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HomeMy WebLinkAbout0059 BLUE WATER DRIVE - Health 59 Blue Water Drive,Centerville A= UPC 12534 No. 2-153LOR HASTINGS, MN v,�_._...... . _....;,..-• ��..•.�.�;......,...-._.,......:cam.--. —.,b_,_e,..,. ,.d._ .�. --- _ ._� No. (D Fee l ©v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYication for nizponl *pgtem Cori.5truction Permit Application for a Permit to Construct( ) Repairy) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. (A e—Watcr Ow er's Name,Address, d Tel.No. rvl11e- �al-niie_. 14vcn Assessor's Map/Parcel �5—C)3C� ci Installer's Name,Address,and Tel.No. �JIJ� —,1 ! Designer's Name,Address and Tel.No. �ktV (an a 1 s N �— Type of Building: r. Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building 5 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ggcL.-D 'gn ow provided gpd Plan Date er of/sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to.ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by thNBoardof Health. Signed Date 4)Z jo Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued f No. C �- l �CO 0. Fee A. f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for h6pogar 6p$tem cow5truction permit Application for a Permit to Construct'( ) Repair) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. u e I a-'G� 0 e�i Y 1tLr'ss Name,Address,apd Tel.No. v e_ C �-e n Assessor'sMap/Parcel Installer's Name,Address,and Tel.No. �� - F (0 Designer's Name,Address and Tel.No. /14 Type of Building: Dwelling No.of Bedrooms Lot Size IBC VG sq.ft. Garbage Grinder ( ) Other Type of Building 5 No.of Persons Showers( ) Cafeteria( ) Other Fixtures 4 Design Flow(min.required) gpd Design flow ow provided gpd Plan Date Num ei5er of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil / ) Nature of Repairs or Alterations(Answer when applicable) Y Date last inspected: Agreement: 1 The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disp 1 system, t- accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation umil-d Cer`"tificate of Compliance has been issued by this oard of Health. Signed /� Date Application Approved by /��~� r Date +(� Application Disapproved by: Date for the following reasons Permit No. Date Issuef d a�-7 �( THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS D Certificate of (Compliance THIS IS TO CERTIF(�,��that the On-site Sewage Disposal/System Constructed ( ) Repaired (Y) Upgraded ( ) r Abandoned( )by- at F-ULam/ at `7 A- r• C.( / /0 has been constructed in accordance / with the provisions f Title 5 and he-for Disposal System Construction Permit No. 0 1p dated Installer � �J1 Designer #bedrooms Approved design flow gpd The issuance of this permit shah not b /�nstrued as a guarantee that the system willa's{&signed. Inspector�� , ---- -- (— (—n —/—p�—j--------------------- — — — — ———No. GV < `' Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS wigogat *p5tem C ugtructiou Permit Permission is hereby granted to Construct ) Re air O Upgrade ( ) Abando ( ) System located at w ai1Z Y V YZ V, f✓ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction rust be ompleted within three years of the dadof this perm t. Date 7 O;S � Approved A� , � TOWN OF BARNSTABLE -'—' LOCATION , y � SEWAGE# r`� VILLAGE .; + ] ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) '} I (size) NO.OF BEDROOMS OWNER PERMIT DATE: J Z if COMPLIANCE DATE: Separation Distance Between the: Y 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 t , h, f v TOWN OF BARNSTABLE ��� LOCATION _'��- SEWAGE# _VILLAGECftN -? 1,� f-1 ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. 6 L�P✓�-S SEPTIC TANK CAPACITY J DQ®hCJ O LEACHING FACILITY: t (type) � � (size) NO. OF BEDROOMS OWNER PERMIT DATE: OL4 [I Z-5 ( 06p COMPLIANCE DATE: �J/q-r7AV 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 r F6 31 ® 3 C -nco Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments3 59 Blue Water Drive w n Property Addressy Vaness a Owner Owner's Name information is �/ '£. required for every Centerville Ma 02632 10/4/2,,:!7 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information ` filling out forms C���'` �alpO on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection r� Company Name 74 Beldan Ln. Centerville Ma 02632 Citylrown State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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. 1 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 ocal Approving Authority 10/4/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or .y has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time..This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �V Commonwealth of Massachusetts _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 59 Blue Water Dr Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a precast leach pit. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ 0 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 El ® yste received normal flows In the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 9Pd x#of bedrooms • 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 8/2017 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): l5ins•3113 Title 5lrricial Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original system installed 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): 1 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: 1000 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is Centerville Ma 02632 10/4/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements 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 should be cleaned soon andd again every 2 years for proper maintenance. Water level was even with outlet invert, tank was structurally sound and not leaking. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): d-box was video inspected from tank and found in good condition, no rot and no high stain lines 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): precast leach pit was dry at time of inspection with a stain line approx 3.5'from bottom 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'y 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Citylrown 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 t v Z p 3 .......... (o'b �z �3 )3Z �3 A$ �$6 r33 �rt' /4K �36 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is Centerville Ma 02632 10/4/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Blue Water Drive Property Address Vaness Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i CO>\I_1/IOT\TLAFAL'TH OF MASS CHUSE'TTS �;z ! EXECUTI�7E OFFICE OF E-_N�V"IROi _.,NfENT_U_-FF_ I?S `1t DEPARTMENT OF EITNTVIRONTIVENTaT, PR0TFCTI0 TITLE 5 OFFICIAL INSPECTION FOR` —NOT FOR VOLUNTARY ASSESS)IENTS SUBSURFACE SEWAGE DISPOSAL SYSTEA1 FORM PART A g CERTIFICATION Property address: / /H,_p "-k-,P— 1 D�6 3a2 - ��o� �� rq Owner's Name: Y✓r: h e r! Owner's Address: S- yg tV A��« �wv v, vvr Ile 1W (9a6A2-- o..T Date of Inspection: J,—6, Name of Inspector: lease print)//' /�L✓'� O<��i�� Company Name: �( it 7 Mailing.Address: wr �oLb�f�. Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the se«vage.disposal system at this address and that the' o n zro �%euc: jc below is true, accurate and complete as of the time of the inspection. The inspection, as perfor*k bas=d on r : : training and experience in the proper function and maintenance of on site sewage disposal syste:'M . 1 am gDEP approved system inspector pursuant to Se n 15.340 of Title 5(310 0TR 15.000). The s:s,_n_: : ' Passes w �` Conditionally Passes co r ?seeds Further Evaluation by the Local_ Apn_raring :�nthar r• Fails v Inspector's Signature:vIn4q Date: 3"d 6-C The system inspector shall submit a copy of this inspection report to the Approving AuthoTi •.-(BaaTi of Wealth DEP)vithin 30 days of completing this inspection. If the system is a shared systeri or has a deli n ,a ,:of i,;.O :G gpd or greater; the inspector and the system warner shall submit the report to the appropriate re :an:a_ o f e of the DEP. The original should be sent to the system ovner and copies sent to the buyer. if appl'cable: air-' he a- ro=.-i .g authority. V - Notes and Comments ***`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. lam/ Title 5 Inspection Form 6,/15!2000 page 1 r f Page 2 of 11 OFFICIAL INSPECTION FORAM--OT FOR VOLI,7TARY ASSESS-NIE\TS SUBSURFACE SEIYAGE DISPOSAL SYSTFAI INSPECTION FORM PART A Q CERTIFICATIOiO(continued) Property Address: / g� w 11-vr Owner: G y►O✓►g _ Date of Inspection: SOT 1?— O r Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A�Systasses: t - a,I have o found any information which indicates that am of the failure criteria describe2 in 3'_`) C.•IR 15.303 or in 310 CMR 15.304 exist. Anv failure criteria not evaluated are indicated belov,-. Comments: B. Sy, em ConditionaIly Passes: One or more system components as described in the "Conditional Pass"section need to be replac-,d or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, ..i11 pass. Answer ves,no or not determined(ti',N.ND)in the for the following statements. If"not de-; n ir.2d"_olea_e explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is;tructita'_ly unsound; exhibits substantial infiltration or exfiltration or tank failure is imminent.System frill pays ir_snecmon f he 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 struct<trally sound.not leaking and if a Cerdficaie of Com. liar 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 disuibutio `o-. doe to robe _or obstructed pipe(s) or due to a broken. settled or uneven distribution box. System V ill pass inspe approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced \tD explain: The system required pumping more than.4 times a v ear due to broken or obstucted nioe(s). - pass inspection if(w th approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: T:.t,. . r.._ Page 3 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY _ASSESSMENTS SUBSURFACE SEWAGE. >7.ISP0C_-kL SYSTEAT INSPECTION FOM1 PART A �p CERTIFICATION(()continued) Property Address: c� ! �� 2 �/a.