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HomeMy WebLinkAbout1241 BUMPS RIVER ROAD - Health 1241 Bumps River Road Centerville A= 188 —078 i 5 M EAD® No.2-153LOR UPC 12534 emead.com • Made in USA Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;a 4 M 1241 BUMPS RIVER RDA Property Address SARAH MINTY l Owner Owner's Name ary information is required for CENTERVILLE MA 02632 6-25-15 s every page. City/Town State Zip Code Date of Inspection �l 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 A. General Information forms on the computer,use 1. Inspector: " only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name VQ P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the I 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-25-15 InspectoOrSignature 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: PROPERTY HAS 2 SYSTEMS ONE IN THE FRONT AND ONE IN THE REAR. BOTH WERE INSPECTED AND FOUND TO BE IN WORKING ORDER AT TIME OF INSPECTION. THE FRONT CONSISTS OF A 1000 GALLON TANK AND PIT. THE REAR IS A 1500 GALLON TANK, D BOX ,AND LEACHING SYSTEM 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 exMtration 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 4 v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 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•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 GSM ,.•�''� 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached-to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded'or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3113 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 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every 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 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owners Name information is required for CENTERVILLE MA 02632 6-25-15 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms (actual): 4 per assessing DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: 2 SYSTEMS WERE FOUND THE FRONT WAS A 1000 GALLON TANK AND LEACH PIT THE REAR WAS A 1500 GALLON TANK D-BOX AND S.A.S CONSISTING OF INFILTRATORS ACCORDING TO AS BUILT CARD NO AS BUILT WAS AVAILABLE FOR THE FRONT SYSTEM Number of current residents: 1 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 years usage(gpd)): Detail 2013-------------109 2014------------198 GPD 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 .� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M , 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every 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: OWNER SAID PUMPING WAS ABOUT 5 YRS AGO Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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): 2 SYSTEMS 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 1241 BUMPS RIVER RD lug - Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: FRONT 1980 AS PER ATTACHED AS-BUILT CARD- BACK WAS INSTALLED IN 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: FRONT 2.5 BACK 1.5 feet Material of construction: 1Z concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: FRONT 1000 BACK 1500 Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 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 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? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): BOTH TANKS LOOKED CLEAN WITH NO SCUM LAYER AND MODERATE SLUDGE THICKNESS HEAVIEST AT INLETS Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date •t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM ,. 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level_: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every page. Citylrown 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,abov&'outlet invert O" BACK SYSTEM 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 IN FRONT WAS FOUND THE REAR D-BOX WAS IN WORKING ORDER WITH NO SIGNS OF CARRY OVER 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: NO OBSERVATION PORT FOUND ON REAR SYSTEM THE FRONT PIT WAS OPENED t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ® leaching chambers number: 4INFILTRATORS ❑ 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.): FRONT PIT HAD A SMALL AMOUNT OF WATER IN THE BOTTOM THE REAR SYSTEM APPEARED TO BE DRY FROM THE VENT PIPE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5feet 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: DESIGN PLAN FOR BACK 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 r • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rr 1241 BUMPS RIVER RD Property Address SARAH MINTY Owner Owner's Name information is required for CENTERVILLE MA 02632 6-25-15 every 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 r - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 4M 1241 BUMPS RIVER RD Properly Address JOHNSON Owner Owner's Name required for is CENTERVILLE required for MA 02632 4/2/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. lr ri Title V Inspection Fonn.