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0421 BUCKSKIN PATH - Health
.421 Buckskin Path Centerville A=.192= 122 is { I No. 42101/3 ORA ain &2 ESSELTE . 10% O O O O N.:. r No. ,,� "I'7 v 1/` / y THE COMMONWEALTH OF MASSACHUSETTS FEE {U� BOARD OF HEALTH ���— G 10\Nn OF 017-n54a hie. APPLICATION FOR DISPOSAk SYSTEM CONS T UCTION PERMIT Application for a Permit to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) - omplete System ❑Individual Components �1a,p �9z 1T)pa:`rcel /2Z` L{21 Map/Parcel# Address Lot# phone# ✓a -� I�7f1 oW/1 eleAP t%1 Installer' Nam n J Dgngr's Nt �V� -'q 1-7 — ='4-2 0t- 34 Z- s Telephone# Telephone# Type of Building: I°5 j cu- , Lot Size Sq.feet Dwelling—No.of Bedrooms -,3 Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(mi .required) 3,30 gpd Calculated design flow gpd Design flow provided gpd Plan: Date 3 Number of sheets �_ Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Gfl 0�1 0'I°S Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed 99r Date Inspections — 1 FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 t No. Ul�l-0 �y j THE COMM:O.NW-EEALTH 'OF MASSACHUSETTS FEE IUD ' _ BOARD .OF HEALTH -. � lo\ljn OF - APPLICATION FOR DISPOS L SYSTEM CONSTRUCTION PERMIT Application fora Permit to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) - _omplete System ❑Individual Components / Map/Parcel# Address / -� Lot# elephone# J// Installer' Name...�^'�` � l�`- DesigneF' N' e/ t ne. aVr? e r-I l y r,-t �`— 'Address/ (� Add ess / 50�' 7 �(,6 � J 3 � �l� l Telephone# ;3 / Telephone# Type of Building: T<11-S 1 C LA i) L-c- Lot Size Sq.feet 1,4 Dwelling—No.of Bedrooms .3 Garbage Grinder ( ), Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) 30 gpd Calculated design flow gpd Design flow provided gpd Plan: Date I LI Number of sheets 1 Revision Date wJ Title , Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator S Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS bk The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of -� TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed 9vi Date Inspections 1 r �k FORM 1 - APPLICATION FOR�DSCP DEP APPROVED FORM 5/96 No. c ILI,n V THE COMMONWEALTH OF MASSACHUSETTS FEE ��0 1 It') I Gt BOARD OF HEALTH CERTIFICATE OF COMPLIANCE ! Description o Work: ❑ Individual Component(s) ❑Complete System The de gned.hereby'certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: "►7` ! � Gn sf at ` } 7 ` /1` l/ I Fl 4)V I 1 t'el I has been installed in accordance with the provisions of -10 pCMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.� ��'G dated �l/cl1l� Approved Design Flow "� 3 � (gpd) Installer (A I L IrCJ t /✓' 1 /// IA1 - y �' ! Designer: 'T J(` \N Inspector , l lit o ==D la e b///f The issuance of this certificate shall not be construed as a guarantee that tie System will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. a J/b/- O I./ THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby-granted_to-Construct ( ) Repair ( ). Upgrade ( ) Abandon ( ) an individual sewage disposal system at Ll�.( �" I 1 l k c4.1. C 7 'n'f 1 as described in the application for Disposal System Construction Permit No. -7 y dated Provided: Construction shall be completed within three years of the date of this p -rxtitt..All local co dit�i/oons must be met. Date 3I(�� ) `1 Board of Health i I �I I y v FORM 2 - DSCP DEP APPROVED FORM 5/96 v FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS- BOSTON f FROM :down cape engineering inc FAX NO. :150836213880 Apr. 17 2014 03:23PM P1 -,,own of Piarustabf.e ke5,is Themas E Gle-lur, ?&AL oAPublic HCOlth DMISIGn Director TIRDMM MCU-0014,A ?,Go Mailm Street,1Eymnm&5,,.M- AL N601 Fax- 508490-eO4 offim, jog-869.4641-4 gaex 77 Date. AddreRs: 01a was issued a ritmmitto ing.all d bLised ou ta.desi�d-rawaby Septic,syxtem d.. initd ff�that the system leti-reliced above -was ims"hqllekl sub-5twilially, acmoTding to certify die the WEoh U�qy jjjoj-a.d,e Tmuor qgjl.Tu'V-e,,d. rjinngo.�-, mach as latual.i-ulorm-LiOu of distribudoia hox 01001 5elrrizi�tank. I certify fl-Lit UbOVC the -c SySt Lh jn.ajor challg�f-3 �('OtlT'n-L Tt-7LV,110ECi -WLAS installed 7vi el't of the�tsptic systen) CLAIReglIlati,ml m4. 'UT j.-n .51FT R cc in. - certified.as desi. ler to iko. ,h-...w DANIEL ji, ITF CIVIL M No.40502 4/17/11 & F TOWN OF BARNSTABLE LOCATION 4 J BUckSPei n P�'jlN SEWAGE# 201(4 ' 0-7 VILLAGE C ,=Mcr U 111 C ASSESSOR'S MAP.