original:.Public 1441th Division Observation Hole Data To Be Completed on Back ***If percola ion test is to be conducted within 100' of wetland,:you must first notify the Barnstable Co#servation Division at least one(1)wedk prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders. ons's e c rave 2``--32- L• �� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsis cy,%Gravel) -- 1 , , o �31v Lt 't a I DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. a Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. osistency, Gravel) .t Flood Insurance Rate Map: Above 500 year flood boundary -No Yes Within 500 year boundary No: Yes, Within 100 year flood boundary No L Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio terial exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on � L (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 t atnt .expertise.a d experi ce descri ed in 3,10 CMR 15.017. Signature Date 6 j Q:�SEPrlMERCFORM.DOC v Barnstable ° 'THE Town of Barnstable Inspectional Services zsicaCdy 1® BARNgTABLP. M" Public Health Division f63q• �� m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9620 March 20, 2019 BUEHLER, CAROLYN M TR 8 BLACK VALLEY RD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 8 Black Valley Road, Centerville, MA was inspected on 03/15/2019 by Patrick T. Sullivan, 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: • Evidence of heavy solids carryover and no storage available. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH c teanr-R. .,�CHO ' Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\8 Black Valley Road Centerville.doc I Town of Barnstable + sARNBTABLE, • Regulatory Services Department __-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 ONE(1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged 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 r Commonwealth of Massachusetts = :_ . . CIO = ; � Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Black_Valley Road `1- Property Address Carolyn Buehler ----- Owner Owner's Name , information is Centerville MA 02632 March 15, 2019 = required for every _.— ervill ---------- — -- ---- — page. City/Town _— _ State _ Zip Code _— Date of Inspection 5 y'} Inspection results must be submitted on this form. Inspection forms may not be altered irr=any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information v($k 13Ce5 l filling out forms on the computer, Patrick T. Sullivan use only the tab _-- __ —_-- — ---- ---- -- key to move your Name of Inspector cursor-do not _Ready Rooter Excvatinnc__. _ _ _. use the return Company Name key. PO Box 89 ran Company Address --------...---------- ---------- Forestdale MA_ — 02644 State Zip Code 508-509-0802 — ------------ S112843 -- --- ----- -- t Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above, the information reported below is true, accurate and complete as of the time of my inspection, and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ® Fails March18, 2019 Inspec or 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.;/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Black Valley Road Property Address Carolyn Buehler _ Owner Owner's Name information is Centerville MA 02632 March 15, 2019 required for every -- ---- -- - -- ----- ---------- — page. City/Town — State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 e ist. Any failure criteria not evaluated are indicated below. Comments: j 2) System Conditionally Passes: i� ❑ 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. i * 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 j❑ ND (Explain below): t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form 1.1. = '  'I?� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Black Valle ry Road _ Property Address Carolyn Buehler Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2019 .----------------.-....------__..----- — — — -- — --- ---------_.----- page. City/Town State -Lip 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 b�ebk 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/pf Board of Health): i ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i ❑ distribution boxas 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): I r 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not Functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 / . . . . Commonwealth of Massachusetts Title��~��N�� �� ���������~��N N��������^��~���� ����0°�1K� �� ���� @ �����m� Nmm�����~���N��mm 0-��mmmm � SubsurfacaSavvmgeOimposa| SyatmnmFonn - NutforVo|untoryAssasamants 8 Black VaUav Road _________________.__________�_�_.