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HomeMy WebLinkAbout0067 BLANTYRE AVENUE - Health 67 Blantyre Ave Centerville A= 229-011 X SMEAD No.2-153LOR UPC 12M OMM&OOM • We.b.1J� 1 O =Mono-w m 4SFI '� .n. �ivii 1T1v1iiireaitii 0 RVI "'assachusetiS . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 67 BLANTYRE AVE R operty Address .ELDRIDGE Owner Owner's Name information is CENTERVILLE rggt.jire4 for _ _ MA 02632 7/10/12 every page. C.aw I own — -_. _ 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. ImporWhen filling A General Information When filling out n forms on the loll computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector _ key. DOUGLAS A BROWN INC Company Name rah _ P.O. BOX 145 Company Address I CENTERVILLE MA 02632 City/Town State Zip Code 503-420-4534 Si42g7 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 10/ 2 Inspector's ignature 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. 0 �/ ) � �2 f t5ins•09/08 Title 5 Official Inspection Form. bsurface S ewage Disposal System•Page 1 of 17 Uoilfimonwealth Of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments s 67 BLANTYRE AVE R upen-y AddFess ELDRIDGE Owner Owner's Name information is required for CENTERVILLE MA 02632 every page. Cityrown - — 7/10/12 State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: IRI 1 have not found any information which indicates that any of the failure criteria describe_d in 316 CMR 15.303 or in 310 CMR 15.304 exist. Any indicated below. failure criteria not evaluated are Comments: SYSTEM HAS SEEN VERY LITTLE USE IN THE PAST 6 YRS AVERAGE H2O USE IS 150 GPD 8) 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 ihspeetloh if the biist hg tank is replaced with a eoMplying septie talk 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•09i08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Ilk Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y( 67 BLANTYRE AVE Property Address ELDRIDGE Owner information is Owner's Name required fQr CENTERVILLE MA 02632 every page. Cityrrown dat ea12 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 bok 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): t ❑ 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for VoluntaryAssessments is 4M 67 BLANTYRE AVE Property Address ELDRIDGE Owner Owner's Name information is required for CENTERVILLE MA 02632 7/10/12 every page. Cityrrown �t State Zip Code — Date of Inspection B. Certification 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. El 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 ❑ Z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Z 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 �1 t+o0'i'iiiit'9iiirir'eallth Of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '< 67 BLANTYRE AVE PropeF-1yAd-dFess ELDRIDGE Owner information is Owner's Name required fQr CENTERVILLE MA 02632 every page. Cityrrown Zip C 7/10/12 State ode 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 around water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well. n M 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 20009pd- 10,000gpd. (1 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 anwered"ye-5" t0 any question in $action 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 �< 67 BLANTYRE AVE Rroperty Address ELDRIDGE Owner informatio n is Owner's Name rgquirgc�fgr CENTER_VILLE MA 02632 7/10/12 every page. Clty/Town C. Checklist State Zip Code Date of Inspection Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No El Pumping p g information was provided b p y the owner, occupant, or Board of Health ❑ ® Were any of the components system com Y p s 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? F] 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: I1 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 4 (design): Number of bedrooms(actual): - 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-OWN Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 67 BLANTYRE AVE rfopeFiy Address ELDRIDGE Owner owner's Name information is required for CENTERVILLE MA 02632 7/10/12 every page. Citylrown -- State J! Zip Code Date of Inspection D. System Information Description: ACCORDING TO DESIGN PLAN SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 3 500 GALLON CHAMBERS WITH STONE AROUND Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑_ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? Yes ❑ No Water meter readings, if available (last 2 years usage d SEE BELOW (`�P )).- Detail 2010=112GPD 2011=150 Sump pump? ❑ Yes ❑ No Last date of occupancy: SEASONAL 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•osioa Title 6 Official Inspection Form:Subsurface Sewage Disposal System•page 7 of 17 1 n...