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 L-ID C AT 110 N S, i W A C, F P It /Al L -A C 'S.S! I N STA L.E t 2"S N A W IE A 1D, J, k Ig. RUILDEi— INt/ OW IN Et 0 A 7 E 'P I OR,M 11 T 1 S'S V E I-�A ID A T E C io MI L i A N, Ct I S S UIED 74. '7k gE, r , •. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ..'( 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name information is CENTERVILLE re wired for MA 02632 4/2/09 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. ImpoWhen filling A. General Information When filling out �1 forms the 3( t—� 14 computer,use 1. Inspector: only the tab key to move your DOUGLAS A. BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A. BROWN INC Company Name tQ P.0 BOX 145 Company Address CENTERVILLE MA 02632 men City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/2/09 Insp tor' i re Date The s tem 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. �oq 4/o� Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name information is required for CENTERVILLE MA 02632 4/2/09 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: HOUSE HAS 2 SYSTEMS 1 IN FRONT 1 IN BACK B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name information is required for CENTERVILLE MA 02632 4/2/09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Title V Inspection Form.doc•0&06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1241 BUMPS RIVER RD Properly Address JOHNSON Owner Owner's Name information is CENTERVILLE re wired for MA 02632 4/2/09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1241 BUMPS RIVER RD Properly Address JOHNSON Owner Owner's Name information is CENTERVILLE required for MA 02632 4/2/09 every page. City mown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 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. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y� 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name information is required re wired for MA 02632 4/2/09 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Title V Inspection Fonn.doc•0&06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1241 BUMPS RIVER RD Properly Address JOHNSON Owner Owner s Name information is required for CENTERVILLE MA 02632 4/2/09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms 3 3 (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): HOUSE VACANT2 YRS Sump pump? ❑ Yes ® No Last date of occupancy: 2006 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: Last date of occupancy/use: Date Other(describe): Title V Inspection Fonn.doc•0&06 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 7 of 15 l r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name information is required for CENTERVILLE MA 02632 4/2/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: FRONT SYSTEM APPEARS TO BE ORIGINAL BACK 11/12/02 Were sewage odors detected when arriving at the site? ❑ Yes ® No Title V Inspectlon Fonn.doc•08/O6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name information is CENTERVILLE required for MA 02632 4/2/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ---------------------- ------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 FRONT/1500 REAR Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y` 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name information is CENTERVILLE required for MA 02632 4/2/09 every page. City own 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.): HOUSE HAS BEEN VACANT FOR TWO YRS TANKS ARE VERY CLEAN Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page to of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name matioisrequired for CENTERVILLE MA 02632 4/2/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title V Inspection Form.doc•08/08 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name information is CENTERVILLE require for MA 02632 4/2/09 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: OPENED PIT IN FRONT IT WAS DRY/NO OBS PORTS IN REAR Type: ® leaching pits number: 1 ® leaching chambers number: 4 ❑ 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.): Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name information is CENTERVILLE re wired for MA 02632 4/2/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title V Inspection Form.doc•08/06 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '< 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name required for is CENTERVILLE required for MA 02632 4/2/09 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Lj P I v 2 � _ J1 6 I� fl Title V Inspection Form.