__-__-_-�___-__-_-�--______________ � Property Address Corolvn8ueMar Owner Owner's Name information is Centerville MA 02832 W1arch15 2U19 required for every _-------- ------ ---- State Zip Code Date of|nsp*�iuo page. City/Town _--_-_' C. Inspection Summary (cont.) R Cesspool or privy is within 50 feet ofa surface water 0 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 pnmbacbo the public hem|th, safety and environment: n The system has septic tank and soil absorption system (SAS) and the SAG is within 1 ]U feet ofo surface water supply or tributary toa surface water supply. F1 The system has a septic tank and SAS and the SAS is within a Zone 1 ofa public water supply. � Fl The system has a septic tank and SAS and the SAS is within 50 feet of a private water � supply well. � F1 The system has a septic tank and SAS and the SAS is less than 100 feet but 5U feet or � more from a private water supply vveU°° Method used to determine distance: This system passes if the well water ana|yais, performed at DEP certified |abonahzry, for fecal oo|iform 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 bo attached ho this form. c. [)thoc ' 4) System Failure Criteria Applicable hoAll Systems: You Dust indicate "Yes" or"No" to each of the following for all inspections-. Yea No Backup of sewage into facility nr ponen6Hue10 overloaded or ~�------------- �~ ^� o|ogg�dSA8oroeaspoo| � Discharge or ponding of effluent to the surface of the ground or surface waters � [�[� �� �� due hoan overloaded ur clogged SAS urcesspool ,mw,omuwm"��""p�m:s"m"^="x�°o o.spo�/»�"°-,�e^m,v .s.",r�^""�,°.nzmmm Commonwealth of Massachusetts =�_-- ; s Title 5 Official Inspection Form 10 _ -= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r~ '' 1, -- %' 8 Black Valley Road Property Address Carom _ —__ — Owner Owner's Name information is MA 02632 March 15, 2019 required for every Centerville _ _ page. CitylTown 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 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT'due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 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 CM 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. r Yes No ❑ ❑ the system is with4400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply r ❑ ❑ the system i�located in a nitrogen sensitive area (Interim Wellhead Protection Area— IW,J;�A) or a mapped Zone II of a public water supply well i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Q3 Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Black Valle Road Property Address Carolyn Buehler Owner Owner's Name information is MA 02632 March 15, 2019 required for every Centerville _ _ --_ __--.- -.--_— —_. page. citylTown 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 NIA) ® ❑ 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 scrum? ® ❑ 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)] i t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page Fi of 18 � ^ ' ^ ' Commonwealth of Massachusetts ' �N~°��N�� 0� ��x���~��~��N N������������~���� ����U���� Title �� �w�� � ��~���N �wm�����r���N��mm �-�.mmmm Subsurface Sewage Disposal System FormNot for Voluntary Assessments 88|Black Road --- --------' | Property Address Cano| n8ueh\or Owner Owner's Name information is Centerville MA 02832 yWanuh15 2U1S �quimdm,nve� __----___ ---- '---- --------- ------- -- --------- State Zip Code Date n,|nspomion page. ~'`r'~`~' D. System Information 1 Residential Flow Conditions: Number of bedrooms (design): �------- Number of bedrooms (aobua|). 3---------- DESIGN flow based on310CKAR1S.2O3U 33O <�PObrexamp|e� 11Ogpdx#ofbedroomo)� -'---------- Description: Number ofcurrent residents: - --------- Ooas /eaidenoehaveagarbagagrinder? El Yes 0 No Does residence have a water treatment unit? El Yes N No � |f yes, discharges ho� ------------'-------------------'--- Is laundry on a separate sewage system? (Include laundry system inspection El yes N No information in this report.) Y es |l No Laundry system inspected? ��l� . �~ Seosona| use? ���� Yes ���� No 2017= 78GPO Water meter readings, if available (last 2 years usage (QPd)): 2O18= 88 (3PD _____ Detail: � No�� Sump pump? �� Yea �� -Current � Last date cfoccupancy: Date t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface'Sewage Disposal System-Page 7 of 18 ' � Commonwealth of Massachusetts = =, , Title 5 Official Inspection Fora �� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Black Valley Road ----------- Property Address Carolyn Buehler Owner Owner's Name information is Centerville MA 02632 March 15, 2019 required for every —_ —_—_ page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: ---- --- --- Design flow (based on 310 CMR 15.203): / Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc / -- — -- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: / — Industrial waste holding tank presp/nt? ❑ Yes ❑ No r Non-sanitary waste discharged tbo the Title 5 system? ❑ Yes ❑ No Water meter readings, if availle: --- --- Last date of occupancy/us % Date Other(describe below)- 3. Pumping Records: Source of information: No previous records found. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? - --- -- --—--- Reason for pumping: ----- -- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Pane 8 of 18 i Commonwealth of Massachusetts 11=. = Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 P Y Y 8_Black Valley Road Property Address Carolyn Buehler Owner Owner's Name information is Centerville MA 02632 March 15, 2019 required for every 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: System installed 1988. Health Dept records. Were sewage odors detected when arriving at the site? [_] Yes ® No 5. Building Sewer (locate on site plan): Depth below grade: 2.5 -- -- -- feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): --- ------ Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 15insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts U3 Title 5 Official Inspection Form 1 p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �a 8 Black Valle r_Road Property Address Carolyn Buehler Owner Owner's Name information is Centerville MA_ 0263 _March 15, 2019 required for every —__—_ — — _-_ page. City/Town State Zip Code Date of Inspection Do System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: ----- -- - — 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 8.5' x 4.5' x 5' 1000gallons Dimensions: --- ---- -- --- Sludge depth: 6+ Distance from top of sludge to bottom of outlet tee or baffle 25 -------------------- Scum thickness 2+'on inlet, 1' on outlet_— Distance from top of scum to top of outlet tee or baffle 5 ------ — Distance from bottom of scum to bottom of outlet tee or baffle 1 ----- --- - --- How were dimensions determined? P!p_tube and tape measure _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Riser brings cover within 6" of grade on inlet. Tank needs to be umped_and cleaned to remove heavy solids during stem replacement. _ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Black Valle Road Property Address Carolyn Buehler Owner Owner's Name information is Centerville MA 02632 March 15, 2019 required far every --- - ----------- ---- -- — -- -- --- — page. CityrTown 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 0-fiberglass ❑ polyethylene ❑ other(explain): i i Dimensions: ------ ------- I Scum thickness /� ---- --- Distance from top of scum to top of outlet tee or baffle ------ -------------- Distance from bottom of scumXo 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: f -- ------ -------- Capacity: ---- — - ---- ------ gallons Design Flow: / - - —--- - jgallons per day t5insp.doe•rev.7/26/2018 ' Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - = , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Black Valley Road Property Address Carolyn Buehler Owner Owner's Name information is Centerville MA 02632 _March 15, 2019 required for every -----_—__ —_ page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) a Alarm present: ❑ Yes ❑ No Alarm level: --------------- Alarm in working order: ❑ Yes ❑ No � I Date of last pumping: pate Comments (condition of alarm and float switches, t.): ff *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): 11 Depth of liquid level above outlet invert 0 --- -- - -- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet one outlet_ 2' below grade. Heavolids carry er_No sign of leakage_ 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 '� = �� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Black Valley Road Property Address Carolyn Buehler Owner Owner's Name information is Centerville MA 02632 March 15, 2019 required for every __—.-- page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 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: 4' x 6' w/ stone. ❑ leaching chambers number: ❑ leaching galleries number: - ❑ leaching trenches number, length: --- ❑ leaching fields number, dimensions: -- ----- ❑ overflow cesspool number: I ❑ 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 1 ==; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Black Valley Road Property Address Carolyn Buehler Owner Owner's Name information is Centerville MA 02632 March 15, 2019 required for every — _ _ 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.).- Liquid level at inlet invert at time of inspection. No storage available. Leach pit is in hydraulic failure. 32" cover sits on 18" access cover. 2' below grade. Riser not installed due to failure. 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 j — -- -- --- Dimensions of cesspool — -- Materials of construction ----- ---- i Indication of groundwater i�flow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ----- - --------------- t 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 I - iJ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '. 8 Black Valley Road Property Address Carolyn Buehler _ Owner Owner's Name ---- --- -- —-- information is Centerville MA 02632 March 15, 2019 required for every _ _-- _—_--- _ page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: ---�� - Dimensions L -- Depth of solids --- Comments (note condition of soil, signs of h raulic 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 c Commonwealth of Massachusetts - _,10 Title 5 Official Inspection Form — '� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 P Y rY = � 8 Black Valley Road Property Address Carmen Buehler Owner Owner's Name information is Centerville _ MA _ 02632 March 1_5, 2019 required for every _—_ page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) V 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 i i 1 ,_ 1J J- t I � I 1_T Y i t5insp.doc•rev.726/2018 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Black Valli Road ---- ------- ----- -- -- -- -- Property Address Carolyn Buehler Owner Owner's Name information is C required for every _.