HomeMy WebLinkAbout0116 BRALEY JENKINS ROAD - Health 116 Braley Jenkins Road
Centerville F/R
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UPC 10259
No. H163OR
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a 116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
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.
Importard:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not
Trevor Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspection
ffi Company Name
P.O. Box 896
Company Address
» East Dennis MA 02641
City/Town State Zip Code
508-385-7608 S113744
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
i ® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
,,--, 9-, 61 /z 4
InspecbA 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.
G
�O
t5ins•3/13 Title 5 Official Inspection bsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/ahvays 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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>y 116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cunt.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
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
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ 0 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 6s below invert or available volume is less
than'/day flow
t5ins•3113 Trtle 5 Official Inspection Fenn:Subsurface Waage Disposal S;stem•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
page. CitylTown 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 east as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either'yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes'in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Irispeclion 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
y 116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
page. City(rown 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(f any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
A septic tank that flows to the D Box,Then into two leaching chambers
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available past 2 years usage (gpd)):
Detail:
Sump Pum ? ❑ Yes No
P
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow,(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
I�
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 s. 116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5128114
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (f 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•3/13 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
116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Flame
information is required for every Centerville MA 02632 5/28/14
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components,date installed (if known) and source of information:
11-8-02
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.9feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting,evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.5
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: 1500g
Sludge depth: 3 in.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle 25 in.
Scum thickness 2 in.
Distance from top of scum to top of outlet tee or baffle 2 in.
Distance from bottom of scum to bottom of outlet tee or baffle 20 in.
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ 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
y 116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
I�
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Flame
information is required for every Centerville MA 02632 5/28/14
page. Cityrrown 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 1 in.
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box,etc.):
D box is level and structurally sound
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
M z 116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/aftemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5im•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a 116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Sul surface Sewage Disposal System Form -Not for Voluntary Assessments
4 5. 116 Braley kins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
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
B
A
(D0
2 A1)24'
A2)33'
A3)40'
B1)30'
B2)31'
B3)41'
3
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 5 116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 41
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: 1 0 to-7 10 1
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS Map shows ground water of the area does not go above 50 feet
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Insp
ection 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
b s. 116 Braley Jenkins Rd
Property Address
Jack Nappi
Owner Owner's Name
information is Centerville MA 02632 5/28/14
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D,or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
L
No. 06; —5 Fe+$5 0.00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pplitation for 30igpooal Opetem Con0truction Permit
Application for a Permit to Construct( . )Repair(x:�Upgrade( )Abandon( ) O Complete System M Individual Components
Location A¢drgs o ff aNfey Jenkins Rd. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel Centerville Judy Notz
M1 71 1 79 Same
Installer's ft A ss, el No. Designer's Name,Address and Tel.No.
` `: } '��inson Septic Servic Eco—Tech Environmental
P.O. Box 1089 43 Triangle Circle
Centerville MA 02632 Sandwich MA 02563
Type of Building:
Dwelling No.of Bedrooms-3 Lot Size sq.ft. Garbage Grinder( )
Other I�pe of Building residentia�;io.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank -e �y (/", 0 Type of S.A.S. G a^ r
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) we will install a new Title-5 leach
system to the plans of Eco — tech environmental # ETE 1295
dated 10/28/02.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by tWsBogdof Health.
Signed d Date
Application Approved by Date ir d
Application Disapproved for&following reasons
Permit No. � i to a—S-2-7 Date Issued 11 y
, ' `�U6
No. ;. F e 5 0.00
�y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
01pprication for Mi0pont bpotem Construction Permit
Application for a Permit to Construct( )Repair(x)pUpgrade( )Abandon( ) El Complete System ®Individual Components
ocation s o6' t Owner's Name,Address and Tel.No.
`� aNfey Jenkins Rd.
Assessor's Centerville JudysNotz
M171 P179 Same
Installer's • e,A s,an e.No Designer's Name,Address and Tel.No.