&PARCEL INSTALLER'S NAME&PHONE NO. 13 EXCa,ha-)i Or) N'77- aL.S3 SEPTIC TANK CAPACITY 1500 ga. LEACHING FACILITY:(type)Trcn c. c S (size) 2x 3 X 33 NO.OF BEDROOMS 19 OWNER A./anc, C arpcnlcr PERMIT DATE: 3- 14 -I SI 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 ori:` 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 A�-a� ' a AZ- Z' , $Z- 23 L A 3- 36 3 03" 2 7,y" A4 ' SS,L Bq-SG ' 0 A AS Z q�G ,• _ � C lcanov� 3S REAR I ac� /n47 el, Town of Barnstable P# Departiment of Regulatory.Services Public Health Division Date l�v nV.^� 200 ain Street,Hyannis MA 02601 Date Scheduled G, -D L/ Time d. ! O 0 • 0 0 Fee P Soil Suitability .Assessment.�- or S e Ill a o, e p Performcd-By: ba 1"1 1 I Witnessed By: LOCATION&GENERAL INFORMATION Location Addreys (.la I u a k t� P�xE Owner's Name Address / Assessor's Map/Parcel: , 2` ZZ \ /� Engineer's Name !y-J w 1..�(// NEW CONSTRUCTION REPAIR Telephone# Land Use: L Q LA/n Slopes % l{/o� r' P ( ) v —� Surface Stones;Distances from: Open Water Body ��/t/l D Q Possible Wet Area >f Gy g Drinking Water Well Drainage Way Vy ft Property l ina 2 v ft Other ft SIMTCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes) ti - co • O t o� ' Pazeat'inaterial(ge to is "[�L;a� �/ ` 1 � ��t/ • Depth to Bedrock tDepit&Oroundwate $landing Water in Hole: /V/ Weeping from Pit F'Ce �/ ZEstlmatedSeasonal Hij610roundwater , Al GG� ems + J— c__4 DET_ERIVIINATION FOR SEASONAL HIGIR WATER TABLE- "IYletbod Used: y O to ,1 Depth Observed standing in obs.hole: la. Depth to still mottles: 1t1, Depth to weeping from side of obs.hole: In, Groundwater Adjustment !G. Index Well# Reading Date: Index Weilleval _ Adj,factor,,,,,_.,,_ Arj,Gromidwaterl.-val , PERCOLATION TEST bate I�D/yTltua M#16 Observation Hole# Tlma at 9" Depth of Pere Time at G' i� Start Pre-soak Time @ _ Time(9"-6 11 ) —_ Bad Pre-soak Rate Mindluch I J Site Suitability Assessment: Site Passed v Sitg Failed: Additional Testing Needed(Y/N) �v . Original: Public Health Division Observation Holc Data To Be Completed on Back------- ***If percolation test its to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to begimoabg. Q:1S EPTICIPERCPORM.D O C ]DEEP.OBSERV•ATION HOLE LOG Hole#�_ Depth from Soil Horizon Soil Texture .Shcl Color Soil• Other Surface(in.) (USDA) (Mansell Mottling (Structure, Stones;Boulders, oT]Sis ten:y,96'Grayel) 0 — lom Z�-�a CI Z15-y0/3 62- 13Z loy� 7/� /d Graved DEEP OBSERVATION HOLF,LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsel]) Mottling (Structure,Stones,Boulders. Qgnsistmay,%Orave 10 512Z-40 CI 10YR —/Pad DEEP OBSERVATION HOLE LOG Bole#. Depth from Soil Horizon Soil Texture Sol]Color Soil Other* Surface(in.) (USDA) (Munscll) Mottling (Structure,Stones,Boulders. o f to c O e IDEEP OBSERVATION HOLE LOG Hole# Depth from Soil horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munscll) Mottling (Structure,St'oues',Boulders. Cositn Flood Insurance Rate Map: � l Above 500 year flood boundary No yes Within 500 year boundary No Yes Within 100 year flood boundary No.,^ Yes _ r .Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious atorial exist in all areas observed thrpughout the area proposed for the soil absorption e p p rp system'1 `1 � , If not,what is the depth of naturally occurring pervious matariall Certification I certify that on /��Z (date)I have passed the soil evaluator examination approved by the , Department of Environmental Protection and that the above analysis was performed by me consistent with . the requited training,expertise and experience described in�10 CMR 15.017. Signature Datb Q:\S.EPTlaPEIZCF0RM.D0C down cape engineering, inc. SIEVE SOILS ANALYSIS 421 BUCKSKIN PATH CENTERVILLE, MA DATE OF REPORT: 3/4/14 JOB : GRAIN SIZE ANALYSIS-SIEVE TEST SITE: 421 BUCKSKIN PATH CENTERVILLE, MA LOCATION: DCE TEST HOLE SIEVE ANALYSIS Weight Sample(Grams): 1.89.8 SIZE :WEIGHT RETAINED € % RETAINED € % PASSED (sum ) --------------:.......................................................--------------------....................................... 1" 0.0€ 0.0% 100.0% --------------;......................................................}---------------------}------------------ 3/4" .0.0€ 0.0% 100.0% --------------:......................................................:--------------------=------------------ 1/2 --------------�......................................................