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HomeMy WebLinkAbout0056 BRALEY JENKINS ROAD - Health 56 BRALEY JENKINS RD, CENTERVILLE A= 171 185 UPC 12534 No.._.?153LOR HASTINGS,MN Commonwealth of Massachusetts Title 5 Official Insp�cction Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >.•'' 56 Braley Jenkins Road Property Address Shelly Davies Owner Owner's Name - - — information is required for every Centerville MA 02632 4114115 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 I on the computer, - � ./ �,� use only the tab 1. Inspector. 1 key to move your cursor-do not Michael DiBuono key the return Name of Inspector Y• DiBuono Sewer and Drain raa Company Name _ -- 8 Johns path i Company Address S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 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 Authoritv 4/14/15 Inspector's Signature Date —The system inspector shall submit a copy of this.inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 17 ✓A Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 56 Braley Jenkins Road Property Address Shelly Davies Owner Owner's Name information is Centerville _ MA 02632 4/14/15 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or,E/always complete all of Section D A) System Passes: ® 1 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 system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in.place. The Distribution box is level and at normal level. The leaching is made up of infiltrators (10'x30'x3') and at time of inspection levels appeared to never have been-above-normal levels. x 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): 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkin s Road Property Address Shelly Davies Owner Owner's Name information is Centerville for every MA 02632 4/14/15 _ page. Cityrrown 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 Sins•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 56 Braley Jenkins Road Property Address Shelly Davies Owner Owner's Name information is required for every Centerville MA 02632 4/14/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water.supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 1/day flow l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Shelly Davies Owner Owners Name information is required for every Centerville MA 02632 4/14/15 page. Cltyrrown 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.Iarge., system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM a,•'' 56 Braley Jenkins Road Property Address Shelly Davies Owner Owners Name information is required for every Centerville MA 02632 4/14/15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following:' Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ I� Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): --------- -- - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 {9J Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Shelly Davies Owner Owners Name information is required for every Centerville MA 02632 4/14/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of infiltrators (10'x30'x3') and at time of inspection levels appeared to never have been above normal levels. Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d 206.04 gpd 9 ( Y 9 (gpd)): Detail: 2013: 150,000 gal and 2014: 135,000 gal Sump pump? ❑ Yes ® No Last date of occupancy: date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) — I Basis of design flow(seats/persons/sq.ft., etc.): — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Shelly Davies Owner Owner's Name information is required for every Centerville MA 02632 4/14/15 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: Bortolotti Construction: 2013 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site glass on truck Reason for pumping: Maintenance 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road _ Property Address Shelly Davies Owner Owners Name information is required for every Centerville MA 02632 4/14/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 7 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18 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.): System is vented throu ht the roof Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon " Sludge depth: 3 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 } Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M a,••''V 56 Braley Jenkins Road Property Address — -- Shelly Davies Owner Owner's Name —— — -- information is required for every Centerville MA 02632 4/14/15 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 24 — Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: NA 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 ;M ,.•'�F 56 Braley Jenkins Road Property Address Shelly Davies Owner Owners Name information is required for every Centerville _ MA 02632 4/14/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. 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 El 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 l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ., 56 Braley Jenkins Road Property Address Shelly Davies Owner information is Owner s Name required for every Centerville MA _02632 4/14/15 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 At Normal Level 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.): Distribution Box is level and at normal level with no signs of carry over or decay. 