We, ` k��Iingon Septic Servic E o—Tech Evvironm ntal
P.O. Box 1089 4 Triangle Cicg��
Centerville, ELFIA02632 Sandwich, KA 02563
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building` residentia]No.of Persons Showers( ) Cafeteria( )
Other Fixtures J
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank e x J ^4 u`w GF lie e Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) we will install a new Title-5 leach
system to the plans of Ecot- tech environmental # ETE 1295
dated 10/28/02.
Date last inspected:
Y . Agreement: ,
" The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by tom' �oalth.
Signed 1 ��F Date
Application Approved by _17C) r Date
Application Disapproved for&following reasons
.x
Peinut No. 2 t)o a —7 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
Notz BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(Kx )Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Syrvice
at 1 1 6 Braley Jenkins Rd. , Centerville has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ?"5-2 7 dated ) t—t 0 72
Installer WE- E. Robinson Sr. Designer David Coughanowr
The issuance of this permit shall not be construed as a guarantee that the sys will functiongs designed.
Date Inspector V24 �. L J
No. 2 00 2-S,?7 Fee$5 0.0 0
NO Z
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
lwigpooal *potem (Construction Permit
Permission is hereby granted to Construct( )Repair(xx)Upgrade( )Abandon( )
System located at 116 Braley Jenkins Rd. , Centerville
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 ermit^
Date: 2 Approved by
R
1
TOWN OF BARNSTABL/E
LOCATION r yscl SEWAG #� v t
.VILLAGE (f L
^� ASSESSOR'S MAP & LOT _
INSTALLER'S NAME&PHONE NO. iL. a rj ?79
SEPTIC TANK C ACITY 'd o--�
i
LEACHING FAC ITY: (type) (size) ''
NO. OF BEDROOMS
EBUILDER OR OWNER
PERMITDATE:1f COMPLIANCE DATE: ll-2S-1U-2
i
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility f! � 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
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3
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t_
TOWN OF BARNSTABLE t
LOCATION �� �r �� SEWAG #�
VILLAG ASSESSOR'S MAP & LOT-16
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ¢16�-� ✓
j
LEACHING FACII.ITY: (type)" �5 , ? `4 � �-,C (size) /?"; J✓ 7
NO. OF BEDROOMS__
BUILDER OR OWNER /, s 7'Z
PERMITDATE: ;t— COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility l� Q 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
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Commonwealth of Massachusetts
Executive Office of Envirolunental Affairs
Dept. of Environmental Protection
ad
One winter Street' Se
Boston,Ma. 02108 John Septic
D.E.P. Title V Septic Inspector
P.O. Box2119
Teaticket, MA 02536
wILUAM F.wELo (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Govemor
� ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
' ev CERTIFICATION _
DEC Y 0 1998
Property Address: 106 BRA LEY JENKINS RD.CENTERVILLE Address of Owner:
Date of Inspection: 1218/98 (If different)
Name of Inspector: JOHN GRACI CHRISTOPHER AND LYNN MASON;
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name, Address and Telephone Number:
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:
x Passes This Inspection Is based on criteria defined In Title V
Conditional) Passes code310 CMR 16.303.My findings are of how the system is
- Y performing at the time of the Inspection.Mylnspection does
_ Need F ther Evaluation By the Local Approving Authority not ImpNany warranty or guarantee of the longevity ofthe
Falls septic system and any of Ito components useful life.
Inspector's Signature: Date: 12/8/98
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
— Co'mpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
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 04127197)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 105 BRAILEY JENKINS RD.CENTERVILLE
Owner: CHRISTOPHER AND LYNN MASON;
Date of Inspection:1218198
_ Sewage backuR or.breakout or high.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to 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 leveled 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 WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
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 in 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
cesspool.
SAS is in hydraulic failure.