}---------------------o------------------- 3/8" 0.0€ 0.0%€ 100.0% --------------:.......................................................---------------------=------------------ #4 0.0€ 0.0%€ 100.0% --------------i......................................................>---------------------1..................................... 4.6% 95.4% #20--------- ..........................................34... -------------18 1%€......................81.9% ....................................................... .....................................#40 `...........................................68:5'-------------36_1% ......................63:9% #50 88.41 46.6%E 53.4% --------------;......................................................}---------------------1..................................... #80 116.11 61.2%E 38.8% ....................................................... #100 128.1 67.5%€ 32.5% --------------i....................................................... 167.5 88.3%€ 11.7% --------------:......................................................:---------------------=------------------ PAN: 189.1€ 100.0%€ 0.0% -------------- --------------------------*------------------------------------ ---- SAMPLE: € 189.8` NOTE:TEST ON PASSING#4 ONLY, 0.8% RETAINED ON#4 <45% O.K. thbo,. � �tH dF.Mgs c DANIELA. ''P o OJALA CIVIL c No.46502 fox,Fci s r ER``oa� SS�ONAL E�,G Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 421 Buckskin Path s Property Address Dam iel &Jill McKay : Owner Owner's Name information is required for every. Centerville MA 02632 10/17/13 . 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. General Information : on the computer, use only the tab- - - key to move your 1. Inspector: cursor-do not Matthew Gilfoy.. I . U use the return Name of Inspector key. B&B Excavation, Inc: �p Company Name 14 Teaberry Lane Company Address � Forestdale MA::. 02644 :City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally Inspected the sewage disposal system atadd ,.�, th address and th4the information reported below is true, accurate and complete as of the time of the:inspection: -We inspection was performed based on my training and experience.in the proper function and``maintenanc�Jof ori'Site sewage disposal systems. I am a DEP approved system inspector pursuant to(Section-T5 34Q of Title 5(310 CMR 15000). The:system: - , ® Passes ElConditionally Passes ❑ Fails f _. ): Needs Further Evaluation by the Local Approving Authority 10/21/13 _Inspector's Si6q&ture- 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. . e � t5ins•3N3__:: Title 5 Official Inspection o ubsurface Sewage;Disposal System:-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System.Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 page. City/Town 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. I 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 r Commonwealth of Massachusetts .. Title 5 Official Ins...pection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 'p 421 Buckskin Path y Property Address . Damiel &Jill McKay Owner Owner's Name information i e required for every Centerville MA 02632 10/17/13 page. - City/Town State Zip Code Date of Inspection C. Checklist Check if:the following have.bee❑ done..You must indicate":yes" or"no" as to each of the following: Yes No E [ 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? M El 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? N a 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? N El Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site?. . ® 0 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: _.... ® 0 Existing information. For example, a plan at the Board of Health.: Determined in the field(if any.of the failure criteria.related to Part C is at issue ® ::approximation of distance is-unacceptable) [310 CMR 15.302(5)] : D. System Information Residential.Flow Conditions: Number of bedrooms (design).::: 3 Number of bedrooms (actual): 3 DESIGN flow based.on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): .. 