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-3/13 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 56 Braley Jenkins Road Property Address Shelly Davies Owner Owners Name information is required for every Centerville MA 02632 4/14/15 page. City.Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 10'x30'x3' ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Infiltrators Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of carry over. no signs of hydruulic failure. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Shelly Davies Owner Owners Name information is required for every Centerville MA 02632 4/14/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of ponding or hydrualic failure. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M ,•'• 56 Braley Jenkins Road Property Address Shelly Davies Owner Owners Name — ------ information is required for every Centerville MA 02632 4/14/15 page. City/Town State Zip Code Date of inspection— D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 TOWN OF BARNSTABLE LOCATION �v �/ , �� ,�,�,� ✓Zi\ VILLAGE / AS SEWAGE — -� ASSESSOR'S MAP&PARCEL INSTALLERS NAND& PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) d /—,4 C ro ,:_ ?�-,�?, _ (size) /d ;�c 3e,IX-.7 ' NO.OF BEDROOMS OWNER PERMIT DATE: 7 j1=U COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist S r 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 teaching facility) FURNISHED BY r— Feet J�2� JV(� duo 13 � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 56 Braley Jenkins Road Property Address Shelly Davies Owner Owners Name information is required for every Centerville MA 02632 4/14/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ ft 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: 6/8/2008 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data shows NGE at 12 ft plan dated 6/8/2008 Engineer David Flaherty. Before filing this Inspection Report, please see Report Completeness Checklist on next page. !Sins•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 56 Braley Jenkins Road Property Address — Shelly Davies Owner Owners Name information is required for every Centerville MA 02632 4/14/15 _ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. . cr"0 V V ~ 1. Fee D THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zpplicatiou for 3h5pont *pgtem Cori.5tructiou Permit Application for a Permit to Construct( ) Repair(4,4upgrade( ) Abandon( ) ❑Complete System U Individual Components Location Address or Lot No. ' 7 Owner's Name,Address,and Tel.No. / CL• L /1 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �4'"2�� ' c GW/�' Designer's Name,Address and Tel.No. y>—L/�����Nj n) 9'3q r9a/� fL 5-a 6 41-r 113- j"a`d-362--50-v Type of Building: Dwelling No.of Bedrooms Lot Size /f,OUO — sq. ft. Garbage Grinder ( � Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 3/� gpd Plan Date Jyft,e ?&-'00 16, Number of sheets Revision Date Title T/4r s' n& / 6 sc, Y +N fits. AJ Size of.Septic Tank ,,ODO GaL E Type of S.A.S. y— 3oSa Description of Soil V. a n Nature of Repairs or Alterations(Answer when applicable) Y it L-owe 11 {•— /G Date last inspected: Agreement: The undersigned agrees to ensure the constru ki9 and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the vi nmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o e Signed Date :Z/ Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. 26 3 Date Issued 77��5 (� fNo .�Oos Fee �Od t' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �-Ix PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Mi5po!5al 6p5tem Con0tructiou permit Application for a Permit to Construct_( ) Repair(c,) Upgrade( ) Abandon( ) ❑ Complete System �Individual Components Location Address or Lot No. Owner's Name,Address;and Tel.No. { Assessor's Map/Parcel / Installer's Name,Address,and Tel.No. /./oy' 2'/c�� CG*oJ/� Designer's Name,Address and Tel.No. y>— ,CAI�%,�f�j n,� 9� 47)9 ZVk-5�97ti /,4- 3GZ-0"y/ Type of Building: , Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder (1)q1:1 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided gpd Plan Date _Tv)r�r /Number of sheets ��r Revision Date Title /,, /.,/ s— , 4+ Size of Septic Tank !./.'ll/1 /./ /=x a r .�a� Type of S.A.S. 3.,y5zj L 4-//l/r,- Description of Soil. 15 , 04, Nature of Repairs or Alterations(Answer when applicable) &., 1lr Date last inspected: Agreement: f The undersigned agrees to ensure the constructed and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enf;�"r•nmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Signed �/,/-,.. Date '7 1 L/A Application Approved by �\ GLlAe1 t?/;'I N I Vl �''l,/e�7 f/ Date -7 I /4/n Application Disapproved by: v w r r r r Date f for the following reasons Permit No. f5 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate, of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) 44 Abandoned( )by llw at f/,, T �_. T:� �.,�r /1 l /�,.,� // has been constructed in accordance i r� with the provisions of Titfe 5 and the for Disposal System Construction Permit No. �� dated Installer /4r r,�,�n r��i Designer Z�� r a #bedrooms Approved design flow �/�> „/ gpd The issuance off�thhis`ermit shallun not be construed as a guarantee that the system will ion as designed. /® Date / /��,� Inspector hs t , .