�e✓ ,f/�7v�� Owner: ✓lOvi Date of Inspection: C. Fur er Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to Bete r_= if _-er! is failing to protect public health. safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CN R 15.303(1)(b)that the system is not functioning in P. manner which will protect public health.safety and the environment: _ Cesspool or privy is within 50 feet of a surface eater Cesspool or pri-,y is within 50 feet of a bordering vegetated wetland or a szl.mach 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 wi n 00 fzzt of a surface water supply or tributary to a surface water supple. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a publ:;a!a-er sum-ply. The system has a septic tank and SAS and the SAS is within 50 feet of a private v ate- supple well. _ The system has a septic tank and SAS and the SAS is less than 100 eet but 50 f et 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 cerified laboraio-', for co'_ifomr bacteria and volatile organic compounds indicates that the-well is free from pollu7io tro~_that ac; it`- and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 porn r,-o•idzd TnaT no oth.=r failure criteria are triggered. A copy of the analysis must be attached to this fora. J 3. Other: Pace 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR N'OLLT'-,NrTAR.Y ASSESSMENTS SUBSURFACE SEWAGE DTSPOS.:.L SYSTEM INSPECTION FO.R�\I PART A .CERTIFICATION(continued) Property Address: / � (�6i Tyr ,Ol�l'v- ' 2✓► Vs Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Y"es No _ �,/�ackup of sewage into facility or system component due to overloaded or clogged S^.S or cesspool t/ DischarCe or ponding of effluent to the surface of the ground or surface waters due-o an o.'e-10 ded e.- /clogged SAS or cesspool _6_/ Static liquid level in the distribution boy:above outlet invert due to an o,;erloade' or clogg.e; S S or ��esspool J�rquid depth in cesspool is less than 6"below invert or available volurne is less than da. fo 1 _,/Required pumping more than 4 tunes in the last year NOT due to clogged or obstncted p_pe(s). Na-- _ r�f times pumped .y 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 trib'.ita y to a surface ;ester supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. V,orn'y portion of a cesspool or priory 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_moo a private water supply well with no acceptable water quality analysis. (This s-N-stem 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 ppmI provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.l / (Yes/No) The system fails. I have determined that one or more of the above failur_ cri e-i exist as described in 310 CMR 15.303,therefore the system fails.The system owner sho:ad contact the Board of Health to determine what will be necessary to correct the failure. E. Large Svstems: 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 n.ust indicate either'-v-,s"or"no" to each of the following: Xe g criteria apply to large systems in addition to the criteria above) system is within 400 feet of a surface drinking:;pater supply system is within 200 feet of a tributary to a surface dr'nking eater supply- systern is located in a nitrogen sensitive area(Interim-Wellhead Protecrion A-tea -I"tom ? or-e II of a public water supply A-ell If you have answered"ves"to any question in Section E the system is considered a - "Yes"in Section D above the lame system has failed. The ov-Mer or operator of ary lame significant threat under Section E or failed under Section D shall upgrade the system in aCco- 15.304. The system ovmer should contact the appropriate regional office of the Dep an, nerr" Page 5 of 11 OFFICIAL INSPECTION FOR —' NOT FOR VOLU\'TAR'i' ASSESSMENTS SUBSURFACE SEWAGE DISPOS__L. SYSTENT I\SPECTIO- FOR%f PART ;B C / CHECKLIST Property Address: / ��� WGi`l�lr' O���✓ Owner: (TG1 Vt 0v1 Date of Inspection: Check if the following have been done. You must indicate "yes"or"no"as to each of the follo,ving.: Pu in2 information was provided by the owner, occupant,or Board of Health _ <7eTe, any of the system components um ed out in flee previous two«eeks ? P P P H e system received normal_flog=.rs in the previous two creek period`.' ���Were Hae large volumes of water been introduced to the s stem recently or i; i-lcz-�e-ron � as par o_ t._ - _....�._as built.plans of the system obtained and examined?(If they were not available note as \' Ai _ 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 ? 