__.enterville MA 02632 March 15, 2019 page. City/Town 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: >5 - — -- 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: maps_maser.state.ma.us/oliver.ph� You must describe how you established the high ground water elevation: Accessed local ground water contors and topo mapping. Base of leach pit 6' below grade, >10' above adjusted ground water___ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsuiace Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ��-- i� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 8 Black Valley Road__ ` Property Address Carmen Buehler Owner Owner's Name information is Centerville MA 02632 March 15, 2019 required for every _---- -- _ ---- -- - - — 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 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.cloc•rev.7/2 61201 8 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 18 of 18 MICROZIDE (hy drochlorothiazide) caps mul es ao f�2 i r COMMONWEALTH OF MASSACHUSETTS " y — EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON D A 02108 (617) 292-5500 TRUDY COXE Secretary . ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM o PART A f CERTIFICATION 1 n nn__II / �[C Name of Owner Property Address: 8 /3�4C4 I'c�I�F7+ /�� ����✓r Address of Owner: rM Date of Inspection: /Z— 4 —9& ` Name of Inspector:(Please Print) 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: CnC in eei�',LG ✓p�Lt S Marring Address: c 1 -w L2 , F,"GS.1-,Jek Lt/ MA D z,&q q Telephone Number: CERTIFICATION STATEMENT certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in th 4' o� and maintenance of on-site se age disposal systems. The system: w�tN Of Passes PETEP T. Conditionally Passes z MCENTEE _ Needs Further Evaluation By the Local Approving Authority CIVIL N _ Fails No.35109 C �. Date: 12 A'PO,r 9EGISTER�`���``Q Inspector's Signature: S 6 FS�NAL E�\ The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DE ) t ty (30) days of _,t completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the > system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES XND COMMENTS 1�g9Iq A . t revised 9/2/98 Page Iof11 ;7 i� Printed on Recycled Paper y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) i l - Property Address: � �/4�k l/a/ley �`� �er]}f/✓r�Lc MA Date Owner:Inspection: "/ -be, � le-c I /lenoe S-Sy iz, q-9� INSPECTION SUMMARY: Check A, B, C, or D: A. ` SYSTEM PASSES: t/ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: } B. SYSTEM CONDITIONALLY PASSES: t One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. z Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank tiI failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced ,I The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass r inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed . y Y r I t I 7. I 1 revised 9/2/98 Page 2of11 ,i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART A , / /�"" CERTIFICATION(con irxwed) Property Address: /3�Ct L({ (/c�1(C%y � CCn k,—v, �A Owner: . k 6--; A k r� Herir+�SSy Date of Inspection: `2— — C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WALL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. r _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the ` well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER A - .x revised 9/2/98 Page 3orit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corrorwed) Property Address: gleid< ✓c.11e /0, Ceo der✓i 11{ , "A Owner: �'4k .0eh <-lenness� Date of Inspection: ±' 3 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: } I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this t determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. ?? Yes No x _ Backup of sewage into facility or system component due to an 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. 4 Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped a Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. — — iAny portion of a cesspool or privy is within 50 feet of a private water supply well. , � 11 I 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 i acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. � C . E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: ,*rhe following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: It I 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 11 of a public water supply well) The owner or operator of.any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. i t; i revised 9/2/98 Page 4ofI t . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a1�1 LK �/�t�LQY �n.ie�✓�f/ M — Date of Inspection: ��� r�1 •► ��'t n t S S V Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ — Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been-receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �( As built plans have been obtained and examined. Note if they are not available with N/A. X — The facility or dwelling was inspected for signs of sewage back-up. t )L — The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. �n�I�drn.g �4 X — All system components,exe6,&ng the Soil Absorption System, have been located on the site. r ' The septic tank.manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: 7S — ,Existing information. For example, Plan at B.O.H. I Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)) X _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintenance.of