� --v No. 1;?00 — Fee �/10J — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=1!5p0,5a1 6p.5tem Construction Vermit t Permission is hereby granted to Construct ( ) Repair ( G/ Upgrade ( ) Abandon ( ) � J / System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the'following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. � /t Date (� Approved by ►r n L U ti Town of Barnstable Regulatory Services Thomas F. Geiler,Director NAM ' Public Health Division 1"9- ► Thomas McKean, Director 200 Main Street,Hyannis. MA 02601 Fax: 50s-790-6304 Office: 508-862-4644 Installer d: Desiggnerfertification Form � oZO� " a Assessor's Map\Parcel I7� IeS -/ Date: 'a�y 0q SewaDe Permie, �Ai J�� Designer. �Ot� _aP_ n Installer 0 /OA q Address: �� 0 ' 60 X 70 Address: l3 � �, � Ml4- l"�cw✓�•�.o , Ito On �g 1 t�' � '���' °" was issued a permit to install a (da:e) (installer) do based on a design dra,.jm by septic s;'stem at �L J�LZ.l v ewn (ad .e55) In n e dated (design.. ; I ctndfy that the septic s.,,stem referenced above was installed substantially according to the design -which; -which ma;° include minor approved changes such as lateral relocation of the distribution boa andlor septic tank. I certify that the septic system referenced above -was installed relocationi ot any cha omp (i.e. nreater than 10' lateral relocation of.the SAS or any vertical nt Of the septic system) but in accordance -Arith State & Local Regulations. Plan revision or certified as-built by designer to follow.. ARNE H yes nst.al Signature) ©N� No 30792 S T NAt (.�ffIx Des; e.,"s Stai—p Here) "(Designer's Sign �) ` . PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF CO;�ZPLl.4NCE WILL NOT BE ISSUED NHEALBTOHTDl�ISION.wq OTHAI\KNDpUS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC Q:Health/Septic/Designer Certification Form 3-26-04.6oc Town of Barnstable Barnstable Regulatory Services Department j aicaC j • UARNSrABLe, MASS. i679• Public Health Division �g ATfb""o� 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO June 4, 2008 Rob Miller 56 Braley Jenkins Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 56 Braley Jenkins, Centerville,MA was last inspected on May 6, 2008,by Patrick M. O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty(60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline-period will result in future enforcement action. PER ORDER OF4R.S., BOARD OF HEALTH Tho as cKean CH Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 9723 Q:\SEPTIC\Letters Septic Inspection Failures\56 Braley Jenkins.doc t Commonwealth of Massachusetts r Title 5--Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '• 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for Y every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. ImpoWhen filling A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 ream Cityrrown State Zip Code 508-428-1779 S1 12855 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 ppivYlny Authority L (" _ _\ �\ 11� May 6, 2008 Ins ector's Signature Date 1 The system inspector shall submit a copy of this inspection report to the Approvf�t�' Authority9(Bodrd of Health or DEP)within 30 days of completing this inspection. If the system is a s ared system o'rT has a design flow of 10,000 gpd or greater, the inspector and the system owner sh II submit tpe report to the appropriate regional office of the DEP. The original should be sent to t e systerfpowner 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. 08-105 Miller.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 . _ Commonwealth of Massachusetts Title 5, Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for Y every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 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 08-105 Miller.doc•08106 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of 15 I t Commonwealth of Massachusetts Title 5, Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is required for Centerville MA 02632 May 6, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ND Explain: 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 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. 08-105 Miller.doc-08108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts . Title 5, Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for y every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a.private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ 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. 08.105 Miller.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I Commonwealth of Massachusetts Title 5, Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for Y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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..l 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 16,000 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. 08-105 Miller.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 L Commonwealth of Massachusetts Title 5- Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for Y every page. Cityfrown State Zip Code Date of Inspection C. Checklist - Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 08-105 Miller.