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 15 r - i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments y 1241 BUMPS RIVER RD Property Address JOHNSON Owner Owner's Name information is CENTERVILLE required for MA 02632 4/2/09 every page. CItyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 5++ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: OFF PLAN FOR SYSTEM IN BACK YARD Tide V Inspection Form.doc•0&08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 No.Z/, pO 09 5_2 FEE V o- C® MONWLA T14 OF 1MASSACHUSETTS EC Board of Health, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) RepairK Upgrade( ) Abandon( ) -XComplete System ❑Individual Components Location JALIJ5 Owner's NameAcmts � Map/Parcel# 8g Address Lot# Telephone# Installer's Name - �C Designer's Name Address ;S `�� Address I t•1A Telephone# BOB —(0 531 0 Telephone# t{ b 9(o Q� b Type of Building _S1de��►o►� Lot Size �� sq.ft. A Cjte Dwelling-No.of Bedrooms - Garbage grinder (V1,� Other-Type of Building IAA 'C�C,P No.of persons C2 Showers (VCafeteria ( ►1� Other Fixtures 22 Design Flow (min.required) J J gpd Calculated design flow _ Design flow provided aya• gpd Plan: Date Q Number of sheets Revision Date 1 c Title �(�s��2[�. cJy G>�Q--C e �� �SL�6�C•� J U sAAr! Description of Soil(s) On Soil Evaluator Form No. Name of Soil Evaluator SAW CAeASEJDate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The unde igned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further,agr; s o n to place th in opeqaUon until a Certificate of Co pli n e has been issued by the Board of Health. Signed Date b Inspections A0, /�1 00 N'o'' r!O J „�`►>� FEE 50. 41, Board of Health, MA. APPLICATION FOR DISPOSAL SYST-EM CONSTRUCTION PERMIT Application for a Permit to Construct( Repair Upgrade( Abandon( ) - `Complete System ❑Individual Components Location ' �, � Qc� � ,C- ��f- - I I Owner's Name \Cv a C l# Add P Ma / arceress '"�y , v�`'� P Lot# *4 Telephone# Installer's Name I �_ �c c o Designer's Name » �`� SV1�5 Address Address Telephone# �Q� (Qtt� -5"S)0Telephone# ll g_ a� C�(o Type of Building �'.\ 'g \C.� Lot Size C70sq.ft. > Dwelling-No.of:Bedrooms *-� Garbage grinder Other-Type of Building N cw ,P No.of persons E Showers Cafeteria ( y Other Fixtures ' Design Flow (min.required) gpd Calculated design flow Z��a� Design flow provided J b•( gpd Plan: Date Number of sheets 1 Revision Date _ .,� Title Description of Soil(s) \Y �,r� C,'C�C C�.0�� ^�C,` r 1uGG`t1 Soil Evaluator Form No. �, � 1 3� Name of Soil Evaluator tlf) \k N1 E nl Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS _ Cyr a The unde igned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and r further agr s to n 'tpto��pla�Bce th�s��tem in ope on until a Certificate ofiCo pliance has been issued by the Board of Health. Signed ' till \/v I »� Date / b Inspections (A /1 V 't..� 4:..- -:..:_tea-� _- :...«..� ,.� -W _».. .^bf:�n ;°'.-..-"i.'.:-�=4 ....... `.�_. Y....�. -.... .. .;•�':. ___' '--:.:'=�.,«.-a.+.��...='e" .:.Y.. ..... _ No. — 5 FEE SO• 00 COMMONWEALTH Of MASSAC14USETTS Board of Health, CERTIFICATE Of COMPLIANCE E Description of Work: ❑Individual Component(s) Complete System The undeersigned hereby eer 'fy tha the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by: �/ I n( �Zb bey 5n , /q , at IA'Al I LA KV-5 I V f y V bQ i US}-MI I E' has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application kq. 'i n dated A p•oved Design Flo /J (gpd) may^ f Installer / LUZ— (/ �//11 A() ..,- ,j✓` / Designer: Inspector: r The issuance of this permit shall not be-construed as a guarantee that the system will function as designed. No.