-,.... Commonwealth of M'�uSSavlFiliSE''tt$ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 67 BLANTYRE AVE PI operty Address ELDRIDGE Owner information is Owner's Name required for CENTERVILLE MA_ 02632 7/10/12 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: i 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 1 Commnwaalth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 67 BLANTYRE AVE Pfoper ty Address ELDRIDGE Owner Owner's Name information is required for CENTERVILLE MA 02632 7/10/12 every page. City town State — Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: SYSTEM INSTALLED IN 2001 OFF DESIGN PLAN Were sewaae odors detected when arrivina at the site? ❑ Yes IRI No Building Sewer(locate on site plan): Depth below grade: 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.): 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 Dimensions: 1500 GALLON Sludge depth: VARYING LIGHT t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Uommon eafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 BLANTYRE AVE -?roper AdAddress ELDRIDGE Owner Owner's Name information is regiked for CENTERVILLE MA 02632 every page. Cityfrown Zip Dat eat In State Code Date of Inspection D. System Information (Cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness TRACE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 El 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 twi •09108 Title 5 Ofiefef Inspeetfen Form:Sufbsuifaee Sewage Disposal System NO 10 of 17 \ Commonwealth of Massachfusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 BLANTYRE AVE Rrawevty Address ELDRIDGE Owner Owner's Name information is required fir CENTERVILLE MA 02632 7/10/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: S 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 l l of 17 �omonrea6th of ��assachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 BLANTYRE AVE Property Addivess ELDRIDGE Owner Owner's Name information is required for CENTERVILLE MA 02632 7/10/12 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box (if present must be opened) (locate on site plan): Depth Of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE OR SIGNS OF FAILURE 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: NO RISERS FOUND t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 BLANTYRE AVE Propegy Address ELDRIDGE Owner Owner's Name information is CENTERVILLE required for MA 02632 7/10/12 every page. Clty/Town State Zi Code P Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number: IBC leachina chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: El 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.): NO SIGNS OF FAILURE IN AREA OF S.A.S 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 g po System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '< 67 BLANTYRE AVE Property Address ELDRIDGE Owner Owner's Name information is required for CENTERVILLE MA 02632 7/10/12 every page. Cityfrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commoinwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 BLANTYRE AVE PropeFiy Address ELDRIDGE Owner Owner's Name information is reglAred fQr CENTERVILLE MA 02632 7/10/12 every page. Crty/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 I t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Uommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 BLANTYRE AVE FFoperty AddFess ELDRIDGE Owner Owner's Name information is CENTERVILLE required for MA_ 02632 7/10/12 every page. Cltyrrown State Zip Code w Date of Inspection D. System Information (cunt.) Site Exam: Z Cheek Slope IBC 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: You must describe how you established the high ground water elevation: OFF DESIGN PLAN BY SULLIVAN ENGINEERING Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 4 ~ CoiiiiirTiii'vi;ealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 67 BLANTYRE AVE Pvopeq AddFess ELDRIDGE Owner Owner's Name information is CENTERVILLE required fQr MA_ 02632 7/10/12 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems) completed IBC System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ms-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 BLANTYRE AVE CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection: 5/10/06 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. Z 37 2- y ,3 > 0 Z t �f r Page 9 of I OFFICIAL INSPECTION F ORAI- NOT FOR VOLUNTARY ASSESSAIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:. 