7e ,. Were the septic tank manholes uncovered,opened; and the interior of the rank ank tnsnec-1ed forh; t.: :0'7u::in of the baffles or tees, material of construction; dimensions; depth of liquid,depth of sludge and den-th a'�scil-n Was the facility owner(and occupants if different from owmer)provided« th info tnaiion on the prone: maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has beer de er -ed eyed o^: Yes o 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 is unacceptable) [310 CMI R 15.302(3)(b)] Page 6 of 1 i OFFICIAL INSPECTION FORM- FOR VOLL1TaIZY ASSES SYFE\TS SUBSURFACE SEWAG E DISPOS.aL SYSTEN'1 I\SPl`^C'TT0N 1`nR-A r PART C: 4 SYSTEM INFOR11ATION Property Address: Gov► ✓y, 6 3.1._ Owner• GCi 0 O Vr Date of Inspection: 0?8 D FLOW CONDITIONS RE SIREN TLAL. dumber of bedrooms(design): Number of bedrooms(actual):-3 DESIGN flow based on 310 C_MR 15.203) (for example: 1 l.0 gpd x=of bedrooms): 3_7D R1 Number of current residents: _ Does residence have a garbage --cinder(yes or no): Is laundry on a separate sewage system(yes or no):;VV_ [if yes separate inspection required Laundry system inspected(yes or no): Seasonal.use: (yes or no):_ Water meter readings, if available (last 2 years usage(gpd)): Sump pump (yes or no):/gyp Last date of occupancy: L4!Q wJ__ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 1 .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): GENTE.RAL INTORMATION Pumping Records Source of information: —"o-e / Was system pumped as part of the inspection(yes or no): V2 If ves, volume pumped: gallons- How was quantity pumped determined? Reason for p ^ping: TYP OF SYSTEM Septic tank. distribution box, soil absorption system Single cesspool _Overflow cesspool _Privy _ Shared system(yes or no) (if yes; attach previcus inspection records. if any) _Innovative./Alternative technology. Attach a copy of the current operation and mainte=_n-e obtained from system owner) Tight tank _Attach a copy of the DEP approv°al Other(describe): Approximate age of all componentsdalt e installed(if]mown)and source of infocr;ation: tVere sewage odors detected when airivin?at the site lyres or no):/� Page ; o4`11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY_ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SI'STFA1IN"SPECTIO FORM PART C Q SYSTE1i1 INFORMATION(continued) Property Address: �/ t�?1(iLe— "14--V. ��� ' Owner: 6a o yr v► c h vvt �� Doi b3�. Date of Inspection: BUILDING SEVER(locate on site plan) Depth below grade: O <11C Materials of construction:_cast iron 4" _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.: Material of construction: concrete_metal_fiberglass_pol\>ethylenz other(explain) If tank is metal list age:_ Is age confirmed by a Cei,ificate of Compliance(yes or no): (a each a co i of certificate) /� — p Dimensions: (p /62 L? f G y G J Sludge depth: v2 "C Distance from toppf sludge to bottom of outlet tee or baffle: Scum thickness:/-eSS— Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffl f / How were dimensions determined: 0%2 9.n ro Tyea/ Comments(on pumping recommendations, inlet and outlet tc.e or baffle condition; st^sctt.ral_ in-eg as reI ed to outlet invert, evi ence of leakage etc.): / ''+ ✓�? /n t/IO d Y R N C/ vlef GREASE TRAP: 4 (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass _�olyethyizne 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 ;;;te =-,• ii _;,_ as related to outlet invert; evidence of leakage; etc.): T:4.1„ C 7.._.,.._,.__ Page 8 of 11 • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY"ASSESSMENTS S A��E."S. IE_ TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPFCTIOe FOP—\I PART C LL C� SYSTEM INFORMATION(continued) Property Address: J / d10 e- e,/ Owner: 62 Vt"p✓J Date of Inspection: TIGHT or HOLDING TANK:/�(tank must be pumped at time of impection)(locate on site Tian) Depth below grade: Material of construction:. concrete . metal fiberglass_polyethylene other`s laii_): Dimensions: Capacity: gallons Desian 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: /�Dl✓''1 a Comments(note if box is level and distribution to outlets equal, anv evidence of solids carrvo er, any. ;denc: of leak e into or out 99f box, et PUMP CHA_OIBER: /( (locate on site plan) Pumps in working order(_yes or noy: Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances. etc): I Page 9 of I 1 ' OFFICIAL INSPECTION ErOR_i7—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-NI PART C Q SYSTEM INFORA'IATION(continued) Property-Address: �! �ue O,vi'ner: 6�jrG'►tit OH _ Date of Inspection: —02 -e O SOIL_ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: TvpeS`�0 y�_ leaching pits; number: leachtng chambers, number: leaching galleries.number: leaching trenches,number,length: leaching fields-number, dimensions: overflow cesspool; number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level ofponding, damp soil. condi ion of v-getation. etc.): /t�0 �G �✓ v2 �— G.e as o S' hs o CESSPOOLS: IV(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 ofponding, conditon of vca_a=:ion. PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (noL-e condition of soil, sins of hydraulic failure: level ofponding. condition of e e.t - r. _T_. . Pate 10 of 11 OFFICIAL INSPECTION FOI2M—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORV PART C SYSTEM INFORIMATION(con'inuec) Property Address: 14e— O«rner• �an0&1 Date of Inspection: SKETCH OF SEWAGE DISPOSAL,SYSTEM Provide a sketch of the sewage disposal system including ties to at least t«-o permanent reference land nar: s or benchmarks. Locate all vwells•.within 100 feet. Locate wwhere public Rater supply enters the bui ding. FfiOnT �S1eP. /5 1�3 /s/ - a 3 3 / T.tic I Page 1 l of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SURSTTRTACE SEWAGE DISPOSAL SY"STE1YI I\SPECTION F-ORAT PART C q SYSTEM INFORIATION(continued) Property Address: .2r/ U��L �i✓ ,a,, e,� p-, e, �� Owner: C G n rpK Date of Inspection: —Q SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 02� feet Please indicate(check) all methods used to determine the high Ground eater elevation: Obtai d from system design plans on record-If checked.date of design plan re,-iev ed: _ served site (abutting property/obse;v ation hole bin 150 feet of SAS) Checked with local Board.ofHealth-explain: 4 A-7S Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mus escrib hove you establish d X hi h gro nd water elex tion: COMMONWEALTH OF MASSACHUSETTS x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m , c DEPARTMENT OF ENVIRONMENTAL PROTECTION � O 49 V s�1b 350 MAIN STREET WEST YARMOUI'H,MA %ra 508-775-2800 VVGGii RRww 4:;; �3 -- �3 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A / y CERTIFICATION MAP 253—PARC 033 Property Address: 59 BLUE WATER DRIVE CENTERVILLE,MA 02632 Owner's Name: LEVIN,KATHERINE Owner's Address 340 WEST MAIN STREET _ HYANNIS,MA 02601 Date of Inspection APRIL 20,2006 s Name of Inspector:(please print) JAMES D.SEARS 't Company Name: A&B Canco Mailing Address: 350 Main Street U; West Yarmouth,MA 02673 -�. r✓ Telephone Number: 509-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information rep,rted below is true,accurate and complete as of the time of the inspection. The inspection was performed based on m 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 CNM 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 4 Date: 4-26-06 The system inspector shall.su mit 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****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 1 t. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 59 BLUE WATER DRIVE CENTERVILLE,MA 02632 Owner: LEV1N'-,KATHERINE Date of Inspection: APRIL 20,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/A I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.30 z exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: ./ ✓ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following 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 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 replaced ND explain: The system required pumping more than 2 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 ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 59 BLUE WATER DRIVE _ CENTERVILLE,MA 02632 Owner: LEVINTE,KATHERINE Date of Inspection: APRIL 20. 2006 C. Further Evaluation is Required by the Board of Health:N/A 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 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 1 of 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: Title 5 Inspection Form 6/15/2000 3 Page of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 59 BLUE WATER DRIVE CENTERVILLLE,MA 02632 Owner: LEVINE,KATHERINE Date of Inspection: 59 BLUE WATER DRIVE D. System Failure Criteria applicable to all systems: N/A You must indicate"yes" or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pit is less than 6"below invert or available volume is less than''/,.day flow 17— Required pumping more than �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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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 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: N/A To be considered a large system the system must service 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 z00 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—IVWPA)or a mapped Zone 11 of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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 CUR 15.30 z. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 Title 5 Inspection Form 6/15/2000 4 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 59 BLUE WATER DRIVE CENTERVILLE,MA 02632 Owner: LEVINE,KATHERINE Date of Inspection: APRIL 20,2006 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,including 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)has been determined based on: Yes No ✓ 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 CNM 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 59 BLUE WATER DRIVE CENTERVILLE,MA 02632 _ Owner: LEVINE,KATHERINE Date of Inspection: APRIL 20,2006 FLOW CONDITIONS RESIDENTIAL✓ Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CNIR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: N/A 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): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: UNKNOWN COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CNIR 15.203): 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: N/A Was system pumped as part of the inspection(yes or no): 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) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1992 PERMIT#02-100 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 BLUE WATER DRIVE CENTERVILLE,MA 02632 Owner: LEVINE,KATHERINE Date of Inspection APRIL 20,2006 BUILDING SEWER(locate on site plan): ✓ Depth below grade: I Materials of construction: Cast iron ✓ 20 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 onsite plan): ✓ Depth below grade: 16" Material of construction: 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 PRE CAST Sludge depth: Distance from top of sludge to the bottom of outlet tee or baffle: g Scum thickness: J 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: —/-'7 S g v t L T � s Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL,TANK&COVERS AT 16"OUTLET BAFFLE. CEMENT COVERS H-20 SHOULD BE CHANGED: NO SIGN OF LEAKAGE OR OVER LOADING. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: s 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 BLUE WATER DRIVE CENTERVILLE,MA 02632 Owner: LEVINE,KATHERINE Date of Inspection: APRIL 20, 2006 TIGHT or HOLDING TANK: N/A (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.,): D-BOX IS 16"X 16"—29"BELOW GRADE,ONE LINE IN—ONE LINE OUT,WALLS ARE GONE. BOX NEEDS TO BE REPLACED. NO SIGN OF OVER LOADING OR SOLID CARRY OVER. PUMP CHAMBER: N/A (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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 BLUE WATER DRIVE CENTERVILLE,MA 02632 Owner: LEVINE,KATHERINE Date of Inspection: APRIL 20, 2006 SOIL ABSORPTION SYSTEM(SAS): if (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: leaching galleries, number leaching trenches,number,length leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE(1)1000-GAL PRE CAST PIT. PIT IS OVER z'BELOW GRADE. CAMERA'D,PTT WALLS CLEAN,NO SIGN OF OVER LOADING OR SOLID CARRY OVER. CESSPOOLS: A (cesspool must be pumped as of ins ction locate on site plan)00 S. N/ ( p p p part pe � p ) 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: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 BLUE WATER DRIVE CENTERVILLE,MA 02632 Owner: LEVINE,KATHERINE Date of Inspection: APRIL 20. 2006 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. 1 .%3 R'Cl,- �'�op, 1�t / 3�P 17 ---------------------------- O do` 1 �I 3F7 , Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 BLUE WATER DRIVE CENTERVILLE,MA 02632 Owner: LEVINE,KATHERINE Date of Inspection: APRIL 20, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 20 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: Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high ground water elevation: TEST HOLE OFF PAST INSPECTION. NO WATER AT 20' BOTTOM OF PIT 10' ABOVE TEST HOLE. BOTTOM OF PIT AT 10' BELOW GRADE. ' d o7�iK Title 5 Inspection Form 6/15/2000 11 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE MASSACHUSETTS \'1 Certificate Of Compliance THIS IS TO CERTIF at the Op-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by S �Litl— at has been constructed in accordance with the ptlAlcl ns f Title 5 and or Dispo al System Construction Permit No. ,� dated Installer LILI � L Designer #bedrooms Approved design flow gpd The issuance of this permit sh4l not b q nstrued as a guarantee that the syste will un 'on si ed. Date �' Inspector A N THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH t ............/owe.................OF.....6 r h/...-----------------------------..._................. Appiiration for Dispu,ial Workii Tnnitrnrtion ramit Application is hereby made for a Permit to Construct (%-) or Repair ( ) an Individual Sewage Disposal System61 at: ... ................. Location-Address or Lot No. gr !Strrlch un.--••-•-•--•---•------------------------ . �� �/�/mss ma.� r� ............................................ ....... Owner Address a ....... .. .. .------ s�.lz r � �47..11�/ r ,E?r �c ----------------------------------------- Installer Address Type of Building Size Lot........ ....Sq. �) aDwelling—No. of Bedrooms.......171—........................Expansion Attic (Alp) Garbage Grinder p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .........-••-••----••---•------- - W Design Flow...................................55•__gallons per person per day. Total daily flow...............................3._2z.0....gallons. WSeptic Tank—Liquid capacity�,:�K&P..gallons Length A.`.G.`... Width. A_'---- Diameter_______ s______ Depth .*.. x Disposal Trench—No. .................... Width...