�20a-S3a FEE COMMONWEALTH OF =CHUSITTS Board of Health, r DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) (Repair(/) Upgrade( ) Abandon( ) an individual sewage disposal system at 12'1 1 -I&.M05 �, U� c POG A , CSk g l 0"LL as described in the application for Disposal System Construction Permit No. a)CO-53, dated I 1 U 9'—Ot�- ' Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. I I-U 0 Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date B�^ � oard of Health V I CARMEN E. SMA Y (508)-548-0796 ENVIRONMENTAL.SERVICES, INC. P.O.Box 627,East Falmouth,MA 02536 November 12, 2002 RE: Certification of Title V Septic System Installation: Residential Property— 1241 Bumps River Road, Centerville,MA Dear Sir or Madam: On November 9, 2002, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at 1241 Bumps River Road, Centerville, MA, based on a design drawn by Shay Environmental Services, Inc, dated,November 8, 2002. XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan I Certify That the Referenced Above Septic System Was Installed With Changes but in Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow. The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is Required. If you have any questions, please do not hesitate to call the undersigned at(508)-548-0796. Sincerely, CARMEN E. SHAY ENVIRONMENTAL SERVICES,INC. jN OF M,gSS�c RMEN y�N E. �+ SHAY N Carmen E. Shay, R.S., C. No. 1181 President 'P� 'G/STER- °`fr S�+h'ITAR�P� Seu' 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 P . 02 r . Sh�;01 :NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION 'TEST AND SOIL EVALUATION EXEMPTION FORM l �? hereby certify that the engineered pian signed by me tic;eC lt�%0-ok concerning the property located at meets all of the Cenae�-c�.11e, Icilow ing criteria • Th!s failed system is connected to a re3ldential dwelling only. There are no _ommercial cr business uses associated with the dwelling. • T,.e soil is ciass;c;ed as.CLASS l and the percolation rate is less than or equa to rt:nutes per rich. The applicant may use historical data to conclude this fac: or may _onduct tests at the si.e without a health agent present. • There :s no incrtaSe in flow and/or change M use proposed • Chen a:-e no van,ances requested or needed. • The boucm :)f the proposed leachin, facility will not be located less char fourteen 1 Y; Ttet above the maximum adjusted groundwater table elevation. ,Adjust the T%ricwater table using the Frimp(or method when applicable) Please complete the following: r�. TOp 01 Grounc 5'lrlace E:ovation (using GIS information) F; t] W Elcvat,or, _ ad;us(ment for ini;h G.W.JrA� -- - ._._. 3•t� t SETWEEN and B ML S:(j'►rED DATE: �1II001 NOTICE above .r.formation, a reoair permit will be issued for cedr^oms nal bedrooms are authorized to t`�e Future without eng!neere: opt,_ system plans. �c_uh!C:Oc, �ciccsm� I I Permit Number: Date: i Completed by: i HIGH GROUNDWATER LEVEL COMPUTATION Site Location: I oZy� �� �lVet LPf�-srt:C-lta`�? Lot No. Owner: Address: IyI41 013 z SCC 1ZL7GC 6•, Contractor: Address:�X G(ea4. - FQlmc�, Notes. i STEP 1 Measure depth to water table to nearest 1/10 h. .............................................................................. Date 8Ica1 y 1 moron ev Year _ I STEP 2 Using Water-Level Range Zone and Index Well Map locate i site and determine: O Appropriate index well.................................................... „l4► i © Water-level range zone .......•............................................. i i • I STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... St mont /Year I , I STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water-level zone (STEP 26) C determine water level adjustment .......................................................................................... S't� STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) I from measured depth to water levelat site (STEP 1) .............••.•.....•.......•....................................... � I i i i L i .C;pe Cod Commission: USG$ Well Data- October 2002 Page 1 of 2 United States Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties, the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey (USGS) observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For your convenience, we've also provided links to USGS national and state data. See the lastt column in the table and the footnotes below. For further information, please contact Hydrologist Gabrielle Belfit at the Commission offices (508-362- 3828). October 2002 I;SGS Site Departure from N um ber'-.< x Location Well No. Water Record Record g Avera a** links to US(:S Level* High* Low* Monthly Overall national water-level database) Barnstable 230 26.3 20.5 26.6 -1.8 -2.7 413956070164301 Barnstable 24W 27.4 20.5 28.6 -2.3 -2.9 414154070165001 Brewster BMW 21 13.6***, !! 