67 BLANTYRE AVE : CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection: 5/10/06 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: ,hype leaching pits,number: X leaching chambers,number: 3 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.): 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 laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.): PRIVY: (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.): I I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r ye TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 67 BLANTYRE 3�0>/ CENTERVILLE / Owners Name: ELDRIDGE Owner's Address: SAME e Date of Inspection:5/10/06 Name of Inspector: (please print) Douglas A.Brown :...; Company Name: Douglas A.Brown Septic Inspections Mailing Address:P.O Box 145 , Centerville,MA 02632 Telephone Number: 508-420-4534 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000), The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature. Date: 5/10/06 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. Notes and Comments SYSTEM APPEARS TO BE IN GOOD WORKING CONDITION ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different Conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/31/2000 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 BLANTYRE AVE CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection: 5/10/06 inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM APPEARS TO BE IN G0,0D WORKING CONDITION B. System Conditionally Passes: one or more system components as described in the"Conditional Pase' 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 following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health, *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 BLANTYRE AVE CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection: 5/10/06 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 15.3030)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2.System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ the system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 GREENWOOD CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection:5/10/06 D. System Failure Criteria applicable to all systems: You must indicate"yes or no to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 coliform bacteria and.volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 CMR 15.303,therefore the system fails. The.system owner should contact the Board of Health to determine what will be necessary to correct the failure, E. Large Systems: Y To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate..either"yes"or no to each of the.following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well Ifyou have answered"yes"to any question in Section E the system is considered a significant threat,or answered y8s`m 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 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 67 BLANTYRE AVE CFNTF,RVII,I,F. Owner: ELDRIDGE Date of Inspection: 5/10/06 Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks ? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out ? X _ Were all system components,excluding,the SAS,located on site? X _ 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? _ X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3 ))(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:67 BLANTYRE AVE CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection. 5/10/06 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NA Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): �_ A Sump pump(yes or no): NO Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): _ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): _ If yes,volume pumped: 1000 gal gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X 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 awner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed(if known)and source of information: 112 01 HICKEY CONST Were sewage odors detected when arriving at the site (yes or no)? NO r Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 BLANTYRE AVE CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection: 5/10/06 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ (locate on site plan) Depth below grade: a11 Material of construction: X concrete_metal_fiberglass _polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 1500 gal Sludge depth: TRACE Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 'TRACE Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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 LOOKS STRUCTUALLY SOUND AT THIS TIME. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete metal_fiberglass—polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 BLANTYRE AVE CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection: 5/10/06 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:. 