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 f Commonwealth of Massachusetts : Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is y required for Centerville MA 02632 May 6, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No 6,000 gal. _ Water meter readings, if available(last 2 years usage (gpd)): 28 28 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied 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: Last date of occupancy/use: Date Other(describe): 08-105 Miller.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 i Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tak pumped two years ago. 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-105 Miller.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 f Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Y required for Centerville MA 02632 May 6 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' 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): 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: 8.5' long x 5.2'wode- 1000 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 26" 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? Measured 08-105 Miller.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 : Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tank is structurally sound and could be used with a new leaching system. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 08.105 Miller.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 15 f I : Commonwealth of Massachusetts Title 5- Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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.): Liquid level was found at bottom of single outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-105 Mitler.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5- Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Type. ® leaching pits number: One 6x6 pit. ❑ 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.): Liquid level iin pit is currently at bottom of inlet pipe with evidence of surcharge over top of structure, pit is in hydraulic failure. 08-105 Miller.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 .'� Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 08-105 Miller.doc•W06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road ,p Property Address Rob Miller Owner Owner's Name information is required for Centerville MA 02632 May 6, 2008 every page. City/town State Zip Code Date of Inspection D. System Information (cont.) 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. Braley Jenkins Road Water Service \ \ \ \ \ \ \ \ Y Y \ \ \ Y \ \ \% \ \ I / / ! / ! I . ! %/ / / \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \/ / ! / / I / / / / / / /\ \ \ \ \ \ \- \ \ \ \ \ \% \ Y% \ \ \ \ \ \ \ \ \ \ \ \ \ / / / / / / ! I / ! / / I / /%/ /I./ / / / 11 %\ \ \ \ \ \ \ \% \% \% \% \ \ \% \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ % % % % %/%/%/%/ / /-%/ / /%/%/ I I%/ % / / / / / J / / / / / / / / / / / / / / / / / 31 25 3 29 '�I 4 ,` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Braley Jenkins Road Property Address Rob Miller Owner Owner's Name information is Centerville MA 02632 May 6, 2008 required for Y 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 ground water: N/A 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: 08-105 Miller.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 I 00tiz: Town of Barnstable , r ,. , ' o Regulatory Services t �B Thomas F. Geiler, Director AIE1��A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable.Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction.Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:ISEPTIC1Disc1aimer Private Septic[nspections.DOC TOWN OF BARNSTABLE LOCATION SEWAGE#c�?V � VILLAGE l.Po iti,Ile ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ( ,4�- 3vr� (size) �� X.z NO.OF BEDROOMSf J OWNER PERMIT DATE: Ire 3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) , Feet FURNISHED BY ✓ 3� r 771 yo'�r 9 COMMONWEALTH OF MASSACHUSETTS A ro EXECUTIVE OFFICE OF ENVIRONMENTAL AF DEPARTMENT OF ENVIRONMENTAL PR O UV ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 C 2 J 9 ✓ 1998 WILLIAM F.WELD * UDY�C�AO Governor ARGEO PAUL CELLUCCI STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO d' bimissioner PART A. CERTIFICATION Property Address: 56 Braley Jenkins Rd., Centerville, MA Address of Owner: 248 Bailey Street Date of Inspection: October 23, 1998 (If different) Canton, MA 02021 Name of Inspector: James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: James M. Ford /7 I Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map - Telephone Number: (508)862-9400 Parc745� 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passe Needs Further Evall on By the Local Approving Authority ails Inspector's Signature: ti Date: October 26, 1998 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or enfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the wont Wide\vet nttp.bwww magnet state ma WOep Pnnted on Recyciec Paper a (tt ` t, .ro,"yts SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A y CERTIFICATION (continued) ci Property