(revised 04127)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 106 BRAILEY JENKINS RD.CENTERVILLE
Owner: CHRISTOPHER AND LYNN MASON;
Date of Inspection:1218198
D] SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
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:
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 II 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 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 106 BRAILEY JENKINS RD.CENTERVILLE
Owner: CHRISTOPHER AND LYNN MASON;
Date of Inspection:1218198
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with NIA.
x The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System,have been located on the site.
x 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.
x 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 Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)]
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 106 BRAILEY JENKINS RD.CENTERVILLE
Owner: CHRISTOPHER AND LYNN MASON;
Date of Inspection:1218198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 9 P d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 2
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):
n1a
Sump Pump(yes or no): No
Last date of occupancy: nIa
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings, if available: nra
Last date of occupancy: nra
OTHER:(Describe) Ma
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
SYSTEM WAS PUMPED LAST YEAR.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: rda
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions 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:
APPROXIMATE AGE of all components, date Installed(if known)and source Information:
SYSTEM WAS INSTALLED IN 1986
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 106 BRAILEY JENKINS RD.CENTERVILLE
Owner: CHRISTOPHER AND LYNN MASON;
Date of Inspection:1218198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: Z'
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age nla . Is age confirmed by Certificate of Compliance Nc (Yes/No)
Dimensions: Le'e"r5'7"W4'10^
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness:1"
Distance from top of scum to top of outlet tee or baffle:S"
Distance form bottom of scum to bottom of outlet tee or baffle: 1T"
How dimensions were determined: MEASURED
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS.
GREASE TRAP:_
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rda
Scum thickness:nfa
Distance from top of scum to top of outlet tee or baffle:rife
Distance from bottom of scum to bottom of outlet tee or baffle: rda
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.)
n/a
BUILDING SEWER:
(Locate on site plan)
Depth below grade: TV
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line•rOWN
Diameter: nla_
Qemments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 0427/9T)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 105 BRAILEY JENKINS RD.CENTERVILLE
Owner: CHRISTOPHER AND LYNN MASON;
Date of Inspection:1218198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: Na
Capacity: rda gallons
Design flow: rva gallons/day
Alarm level:--Na Alarm In working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Na
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Na
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 106 BRAILEY JENKINS RD.CENTERVILLE
Owner: CHRISTOPHER AND LYNN MASON;
Date of Inspection:1218199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rda
Type:
leaching pits, number: 1000 GALLON LEACH Prr
leaching chambers,number:rda
leaching galleries, number: rda
leaching trenches, number,length: rda
leaching fields, number, dimensions:rJa
overflow cesspool,number:n1a
Alternate system: rda Name of Technology._wa
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
THE LEACH Prr IS STRUCTURALL SOUND AND FUNTIONING PROPERLY.THE PIT HAD 2S'OF WATER IN IT.
CESSPOOLS:_
(locate on site plan)
Number and configuration: We
Depth-top of liquid to inlet invert: rva
Depth of solids layer: rda
Depth of scum layer: rva
Dimensions of cesspool: rda
Materials of construction: Wa
Indication of groundwater: ^Ia
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
nfa
PRIVY:_
(locate on site plan)
Materials of construction: Na Dimensions: rda
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
nla
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
106 BRAILEY JENKINS RD.CENTERVILLE
CHRISTOPHER AND LYNN MASON;
1218198
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)
to
Ac 3q y
AD
60 y
(revised0427197) Page ! of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contlnued)
106 BRAILEY JENKINS RD.CENTERVILLE
CHRISTOPHER AND LYNN MASON;
1218/99
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
X 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
A
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
GROUNDWATER DETERMINED FROM USGS MAPS AND CHARTS AND OBSERVATION,BOTTOM OF PR IS A1O'
(revised04127197) page 10 of 10
No......�6� a9' Fps...
..-- _
". THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH`. �
-Appliratiun for Dispas al Works Tunatnutiun ramit
Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sew�lage�Df isppsal
System at: / `- /� y� 55 11 11�j
................' ..------....- --•-... .... •-•--........ ........ --•--••-•------------------------ ---- - .._................
] Location-Address / or •Lot No.
........ ... . .......: = - Q...