SubSurface Disposal Systems. F`yy/1 �I �l 4. r xi revised 9/2/98 Pagesofii 3, h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION Property Address: Q 91ric-K ve, )it, l24, C.er,4- ,, ✓r l Lk� Owner: ��} 4 �c�{Ll LLe N Ke ri►1C S S Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 1/0 g.p.d./bedroom. Number of bedrooms(design):_ Number of bedrooms(actual):3 Total DESIGN flow GS Number of current residents: Garbage grinder(yes or no):—tjO Laundry(separate system) (yes or no):NO ; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no): Noy Water meter readings, if available (last two year's usage(gpd): N° All Q' Sump Pump (yes or no): Nc Last date of occupancy: y 0 6C t-t / :3 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: j OTHER:(Describe) Last date of occupancy: ' GENERAL INFORMATION PUMPING RECORDS an dd source of infgrmation: a,--Urihar,e hac/ sfe� ��,��acc� 3-9 1nc-e gsc �-ou5 h t new System pumped as part of inspection: (yes or no)_�)� If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM .Septic tank/distribution box/soil absorption system dingle cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other / APPROXIMATE AGE of all components, date installed(if known) and source of information: 10 y eA�� of q II Sewage odors detected when arriving at the site: (yes or no)_[L)p f + revised 9/2/98 Page6ofll i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r. SYSTEM INFORMATION (continued) Property Address: 6/QcK ✓4 ke y 94, M A Owner: /�oj�ei f C4 He-nn SS Date of Inspection: 1z : -4 -98 BUILDING SEWER: (Locate on site plan) A)f A Depth below grade:_ } Material of construction: cast iron 40 PVC_other(explain) j r, Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) .ti SEPTIC TANK:_ (locate on site plan) t II-- ri Depth below grader(+ = q!T j ZZ Material of construction:- concrete_metal_Fiberglass _Polyethylene_other(explain) 1 If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: A,,Pzx X x- ��O ll o�� �✓15��44 17�.tien5iu.+s Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 2 9 Scum thickness:_ 5/ t Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle:N�A How dimensions were determined: 192paSurecl Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to�utlet invert, structural integrity, evidence of leakage, etc.) fT a>7Li .5 C- U w c GREASE TRAP: / (locate on site plan) N!/3 Depth below trade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) r , Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: p� (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, a, evidence of leakage, etc.) ' j revised 9/2/98 Page 7of11 I , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: f�/qC4 vr,/&-y � 8 Owner: go he rf C4 rh Le_e Date of Inspection: 4 —YF TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) N /A Depth below grade:_ Material of construction: concrete metal—Fiberglass—Polyethylene—other(explain) 4 Dimensions: Capacity: gallons ' Design flow: gallons/day t Alarm present Alarm level: Alarm in working order:Yes_ No Date of previous pumping: Comments: T (condition of inlet tee, condition of alarm and float switches, etc.) . i f. I r DISTRIBUTION BOX: 2-CO (locate on site plan) I�' X /� Co v-e✓' ��f� ��a w ) ra c.1R � 1J Depth of liquid level above outlet invert: s i Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, t e .) nJo e.'I 'cr<QnCo 111� /cc, &ctC.-P PUMP CHAMBER:_ / 4. (locate on bite plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: x..=_. (note condition of pump chamber,condition of pumps and appurtenances,etc.) t 1 r revised 9/2/98 Pages of11 ( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,LL., VOLzi rz< / C2 n }��✓ I Owner. 1`0�.2/�- � `�4�-�-1�+-� J ►x-h"tP S S- iDate of Inspection: SOIL ABSORPTION SYSTEM(SAS): tV (locate on site plan, if possible; excavation not required,location may be approximate by non-intrusive methods) t If not located, explain: ✓2.e,� j,�.j = Zy i f U Y Type: f leaching pits, number:_ Wl y —(0 leaching chambers,number:_ leaching galleries,number:_ (p00 5 n�1b n Cqj--;Ct J leaching trenches, number, length: � �tS— leaching fields, number, dimensions: Flo _C -7Z "y overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) t,j jle i' le Z "I w r Chi — y 1 i r CESSPOOLS:_ (locate on site plan) Number and configuration: 1 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 (cesspool must be pumped as part of inspection) r i Comments; (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) i y: PRIVY:_ /U1 A- (locate on site plan) Materials of construction: Dimensions: 'i Depth of'solids: Comments: i (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) i �I ^ I revised 9/2/98 Page 9of11 =3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4C U- VC, Owner: Date of Inspection: � v� �!