6.9 13.6 !! -3.0 -3.4 414518070020301 Chatham CGW138 25.6 20.9 26.6 -0.9 -1.6 414100070011101 Mashpee MIW 29 9.9 5.6 10.0 -0.6 -1.3 413525070291904 Sandwich ZI52 48.0 45.9 48.2 -0.4 -0.7 414418070241601_ Sandwich SDW 54.7*** 45.8 55.1 -4.2 -4.6 414124070265901 Truro TSW 89 12.5 10.2 13.0 -0.1 -0.4 420206070045901 Wellfleet W 7W 12.4 7.3 12.8 -1.4 -2.0 415353069585401 http://www.capecodcommission.org/wells.htm 11/8/2002 t 7 FORM 11 — SOIL EVALUATOR FORN Page 1 of No.: Date: 10/28/02 COMMONWEALTH OF MASSACHUSETTS Barnstable , Massachusetts Performed By: Carmen E. Shay Date: 10/28/02 Witnessed By: Waiver Location Address or#1241 Bumps River Road Owners Name: Mr. Harry Johnson Centerville, MA Address and #1241 Bumps River Road, Centerville Lot# (Map— 188,Parcel 78) Telephone Number: New Construction : X Repair : OFFICE REVIEW: Published Soil Survey Available: No ❑ Yes ❑ Year Published: Publication Scale: Soil Map Unit: Drainage Class: Soil Limitations: Surficial Geologic Report Available: No❑ Yes❑ Year Published: Publication Scale: Geologic Material: (Map Unit): Landform: Glacial Outwash Flood Insurance Rate Map: Above 500 Year Flood Boundary: No ❑ Yes Within 500 Year Flood Boundary: No 57 Yes ❑ Within 100 Year Flood Boundary: No F 7x Yes ❑ Wetland Area: None National Wetland Inventory Map (map Unit): Wetlands Conservancy Program Map (map unit): Current Water Resource Conditions (USGS): Month Range: Above Normal ❑ Normal X❑ Below Normal ❑ Other References Reviewed: USGS Topographic Map DEP APPROVED FORM 12/7/95 s FORM 11 — SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No.: #1241 Bumps River Road, Centerville, MA On -Site Review Deep Hole Number: #1 Date: 10/28/02 Time: 10:00 AM Weather: Sunny, Cool Location (identify on site plan): Refer to Sketch Landform: Outwash Plane Position on Landscape (sketch on back): Refer to Sketch Distances From: Open Water Body N/A feet Drainage Way N/A feet Possible Wet Area N/A feet Property Line 25' feet Drinking Water Well N/A feet Other DEEP OBSERVATION HOLE LOG Depth From soil Soil Soil Soil Other Surface Horizon Texture Color Mottling Structure, Stones, (inches) (USDA) (Munsel) Boulders, Consistency, % Gravel 0" — 12" AB Loamy 10 YR 3/2 None <5% Gravel, Friable Sand Friable 12" — 36" BW Loamy 10 Y/R None <5% Gravel, Friable Sand 5/6 Friable 36" — 168" C' Medium 2.5 Y 7/4 None Medium Sand, 10% Sand gravel, Loose Parent Material (Geologic): Glacial Outwash Depth to Bedrock:None encountered Depth to Groundwater: Standing Water in the Hole: None Weeping From Face: None Estimated Seasonal High Water Table 168" Assumed — No groundwater Observed DEP APPROVED FORM 12/7/95 FORM 11 - SOIL PEVALUATOR FORM Page 3 of 3 Location Address or Lot No.: #1241 Bumps River Road, Centerville, MA Determination of Seasonal High Water Table Method Used: ❑ Depth observed standing in Observation Hole: N/A inches ❑ Depth weeping from side of Observation Hole: 168 inches (assumed) ❑ Depth to Soil Mottles: None inches ❑ Groundwater Adjustment: None feet Index Well Number: Reading Date: Index Well Level: Adjustment Factor: Adjusted Groundwater Level: N/A DEPTH OF NATURALLY OCCURING PERVIOUS MATERIAL: Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system: Yes CERTIFICATION: I Certify That on September 17, 2000, (date), I have passed the soil evaluators examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature: Date: � ' a FORM 12 — PERCOLATION TEST Location Address or Lot No.: #1241 Bumps River Road COMMONWEALTH OF MASSACHUSETTS Centerville , Massachusetts Percolation Test Date: 10/16/02 Time: 10:30 AM Observation Hole #: #1 Depth of Perc 36" — 54 Start Pre-soak 10:28 AM End Pre-soak 10:38 AM Time at 12" Would Not Hold 24 Gallon Presoak Time at 9 Time at 6" Time (9-6") Rate Min./inch < 2MPI * Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Performed By: Carmen E. Shay Witnessed By: Waiver Comments: Would Not Hold 24 Gallon Presoak - <2 MPI Site Passed X Site Failed DEP APPROVED FORM 12/7/95 r� T OFONSTABLE LOCATION D &,,os SEWAGE# �✓ VILLAGE V i 'C ASSESS 'S MAP & LOT '- INSTALLER'S NA &PHONE NO. ��ME �- . SEPTIC TANK CAPACITY 4- � .� d ! LEACHING FACILITY: (type) � + �- _ (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 10J—COMTLIANCE DATE: 4 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 g � j i T OF STABLE �"C• M LOCAVON � I k I f o SEWAGE# —2!