F 1KC A ress
Wa ----••••-• .................. - ----- -------- . . — -------��_...x..-- ---�----------------------------—2,c---------------------
Installer Address
Type of Building Size Lot_-/ ' q. feet
U Dwelling—No. of Bedrooms........................ Expansion Attie- Garbage Grinder-f- )—
aOther—Type of Building _. jc No. of persons........4................ Showers
dOther fixtures�--..:_-----•---••------•----•----•-----•----••.-••--•-•-----•-•-••••--•--•-----------•---•-----•-----...-••••--•-•........................••--
W Design Flow..•......................15-r�._._..gallons per person �r da�. Total d lly flow.._.._--3. _._._.___.__. ons.
WSeptic Tank—Liquid capacity�0ygallons Length ...�:... Width..�__!_� Diameter________ ____ Depth..... ....
x Disposal Trench—No. .................... Width.................... Total Length................. Total leaching area............ ...sq. ft.
¢ 1 Z_ __- De th below inlet...e i �Total leaching area..�_Z�s ft.
� Seepage Pit No........... Iameter----•---• -----. p ......... g q.
Other Distribution box ( e Dosing tank `
Z Percolation Test Results Performed by.__ - -X.. ''. �.._. ................ Date..../ ._r
aTest Pit No. 1.... _. minutes per inch Depth of Test Pit.....!_ _.b._. Depth to ground water_._. _ .............
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
........................................................ -----------------••--•-
Description of Soil-------••----��..e--j--�--��:-d-}------��1._s�-,� --------------------------- - -------------•-----�------- --- �,
U •-•------.....-•-•---------•---•......--•-•-•-••-•. `r`� "' C!eJ...-•--------------------------------------------•-----•-•-----------------•-----•-------------•---...--
W ••---•-------------••. .................................................................................................................................................................................
UNature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
oper until a sate of Compliance has been issued by the boa�iealth.
�/ `Q
Signed../� . . --•.....__. �"'�&..._._
ate //++Application Approved BY6 1••• -•......... ....... ......•-• ..----�f.jD
.Z _...
Date
Application Disapproved for the following reasons:..............................................................................................................
--....--•-•-•-•------•----....-•------------------•-----------....---------••----•--------•-------------.._.....-----------------------------•--.....--•-----------•-•--------------------------••---•---
e�i Date
Permit No.........516e=... .!Z- ----•----•------. Issued......................
...............................
Date —
I- 'I.444
7Z,-)
-
No......................... Fxs..................._........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �
----•-• e—1 4— F 71
...............•-•...........-•-•-
App iration for Disposal Works Tono rnrtion 1hrntit
Application is hereby made for a Permit to Construct (t-)"or Repair ( ) an Individual Sewage,Disp?saal
System at: r
L a�— l � � �- ct e y Vie._ , s /�<,f� e.� 2✓ v-'J 1 �
- -Location-.Address----••.............r............. -----------------------------'or Lot ..... ........_.... ------------------
.................. ........................... ...... .........!.......... .......................................................................................
Address
W ^•-•--.._.. •........... ..........................•....................
Installer Address v-a—
Type of Building Size Lot.. .......................Sq. feet
Dwelling—No. of Bedrooms.. ....................Expansion Attic( ) Garbage Grinder(`-•")`
aOther—Type of Building 1....�...."' ,;'��No. of persons............................ Showers (.-)''=Cafeteria
Other fixtures�31 _, -- - -----•----------------------
W Design Flow......................... ......gallons per person per day. Total daily flow.......................................... ....gallons. ,
G: Septic Tank—Liquid capacityZ�°~gallons Length.••-•-....(0.'. Width.. _........... Diameter________________ Depth..` ...........
Disposal Trench—No. .................... Width__............_.... Total Length..............._ .,Total leaching area.___.,__,_.__:.._-sq. ft.
Seepage Pit No..................... . iameter..... ....... Depth below inlet....j'.`�.... Total leaching area..._eL.........:,sq. ft.
z Other Distribution box ( Dosing tank
Percolation Test Results Performed by...............................................� .. ............... Date.......d/............,_ .
Test Pit No. I................minutes per inch Depth of Test Pit......................... Depth to ground water-_----------_-_--_.--__.