-r�1✓�-�'S.SY SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 100 e.F -i l e S;A, 5 , ( u 5Y'*:h kte� sys 4-F re)- y c9ver ACC SS 1 .55 iN LLT Dt-4 ��cw 13 ( 27 AZ Is-7,S-'; 0UtL6T O 13 Z 31�7' r>R>L�wt t: 3 � A 30 Z7 � LEArv140L p ,T I �. I( i r3 / v H6o �- �1 3LJkC�K \/ �L j fl. i ~ 4 II revised 9/2/98 Page loorn j I I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S &iycr/ r/ei fief t�1 Owner: 9"664 El Ca AA Leer 14-C44 SSj, Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar { Shallow wells 's Estimated Depth to Groundwater_Feet s Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) ! Determined from local conditions Checked with local Board of health Checked FEMA.Maps Checked pumping records Checked local excavators, installers �l Used USGS Data C� � S" D"�� A Describe Kbw you established the High Groundwater Elevation. (Must be completed) ' r 49Z �}1t'f„c% MRP Sk" G w. @ CSrp�nCl wad C: L 3i . S Tea L S : Iji revised 9/2/98 Page 11of11 b � A,c� 17D _ No. — Fps. .... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD ® HEALTH -------- .OF................. ................... .---------------__-----------•---------••---- Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Sys ----------- --- ion- r s � or Lo 0 .. ......... - - . -•- .............. ------- -----•••---•------._...•••--•------ .-- -- ••. •-- •--••--.............._..---•-----•-- wner Address - a ------• -- GJ.�i .................................... --•-••-•-- ---- -•--------• ---------------------------------------- Installer Address ..�� Type of Building Size Lot__1,��-�__ _Sq. feet Dwelling—No. of Bedrooms------------ ....._-----------------------Expansion Attic Garbage Grinder ( d Other—T e of Building No. of persons____________________________ Showers — Cafeteria Q' Other fi tures W Design Flow___________ ____ ................gallons per person per day. Total daily flow----,75. _ ...................gallons. Q; Septic Tank—Liquid capacity.' allons Length________________ Width________________ Diameter---------------- Depth................ Disposal Trench—..�To_ ____ ______________ Width.................... Total Length.................... Total leaching area-_______________..__sq. ft. c � Seepage Pit No.._t ._ Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by......................................................................... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water-----------__________-_- (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water________________________ ----------------------------------------••------------------------------•-------•---•--•----•-----........------...__......----------------------------•---- ODescription of Soil......................................................................---•----•--------------------------------------------------------------------------------------•- x U --•--- W •••--•---------------•--•--------••---••-•--••••-•-•-----------•...•••-••-••---------------•----•--------•---------------••-•-••-----•••----•--•----••------•----•••----•-•••--•----•-•---•------•----•- UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ -----------------------------••-----••----------•---------•-•---•-••-•---•-•-----•-•----------•--...__...-•-------------••-••••----••------•--•-•--•••----------•----••...•••------_._...........---•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ii I p of the State Sanitary Code—The undersigned rther agrees not to place the system in operation until a Certificate of mpliance has been ' s by the bear4oealth... Signed••- ....... .........---- - .......---------------C% Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons---------------------------------------------•------------------------------------------------------------------- --------------------------••---------•--••-•------•--------•-------------•-------------------------•-------••-•------------•-•-•---------•-•-•-------•-------•----••-----•--•--•••••--•---••-•--•-•--•- �� Date PermitNo.. ram--- ..... ................................ Issued....................................................... Date I x J THE COMMONWEALTH OF MASSACHUSETTS r' BOARD OF HEALTH Ir Appliration for M-4posal Works Tomitrnrtion Prrutit Application is hereby made for a Permit to Construct (t")' or Repair ( ) an Individual Sewage Disposal system',t .. '........ r f . } tion `c ss ^� f``a..-... or LQKT'N'd'_ ..�..5' ,t'I •yc p -.-......•.✓. �./`'�f�6•°'...... .i................fW. fi....................... .rf R+".�F� ..... Owner ¢� Address I .........•..............!... . ...e Installer Address Type of Building Size Lot e! �:_ Z ...Sq. feet Dwelling—No. of Bedrooms....... ................................Expansion Attic (Mci Garbage Grinder pal Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures................................ .. W Design Flow....... _:: --,---gallons per person per day. Total daily flow--- - ............................gallons. <2 ----------------g P P P Y Y WSeptic Tank—Liquid*capacit} •_ - '. gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No... .............. Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No._!wr"!------------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. it. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_____-_-_--__-_-__ a ... •----------------------------------------------- •....... •.......... ........ ...... .--------------- --•----------------------------------- -... .