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments ^M 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: 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(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No 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•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 M 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 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: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1216 gallons How was quantity pumped determined? site glass Reason for pumping: to check for inflow of groundwater&structural integrity Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Tide 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 M 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1971 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1'10" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: > 10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in working condition. No sign of leakage Septic Tank(locate on site plan): 9 Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ® other(explain) block cesspool acting as septic tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: 5'x 5'5" Sludge depth: 1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 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 no outlet tee Scum thickness 11" Distance from top of scum to top of outlet tee or baffle no outlet tee Distance from bottom of scum to bottom of outlet tee or baffle no outlet tee How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection cesspool is acting as a septic tank and appears to be structurally sound with no inflow of groundwater. No sign of leakage. Recommend installing outlet tee. 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 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 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.): *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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 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 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.): No d-box 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): At time of inspection leaching/overflow cesspool appears to be functioning. Water level 2' below invert. Any increase in flow could result in failure. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M s 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 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.): System consists of cesspool acting as a septic tank and an overflow cesspool acting as leaching working at this time Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM y 421 Buckskin Path Property Address Dam'iel &Jill.McKay Owner Owner's Name information is required for every Centerville MA : 02632 10/17/13 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 D :drawing attached separately 1��Rtvt:- s A a O AL = apt t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 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: >2' below leachingfeet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: a hand hole was augered at time of previous inspection. No GW 2' below system 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Buckskin Path Property Address Damiel &Jill McKay Owner Owner's Name information is required for every Centerville MA 02632 10/17/13 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 421 Buckskin Path Centerville Owner's Name: Adele Povilavicius Owner's Address: Date of Insp ection: 7/10/2007 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 $� Sandwich,MA 02563 VZ� r Telephone Number: (508) 888-6055 CERTIFICATION STATEMENT N) I certifythat I have personally p y inspected the sewage disposal system at this address and that the m_fQrmation�r�'porte'_ 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 system§JI am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The Systgm: asses Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: f�..�-- 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. Notes and Comments �f f1 Mom•`-�A.GS� <'�r c�^.A�lr., 1�.�.5 �-�a. � _ macs��" �/V .\P v�r+p,i� ''3V, c�,�'��b�.a-.cA.-^.:\' 'S�:.:-s•�' v..V . A�l (�1uvwwi�'`>'�� �'Y" C��w.�tr\1.:�..C �`��v�7 ****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. 