Address;,-�56 Braley Jenkins Rd., Centerville, MA Owner: Edward O'Hearn Date of Inspection: October 23, 1998 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water-level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WELL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone i of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private,water supply well, unless a well water analysis for conform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 56 Braley Jenkins Rd., Centerville, MA Owner: Edward O'Hearn Date of Inspection: October 23, 1998 D) SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coiiform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE_ DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 56 Braley Jenkins Rd., Centerville, MA Owner: Edward O'Hearn Date of Inspection: October 23, 1998 Check if the following have been done: You must indicate either "Yes" or "No"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner, occupant, and Board of Health. ✓ m h n None of the system components have been pumped for at least two weeks and the system as been receiving . g normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs.of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components, excluding the Soil Absorption System, have been located on the site. ✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ _ The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. ✓ _ Existing information. Ex. Plan at B.O.H. ✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)]. (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 56 Braley Jenkins Rd., Centerville, MA Owner: Edward O'Hearn Date of Inspection: October 23, 1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: n/a Garbage grinder(yes or no): No Laundry connected to system (yes or no): Yes Seasonal use (yes or no): No Water meter readings, if available(last two(2) year usage(gpd): 1998-55,000 gals., 1997- 133,000 gals.; 1996- 113,000 gals. Sump Pump(yes or no): No Last date of occupancy: Used on weekends. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present(yes or no): Industrial Waste Holding Tank present(yes or no): Non-sanitary waste discharged to the Tide 5 system(yes or no): Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped approximately two months ago-per owner. System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons 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) I/A Technology etc. Copy of up to date contract? Other APPROXHV ATE AGE of all components, date installed (if known) and source of information: December 1986-per as built card. Sewage odors detected when arriving at the site (yes or no): No (revised 04/25/97) Page 5 of 10 M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 56 Braley Jenkins Rd., Centerville, MA Owner: Edward O'Hearn Date of Inspection: October 23, 1998 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: Yes (locate on site plan) Depth below grade: 8" Material of construction: ✓concrete _metal _Fiberglass Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8' X 5' X 4'6" (1000 gal.) Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle: -- 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: — How dimensions were determined: -- Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) The tank was 114 full The tees were Present. GREASE TRAP: None (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised(14/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 56 Braley Jenkins Rd., Centerville, MA Owner: Edward O'Hearn Date of Inspection: October 23, 1998 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or 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 level: Alarm in working order_Yes; _No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Yes (locate on site plan) Depth of liquid level above outlet invert: Even Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) The box was level and there was no evidence of solids carryover or leakage. PUMP CHAMBER: None (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.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 56 Braley Jenkins Rd:, Centerville, MA Owner: Edward O'Hearn Date of Inspection: October 23, 1998 SOIL ABSORPTION SYSTEM (SAS): Yes (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 1 leaching chambers, number:. leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) There were no signs of ponding or failure. Grass covered the system. The bottom to grade was approximately 8'. CESSPOOLS: None (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: None (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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued Property Address: 56 Braley Jenkins Rd., Centerville, MA Owner: Edward O'Hearn Date of Inspection: October 23, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks. Locate all wells within 100' (Locate where public water supply comes into house). GP,r e so I I r 37 ti S 4 36 y� 5 I (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 56 Braley Jenkins Rd., Centerville, MA Owner: Edward O'Hearn Date of Inspection: October 23, 1998 Depth to Groundwater: feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers ✓ Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) Using the Barnstable Water Contours map and topographic maps, the maps are showing 15'to water at this site. This report has been prepared and the system inspected and passed as of October 23, 1998. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. (revised 04/25/97) Page 10 of 10 sT N OF BARNSTABLB LOCATION l�1 Ul. �' /ZLtCE'`/ ��K�nS SEWAGE VILLAGE Ote, Jl t ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. I&V IO 9/C jc t 7 7/-` 12-8 d° SEPTIC TANK CAPACITY LEACHING FACILITY:(type) PLC (size) ,NO. OF BEDROOMS PRIVATE WELL OR UBLIC WAT�ER ® �1 �JC7��DLeS BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: Z h'1�1 VARIANCE GRANTED: Yes No 6 �\ � r �of 0 No .. .1� Fss..... ........ THE COMi, IPNWEALTH OF MASSACHUSETTS, BOARD OF HEALTH fig- ------------------ Appliratinn for Disposal 4arks Tons rn.rtiod Prruti# Application is hereby made for a Permit to Construct ( or tepair ( ) an Individual Sewage Disposal System at: •Location-A dress 0000 Lot Ow r >btn -ZA Cif dr'ess .................. S Ad ---.-••---••••.._.. � Installer ��4� - - -----------------!.J Address P.—. U Type of Building Size Lot.. . 0.(70....Sq. feet Dwelling—No. of Bedrooms___________________________________________Expansion Attics T Garbage Grinder+-- — Other—T e of Building p ______________ Showers „� =Cafeterias" a —Type g - - ----- No. of persons......... Other fixtures ._.._.__._. ........................................................ Design Flow.........................��..-�.....gallons per person pej day. Totalily flow____ ..................gallons. , WSeptic Tank—Liquid*capacity�_3!'gallons Length---9... �__ Width._ ... ''..•Diameter---------------- Depth. .... x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area.................---sq. ft. Seepage Pit No........ ..._..e. . ameter--_f_� Depth below inlet... -... Total leaching area..:-� .sq. ft. Z Other Distribution box ( �) Dosing tank- - '-' Percolation Test Results Performed by....A1 �.. _.` _____________ Date... z' `S_..__. a Test Pit No. 1.__.--. -minutes per inch Depth of Test Pit-----/.�V..... Depth to ground water..... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water ................... P4 ---•----•---------------------------r....._--_. ._ . ...--;�-----•--•----•---...-----------•--••----•---....--•----•---.........----- o �,,9 �- ---- ...� Z- Descriptionof Soil ..:. ............. --- .....-------------------------------------------------••--------•---------------- W c ••------------------------------- --------------------------------------------------------------------------------------------------------•-----------------------------•----------------------- W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the board f ealth. c:gRod. s A ---------- ---------------------- ............ AP-...----- �-- � Date Application Approved By..... : _______________ - --------------------------•--•------ Date Application Disapproved for the following reasons:.............................................------•---------••----------------•-----..._...--•------••-....... ..---•............................................•--------...--•--------••--••--•-••---•._._...----•--••-----•------------------------------------------------------------............................ Permit No. ,�-�-...................... Issued.................................. Date Date z. i No. ... ..a✓' Fzs..... ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 .................................... ~OF.........:.....--•---.................--------------..........----....................... Appfiration for Uhipoii a1 Workii Tnnitrnr#iun Frrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: -Location-Address--^�" Ow r -e V t-n Address s.. .. _....�: .;. ;�.0 .. ..:z:-�:...C��__....?-�--,,,,,,,,,,.Address .....................:..................-----.... Installer Address d Type of Building Size Lot...Z��_S a v Sq. feet U Dwelling—No. of Bedrooms,..,.._..._. '...........................Expansion Attic�(/� Garbage Grinder- Other—Type (--) a of Building ...Z -='_�._ No. of persons...................... Showers (r-)— Cafeteria•-()- Otherfixtures ...........=....................................................................................................................................... Design Flow..........................--:?�....... gallons per person per day. Total daily flow.... -� Ions.�... - WSeptic Tank—Liquid capacity .!?�°gallons Length___6...G_.. Width. ....`.. Diameter................ Depth.- .�... ✓ x Disposal Trench—No..................... Width.................... Total Length................. Total leaching area-___-•_-_.._---.-...sq. ft. Seepage Pit No-----­-------------- I ameter.._�.�_ ----__ Depth below inlet : �... Total leaching area.__7`��.sq. ft. ..... . Z Other Distribution box Dosing tank---('-) '-' Percolation Test Results Performed by._._)-'�X; .-a?..<__�rE............. Date... .� � �`�` ..._.. G . / 2 Test Pit No. L....-....2._mmutes per inch Depth of Test Pit.....�.�.�.... Depth to ground water_.___.----'.._ � 6Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.......-............ Depth to ground water........................ a .....................................=----------.........;-----.....