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HomeMy WebLinkAbout0057 BREZNER LANE - Health 57 Brenner Lane, Centerville A= f 1 I SIIII �'`����0eO1a UPC 12534 No. 2-153LOR HASTINGS, MN ' .:W ,,,....m::,.,,.�' .,.�`.�s::LiJr.Wu.w;.'Jl,...w�.: •-, ...,�. , :,..,,...�.�� �,. ;,.. _.' ,�"..- Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; An 57 Brezner Lane �v Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every 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 filling out forms A. Inspector Information on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. Co Route 130 u� Company Address Sandwich Ma 02563 City/Town State Zip Code rya (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails nmN afl9�nreaq� H emeu=on�w®eaoaeamweon yet.c•us Brett Hickey .,<, ;,ps�� ;,;,;;mm 8-30-19 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts T ' +n Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 P Y rY 57 Brezner Lane Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: . ❑� I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner Lane Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 c Commonwealth of Massachusetts 1p� Title 5 Official Inspection Form 11Ol Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 57 Brezner Lane Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts �e Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 57 Brezner Lane u Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than '/day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El 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. ❑ O Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c� Commonwealth of Massachusetts p Title 5 Official Inspection Form 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 57 Brezner Lane Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ Q 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) ❑ F-1 Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El El 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? ❑ a 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 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)] t5insp.doc-rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner Lane Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): 330/GPD DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes rol No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes R] No information in this report.) Laundry system inspected? ❑ Yes E] No Seasonal use? ❑ Yes [E No See below Water meter readings, if available(last 2 years usage (gpd)): Detail: ***2018- 36,000gallons 2017- 39,000gaIIons*** Sump pump? ❑ Yes ❑■ No Last date of occupancy: current Date t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner Lane u Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: . Industrial waste holding tank 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 below): 3. Pumping Records: Source of information: Owner- last pumped 1 year ago Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner Lane �v Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2006 per plans Were sewage odors detected when arriving at the site? ❑ Yes ❑u No 5. Building Sewer(locate on site plan): 2,6„ Depth below grade: feet Material of construction: ❑ cast iron M 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner Lane LL f/ Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page.e. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 11611 Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed b a Certificate of Compliance? attach a co of certificate ❑ Yes ❑ No 9 Y P ( PY ) 1 Dimensions: 500gallons 591 Sludge depth: 3191 Distance from top of sludge to bottom of outlet tee or baffle 1 rr Scum thickness 619 Distance from top of scum to top of outlet tee or baffle 1511 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 ' Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brenner Lane V Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): NA 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner Lane V� Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert 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.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Iol Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .v 57 Brezner Lane Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2)500 gallon chambers rX-1 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts +� Title 5 Official Inspection Form Io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 57 Brezner Lane Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Leaching was dry when viewed with no evidence of past back up. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner Lane Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts ' ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 57 Brezner Lane Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately Driveway LES A1-27' 61.16' A2.2,V B2.16' t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner Lane Property Address Ana Zick Owner Owner's Name information is Centerville Ma 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope On Surface water [WE Check cellar ■❑ Shallow wells Estimated depth to high ground water: No GW @feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed: >5' below SASDate ❑ 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: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner Lane i u Property Address Ana Zick Owner Owner's Name information is required for every Centerville Ma 02632 8-30-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ■❑ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed 0■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner In Property Address The Connolly Realty trust ~. Owner Owner's Name information is required for every Centerville ✓ Ma 02632 1/28/16 