1 i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 421 Buckskin Path Centerville Owner: Adele Povilavicius Date of Inspection: 7/10/2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: �ave 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: i 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,a proved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for e following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltratio or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic to as approved by the Board of Health. *A metal septic tank will pass inspection if it is s cturally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old i available. ND explain: Observation of sewage backup or br ak out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,sett d or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pu ping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with apprq al of the Board of Health): broken pipe(s)are replaced I obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 421 Buckskin Path Centerville Owner: Adele Povilavicius Date of Inspection: 7/10/2007 C. Further Evaluation is Required by the/nn the Conditions exist which require further he Board of Health in order to determine if the system is failing to protect public health, safety or the 1. System will pass unless Board of Hes in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerotect public health,safety and the environment: Cesspool or privy is within 50 fe t of a surface water —Cesspool or privy is within 50 f et of a bordering vegetated wetland or a salt marsh 2. System will fail unless the/Board of Health (and Public Water Svpplier,if any)determines that the system is functioning in a manner that protects the public health,safe y and environment: _The system has a septic tank and soil absorption system(SA 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 ithin a Zone 1 of a public water supply. The system has a septic tank and SAS and the SA is within 50 feet of a private water supply well. _The system has a septic tank and SAS and the AS is less than 100 feet but 50 feet or more from a private water supply well". Method used to dete ine distance "This system passes if the well water analysi performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicate that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate ni ogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the an ysis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 421 Buckskin Path Centerville Owner: Adele Povilavicius Date of Inspection: 7/10/2007 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 and overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above 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 se e a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of e following: (The following criteria apply to large systems in ddition to the criteria above) yes no _ the system is within 400 feet of a s rface drinking water supply the system is within 200 feet of tributary to a surface drinking water supply _the system is located in a nitr gen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water su ply well If you have answered"yes"to any uestion 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 421 Buckskin Path Centerville Owner: Adele Povilavicius Date of Inspection: 7/10/2007 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 than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Existing information.For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] i Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 421 Buckskin Path Centerville Owner: Adele Povilavicius Date of Inspection: 7/10/2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):ALA" Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 'ycp Number of current residents: CJ Does residence have a garbage grinder(yes or no):,. Is laundry on a separate sewage system(yes or no):k�Z, [if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use: (yes or no):xa�) Water meter readings, if available(last 2 years usage(gpd)): ra.� Sump Pump(yes or no):.t- Last date of occupancy: �:.� s" COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.20 ): gpd Basis of design flow(seats/persons/s ./ft. etc.): Grease trap present(yes or no): Industrial waste holding tank prese t(yes or no): Non-sanitary waste discharged to e Title 5 system(yes or no): Water meter readings, if availab Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: r)er�lg,"v.�y Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Septic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval ✓Other(describe): � ,•�.�'� r'.Q � =�� `--jC `. 