--------..............----............................................................... O Description of Soil---------------5_F 7 i✓ ........ •--••==•-----.....Cr7. . fr / =G x -----------------•------------------------------------................. V --------------- •------- ----------------- •-------------------------------------•------ ....-------- ...------------------------------------------------- •----------------------------------------------- 11 W ------------------------------------------------:•'••---•-••-•-------•--••-------------••------------•--•-•-•••••-------------•----•••-------------------------•--•••--•-----•--•-- --•-------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... . .............................................................-................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT12 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 alth. �� r _` `. �igned LJ 16 � ------•---••---------•--- ....--•- -------------------- Application Approved By....... �� ....�.1��`�� .. _� ---•-- ��1 �'•--------•-=•---- --------------- Date Application Disapproved for the following reasons----------------------------------------------------•---•------•-----------------•------------------------....._. ..............................................---------......------------••--•------....•-•-------••••-----•-----•••••-••-•--••-----•---•••------••--•----•---•---•--•-----••---------•----••-------•-- Date PermitNo. ---���5------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ?.l .j?............0F.......) '....1 S. R ....................... Tutifira tr of fin mptianrr THIS IS T CERTIFY That the Individual Sewage Disposal System constructed ( or Repaired ( ) �� - ------------ j _ Installer at.-----•-- 'Z? t �5.�......._ _ ! =._y.... �V _ r-�S02_✓tl�Lf ------------------------------------------------•-•----••--•••-•- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No- .....!Y7.9...... dated....._ _ ---------- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GBJAtLANTEE THAT THE SYSTEM WILL F Tl. NSA 1SFACTORY. DATE--•................ ....... Inspector.................................................................................. l THE COMMONWEALTH OF MASSACHUSETTS q/IUk T .7'e4, q, N 5 A71 BOARD OF HEALTH 4— ,�w ';wGf� l v -f"`7► ..........of. ..............•-.... N • .................. FE Biginsal Works 0.11u trnr#inn rrumt N. ', 4 Permission is hereby granted---------- ----- - ,. - •---••--•- ---• ...J-e \... . .................... to Construct ( 5-J� Repair ( ) ann Individual ewagg-Disposal System %� at No............ ......... �' -j_j'rl_US '` y ` ........ .... 'mot_ Street as shown on the application for Disposal Works Construction Permit I _: ,f .... Dated.._`--'� ............ f = ..................=To................................._ DATE. �..1. .................................. Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 4 r er Mit tin cr - - -- a c: .y T v •rCon;Yleted by C .IZ . SHOX7" ff HIGH GROUND-WATER LEVEL COMPUTATION Site Location: ��J:AtCy Tc�/k�Ns I2D �'�,✓r�,z✓!t[E' Lot No. �" Owner: X). Address: Contractor: Address: 1,31 pL, #t /32 14/�}�/�✓�s,i1'1A Notes: oi::�l.S a USf' T4✓' LOT STEP 1 Measure depth to water table to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ��/�7 9� date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A/r✓23o A) Appropriate index well . . . . . . . . . . . . B) Water-level range zone . . . . . . . . . . . . STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water- level for index .well . . . . . .Was mo yr STEP 4 Using Table of Water-level Adjustments for index well STEP 2A , current d&pth to water level for index well (STEP 3) , and water-level zone (STEP 2B) determine water-level adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STEP 5 Estiriate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p o 4 S, 8 water- C E L 39,0 13 ,= 7- Leucti 43 ,0 M►.d. SOI L LOG F;l . 7 DATE: WITNESSED B Y: 7/ /'y) � ��.L. .��" ✓' .�3, �.�J, �Z- Z � Yam' l' ' 2 iL.- o �•7 ,-Y-� NL Au s�.�✓z7 y 1 4- i M � sz� fl . asv S�PF (� p ELEV. F MANHOLES AND COVER TO 'BE BUILT WITHIN _— -- , o —�— TOP O �r FOUNDATION -- -'" 12" OF FINISHED GRADE . .- AA I N. 27 SLOPE h; � NISHED 6RADE ,.� ' • ,• o Nj L3C Ofo eCAST i RO ' ., OR - . . .,... . PVC SC . 40 IST _ g . Ilk PVC SCH. 40 • +_-�„ /,�• PITCH I�q,"' FT. � 2'LEVE'C, r, MIN. 2" LAYER 10 rp.' PITCH �a�� ��,� , .•p. 'cam. 1/8 112 PEA STONE E L 47.� o,'' 1/4/F T. ,�✓„' 'y,,,� q?,o� 44. INVERT ' ? GALLON iNVERT� DIET. INVERT ;, D F• ci 0'? - i { NVERT SEPTIC TANK � G._. 80X '%" 'd = Op 3/4rr 1 1/2"DIA . ' # •r ,, •e. r INVERT 4�. �, .3,J`^ v WASHED STONE 1•d7 ✓.S /04�q ?SIT' ' fa 23 � INVERT i+ t7 wdI74" ALL AROUND . tlj10 GARBAGE -. __-___ /--- ��-- i3/ a C3 � C3 C3Ci -- 111 ��- S i , :� MIN N . G R I N D E R ELEV. BOTTOM __ OF PIT = Q . `, rr ELEV. 39,0 PROFILE OF GROUND WATER TABLE P.er1-07- )34 SANITARY DISPOSAL SYSTEM 7-;!!-s7- PQ4r NOT TO SCALE DESIGN DATA CA -Ji- ) CONSTRUCTION OF SANITARY DISPOSAL +� BEDROOMS 3 ,73 SYSTEM SHALL CONFORM TO MASS. DESIGN FLOWS GAL./DAY E NVi RONMENTAL CODE TITLE V- REVISED 7- 1 - 77� LEACH RATE MIN./INCH AND THE TOWN OF R.P—VZ � .. PROPOSED LEACH CAPACITY : HEALTH REGULATIONS. 