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ............................................................. Al.......
.---.J....
4 '� ° Bch_ -� . � ......-� c,... .. tea/,,.% ✓s� � 7
Description of Soil--------------=-------•-•----•-•-----••-------------...--•--...-•--••---•------•-----------------------------------=-------•-•------------°••----••------.......
r' r....... cr ✓ G
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
............-..............................-............................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITTIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
opera until a er l•sate of Compliance has been issued by the board of health.
` Signed---..:`' -------•--•...................f.......--------•---•-•---••------.........
} � Date
ApplicationApproved By--•-•••--•---•--••--••--••--•---•--•---J-- - ------•.............•-•--.............---•-• ------.......f------cep•-� .-
Application Disapproved for the following reasons:.............................................-•--------------•-------.....------------•-•••---........._....._
--•------------------------------------•-•------------•--•--•-----------------•-•-------.......-----•---_._...................---•------------------------------•--•-------------------•••------••--..---
Date
PermitNo......................................................... Issued.....................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
L✓/✓ Z3"-7'Z//__S '.7 2 .�
..........................................OF................... ............................p......... .........w....
%rr#ifiratr of Tontplianrr
THIS IS TO CERTIFY,_,, That the Individuae :age Disposal System constructeli '( �r Repaired ( )
y.............................. ... ................................................
......
- -------------------------..............-........
J
,._� 7— 0/—cat J `J G�-'7 /'� /!S I�G
------•---------------------------------------- ------------•-----------------------------••-•-------------
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......................................... dated............................................0...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... .....-..�...� 7-••-------------------- Inspector..---.....-- ........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
No......................... FEE..--� ~..
Disjunal—liff-kii Tono#ruc tion Vrrmit f .
- -e
Permission is hereby granted.. ��
to Construct ( � or Rfe�pair ( ) an Individual Sew,;jge Dispo al System_ 6I
Street '7'-_ .�.
as shown on the application for Disposal Works Construction Permit No.........:........... Dated...........5..�... .....
'lb
\�� 7,1.
ii - - Board of-Health
v�w
DATE.------.f '&�-----------------•--.-----
-•.-.-•-
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
i
TOWN OF BARNSTABLE
LOCATION y \ems — ;t,s SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT p
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY 1000
I �
LEACHING FACILITY:(type) (size) Q
NO. OF BEDROOMSPRIVATE WELL OR UBLIC WATER
BUILDER OR OWNER [ .e� e,\— S \\ O W S
DATE PERMIT ISSUED: _ L 1-- �d L
DATE . COMPLIANCE ISSUED: 25
VARIANCE GRANTED: Yes No (.�--
� 1
i
3�
PLAN REFERENCE CONTOURS GF °DAD
PLAN BOOK 103 PAGE 60 EXISTING - - - - - - - 50 �
Z ASSESSOR'S MAP: 36 MINIMAL GRADING PROPOSED SHUBAEL ROAD
a o�� LOT: 245
LL
J
N LOCUS
�Z may 8 WHO g
BENCH MARK ceNrERwLLE. MA
TOP OF FOUNDATION L O C US M A P
ELEVATION - 630.10 58 NOT TO SCALE
LL Z USGS DATUM AS:t�UMED
00
}� o {i KEY
<" `� _ LOT 146
J— z /
N H J W w `; AREA - 15000 sr +- EXISTING
W� U J > sy�o 1000 GALLON o 0
tA
s Q J Z _ ;� ' SEPTIC TANK
J C� w 1 D-BOX o
= w J ��HpNLc TEST PIT
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�BLEUN �� I o
Q)
TREE
�- Jor m m
W I p W EXIS TING
ull
z �N m , <' o X LEACH PIT O
w LL z o LINE / i m ,°T,�"
woo w �- �, GAS a,o p
v _ �zw � -�, r �Z �; 24 ftx12.5 ftx2ft
w ��m m �p,"�ER L o Z O G) / LEACHING GALLERY
Q c0 l z C� O
3 24 tt
o � SHE
DRIVE ,
W PAVED
Z
J \ w � 0 z
H 3 z -J / /fi SEWAGE DISPOSAL SYSTEM PLAN
O o o 0m U ���' 150 00
-TO SERVE EXISTING DWELLING
r,KZ LL w o 58T JUDITH NOTZ
� O w O
U-) u-> OF 116 BRALEY JENKINS RD CENTERVILLE. MA
o
DAVID
P��sq�y�':
ECO-T H ENVIRONMENTAL
NVIRONM
ENTAL
LL to PLAN Z Cou',J6 i 4 TRIANGLE CIRCLE SANDWICH MA 02560 � a
DRAIN 1ups -0894
s 508 364SCALE: in 20 ft 1/2H /J ETE-1295 f OCT 28
THIS PLAN IS TO BE CONSIDERED—A DRAFT PLAN UNLESS IT
BEARS THE STAMP AND SIGNATURE OF THE DESIGN ENGINEER
ORIGINAL PLANS INTENDED FOR SUBMITTAL TO THE BOARD
OF HEALTH WILL BE SIGNED N BLUE AND STAMPED N RED.