page. City/Town State Zip Code Date of Inspection .. R7 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 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain reb Company Name 8 Johns path Company Address S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 SI 13522 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 t cal Approving Authority 1/28/16 In pector'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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface SewageDisposal sposal System Form Not for Voluntary Assessments � M 57 Brezner In Property Address The Connolly Realty trust Oitu�ler Owner's Name infS'rmation is Centerville Ma 02632 1/28/16 rewired for every page. Citylrown State Zip Code Date of Inspection a-cY B. Certification (cont.) ; Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1500 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 several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels 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): l5ins•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 M 57 Brezner In Property Address The Connolly Realty trust Owner Owners Name information is Centerville Ma 02632 1/28/16 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.), ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 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 ❑ ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304, The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the followinghave been done. You must indicate "d Cate 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 CM 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system contains a 1500 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 several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels. 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 119 GPD 9 ( Y 9 (gP ))� Detail: 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) 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Brezner In Property Address The Connolly Realty trust i Y Y Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 page. Cityrrown 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: None provided Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Site glass on truck Reason for pumping: Maintenance Type of System: Y ® 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•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 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 10 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 throught the roof. Septic Tank(locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 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 °M ,•°' 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is Centerville Ma 02632 r 1/28/16 required for every page. Cityrrown 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 1" 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.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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 GSM ,•'' 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 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 ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 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 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 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is Centerville Ma 02632 1/28/16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 500 gl ❑ 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.): No signs of carry over and no signs of hydraulic 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 l5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts H - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of ponding or hydraulic 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 Offici�a�l Ins �ect �o�n�� Form p w Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments 57 Brezner In t•y• Property Address ` The Connolly Realty trust Owner Owner's Name information is required for everyg Centerville Ma 02632 1/28/16 page. Cityrrown State Zip Code Date oflinspection 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 0 drawing attached separately r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is Centerville Ma 02632 1/28/16 required for every 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 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 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: 10+ 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Site plan on file ❑ 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 on plan dated 3/2/06 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 57 Brezner In Property Address The Connolly Realty trust Owner Owner's Name information is required for every Centerville Ma 02632 1/28/16 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 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No:,C=:Mco -"o : ; 4� �{ Fee$' 00.00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpplication for Migo.5aY *p5tem Construction Verna Application for a Permit to Construct( ) Repair(Y� Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 7 71 —7 8 7 3 57 Brezner Ln, Centerville Katherine Connolly Assessor'sMap/parcel 230/142 57 Brezner Ln, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco-Tech PO Box 1089 Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder (no Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3--s o gpd Design flow provided 73 d a0 gpd Plan Date Number of sheets Revision Date Title I. Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 septic M system to plans of Eco—Tech, #ETE-2251 Date last inspected: Agreement: The undersigned agrees to ensure the constru ' and d maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Ti e 5 of nvironmental Code and not to place the system in operation until a Certificate of Compliance has been issued b i d of Health. Sign d Date Application Approved by Date /© 10 Application Disapproved by: Date for the following reasons Permit No. )co Date Issued No. ��� .. �� '"' x '( 't Fees 1 0 0.0 0 6.-- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Migogar �&p.5temc CCon.5trurttori Verm t Application for a Permit to Construct O Repair(4 Upgrade{ ) Abandon O ❑ Complete System ❑Individual Components t Location Address or Lot No. Owner's Name,Address,and Tel.No. 7 71—7 8 7 3. 57 Brezner Ln, Centerville Katherine Connollyu Assessor'sMap/parcel 230/142 57 Brezner Ln, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 t, Wm E Robinson Sr Septic Eco—Tech PO Box 1089, Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder (n9 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided Q gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 septic system to plans of Eco-Tech, ,#ETE-2251 Date last inspected: A 'iernent: The undersigned agrees to ensure the constru�t'� an�f d maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 ofthe-Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b4ti rrof Health. S'gn d Date Application Approved by Date --,, 10 (, -Application Disapproved by: Date for the following reasons Permit No. C)' &_01 ( Date Issued 3 0 ------------------ - ----------------- THE COMMONWEALTH OF MASSACHUSETTS Connolly BARNSTABLE,MASSACHUSETTS Certificate of CComphance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( X) Upgraded ( ) Abandoned( )by Wm E Robinson Sr Septic Service at 57 Brezner Lane, Centerville has been constructed in accordance l/ with the provisions of Title 5 and the for Disposal System Construction Permit No. moo & o q k dated 3j/10 Installer '�:—'C)D Fr, Designer Cn,. 1 ArtouJ r— #bedrooms Approved design flow _ 3 gpd The issuance of this permi shall n=t be construed as a guarantee that the ystem wt n 'o s signedr�"'—"~— Date Inspector. i -------------------------------------------- No. �(0 oq I FeV0 0.0 0 Connoll THE COMMONWEALTH OF MASSACHUSETTS PU'IIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Digpont �&p$tem CCon!truction Verna Permission is hereby granted to Construct ( ) Repair ( X) Upgrade ( ) Abandon ( ) System located at 57 Brezner Lane, 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: Constructi n m t be completed within three years of the ate of this Date ��� �v Approve Town of Barnstable i` T0`yo Regulatory Services Thomas F. Geiler, Director BARNSfABI E, MASS. �' Public Health Division t63q. �0 ATFDN50�a Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Sewage Permit# Assessor's Map\Parcel 230/1 42 Designer: Eco-Tech Installer: Wm E Robinson Septic Address: 43 Triangle Cir Address: PO Box 1089 Sandwich Centerville On Wm E Robinson Septic was issued a permit to install a (date) (installer) septic system at 57 Brezner Ln, Centerville based on a design drawn by (address) Eco—Tech dated 03-02-06 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. ,ir MgSsq i l l- 4DRUID �111P (Installer's Signature) o D. TA COUGHANOWR in - No. 1093 04(D ` �` �o G1STE"" s'1 A'f W' (Designer's Signature) (Affix Desi�'_ errs tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FOItM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-26-04.doc TOWN OF BARNSTABLE x LOCATION S-7 (3 Sy,� IArJe SEWAGE # aoa� _ UD VILLAG ASSESSOR'S MAP & LOT 2L "1°V2-' 4. INSTALLER'S NAME&PHONE NO. IZAOSone kgEC SEPTIC TANK CAPACITY 1500 LEACHING FACILITY: (type) &n_-4 _ (size) Zyxt�SXZ NO.OF BEDROOMS 3 BUILDER OR OWNER K• `CONMU't4 — PERMITDATE: COMPLIANCE DATE`. Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r Ltj 35 r -� 2 `701 2 7 r 3 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only F PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, !J RV I D Co�1-1 A-N dam', hereby certify that the engineered plan signed by me dated 1C,I'C� concerning the property located at 97 meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering) and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following:A) Top of Ground Surface Elevation (using GIS information) 45, 7D B) G.W. Elevation +adjustment for high G.W. = 31-- l e I eu GO�e DIFFERENCE BETWEEN A and B 7 SIGNED :QY"'""` DATE: POO NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc 1 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection RfcEi�EO �� William F.weld Q EC 1 4 199 Governor Trudy Coxe AP-wr Secretary,EOt A ( ! David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ��LL PART A :3 ,V n eA, k.O MC. CERTIFICATION f3 a"—*Nf L C�hre�v�7/� Property Address: Address of Owner: Date of Inspection: /;z-�//�� (If different) Name of Inspector: W.E. Robinson Sr. Company Name, Address and Telephone Number: W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT �-7 ��77--77 I certify that I have personally inspected the sewage dispos l s�sCer i§it 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 sew ge disposal systems. The system: _1 Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: z f Date: /I'?