/f--) ASSESS aR'S MAP& LOT�V-7-12q INSTALLER'S NAME&PHONE NO SEPTIC TANK CAPACITY C V'0 LEACHING FACILITY: (type) } l. —d^ (size) 3y 1� NO.OF BEDROOMS 1j BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: 9 lJ 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 ^ i q/! s � No�_........ _ F�s. .r....... . THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HEALTH � y. ©-Cc1q..................OF... -d.-n.S--A-14k--.....-.............-•----•-----.._...............__ Appliration for Disposal Works Tunstrurtiun thrutit Application is hereby made for a Permit to Construct ( ) or Repair (4ran Individual Sewage Disposal System at: �� / ...... ft ... ---- -P at A- ......--•- .............. �+ --• 'Location-Address or Lot o- ......................_._........................................................................ --•-••--------•--...--•-•---•--....`.........---......_._.....-------------•-•---•--••---...--•-.. aI / Owner Address�s---------------............................... ---•-••-•-- •-•----•------•----•-•------••----••--• Installer Address dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) Cafeteria ( ) Q' Other fixtures .-----••---•-•-•--•-••---••••-•- W Design Flow____________________________________________gallons per person per day. Total daily flow......................._....................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-_________..__ Depth................ Disposal Trench—No______________________ Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_____________________-_- fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water________________________ •-------•----------------------------------•--•--------------------.........._........_._._.._-••---......................................................... 0 Description of Soil........................................................................................................................................................................ ---------------------------•---------....................•-------•--------------------------------------------------------------------------•------------ -•-•----------- -------------•-•--•---•-••-------••--••-•--••••--•••------•---•-••••••--•••--•-•------•-•----•------------------••-•---------•--•-•-----•-----••--••-•--••-•-------•••-•--- U Nature of Repairs or Alterations—Answer when plicable __�---------- �oDo.. k. ._._.., � - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'i IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until�a Certificate of Compliance has been issued by the board of health. Sigma- L.................................. �z - ............_. A _-•-- Date Application Approved BY � .... .. . Date Application Disapproved for the following reasons: ...............•----..._----_._..._._.__,..••---•-••-•-•---------•-•••---..._..........•--------_...._....--••-•--•-------------------•-•-•-•••-••---••-•-------•-----•--••-----•_..-----------....--•--- Date Y Permit No.. .... Issued t Date .t000 I rto �....3 ... FPS : /............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..0 )rl-------------------0F.... . t rC.!'L _7.•• ..................................................... ppliratiun for Disposal Works Toustrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: -. . . - ......... .. -- _- ............... . . __ ... ..... ... .............. - Location-Address or Lot o. ......................_^--...................................................................... ---.....------------------••-•-......•-----.......•------••-•----........_.......................- 49 Qwner & Address Installer Address Type of Building Size Lot..........................::Sq. feet "Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building ....... No. of persons____________________________ Showers — Cafeteria dOther fixtures ' W Design Flow............................................gallons per person per day. Total daily flow______._.___.______-..___-_._____......_____gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter_____________.__ Depth................ Disposal Trench—No_____________________ Width'!.................. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter................:... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutesperinch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-----------------------------•---------------------------..._.....-------------•-----....................................................................... Descriptionof Soil..................................