67 BLANTYRE AVE CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection: 5/10/06 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: X leaching chambers,number: 3 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.): 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 or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.): i Page 10 of I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 BLANTYRE AVE CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection: 5/10/06 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. A - � s =r�N 2-- 3 7 l a31r 3G 0 I .Z Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 BLANTYRE AVE CENTERVILLE Owner's Name: ELDRIDGE Owner's Address: SAME Date of Inspection: 5/10/06 SITE EXAM c Slopc: Surface water: Check cellar: Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _ Accessed USGS database-explain: You must describe how you established the high ground water elevation: ]Feev v / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Miopooar 6potem Congtructfon Permit Application for a Permit to Construct( )Repair(—f Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.(07 3LA.W1 Y R E ME- Owner's Name,Address and Tel.No. CSN'IERVU..LE WILLIAM ELbfktt)bE Assessor'sMap/Parcel Z'Zgdll (o7 %LAWTYRE AVE. CExrt��vt\.L_E,lYltt} Installer's Name,Address, Tel.No. 4 k h Designer's Name,Address and Tel.No. d & SULL VA1J 6N(o weem0ib �]� 7 PARKek RD. 4a.'6VK (059 7 7 / �/!2R' QSTegV l�l t,MN 0z6SS -4 ZB-W144 Type of Building: Dwelling No.of Bedrooms y Lot Size .49 1?_ 24=t. Garbage Grinder(Na) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 4 S gallons per day. Calculated daily flow 44 0 gallons. Plan Date SEPTEM13ErZ -Zr-. 2.001 Number of sheets I Revision Date Title S ITe PLkA) 'P REPOSED 5E?TNL U'P(oR kbE Size of Septic Tank 150b r ht_ Type of S.A.S.4° IN Ito 19 Description of Soil: O- 1' CAAM� .l-l A ion 3/Z C LOYK S& (OXt6121k6-NfJ MO"RELtIJ(e) 1.+geK Euc6uMERE4� Q EL. Z3 5z: Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees£o 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 Certifi- cate of Compliance has been issued by this d of Heal j Signed Date Application Approved by Date 's Application Disapproved for the following reasons Permit No. � /` �'� Date Issued 4. y*/l o Fee Entered in computer: V _ - THE COMMONWEALTKOF'`MASSACHUSETTS - es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 0(pprtcattonlor )Sts�pooar bpoten. Conotruction Permit r ` Application for a Permit to Construct`( . )Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components 4, Location Address or Lot No.Col bLkW 7 Y R E Iry E. Owner's Name,Address and Tel.No. LE.N1&RVu-LG WILLAAM ELDRIDCC Assessor'sMap/Parcel 2-Z901\ V7 P,,LANTY'RE AvC CGVTI:.ti-v(L.L_E, *) Installer°s�Name Address,_and Tel.=No�_ / Designer's Name,Address and Tel.No. �_ ---- ►G to h �f SuL�a�Av ENU�uEEZ�vC 71�A �,ox (r I�q - L 44 Type of Building: Dwelling— No.of Bedrooms Li Lot Size Lill /\(_ sq;;7-ft. Garbage Grinder(NO) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow LI S 0 gallons per day. Calculated daily flow LI 4 0 gallons. Plan Date ZG, Z00t Number of sheets I Revision Date --- Title SRE ["LAA (PS12 -SEA 5ErT1L UP(oR1��E Size of Septic Tank ►50b C-h Type of S.A.S. ` Description of Soil; 0-.-I LOAM, •l-1 A IoYR 3/z , i'Z' G I0Y�Z C (UYrZ S�(o �OX1D12i+�(O-NO MOTZeLI)Jtol I,�ATr� L uCLIuIJt�iLtz1� �l-• Z3 .'JZ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this °o d of Heal 1 � �-..;��, Signed Date //O" _� Application Approved by 104te:�'f Application Disapproved for the:following reasons -s. Permit No. 4(A—11150,17.7 Date Issued /'°$ ———————————— —————————————————————————— THE COMMONWEALTH OF MASSACHUSETTS � d BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER Y, that the On-s a Sewage Disposal System Constructed( )Repaired( Upgraded( ) Abandoned( )by '�c e kC4 N at G7 PjLANT I e CENT-ZUILLI MA has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N 6. /—*77 ated/i0°-`/0` Installer Designer The Dante issuance of this ermit shill not be construed as a guarantee that the'syste %will ffunct`on s designed. /1 l 1 r4 J C� Insp ector > ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigozar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( V1.5 Upgrade( )Abandon( ) Systemlocatedat Cal 3LANTytZC- AVt. CE1JctZ����� Vl1A and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co.astrucwtio_nmust be completed within three years of the date of thi -tmit. Approv Date: { TOWN OF BARNSTABLE LOCATION SEWAGE # e9W��' VILLAGE :_: ASSESSOR'S MAP & LO74 T INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /✓f/ LEACHING FACILITY: (type) (size) NO. OF BEDROOMS Ps ix S) BUILDER R PERMITDATE: ©� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility. (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If'any wetlands exist Feet within 300 feet of leaching facility) Furnished by i i I f TOWN OF BARNSTABLE , Lr"s!CATION bf XA SEWAGE # a 467T VILLAGE a ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ��Ie ` �. LEACHING FACILITY: (type) — (size) NO. OF BEDROOMS X �) BUILDER ORO;ISOWI- R'E PERMITDATE: & f� �� COMPLIANCE DATE: I 2 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 .�, e 4 � ��W. � �'�� ' ` �� 1,972 No................_.._..! Fus..... 5................ THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ..........�--4----- ...........OF........ .09 A GE......................................... • ApplirFation for Disposal Works Tonstrnrtiun thrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: r ................_.... ......C. ........ ......... ........gr..........--•._ •. ------.-..---- Location-Address - 2,110* -•-•--------- ........ '.:41 -------------------- --------•••••• .�'- G` ......_.._...... ......• .........._ A!G!1.111.V Aess+ 5 Installer y� Address Type of Building . '' 4t Size Lot. , --L .5_.... t a Dwelling Building of Bedrooms.__....•.._......5......................Expansion A�ttf' ( ) Garbage Grinder( p., Other—Type of Building ............................ No. of persons..............-� ---.-_--- Showers (Y, — Cafeteria ( ) a' Other fixtures __________________________________ W Design Flow..................5!`r ......._....._..gallons per person pier day. Total daily flow____-___-_____._3�C...............gallons. Septic Tank—Liquid capacity. 5COgallons Length_J10!7 o''.. Width.-V--I __- Diameter________________ Depth.S.719".. W Disposal Trench—No. .................... Width.................... Total Length.................... 444 ........_ Total leaching area.................... ft. Seepage Pit No-----------'--------- iameter.........�__..... Depth below inlet_...&........... Total leaching area... !4 ..sq. ft. Z Other Distribution box ( ► Dosing tank ( ) aPercolation Test Results Performed by.................................... Date........................................ Test Pit No. 1.... Z_.__minutes per inch Depth of Test Pit _._....I Z...___ Depth to ground water........_........_.. (i Test Pit No. 2546%.W._minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:4 ......... .. Description of Soil_.._0_-'Z�....��._+.�-t1�S,a.Q ....... !.�------(p^_��----- i�11!l..�e�_A W UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed I'94ividual Sewa Disposal System in accordance with the provisions of iITI:j 5 of the State Sanitary Code— e undersigned rther ees not to place the system in operation until a Certificate of'Compliance has beA��edby the boa iealth. Sign -- - ._..... ..... •-- --.._.....••. ••--••......-•--•.•-_... ..............................•- � Date Application Approved By...=e + --- •. • . �. ----.. ..-- Date Application Disapproved for the following reasons:-----•-•-----------------------------------------------------------------------•--•--•------•--•-•-•••......•--- Date Permit No......................................................... Issued_ 2^.2 ._- ....._ Date No................... i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH x ...._....- 1/4.�. .................OF...........-...-.Z.0 d1A Gz....------............................... e , Appliration for Di-qp.aiial Works Tonstrurtion Vamit i p Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: \` .......... _... ......... . ••-• ............ ...................... ...•-•. -••--••--•••------•-•••-......................... Location. dress or Lot No. w 0 ................ ••. ............••• ••--• -•----•-•••• • ••• •. . •. .. .................................................................................................. Address W ............ ------- Installer Address Type of Building Size Lot_ �------_.��" �""�t. Dwelling—No.No. of Bedrooms....................` ...•._....._...._..Expansion Attic (. ) Garbage Grinder a 'i p, Other—Type of Building ......................... f--No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................................. W Design Flow......................S........*......-.__gallons per person per day. Total daily*flow................ 1 ...............gallons. WSeptic Tank—Liquid capacity.1500_gallons Length-P-7 4'.�__. 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..9!- ...sq. ft. z Other Distribytion box ( ') Dosing.tank ( ) '-, Percolation 'Vest Results Performed by...............................................• • r -•-----•---•----- Date........................................ Test Pit No. I.... .....minutes per inch Depth :of Test Pit...... ....._. Depth to ground water.......'".".'............ (i Test Pit No. 2.-i�._ ..minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil •Z.--.. tM. .. ? 1 - Al x W >4rI 9 M ........................................................................................................................................................................................................ UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ Agreement: r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11S 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign ..............i..................... � ��Application Approved BY t"' +------------------ --- t ' Date Application Disapproved for the following reasons:..................------•••.••-----•-•••-----....----•--•--••......--•-•-•--••--------- -••------.......... -•------------•......................•--.....---...............