c
27.2002
SOIL TEST LOG S0LEEVALUATOR: DAVIDOF TEST: BDRCOUGHANOWR. RS DESIGN CALCULATIONS
NO GROUNDWATER ENCOUNTERED
TEST PIT I PARENT MATERIAL: PROGLACIAL OUTWASH DESIGN FLOW 3 BEDROOMS X 110 GPD - 330 GPD
ELEVATION - 57.50 +- PERC AT 78 in : 2 MIN/INCH IN C SOILS
SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS
INCHES) HORIZON TEXTURE USDA (MUNSELL) MOTTLNG OR SOL OTHER ., QSE EXISTING 1000 GALLON SEPTIC TANK IF IS SOUND STRUCTURAL
CONDITION. IF NOT, INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED)
0-4 EAP LOAMY SAND 7.5 YR 2.5/2 NONE FRIABLE DISTRIBUTION BOX: USE 3 OUTLET D-BOX.
4-34 BN LOAMY SAND 7.5 YR 4/4 NONE FRIABLE
34-48 CI MEDIUM SAND 2.5 Y 0/4 NONE LOOSE-20% STONES SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH
48-08 C2 COARSE SAND 2.5 Y 6/3 NONE LOOSE A b o t - ( 24 x 12.5 ) - 300 sf
Asd*w - ( 24 - 24 - 12.5 - 12.5 ) x 2 - 146 sf
Atot - 446 sf
Vt 0.74 x 446 - 330.04 GPD
USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED
GROUNDWATER
ADJUSTMENT
EXISTING GROUNDWATER LEVEL
BASED ON BARNSTABLE GIS
DEPARTMENT RECORDS LEACHING GALLERY
OBSERVED GW: 36.0
ZONE D
WELL. SDw-252 CONSTRUCTION DETAIL
READING: SEPT 2002
LEVEL: 47,9 ORYWELL UNIT STONE
ADJUSTMENT: 5.0 ft s'-2 f EFF.X DEPTH
ADJUSTED GW: 41.0 2 ft EFF. DEPTH
24,0 f t
NOTES
. � o
1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN ui
N
2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM.
3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS
OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15)
4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES 2.5' 8.5' 2 fr 8.5' 2.5'
BEFORE EXCAVATING FOR SYSTEM. Nor ro
5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED 24.0 ft SCALE
6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE
7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN
8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES
AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK
9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT
PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. SEWAGE DISPOSAL SYSTEM PLAN
10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. -TO SERVE EXISTING DWELLING
II) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL
STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH
SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING JUDITH NOTZ
12) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED 116 BRALEY JENKINS RD CENTERVILLE. MA
FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE.
ECO-TECH ENVIRONMENTAL
43 TRIANGLE CIRCLE SANDWICH MA 02563
ETE-1295 JOCT 28. 2002 2/2
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