-................ Total Length.................... Total leaching area....................sq. ft. Seepage Pit NO.___otc4..-------- Diameter....1?.---------- Depth below inlet.....-=.............. Total leaching area.32.0.....sq. ft. Z Other Distribution box (K ) Dosing tank ( ) `-' Percolation Test Results Performed by._4,__ ___ '<<(! ----F.<iJ� ter................ Date a <1-./__9 �...... Test Pit No. 1----------------minutes per inch l�e th of Test Pit-____--__•__._-__.. Depth to ground water.. P P P � f3, Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground wa s _ ,..: . $fiEP+i 'iV Description of So>1--------------S-->.et?1cc��ut••--. iP__ ►_f/Prt�a _ -_iz--T--G�?gs,s/.w1 -•-••- ,r At LYE % y; V _!. ..2�.L..' J.1 _ .S.s :rQI�J. .=S �111 !�_ 4tlsf.!+ i���?�T it i �7 0 /? �f!��_..._ -----wiusom--•-- A U Nature of Repairs or Alterations—Answer when applicable................................................................. t' ----------------------------•------•-------•-------•-------•----------------•-------....-----•----••-------------------•-----------------------------------------•••••-•-- '..a Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .."/a..."...o.� Date Application Approved BY -... ��......_- ^.- � Irate Application Disapproved for the following reasons: ..................................................... .... . ... ... .. . . ....................... .. ......... --------------------------------------------------------------------------------------------------------------- ............ to PermitNo. ..... ..........I......�.�..............---.....--... Issued ------------------------------- -------.- Date No.. .. /�.�......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /.own.................OF.......l�. !7q7'f 6/ .............................................. Appliration for Uispusa1 Work.5 Tnnitrnrtinn ami# Application is hereby made for a Permit to Construct ()L) or Repair ( ) an Individual Sewage Disposal System at: 61oc Wo/rr JX>riur_ ZoTS ... _ ........ ......................... ..•---••----•...--------•----------------- .._...------............................. .Location-Address or Lot No. .................................................. Z.f._.. ................................ ............ Owner Address ............................................ .... 2._A/x �? Z. max. Installer Address Type of Building Size Lot......-51/..&0-7-----Sq. feet Dwelling—No. of Bedrooms.......%-!.-c. .......................Expansion Attic (4/0) Garbage Grinder WO) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 0.1 Other fixtures -------------------------------- - WDesign Flow...................................5S..gallons per person per day. Total d it y flow..............................�3 ..Q.. g�allons. WSeptic Tank—Liquid capacityl5 .gallons Length A..-'4(. ----.... Width- ----------- Diameter..._-.-......._. Depth ...... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. i Seepage Pit No....a1_4.-------- Diameter....Y.L.......... Depth below inlet....da............ Total leaching area-5-3.0.....sq. ft. Z Other Distribution box (i( ) Dosing tank ( ) Percolation Test Results Performed by. �� ...€%�� ___`_lll��Secr................ Date'------ _� ....... aTest Pit No. I................minutes per inch Depth of Test Pit_...._._............ Depth to ground water........................ f? Test Pit No. 2................minutes per inch De�th of Test Pit-------------------- Depth to ground water.._ _$hAAAA4 a ��' s _ "���-L[ f�P- ' sod-}�Z --sus`_!7I1�c1�fi j.--------•------ �!-- O Description of Soil._S,s.�=.9ra;r.��/�s��rM• ,�sr 0•w-S/ �.1---�2-t--�----`-- c-,S13��r------------�7. � ' ' / / L �� 9TEPHEpd- r ---------- RLLYfV V --------- -------- . - --------------PP----------------------------------•---------•--...--------------------- '• �' Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------- o r Agreement: "10 JAL '4Ii^,gZ The undersigned agrees,to install the aforedescribed Individual Sewage Disposal System in accord` izcevflit` the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of h lth. Signed ........:............... ....................3—col ............... .. /J Date Application Approved By .......... ........... ` --G,-------- -------------------------------------------- --- Da[e Application Disapproved for the following reasons- --------------------------------------------------------- -- -------- ......................................................... ----------------- - - -- --------- -------------------- --------------- Date Permit No. " 1..................................... Issued .--- ---------"_'".....---..���..-------- ....... .. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH V- .. .N.... ........ OF . -------------------------------- e rtifirate of Contylianre THIS TO CERTIFY, Tha thing' idual Sewa e posal System constructed�p ) or Repaired 11i7'---- --- ............. ' ....L --------�.