--------•------- -- ------------------------------------.......... Date PermitNo. Issued•....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................1�!... 'l.!t�11.O F. 't'" ............... Trrtifiratr of Toutpliattrr 0. 40 T I Ind Se gage .� is o al System constructed ( ) or Repaired ( ) by..... ..... ....•--- ---•- ""'°` � ----- -------------•-- at......•-•.•..... --- ...... ------......-------------------�' ff`-.�....... -----/---. -------- ------ ... --- ----••--------------- has' been installed in accordance with the provisions of T � tto e State Sanitary Cole": d,es* L4 in the application-for Disposal Works Construction Permit No......................................... dated_............................................... THE `ISSUANCE OF THIS,CERTIFICATE SHALT. NOT BE CONSTRUED-AS A GUARANTEE`THAT THE SYSTEM`WILL„ FUNCTION SATISFACTORY. ector.r DATE ------••-•--......--'--•-------•-•-•--.......• Insp ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD. OF ALTH ............. ..... '' ............................................... .............--••-................. No...................2FEE........................ R Permission 'is hereby granted.............. ---------- E. •------------• ....... Construct ( nor epair ) I i dual t?vt ag i os S s AC Stree �y' as shown on the application for Disposal Works Construction Permit ' ... ... ............... ,. r .Board of Health DATE.--•---•----------------- - FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - - C7A t%--f ;r x>w : t to i 3 �o tot G.P.D t Gl�i 52PTtiG TQ.WtL = 495 'd200%" .` Rao 6.pr.> u�E I�ao 't>15 PC0SAL- GPI-( V;6 (cPon 64 31 tx�.tiAt.L ALMA l as iF-� oz"5 - �4"'20 Gpv SOTTOMI A2F-A,- 12, 5 `l6 SF t•o Ole, ToTr4 t- L7ESt 6 N ___ it, nn Psec :>L,&'r tc>w P,,4TC-. t i to 2 Mtt.J oe- A. f A tt , TOP Fop = too" it Ir 4..�v� ,�A► Iuu • 97,U LOAM (S00 Iwv- 4 DKIr tYbt AL1... QG'? Sisp,S. x. %4 Bo S6Pt'IG I TpU1L � 14V. twv Caa�, GAL, e�G,a qG•Z :.. LSA4(-A !r PIT VJM4 ' wArsu�u f It Vo we lAWD �.s CAL.T t FI�.Sa Vt--oT pt_A to �cZo F� L t,,carto�-1 106TEQ-yl �85 i2, f Wo Sc4L 5G 111, 4.6 U A'T'Qr-- /-a t GrL2TtF`f TNAT T"S:- �OVWDA"C OQ swmm4.1 pt-Q 1.1r C2�i=Ek .iG� "alL'e.0..1 GompL-Y s wtrH -rwE - AND SET-BAGtC CLMQUI¢r--MS"TS of We LC pa-rE Ig BAx�-Ee �, u�� t4.r�•. 2%sT a TLEt> L&w ra ;( .V per. T64 4 Pt,.&Q tt UOT 'BASED OU AU ItJ4MM�.uT CXVTE.iZVI • r Ao(A.S+S• 5V2%re`f 4 TOC► 0t=FlQwT9 4"00LtP WOT VW USer> QpPt.tGAuT 1D T�E1ltiCM i NE i,•oT I.tIJEz. �eVt� �`'lJ��1,.... ... 24 �fl PST 30 C4 t \�= 4v � a7 l O C A.T Fo-IN SEWAGE PERMIT NO. VILL*GE r-1A INSTALLER'S NAME i ADDRESS �//�/Ar-s /,J/�i✓rtl D Gr? s?frfi /Z/l 9 UILDE R OR OWNER �ir�Te'�tyi//ems DATE PERMIT ISSUED DATE COMPLIANCE ISSUED jj. /411_ 2 jp �. gy i t E 5 1 ] 1 DESIGN DATA F.G. 34.0 FG.34.2 Single Family-4 Bedroomrl ' UCRFi\NG olTcl f No Garbage Grinder Add 0.5 of Stone Above Leach.Chamber Daily Flow: I10 x 4 =440 gpd 31.2 _30.2 to Meet 3 Max.Fi II. Septic Tank:440 gpd x 200%=880 gpd 1500 Gallon r Top 30.7 Use a 1500 Gallon Septic Tank. 31.0 Septic Tank 30.8 Bot. 29.2 LEACHING AREA I Adjust Exist.House 30.6 30.4 5 LaT P.T2F_A 440 gpd/0.74=595 s.f.Required Sewer to New Invert. Z 0.49 Sidewalk 2(12'+38')2=2C0 s.f. Bedding as Corrected Ground Water Bottom Area:12' x 38 = 456) s.f. Per Title 5 Elev.24.2 12/08/99 0 656 s.f.Total Prcvided. See Dunbar Variance. LEACHING CHAMBER DESIGN DELVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM Ot W Al I Pipes to be Schedule 40 PVC. Use 3 Not to Scale o_ -500 Gallon Leaching Chambers in a m 12'x38' Washed Stone Field as Shown. 0 o � 3 N m 0 ' W Firdeh 0 NOT To SCALE_ Grade 2 % Filter m .Com ailed FIII /F _ n Fabric D N$R w w N 1/8"=I/2" j Pea Stone in 4 Leochinq _l I/2" NOTES 3 N Clwmber Washed Double - v 1. Water Supply For This Lot is Municipal Water. i2 a,—I—'o I 2.Location of Utilities Shown on This Plan Are Approx. FA. At Least 72 Hours Prior to Any Excavation For This Project The Contractor Shall Make The Required CROSS SECTION OF CHAMBERNotification to DIG SAFE-1-888-344-7233. 3.The Contractor is Required to Secure Appropriate TX ._ Permits From Town Agencies For Construction Defined byThis Plan. / 4.Install Risers as Required to Within 12"of Finished Grade. S.All Structures Buried Four Feet (4') or More or I 1__� _ / Subject to Vehicular tobe H-20 Loading. N ovI ?_0'W 1-60.0cr 1 6.Septic System to be Installed in Accordance With 310 CMR 15.00 Latest Revision And The Town of BLANTYRE AVE. Barnstable Board of Health Regulations. PLAN VIEW , 7. All Piping to be Sch.40 PVC. Scale: I tt=30t '.1 - I i 3 - 5G0 GAI_�o\.1 eP, ¢ e L6AC.W%NCr GHC\M%rzRS i -0 �Ga a Ip� AS- BUILT SEPT/C UPGRADE 3/,V II/2"E)OUIBL-izz ; SITE PLAN cQ WAS"et) STONE .' AT C� 67 BLANTYRE.AVENUE FROM E>-BOX CENTERVILLE , MASS. . OR WILLIAM ELDRIDGE LEACHING CHAMBER PLAN SCALE: AS SHOWN DATE' SEPT. 26, 20CI Not toScale SULLIVAN ENGINEERING INC. OSTERVILLE , MASS. <_ 1 �' 0