•------------- 0 Description of Soil........................................................................................................................................................................ x W UNature of Repairs or Alterations—Answer when applicable- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of ?Tt- E ',I or the State Sanitary Code— The undersigned�urttier agrees not to place the system in operation until a Certificate of Compliance has been sued by the..board of health. f Signed rr rf .+ Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons---------------•-------------------------•--------•-----------••-----•----•------------•----••---•-•••••----... --•••-••-------------•---•---•---•-•-•••••--..lir---•----••-•-----•--------•••--------......--••-----•••-•---•-------•----••••-•-••••••-•••-•---•-----------•---•---•••---•-•--------•-•••••••-_..... Date { G Permit Now. . .................................. Issued--•------------••............................•---•----- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................r ...............OF......... ............................... Trrtifiratr of TompliFturr TH-T'�S� TO CERTIFY, That the Individual Sewage Disposal System constructed by ` ski/- �T ..... . . -------------------• ------. ---------- -•----------•----- .......-- + Installer r" at - ... 1sRt_I _.._.. £/� i V '� I --- -----•- has been installed in accordance with the provisions o mT -E j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No ��__ _•_-.`"'��-- dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. �� DATE.............. ...-d.::...�.-•---•-----.....------ Inspector...-•-- ......... ,.._J.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ z'�72 ............... ...... ....... .-.....-..................•--......................... FEE ..................... Dispoga1 Morkii Tonstrurtion rrutit Permission is hereby granted------ -----... -------------•------•--••--•--•-------•---.......---------.....--••-•---------- to Constructor Repair ( ) 1 Ind'vidu Se��a Disposal System _ T .-. t'- G �t . �' "�j............... --.........�................ •-- ``�.•l ,_ ----------------------------------------------- No ..._� . -yi �as shown on the application for Disposal Works Construction _76mit Igo 7__4�`_.�ated..'r'_____ .�� :v�:�--•-.-.... / - IV, — ' Board of Health DATE.' ,""'.'w ---------•--------- t l - , FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ¢p � !'_ � +� �>✓51 G 11 ��. IOTA �' ✓ �'F„ ,� - S1M6tM TAX)u� - epnxwrt5 ^DAIQY Lo S�PnL-I-Rt.s�C : 33D n�saX s �4956�4� i 5 151 Q L15E 1 Gaia C- erLQ►.� S�gr1C-1 aaaK 90, r 17 ls'Po S�L�rT-�- u s E 1�� C a�.�.o u"►�rr Ems, .� Astp" r 160 3 F r Upi4mr %sot,F 02.s: 3z5U� t 2g T Ill A-LEA. CAPA& r<t 606F e; 1.0 so rapes ��V�� �'a-r� -[7>c41 ec N 'F LO u.!/s 425 C.F767 -T-o-rA L. �` �:r �t E�CAL. .TIatJ-RA..-TC I,-vzoq l .Ati:�.255 „t, l f'c,<<R '� �4o t 'l 4`73 FNCHARD Na 124'T's • T aLE. •A,� s � ���.. g 23�13a" f=G, 5zT T6 T '6 To�OF FtiXV sue:..$.. �, laaa cx '5b•G, 50,$ L, �i�, 50!O NY IN o' lEp. cl F.IT e �s-rau H C E RT I F I ED P1-aT At-A EL AA.o 1-0 CAT 1aN: �'—ENT'ECY1L,LIF- t`kk5s �1�.g0 1•L • t � N o ATEV- y TtLOPpSE� I�EErl511✓'Rt2 I �EKT 1 F Y 'l'1-1 ITT'T[�E�ou N►��'�t c!�.Q "s H uw IJ �` -{EtZi=r�t�1 cralyCP!-•-`t5 �1 t�T'N T1-4� 5t�s I-tra� �,.rl L. ��t�.1>�res ��� 5�'T'>-a,�cK "RE�c.1.1�Et�4�NT'S �F-T'�-lE �g►tom�l �.t_E=.�^-� �lhX . rvvc/r.i �F 1�ARN6TA$t�. A Q10 1S ►�O"i" �T�L_1CA1�lT� / l_l_.��.I�t t s .1._ �z7CA�� 4c11T!-4tU 'T"t-i';E '1='1�ZJI?AI..h11.1. THis R..,r�ti 15 N�1'$ASC.P DNAN INSTRUMI;NI �'} SuKYE`f /',NO THE OFFSE1'5 5HOWN 5HauLU tLI 7T C;' TZ) ES"T&T31_15 H LET L 1 N E S. ..., 1:3 X 76'ic: TOWN OF BARNSTABLE _v LOCATIO ( j �,�c i/�f f W SEWAGE # �— tlVILLAGEi/a' r ASSESSOR'S MAP & LOT% ,�I NSTALLER'S NAME & PHONE NO Lqc ° oSEPTIC TANK CAPACITY N 'Y'LEACHING FACILITY:(type) '}� (size) Gd1 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ' Ile,J s"4 l/� DATE PERMIT ISSUED: dZ,-2 DATE COMPLIANCE ISSUED• 15 -- f O - $ VARIANCE GRANTED: Yes No ,/ �� �� � �� 3,� �,��� �� �� �� APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION Lot 675 - Seth., Parker Road NO. P- 4) VILLAGE Centerville DATE 2-8-85 APPLICANT Alan E. Small, Inc. FEE $35 . 00 'ADDRESS Prince Hinckley Road, Centerville TELEPHONE NO. (Non-refundable) ENGINEER Baxter & -Nye,' Inc.-Peter Sullivan TELEPHONE NO. 428-9131 DATE SCHEDULED (Applicant' s signature) II SOIL LOG SUB-DIVISION NAMEC,�t 82\1 i l,LE JAW:t�,_Los7DATE l2-�/ g5/_TIME 0% 3Z EXPANSION. AREA: YES NO tW e `LLL _ENGINEER N TOWN WATER `PRIVATE WELL BOARD OF HEALTH EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in "proximity, to test holes)` NOTES: Q4t .2.21 ' � v � v .1 a PERCOLATION RATE: 1—Z (vtct��� TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 2 2 2 3 3 4 4 5 C,L 5 6 �fl 6 7 8 8 9 9 10 10 11 11 12 �� 12 13 13 14 � Yr�1 14 �h�•t�"��(1" 1 15 5 _. 16 16 ti SUITABLE FOR SUB—SURFACE SEWAGE: LEACHING FIELD K LEACHING PITS LEACHING TRENCHE�pS_PD _ UNSUITABLE FOR SUB—SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P .--E. AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT f LEGEND CENTERVILLE PROPOSED CONTOUR ® PROPOSED SPOT GRADE Z E6 � ETM PARKER R . —— 98 —— EXISTING CONTOUR o vent + 96.52 EXISTING SPOT GRADE } 0 �� W— EXISTING WATER SERVICE CU,ye AMES wAY / 0 \ TEST PIT F�'T 5 Mi44 ��� ens R� / 0 moo. TP 2 53 0 �� 1 b ROUTE 28 /°' L,, ' —1 I ;� LOCUS MAP BENCH* MARK G LOCUS INFORMATION PAINT SPOT ON PARCEL ID: MAP 170 PAR. 188 521// BULKHEAD CORNER TITLE REF: 14301/264 5 3. 