--I 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 copieb sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AJ SYSTEM ASSES: 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. BJ 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, 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 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(611)292.5500 Printed on Recycled Paper : a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: -'` ' Owner: 1(3 e7 K,ON I• Date of Inspection: j;2__ 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 ipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Bo-rd of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The syste 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 RE UIRED 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 nvironment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT TH PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy s within 50 feet of a surface water Cesspool or pri 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 N A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system nas a septic tank and soil absorption system and is.withi,n 100 feet to a surface water supply or tributary to a surface water supply. _ The wstem hay a septic tank nd soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank nd soil absorption system and is within 50 feet of a private water supply well. _ The systen, has a septic tank nd soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well ter analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from t t facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: I have determined that the system violates o e or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. a Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facili system component due to an overloaded or dogged 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. / (revised 8/15/95) ` 2 t � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Or e /7 e� ti�n�- l� e Q`"vi Owner: 6'd GLrn i Date of Inspection: _11_q D]SYSTEM FAILS(continued): Sta' liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid pth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required mping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of 'mes pumped Any portion o the Soil Absorption System, cesspool or privy is below the high groundwater 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 cesspool or privy is within a Zone I of.a public well. Any portion a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a esspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water uality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, olatile organic compounds, ammonia nitrogen and nitrate nitrogen. E]LARGE SYSTEM FAILS: The following criteria app to large systems in addition to the criteria above: The design flow of system is 1 00 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because on or more of the following conditions exist: the system is within 400 t of a surface drinking water supply the system is within 200 f t of a tributary to a surface drinking water supply the system is located in nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply wel The owner or operator of any such syste shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.0 . Please consult the local regional office of the Department for further information. `(revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B d ivn e-r ; CHECKLIST Property Address: S- / 131 e j ✓7 e r- r Owner: C e ,f v, Date of Inspection: Ig-//_d; Check if the following have been done: "I/Pumping information was requested of the owner, occupant, and Board of Health. `-None of the system components have been pumped for at least two weeks and the system has been receiving nominal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. LAs built plans have been obtained and examined. Note if they are not available with N/A. L(e facility or dwelling was inspected for signs of sewage back-up. 41fhe system does not receive non-sanitary or industrial waste flow _4,a site was inspected for signs of breakout. —L'4I 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. L-The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _L/The facility o%%ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. 4 (revised 6/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7 �'�Z 3 e i- ,� �h L C'����,,•vi���� Owner: c/ J d/.'rn j Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 3 34) gallons Number of bedrooms: Number of current residents: , Garbage grinder(yes or no): D(/ Laundry connected to system (yes or no):_ Seasonal use (yes or no): ®� Water meter readings, if available: Last date of occupancy: 5- COMMERZIAL/INDUSTRIAL: Type of establi hment: Design flow: allons/day Grease trap pres nt: (yes or no)_ Industrial Waste olding Tank present: (yes or no)_ Non-sanitary wall a discharged to the Title 5 system: (yes or no)_ Water meter rea I ings, if available: Last date of occ panty: OTHER: (Des ibe) Last date of fancy: GENERAL INFORMATION PUMPING RECORDS and source of information: � r System pumped as part of inspection: (yes or no)- If yes, volume pumped. /`?- a ..V gallons Reason for pumping: _7T I,6 1 TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool X.Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: `—:;L. 5 T es V Sewage odors detected when arriving at the site: (y or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1,3,r e /7 C/, f n e— C ed!7�e U///f—. Owner: Date of Inspection: SEPTI TANK:_ (locate site plan) Depth belo grade: Material of nstruction: _concrete _metal _FRP—other(explain) Dimensions: Sludge depth: Distance from t p of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from t p of scum to top of outlet tee or baffle: Distance from ttom of scum to bottom of outlet tee or baffle: Comments: (recommendati for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidenc of leakage, etc.) GREASE TRAP:_ (locate on site plan) Depth below grade: Material of constructi n: _concrete _metal _FRP_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom nt 5r im t,bottom of outlet tee or baffie: Comments: (recommendation for pumps g, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leaka c•, etc., If AV (revised 8/15/95) 6 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5 7 J3 re 717 e, - 9 r C, 2.