3,S7-,v Z') �- 1. a7�'�G� eeEti SEPTIC TANK, DISTRIBUTION BOX AND LEACHING PITTO BE OF REINFORCED CONCRETE GAL/DAY MIN. CONCRETE STRENGTH 3000 PSI MIN. STEEL STRENGTH 20,OOQPSI H 10 DESIGN LOADING * DRIVEWAYS NOTTO BE LOCATED OVER SYSTEM UNLESS H - 20 DESIGN LOADING IS USED. je ALL PIPES AND FITTINGSTO BE WATERTIGHT AND e TO BE OF CAST IRON OR SCHED 40 P.V. C. SSITEi PLAN SHOWING PROPOSED CONSTRUCTION R SH.OF SHS LEGEND L 0 C A T 1 ® N: �;e A/-7,�.� �. . e-��r-��V.14 j _ FOR : L-. ,�'-e - S 0�. L C)�- "`f ,G ° / '- A P P R O V E D 19 SCALE: / - DATE BOARD OF HEALTH BUILDING SETBACK REGULATIONS PER EXISTING CONTOUR — -16--- RE F E R E N C E: Z- /.S• 2 �'L •2✓ , rGc• CMG . BUILDING INSPECTOR OR BUILDf,NG COMMISSIONER . C PROPOSED CONTOUR iFi GATE AGENT �'^✓� T2 MIN, FRONT SETBACK 2C7 EXISTING SPOT ELEVATION 17. 6 MIN. SIDE SETBACK / cam ' PROPOSED WATER SERVICE W �yAOfy/ TEST HOLE LOCATION CRAIG �4 MIN. REAR SETBACK SHOT C . R . S H R Tv ( N mow • d i 7483 rTp PROFESSIONAL LAND SURVEYORS & ENGINEERS 1586 MAIN- STREET (RTE. 6A) EAST DENNIS, MASS. 02641 J. N. 40 ALL 'SYSTEM S SHALL SYSTEM PROFILE MARKED WITH CMAGNETIC TTAPE OR BE NOTES (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS APPROXIMATE NGVD ACCESS COVERS TO WITHIN 6" OF FIN. GRADE - 2. MUNICIPAL WATER IS EXISTING s� � TOP FOUND. EL. 53.7' PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE \ 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 52.0' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM PRECAST H-10 4. DESIGN LOADING FOR ALL PROPOSED PRECAST o 0 RISERS (TYP.) 4"0SCH40 PVC UNITS TO BE AASHO H-Q �� \ ,'•. 2 51.7't INSTALL INLET IN T MADE WATERTIGHT. PIPES LEVEL 1ST 2' 2" DOUBLE WAS PEASTONE 5. PIPE JOINTS 0 BE • . TEE 1' ABOVE I �o Loc s �t.T **EXISTING 1000 GAL OUTLET INVERT OR GEOT"Xlfl E FABRIC EXISTING 10 SEPTIC TANK 14" 47.5' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE o° a EXISTING TEE TEE .y 50.3'f WITH 310 CMR 15.000 (TITLE V.) °o°c C> , 0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND c �• GAS BAFFLE :, °°°o °°° 0 47.( 0 2.8' AT SIDES NOT TO BE USED FOR LOT LINE STAKING OR ANY 47.18' t47 0.8' AT ENDS OTHER PURPOSE. ' ��� 2 45.0' 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. o a cl- DEPTH OF FLOW = 4' 9. COMPONENTS NOT TO BE BACKFILLED OR TEE SIZES: 6" CRUSHED STONE OR MECHANICAL 3/4" TO 1 1/2" (DOUBLE, WASHED STONE CONCEALED WITHOUT INSPECTION BY BOARD OF INLET DEPTH = 10„ COMPACTION. (15.221 (2]) o HEALTH AND PERMISSION OBTAINED FROM BOARD OF OUTLET DEPTH = 14 "' �� 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP VERIFYING THE LOCATION OF ALL UNDERGROUND & (]fix SLOPE) ( 1 % SLOPE) 40.0' BOTTOM TH-1 OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF SCALE 1"=2000'f NO GROUNDWATER FOUND WORK. FOUNDATION EXISTING SEPTIC TANK 23' D' BOX 39 LEACHING 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 171 PARCEL 185 FACILITY SHALL BE REMOVED 5' BENEATH AND AROUND THE *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **THE INSTALLER SHALL CONFIRM MIN. PROPOSED LEACHING FACILITY. LOCUS IS WITHIN AP OVERLAY DISTRICT UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS SEPTIC TANK SIZE AT 1000 GALLONS AND 12. EXISTING LEACHING FACILITY SHALL BE PUMPED PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM ITS SUITABILITY FOR RE-USE AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. LEGEND �] 99- EXISTING CONTOUR X 991 EXIST. SPOT ELEV. 99 PROPOSED CONTOUR / 198•41 PROPOSED SPOT EL. TH1 / TEST HOLE � c\ 2YYY- SLOPE OF GROUND \ SYSTEM DESIGN: ciaD UTILITY POLE 0 \ \ GARBAGE DISPOSER IS NOT ALLOWED FIRE HYDRANT / PAVED T BENCH MARK - CORNER OF N IM NOT AM SYMBOLS ►AY,APPM w MAMIG (/� DRIVE \� c� 7s� CONCRETE BULKHEAD 5.3.?__ DESIGN FLOW: ; BEDROOMS C 110 GPD - 330 GPD ��� / \ \ I\ 00' USE A 330 GPD DESIGN FLOW / 0 k TEST HOLE LOGS �P, \x SEPTIC TANK: 330 GPD (2) = 660 ,y X\ **RE-USE EXISTING 1000 GAL. SEPTIC TANK ENGINEER: DAVID FLAHERTY, R.S., SE2755 / � k \ � \ LEACHING: WITNESS: DONNA MIORANDI, R.S. �� / `L 3>>�,F\\oF X\X SIDES: 2 (30 + 10) 2 (.74) = 118 GPD JUN E 9, 2008 � o DATE: / �c \gltN `' \ BOTTOM 30 x 10 (.74) = 222 GPD EXISTING PERC. RATE _ < 2 MIN/INCH �c DWELLING 3 BR FLAG ^1 �� �` ALP o TOTAL: 460 S.F. 340 GPD CLASS I SOILS p# 12243 �c TOP OF FNDN ATI0 / �, TH-2 �.. / EL. 53.7' p USE (4) STANDARD "3050" INFILTRATORS H-1' `36' WITH 0.8' STONE AT ENDS AND 2.8' AT SIDES ELEV. ELEV. �1 51 LOT 152 0" 50.0 0" 50.0 15,000f SF CONC.APRON ryo' A A 0.3f AC. DIECK SHED LS LS So MA " 10YR 3/3 " 10YR 3/3 \ APPROVED DATE BOARD OF HEALTH 9 10 POOL � \B B TITLE 5 SITE PLAN o0 LS LS Q) of 31" 47.4 30 47.5 10YR 5/6 10YR 5/6 / 56 BRALEY JENKINS RD. 7s0. (CENTERVILLE) BARNSTABLE, MA \ PREPARED FOR C C \ BORTOLOTTI CONST./ PERC k / ROBERT MILLER M FS M FS k\ \ k DATE: JUNE 24, 2008 off 508-362-4541 2.5Y 5/4 2.5Y 5/4 fax 508-362-9880 N OFNS' ( downcape.com tK ofssq� �DANIELA9cy� a 0 0 DAANIEL yG�, 0 OivLA d�W/1 Cope eaginee�inz h7c. " J A. � L � civil engineers No. 02 No.4 �o land surveyors 120 40.0 1 40.0 -� � NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' (,�Z,yr� °'°Fs 0o s o a� �' - 939 Main Street ( Rte 6A) YARMOUTHPORT MA 02675 0 10 20 30 40 50 FEET DATE A. OJALA, P.E., P.L.S. LICE #08- 1 > 8 08-118 BORTOLOTTI_MILLER.DWG (DDF)