55f�3^�` Approximate age of all components,date installed(if known)and source of information: \S`'I I . C3 Were sewage odors detected when arriving at the site(yes or n6):,A—'Q') r. f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 421 Buckskin Path Centerville Owner: Adele Povilavicius Date of Inspection: 7/10/2007 BUILDING SEWER(locate on site plan) Depth below grade: it Materials of construction:_cast iron_40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): ,/(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene other(explain) C�.�,�, .�-�T� `ac --.t_Slc If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: S Sludge depth: ©" Distance from the top of sludge to bottom of outlet tee or baffle: Scum thickness: ©" Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 1 4 t,, ,,b,`�," -Z- ,4:;;! ;mac , Comments(on pumping recommendations,inlet and dutlet tee(5r�baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:—concrete/metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to t of outlet tee or baffle: Distance from bottom of scu to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping r commendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inve ,evidence of leakage,etc.): i I Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 421 Buckskin Path Centerville Owner: Adele Povilavicius Date of Inspection: 7/10/2007 TIGHT or HOLDING TANK: (tank must b pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete tal_fiberglass_polyethylene_other(explain): Dimensions: Capacity: Ions Design Flow: gallons/day Alarm present(yes or no): Alarm level: Ala in working order(yes or no): Date of last pumping:�-- Comments(condition o at/ larm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above o�ddistribution Comments(not if box is leve to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, c.): i PUMP CHAMBER: (locate on site!�Ian) Pumps in working order(yes or no): Alarms in working order(yes or no)- Comments(note condition of pu chamber, condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 421 Buckskin Path Centerville Owner: Adele Povilavicius Date of Inspection: 7/10/2007 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: 'overflow cesspool,number:_I 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.): y .l (�q �3�', I Vy y 1�r•s sd g W,y�!.?"L 1 �+� •�!•4�s� Ci'� �X`+�-�.` �1a ��..1'k1.c..��`�.�— �aA L�c�t'� CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs f hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 421 Buckskin Path Centerville Owner: Adele Povilavicius Date of Inspection: 7/10/2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. I � I '�S o � 0 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 421 Buckskin Path Centerville Owner: Adele Povilavicius Date of Inspection: 7/10/2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 7 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record—If checked,date of design plan reviewed: _l,,L-'Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) :�Z_AccessedUSGSdatabase-explain: 35., You must describe how you established the high ground water elevation: —,,.gym �.-�.,...�. --���-r '."�- •� o..�.. ' �e c �x.\.ol�, 64 Lac Cl v- A\ -i TOWN OF' .o LOCATION: VILLAGE: 1"`41,*l'LOT#: «a- 1 PERMIT#: INSTALLER'S NAME: INSTALLER'S PHONE#: LEACHING FACILITY: (type) Ccsspn,.k (')t,-r.�(m4size) NO. OF BEDROOMS: Y BUILDEROROWNER: PERMIT DATE: COMPLIANCE DATE: �e. 0 DRAW DIAGRAM ON BACK D3 o � O 3 � = 3D SEWAGGE PERMIT NO. V'! c_ G E ASSESSORS MAP NO: c Hr 2 e'c-v i C PARCEL NO.: 12z— 9 U I L D E 0R OWNER !a l. .. UE0 i �'' � t ALL STEM SHALL SYSTEM PROFILE MART ED WTHCMAGNETICTTAPE OR BE -- PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. NOTES on s ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 1. DATUM IS APPROX. NGVD Three \ TOP FOUND. EL. 61.5' 2. MUNICIPAL WATER IS EXISTING � CO:------------------------------ I Wequaquet 60.0' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 59.5' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. o Lake PRECAST H-10 PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL RADE Locust RISERS (TYP.) 4. DESIGN LOADING FOR ALL PROPOSED PRECAST o oo 2'o 4"OSCH40 PVC UNITS TO BE AASHO H-10 o oµe�� PROP. TEE PIPES LEVEL 1ST 2' \Of\ 2" DOUBLE-WASHED PEASTON + OR GEOTEXTILE FABRiC 5. PIPE JOINTS TO BE MADE WATERTIGHT. �C o * lb 58.8 1500 GAL H-10 54.5 a 10" 14" 6. ' S8.0' TEE SEPTIC TANK TEE WITH0310T CMR 1105.000 (TITLED BE IN ACCORDANCE Q 7.75 ° o ° ° o - ° ° ° ° ° 00000°o°o°o°;0;0P0p0-0-0o° o000000o0o0o0 n O .