=-------------------------------------------------------------------------------------------------------------------------------------- x W � -- j. ........................................................... ...__._.____ UNature,of Repairs or Alterations Answer when pplicable._.__�.6_ 1� c,-______-_.et S�'2 �F�� �o 0 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITTLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complii�nce has been issued by the board of health. r ..............................................................` ?�Sig ' . Date �APPlication Approved BY 7 _� `_.. .`__ Date Application Disapproved for the following reasons_____________________:_._____•-______--_____.______.._ -•-••--••---•---•----•--•----- .............. -----------------------------------------------------------------•------•-•--------------------.__...----•-•------------------------.-•----•-------•---•----••--•••-•_._..-----•---- ----•-----••-- Date Permit No......................................................... Issued_............................................ :::.. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD/ OF HEALTH JJu? 7.............OF....!'•,::�..r ?._S.rl.,7..z................... ........ .._._................................... Trrtifiratr of Tuutplittnrr E -TWHIS I TO RTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired by......j-•--•_..._. .- ...........................----................................................................................................... Inst •---•-•-• er has been installed in accordance with the provisions of r of The State Sanitary Code as des ribed in the application for Disposal Works Construction Permit No,, ?- ..�'WJ dated----•'�-.�''�� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... .:....(O....�.....�....-•••..................... Inspector....- . ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ! r"�c.�:.� 7.................oF...���.�"��5�`�.`��F........ _.._...-----••-•---....... �} tl No- •---•---:�l FEE........................ Disposal Ivoks notrnrtiun autit - -- Permission is hereby granted ------------------------- to Construct ( ) or Repair ( A'an Individual Sewa a Disposal System at No... �f"' f f. �� '�.-•i'�' Street as shown on the application for Disposal Works Construction F16knit .3 �� ' ---- ---------- Dated--- ..--------- G > s �" ✓ rd r DATE--M � oa of_ al� FORM 1255 HOSES & WARREN, INC.. PUBLISHERS ""'� LOCATION ., 1/ SEWAGE PERMIT NO. VILLAGE C- I N S T A LLER'S NAME i AD RESS L�cucc kL e U I L D E OR OWNER f DATE PERMIT ISSUED } DATE COMPLIANCE ISSUED ��_�� r e ------ F 7 7 7777777777777;=�-777 p: VENT PIPE (0 Least 24 inches tall) Schedule 40 PVC w/Chorcoal Odior SECTION A �-A p Filter 1� LOCUS MAP 3-24* DI ACCESS MAWOLES 10' min. from PROFILE VIE W OF ADDITION TO LEACHING SYSTEM �hzse to Septic tank *NOTE- ALL PIPES ARE TO BE 4� SCHEDULE 40 P-V.C, 3" of 1/8' - 1/2' Washed Pecstorte to. -6.— Existing Foundation _J Septic tank covers must be T.O.F. elev. 100,00 3/4" to 1 1/2 Washed Crushed Slone within 6 in. a( finished grade —Anode over SAS 99,50 11 orode over Septic Ton k 99.00 -Grade over O-BOX 99-50 .0 RD Bumps RIVER S O.02 3 HO E L (H-20) DIST. BOX 3' maximum Cover Yap of SAS EI#.. -96.50 NUT SITE T S 10, S-0.04 INLET OuT _y EXIST. PIPE— F, NEW 1,500 GAL Effective Dep it, THE ACCESS COVERS FOR THE SEPTIC TANK, FROM FOUNDATION ch SEPTIC TANK DISTRIBUTION BOX AND LEACHING COMPONENT L rn H-10 20' C�beft C! >"L SHALL BE RAISED To WITHIN 6' OF -H D GRADE,ID Q0 FINISHED 0 J1, CONCRETE FULL F0UNWlOt+ 7 7. 7. 1- 17) 01 0 8 4 Units @ 61 STEEL REINFORCED PRECAST CONCRETE INSTALL 7UF-TITE GAS BAFFLES OR EOUALS STONE UNDER CHAMBERS ON ALL OUTLET TEE ENDS. 24' 01 PLAN VIEW SYSTEM PROFILE 11 3', L V 2000' >. A 4`--­ — Not to Scott T 4 4 —30,_ 3-24" REMOVABLE COVERS 5. Effective Length > GENERAL NOTES �ompoctc-d stone 3' min, clearance 1. Contractor is responsible for Digsofe notification 6 in�of 3/4'-1 1/2" C Efrtcti,e Voth SOIL ABsbRPTI[)N SYSTEM (S;�S) 13, INLET"T' INLET _�±, inlet I. ..ti.1 -------- RH3 COJTLET and protection of all underground utilities and pipes. CULTEC MODEL 125 (H-20 LOADING)/ SHOFEY PRECASTE TF-t- INL q5 2 The septic tank and distribution box shall be set NOTE ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE (OR EOUIVALENT) Not to Scale 5' 7 L__J I level on 6" of 3/4"-1 1/2" stone. J ' ,1 5' -7" NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" EFFECTIVE