2 5 PLAN REF: 386/094 \ I BARNSTABLE GIS DATU \ G GF FLOOD ZONE: PROPERTY NOT IN FLOOD ZONE 00' // EXIST. 1,000G \ / SEPTIC TANK SEPTIC SYSTEM REPAIR PLAN LOCATED AT: P 8 BLACK VALLEY ROAD oT >1/, C, , - - � CENTERVILLE, MA \ s�� \ // \ \ 53 PREPARED FOR \ \ CAROLYN M . BUEHLER/ 51 DRAIN ® READY ROOTER EXC. �o� �/ �50 APRIL 17, 2019 j � � / � O DA E L O T 675 \ _ _AREA = 15043 sf+— \// / h� 1140 <� OCF PLAN BOOK PAGE 94 / / �� '�G�STE o ASSR MAP1 70 PCL 188 / 49 '4NITAR�a� � r I 49, / PLAN O ' — — — — MEYER & SONS, INC. / SCALE.. P.O. BOX 981 1 in = 20 ft O \ O EAST SANDWICH, MA. 02537 O 20 40 r139.27' O 10 20 40 ` PH: (508)360-3311 FAX: (774)413-9468 DRAIN meyerandsonstitle5®gm ail.com SHEET 1 OF 2 J 1894 ELEV. TOP DROP FND. NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (53.3) � = 53.85� F.G.EL: 53.30 F.G.EL: 53.10 F.G. EL: 53.13 VENT •a � MAINTAIN 2% MIN SLOPE OVER LEACHING AREA alow IF .a " F.G.EL: 50.75 ;, 2" OF 3/8" DOUBLE WAS7 HED 3/4" - 1-1/2" ,. . STONE OR FILTER FABRIC DOUBLE WASHED STONE IE3EMEOEM. C) a 6" • ~" 4" SCH 40 PVC a 10 I 14" 6 0 S= 1% (MIN. 7 ®®®®®®®®®®® 4 E SCH ARE 40 PVCE INV. 49.0 ) 2 EFF. DEPTH ®®®®®®®®®®® INV.49.45 INV. 48.83 4' 2 X 8.5' "41 GAS PROPOSED DB-30-1 EXISTING BAFFLE EFFECTIVE LENGTH = 25' _ DISTRIBUTION BOX INV. 49.70 (H20) INV. ELEV.= 48.50 EXISTING 1 ,000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON ����ttUF M9ss9 BREAKOUT OUTLET TEE AS MANUFACTURED BY DAPZR �y ELEV.= 49.50 NOTES: TUF-TITE, ZABEL, OR EQUAL TOP CONC. ELEV.= 49.50 1) CONTRACTOR SHALL VERIFY ALL EXISTING �_ v, PIPE INVERTS PRIOR To CONSTRUCTION vv No. 1140 INV. ELEV.= 48.50ME33 ®®®®®®Ila 2) D-BOX SHALL BE SET LEVEL AND TRUE TO � /STM ®®®®®®GRADE ON A MECHANICALLY COMPACTED SIX ®®®®®® INCH CRUSHED STONE BASE, AS SPECIFIED IN SANITAR�a� BOTTOM EL.= 46.50 3.75' 5 FT. 3.75' 310 CMR 15.221(2) 4 n I , 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK 4 SUITABLE SOIL PROV. EFFECTIVE WIDTH = 12:5' WITH 1500 GALLON SEPTIC TANK IF FAILED, APPROX. 14.83' TO GW DAMAGED OR UNDERSIZED. SEPTIC SYSTEM PROFILE 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 41 .63 _ SOIL ABSORPTION SYSTEM (SECTION) GAS BAFFLE AS REQUIRED (PER BARNS GIS, APPROX. GW ® EL. 31) (500 GALLON H-20 LEACH CHAMBER) GENERAL NOTES: 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL LOGS P#: 15943 DESIGN CRITERIA BOARD OF HEALTH AND THE DESIGN ENGINEER. NUMBER OF BEDROOMS: 3 BEDROOM DESIGN 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: APRIL 8, 2019 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614 LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: DESIGN PERCOLATION RATE: <2 MIN/IN - 310 CMR 15.405 (1) (B): WITNESS: DAVE STANTON, BARNSTABLE HEALTH DEPT. DAILY FLOW: 110 G.P.D. X 3 BR = 330 G.P.D. 1) A 0.80 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING GARBAGE GRINDER: NO (not designed for garbage grinder) TO BE 3.80 Fr (MAX) BELOW GRADE VS REQ'D 3 Fr. (H20/VENr PROVIDED) Elev. TP-1 Depth Elev. TP-2 Depth 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 53.13 A 0" 53.64 A 0" SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE EXIST. 1,000 GAL. SEPTIC TANK TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE LOAMY SAND LOAMY SAND LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F. DESIGN ENGINEER. 52.13 12"10YR 3/2 52.72 10YR 3/2 11' 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING B B FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN LOAMY SAND LOAMY SAND USE TWO (2) 500 GALLON H-20 PRECAST LEACH CHAMBERS W/ 4' ENGINEER BEFORE CONSTRUCTION CONTINUES. 10YR 6/6 10YR 6/6 , , , 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 50.46 C 32" 50.80 C 34" STONE ON ENDS & 3.75 STONE ON SIDES: 25 L x 12.5 W x 2 D 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF BOTTOM AREA: 25 x 12.5 = 312.5 SF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. MEDIUM MEDIUM PERC TEST SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. • EL 4880 SAND SAND 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 2.5Y 7/4 2.5Y 7/4 TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. t It 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND REMOVED PER TITLE 5. 41.63 138" 42.14 138" PROPOSED SEPTIC SYSTEM UPGRADE PLAN 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION �• 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY PERC RATE <2 MIN/IN. (-C" HORIZON) U BLACK VALLEY ROAD, CENTERVILLE, MA AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY - NO GROUNDWATER OBSERVED 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. Prepared for: Buehler/Ready Rooter Exc. 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. Design and Site Plan by: SCALE DRAWN DATE 15. ALL PIPING TO BE 4' SCH 40 O 1/8-/FT (UNLESS SPECIFIED) • I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 MEYER&SONS,INC. N.T.S. DMM 04/17/19 to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO BOX 981 REV DATE SHEET NO. requirements of 310 CMR 15.017. 1 further certify that.1 have passed the Soil Eval. Exam in October, 1999. EAST SANDWICH,MA 02537 CHECKED 508-362-2922 DMM 2 of 2