• o 0 0 0 0 ° 10'/ ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° o ° ° o o ° o ° o ° o 000 000000000000 540�0�0000000Ooo0o0�0�0�0�0�0�0�0'o'>�0o0°0°0�0�0�o 0.0�0o0�000000 o �` GAS BAFFLE ::: 51 .85 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND D s o��_ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0;0 0 0 0 0 0 0 0 0 0 0 0 O 00000uououogog0000go,o000o00000000 i0000 0 -0-000 o°00000000ox0000 O a 4' LIQ. LEVEL (ACME OR EQUAL) 20' 03' - FOR LOT LINE STAKING OR ANY° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° " ° ° ° ° ° ° ° ° ° ° ° ° ° NOT TO BE USED c 54. 54. 4" PVC SET AT .005'/' SLOPE OTHER PURPOSE. :; moo 0 0 0 0 0 0-0;0 ° ° o o•o o;o�oo 0 0 o`c. ON 24 DOUBLE WASHED 3 4- 1 1/2" STONE •000000000°00000000000000000000000000000000000 6" MIN. SUMP ° 0o0°°°°°°oo°r_'°n?°°����°°0° 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. - 12" MIN INT. DIM. (2) 33' X 3' W x 2' DEEP TRENCHES yea a 6" CRUSHED STONE OR MECHANICAL I o IC 3.65 ** e ash p 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT INSPECTION BY BOARD OF COMPACTION. (15.221 [2]) S 3 'G� o HEALTH AND PERMISSION OBTAINED FROM BOARD ( 2.8% SLOPE) ( 44 % SLOPE) ( 1 % SLOPE) 1 6'+ OF HEALTH. LOCUS MAP BOTTOM TEST HOLES 1 & 2 EL 48.2' 10. CONTRACTOR SHALL BE RESPONSIBLE FOR ' LEACHING **INSTAL_ER TO CONFIRM SUITABLE SOILS AND CALLING DIGSAFE (1-888-344-7233) AND NOT TO SCALE FOUNDATION- 27 SEPTIC TANK 8 D' BOX 5' FACILITY NO WATER FOR 5' MIN. BENEATH SAS VERIFYING THE LOCATION OF ALL UNDERGROUND & PRIOR TO INSTALLING ANY PORTION OF OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL SEPTIC SYSTEM WORK. ASSESSORS MAP 192 PARCEL 122 UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS G-W AT ELEV. 35' PER TOWN MAP 11. ANY UNSUITABLE MATERIAL ENCOUNTERED PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE SAND. IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR BY HEALTH INSPECTOR PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED PROP. VENT WITH CHARCOAL FILTER BY THE BOARD OF HEALTH REVISED DURING A PUBLIC CONAND BUGSCRE T (FINAL PLACEMENT BY HEARING HELD ON AUG. 4, 2009 CONSTULT RACTOR WIT HOMEOWNER 3) FAILED SYSTEMS ONLY : SOIL ABSORPTION SYSTEM INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW SYSTEM DESIGN. GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) O CASE SHAL BED I TH H-20 LOCATED MORE THAN LOADING, THAN SIX FEET T IN NBELOW GRADE.L THE SAS STOCKgO f (TYp�' GARBAGE DISPOSER IS NOT ALLOWED TH 1 DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD 5 . 6� -- 180.86' USE A 330 GPD DESIGN FLOW 59-:5 TH 2 SEPTIC TANK: 330 GPD (2) = 660 .49 USE A 1500 GAL. SEPTIC TANK TEST HOLE LOGS '�� LEACHING: +59. K� 5 SIDES: 2[2 (32 + 3) 2 (.74)] = 207 GPD DANIEL E. GONSALVES, SE o�'� 6000 ENGINEER: =� BOTTOM 2[32 x 3 (.74)] = 142 GPD ��, WITNESS: DONNA MIORANDI, RS 59.35 �� ' PQP��a 60.9 ; _1 LOT 2 TOTAL: 472 S.F. 349 GPD DATE: FEBRUARY 25' 59.13 C P 2014 60.94 9 17,127 Sq. Ft. � 50 6'.1s *61.39 USE (2) 32' LONG x 3' WIDE x 2' DEEP PERC. RATE _ < 2 MIN/INCH IN C2 LEACH TRENCHES OF PERF. SCH. 40 PVC PIPE AND STONE 59.2 � +60.3 1 0 SHED 59.32 o r;1-S6 `� CLASS I SOILS P# 14299 6 BENCH MARK - TOP D)F CONC. STEP. L. = 6..5' / �60.65 P ELEV. ELEV. ,+ 1�_00 61.s4 // 4 4 / A A � �+59.99 MA EXIST. DWELL. / APPROVED DATE BOARD OF HEALTH /LS �� �LS UNSUIT. TOP FNDN. 10YR 4/2 UNSUIT. 10YR 4/2 ELEV. 61.5' .� 6" 6" \ \ 6 .15 0 32 9 TITLE 5 SITE PLAN B B � � -�� \ �59.29 P P ��9� 59.89 9Ct� g / �SL UNSUIT. �L UNSUIT. + 60_77 // OF 10YR 5/6 10YR 5/6 60\86 �N 24" 24" 60.31 P �,;� F, G� 421 BUCKSKIN PATH c1 c1 CENTERVILLE / UNSUIT. / /LS UNSUIT. /LS \ // PREPARED FOR 2.5Y 6/3 54.0 /2.5Y 6/3/, 1 F +�.72 62„ 62 54.0' \ // B&B EXCAVATION/CARPENTER C2 C2 y58.28 MARCH 4, 2014 80 PERC / �LjNOF A0S9C k%'�tHOF4fj M off 508-362-4541 M CS M CS / IE 0 ,� qc / / / �� Ss t- fax 508-362-9880 57.91 ��� DANIEL ° DANIEL ���\!� I downcope.com 5-10% GRAVEL 5-10% GRAVEL 0 A. CIVIL OJ LA down cape en601/leer1#760 inc. 132" 1 OYR 7/4 48.2' 132" 10YR 7/4 48.2' No.4G502� �Q 0980 F�",S T Elk op �� l' civil engineers NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' � �,SS/ONA 1E � �. land surveyors �-`'I-�`'� 939 Main Street ( R to 6A) o 10 20 30 40 FF� I DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675