------li'.�--------- ----------1-. . . . .............--..-.... J-G� 4� Installer ........ ---------------------------------------------------------------------------- ------------------------------------------------------------ as been installed in accordance with the provisions of TITLE e State Environmental Code as described in the application for Disposal W rks Construction Permit No. .,�.---.....`... .......... dated THE ISSUANCE F THI CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCT JN S TISFAACTORY. DATE-...---........................--------7....-�--�--7,2------------------..---------- Inspector ...................... ...'.—'..------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH .��- .................OF.....0.• �. No.. ......--•. FEE.......-•--•-=•-----... M111111sal rkg t�Vr 'Permission is hereby granted--------------- --- ---------- - -- ----- . ................................................... to Construct ( '1-ror Repair ( ) an I dividua/I S>e�a Dispo System at No.------dam-� ......��_-A .... ------ .. .. --...- Street as shown on the application for Disposal Works Construction PexejfR Nbp'�.__ ! Dtted ---� .......... ��•�- .._ Jl Board of Health DATE.-_-*-� / --- --....................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TOWN OF BARNSTABLE LOCATION 9 SEWAGE# 1` -/f 0 VILLAGE C�tiT ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ,01 T— (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 D -/,p - ate' STEP rRoN� 0 o o � l ,p TOWN OF BARNSTABLE LOCATION V��/ G�/.��f ie SEWAGE# VILLAGE C /vT ASSESSOR'S MAP&LOT WSTY �� �,9N r O I1ER'S NAME&PHONE NO. �— SEPTIC TANK CAPACITY 's�� e �iC/S��C /(a LEACHING FACILITY.(type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: CBNtPL4A?ieE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 (3 c it 571P l2� 0 \ 3i fir , ��. -(:OD BREAKOUT CALCULATION: PERCOLATION SOIL TEST 10' MIN. PRECAST CONCRETE RISER, AS REQUIRED DATE OF SOIL TEST 28-9�'q 4' SCH. 40 PVC PIPE SEE NOTES 2 do 3 P[ouidc fo5't fcct WITNESSED BY -- A1NNtr.1C, i 13.C� MIN. PITCH 1/8" PER FT. PERCOLATION RATE L 2 MIN./INCH T.O. FOUNDATION eACKFiLL WITH TEST PIT 1 TEST PIT 2 e �rt 53.0 52 L rr�20 CLEAN SAND 8' MIN. ELEV.- O_ ELEV.- SZ,O -0.00 Tag SJ tL- —o.00 � 'I'of -2 o MOD, F1 Ne 6f-A5 a PITCH —5,5 11 4 1/4" PER FT. / MED SMdD `11�otr'— 7,0� MC:O.��r3 B SA" t> " FLOW LINE b?�-IVEI,.,. (� r 2" LAYER OF mwt),/rite r> loll " WASHED 1ST 14 ONE —12,D (e: 37,0) qq,3 rM'„ 48,e 2-0" lo WATER LEVEL ADJUSTMENT: p DESIGN CALC TIONS : 4,lvsj"reG '"''T LEVEL r (cc 38,L 4'-0" 4 B.6 A 8.4 / o LIQUID r O O ! 3/4" - t 1/2' NUMBER OF BEDROOMS 3 LEVEL , gc�S F 8�56WASHED STONE TEST DATE ' ` ZS '8 1 12,D =WATER LEVEL GARBAGE DISPOSAL UNIT 1/0 DISTRIBUTION Qg'Z / wXK TOTAL ESTIMATED FLOW BOX % INDEX WELL AIUI 2+7 ( //0 GAL./BR./DAY X — BR.) .BO GAL. /DAY WATER LEVEL RANGE ZONE G REQUIRED SEP11C TANK CAPACITY 49.5 GAL / o DEPTH TO WATER LEVEL FOR INDEX WELL ACTUAL SIZE OF SEPTIC TANK 750QGAL FOR THIS MONTH 26 LEACHING AREA REQUIREMENTS SIDEWALL AREA _ GAL./S.F. 1 500 GALLON SEPTIC TANK L3� , 3i WATER LEVEL ADJUSTMENT 7, a BOTTOM AREA GAL/S.F. LEACHING CAPACITY (BOTTOM + SIDEWALL) 6 7 8 GAL DEPTH TO HIGH WATER _ ► ifs, SEWAGE DISPOSAL SYSTEM PROFILE RE� MEACHINc CAPACITY &20 GAL NOT To SCALE BOTTOM OF TEST HOLE pp W1 3 /Vo rrs ' — ��va>psL NOTES: I . LIr".t u{ way!* stlolt c.c.^f t ;;f :it"K'- -,I hmybaicS ow ziLf- ftr,ccr . LEACHING PIT Z. All t-o,,f leorlcrs svic ll clruln' ivitc, cEryweWs , 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO .D.E.Q.E. TITLE 5 AND THE TOWN OF1���T3ptg°�S. RULES AND Nowork s1ic. l1 Prn,c c_c.d vet 11 Zvi Cfz4er o f C,ra,ncG -huyy;, is, Iggt�K REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 12" OF FINISHED GRADE. 3. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE MORTARED IN PLACE. i' 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING. �J �✓ 5. HORIZONTAL AND VERTICAL CONTROL, SEE LEVY, ELDREDGE & WAGNER FIELD NOTEBOOK #:? 6 WET'L.M v0 Loca-rjoN FLP&&ED 8Y BRADFolzE> � .HAi1 t- . ON 9-Z-8.7. fi,eT 9 7 4//owab/c F/oc.., SI toG4= 431f,60 x Z3O IacQ/ac.c 391 c�rcQ LOT L{ L= Iq2,-7Io" �/ Go�°':tlxi 4 Ag-eA � W�141 LEGEND: EXISTING SPOT ELEVATION OOXO EXISTING CONTOUR-------00----- O �. �N z ,3 FINAL SPOT ELEVATION ,,,�_ ----` ✓� ( R/E M FINAL CONTOUR SOIL TEST LOCATION TOWN WATER W W SEPTIC TANK DISTRIPRIMARY�L° ° �LEACHING PIT 73� nn RESERVE LEACHING PIT I� o / 31 !/ / Q WF#12 I�L7Ty INITIAL ISSUE 54 N �wF o - `� \`r �jt f�4 F _� - NO. DATE w yI' / DESCRIPTION 8Y. 4,F. Upc.hiJtl� WF�t SrrTL�Fi_�D t A �,.. wFstr� �a1 p EQ G FI I e. !v '-- _ •-' - O R D E R o f C o 0.own otils, I S S u Ccp on . 2>6.31' � A SCALE: 1" 4p' JOB N0. 12 57 p �' Z ALLYN fi STEPHEN o ° WILSON APPROVED: BOARD OF HEALTH vo LEVY, ELDREDGE & WAGNER ASSOCIAT s/7/" LOCATION MAP . DATE AGENT ENGINM LSNDSCAPE ARCArfBC,"iS PLANNERS LW SURVEYORS ��' 889 WEST MAIN STREET CENTERVTT.T.E MA. 02632 '