�.7 7-er U Owner: 5D It m i Date of Inspection: I _ `4 TIGHT OR OLDING TANK:_ (locate on site Ian) Depth below gra Material of constru 'on: _concrete metal _FRP—other(explain) Dimensions: " Capacity: kallons Design flowjin allons/day Alarm level: Comments: (condition ondition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level a ove outlet invert: Comments: (note if level and dis ribution is equal, evidence of solids carryo�:er, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order:(ye or no) Comments: (note condition of pump hamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S 7 i3 r c 3 e r' �• ' 17 e— C e M 7��v/ Owner: )3att M / Date of Inspection: 1 1—q J SOIL ABSORPTION SYSTEM (SAS): (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, numben-L leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) .b Z77,57 CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: [� Depth of scum layer: 1 Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection)��i T�< Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) �A e-) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: e Owner: Date of Inspection: Y ' SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' { ' I b102 DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: 9 (rgvised 8/15/95) TOWN OF BARNSTABLE b LOCATION Q/a 44✓ SEWAGE##/2L� VILLAGE /"L- ASSESSOR'S MAP&LO 114STALLER'S NAME&PHONE NO. _<o SEPTIC TANK CAPACITY ^ LEACHING FACILITY: (type) P (size) 6 NO.OF BEDROOMS 3 BUILDER OR OWNER �Y� Q ✓✓) 4� PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet l g ty 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 ffcility) Feet Furnished by r j2w FLOW PROFILE ALL PIPE ELEVATIONS SPECIFIED ARE INVERT ELEVATIONS VENT PIPE TOP FOUNDATION RAISE COVERS TO WITHIN EL = 46.4? +- 6 in OF FINAL GRADE ONE INSPECTION RISER FOR LEACHING GALLERY f D-BOX ( 2 t/2 ER OF STON V8 3" DROP FLOW LINE el 10 14*. PRECAST LE - 72 48- SASS DRYWELL 1111V3/4--11/4- So BAFFLE STONE ' \443.00 6 1� BOTTOM OF 5 STON 42.38 LEACHING SYSTEMSOIL ORPTION G BASE 6 t� STONE BASE 42.55 GALLERY 43.25 42.25 5.00 Ft 1500 GALLON (END VIEW► 40.25 A-17.7 Ft SEPTIC TANK 32.5 FL al 5 FL 12.5 FL B-36.5 F 6) 14 FL ESTIMATE 34.49 SEASONAL HIGH GROUNDWATER 0 UJ 1 I m �> O rn? 11 -D y F > Ix U1 r -+ �� +o C)O ���� �� -C O 3 0 rn r 00 �r1�0 D z m z Ln m o>N m N> COIyy�O ~' F ` �� N m rn z CO pFo W D ��a�� N �/ -i> n sli�s� >-I 3 m -� tzr-ornm Z m°0 3N n � 11 z �z o ��a�� cn-bL O 3 c, Z m c C (nor, N CD � =rn O �► mmrgm� 3 z �J r—(n ut Z r N hl ncn G7 � p m r N Z rn z �0 m m Gtl I 0 i ci mr- rn RI,,,Z:,• p Z-,<U 3 s m n z z < O ��Z� 4zz '� C M ' o m > r M rn �----� m o^c ;7 n Ln o In - M�o c -� x rn o m n = a O L') p rq r- z a �, �,, Rl N t!) �'z�z � X z n f m -0 ;u -�I x co M m rn (n Ul y O m I _0�+ ry m Z m Oz -< - O IOc.Z ;rm �Z X m�m N C z N �3y m00 yrrl �c e m z �7 m rr-- (� Z:rm- O r Q z [) Y Jv^'/PEQ Z �Z� CO � O z -< � O � � � � °a m �Z r ' I on k ��lo Rqq Z' n Z -i ' z U7 rn M cn c = 3 ;a —� rr nn R ' m ZomM 3M rrn `"m p co n Z ND�m Z r Cn 0 -0 Z > a <m no N a) � m > m SOIL TEST ' LOG DESIGN CALCULATIONS DATE OF TEST: FEBRUARY 24, 2006 SOIL EVALUATOR: DAVID D. COUGHANOWR. RS DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPO WITNESS REOUIREMENT WAIVED - NO VARIANCES SOUGHT NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS TEST PIT 1 PARENT MATERIAL: PROGLACIAL OUTWASH INSTALL SHOREY PRECAST 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) PERC AT 58 Lri : 2 MIN/INCH IN C SOILS ELEVATION = 45.82 +_ DISTRIBUTION BOX: USE 3 OUTLET D-BOX. (WC)TH HORIZON TEXU DTSO L cM SOIL L COL L1 MOTTLING OR MO T OTHER SOIL ABSORBTION SYSTEM: A 24 FL x 12.5 Ft x 2 F L LEACHING GALLERY CAN LEACH 4552 Abot = ( 24 x 12.5 ) = 300 sF 044 Ap SANDY LOAM 10 YR 4/2 NONE FRIABLE A L o L = 446 s F 2 4 + 12.5 + 12.5 l x 2 = 14 6 s F 14-34 8 LOAMY SAND 10 YR 5/4 NONE FRIABLE VL 0.74 x 446 = 330.04 GPO 42.99 34-144 C MEDIUM SAND 10 YR 6/4 NONE LOOSE USE A 24 FL x 12.5 FL x 2. FL GALLERY. Vt = 330.04 GPD > 330 GPD REOUIREO 33.82 TEST PIT 2 POA ENTUNDWATER MAATERIA EPROGLAC ALD OUTWASH ELEVATION = 45.70 +_PERC AT 58 to : 2 MIN/INCH IN C SOILS DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER LEACHING GALLERY (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 5PJ0 GALLON DRYWELL 45.?0 DIMENSIONS AND DETAIL 0-12 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE CONSTRUCTION DETAIL USE""10Lr41T 12-36 a . LOAMY SAND 10 YR 5/4 NONE FRIABLE YWELL UNIT INSTALL ONE INSPECTION 42 x -9 70 6'-6' 4'-L0"ac 2' ^ STON RISER TO WITHIN SIX 2 FE EFF. p -9 �. INCHES OF FINAL GRADE 36-132 C MEDIUM SAND 10 YR 6/4 NONE LOOSE AND INDICATE LOCATION 34.10 -- 24.0 F! ON AS-BUILT PLAN m 0 33 NOTES N Q ooQ000�000Q o_ 0o in 0000000d000 0 11 GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN 3.5' S.S. 6.5 3.5' 21 ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 24.0 Ft NOT TO 102 Jr-7 31 ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS SCALE OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 151 41 INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. 51 EXISTING CESSPOOLS TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED 61 ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON, FINES AND DUST IN PLACE 7) LINES EXITING O-BOX TO RUN LEVEL FOR 2'-0- BEFORE PITCHING DOWN SEWAGE DISPOSAL SYSTEM ,PLAN 81 ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK -TO SERVE EXISTING DWELLING 91 SPYSTEM IS NOT DESIGNED ARK OR DRIVE VEHICLESTO WITHSTAND VEHIC OVER SEPTIC SYS EMLAR LOADING. DO NOT KATHERINE K. CONNOLLY 1-01-INSTALLER--TO-OBfiAIN-O-ISP-0-SAL WOR-K-S-PERM-I;T� _BE'F-ORE-S-TA-RTTNG-WORK. 57 BREZNER LANE CENTERVILLE. MA 111 SEPTIC TANKS SHALL BE INSTALLED LEVEL 'AIVO` TRUE TO GRADE ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH ECO-TECH ENVIRONMENTAL SIX' `INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING 43 TRIANGLE CIRCLE SANDWICH MA 02563 t ETE-225I MARCH 2. 20061 1212