HEIGHT IS 12" 4'-0' min. 1 Backfill should be clean Sand or grovel with no E stones over 3" in size. Liquid depth 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc- 5. The contractor shall install this system in accordance 10'-0* with Title V of the Massachusetts state code, the approved plan and Local Regulations. CROSS SECTION END-SECTION 6. If, during installation the contractor encounters any soil conditions or site conditions that are different from those shown on the soil log or in our design TYPICAL 1 -500 GALLON SEPTIC TANK installation must halt & immediate notification be NOT TO SCALE rnade to Carmen E. Shay - Environmental Services, Inc. 7. No vehicle or heavy machinery shall drive over the FOUNDATION' 'SEPTIC TANK D-BOX LEACHING FACILITY (H- 10 LOADIN,(, septic system unless noted as H-20 septic components 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes. 10. All solid piping, tees & fittings shall be 4" diameter PERCOLATION TEST Schedule 40 NSF PVC pipes with water tight joints- 11. SITE and Surrounding Properties are not Connected 0 20 40 50 Date of Percolation Test: OCTOBER 28, 2002 to Municipal Water, CARMEN E. SHAY- R.S., C.S.E. Test Performed By C Results Witnessed By WAIVER per BARNSTABLE BOH Excavator: ROBERTS SEPTIC SERVICE NOTE: Percolation Rate: Less 'Thon 2 min /inch 0 3 FEET BELOW GRADE. THE PROPERTY LINES ARE APPROXIMATE AND COMPILED FROM THE SURVEY PLAN GENERATED BY BEARSE & LAW, SURVEYORS of CENTERVILLE, MA ENTITLED " PLAN OF LAND OF JOHN H. JOHNSON", Test Hole -------- ------- -------- No. 1 CENTERVILLE, MA", DATED DECEMBER 23, 1958 DEPTH SOILS ELEV AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 0 99 50 Sandy Loom THE SEPTIC SYSTEM INSTALLATION- 10 YIR 3/2 0"-1 2" Ay 98.50 Sandy Loom IOYR 5/6 -------- -100 12�-36' 96 50. Med- oar NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE Sand P1 173.69' 2 5 y 7/4 FROM THE EXISTING SEPTIC SYSTEM TO BE DISPOSED N 14d 00' 00 W i . OF AS PER BOARD OF HEALTH SPECIFICATIONS, 36--120" C, 85.50 - ------------- N 14d 46' EXISTING CESSPOOL TO BE PUMPED DRY & FILLED WITH CLEAN FILL MATERIAL. 2- 43' ASSESSORS MAP 188 PARCEL 078 ZONING - RESIDENTIAL FLOOD ZONE C Perc #1 J Depth to Perc: 4d' to 58" Perc Rote=<2 mindinch 01 ----------- ---Not �P�serve Groundwater THERE ARE NO WETLANDS LOCATED WITHIN-A 1 50�--RADIUS TEST 'HOLE Elev. 120"BOTTOM Or OF THE PROPERTY ADJUSTED H20 E144. No Ad�ustment Required. co co 30 ALL OUTLET PIPES FROM THE DISTRIBUTION BOX SHALL BE LEGEND 12' CONCRETE COVER SET LEVEL FOR AT LEAST 2 FT, kn TEST HOLE #1 Failed ELEV.= 99.25 V 3 - 5' OUTLET Cesspool' KNOCKOUTS D-Box Fs8xol DENOTES PROPOSED Is 5* 12- INLET OUTLET ;I SPOT GRADE 0 1500 gal- 2 DENOTES EXISTING Septic Ton'k 0 X 104.46 SPOT GRADE 4" SCH. 40 To 235 1.75" PLAN SECTION CROSS-SECTION - PROJECT BENCH MARK PL PROPERTY LINE TOP OF FOUNDATION 3 HOLE DISTRIBUTION BOX H-10 LOADING 97 PROPOSED CONTOUR ELEV. 100 (assumed) NOT TO SCALE 97— — — — — —97 EXISTING CONTOUR #1241 DEEP TEST HOLE 113A AGE Desicin �ciculotion PERCOLATION TEST LOCATION 1\1 00 EXISTING 3 Number of Bedrooms: 2 Equivolent to 220 GoL)Day (330 Gol./Day Min, per Title V) O Garbage Grinder: No FENCE 13E DR110M ------ Leaching Capacity Proposed: 330 Col./Day Minimulm (Min. Per Title V) I)SIVEWAly HOUSF 41 Septic Tank 3 x 330 Gol./Day = 660 USE!1,500 GAL. Septic Tank. EVEPRIVATE DRINKING WATER WELL "96' SOIL ABSORPTION AREA: Using percolation rote f <2 min /inch TOF= ELEV, 100 Bottom Area 0.74 gal/sq, ft. x 300 sq. fi, = 222 go]oris 96-- Sidewall Area� 074 gal./sq, ft. x 1 160 sq, f�t- 118.40 gollons REVISION 'S Providing 340.40 gollons LOT 4 _CTIVE DEPTH, NO. DATE: 11001, Use (4) CULTEC MODEL 135 UNITS, HAVING A�1' EFFECTIVE DEFINITION 56,590 S.F. TO BE USED WITH 4 0' OF WASHED STONE ON TH� SIDES, 3' Of- WASHED STONE ON THE ENDS AND 1' OF WASHED STONE BENEATH THE ENTIRE SAS. X 316.00,,-- -------------- S 21d 25' 20 E ---------- PREPARED F R PROPOSED :_- IJBSURFACE SEWAGE_E DISPOSAL S\ STEM -------------- ------------- OF # 1241 BUMPS RIVER ROAD HARRY LUCILLE jOHNSON CENTERVILLE, MA (60 FOOT RI(3HT OF WAYS 1 Z- 41 BUMPS RIVER ROAD PREPARED BY: -\�A OF 414,jj,� UENTERVILLE , MA N CARNEY F. S11A I SH EiVVIRONAIENTAL SERVICES, INC. 0. 81 34 THATCHERS LANE 190 T EAST FALMOUTH, MA 02536 I AR\N TEL/FAX 508-548-0796 SCALE: 1 "=20' DRAWN BY� CES DATE NOVEMBER 3, 2002 PROJECT#SD-356 FILENAME-. SD356PP.DWG SHEET 1 OF 1 L C BUMP-, RIVER RD 0.' �(H-2 OL- ) (3� GAL 0 T N AN� 0 It L4 N 14d 4C !T,'7_77,7