HomeMy WebLinkAbout1257 BUMPS RIVER ROAD - Health 1257 Bumps River Road
Centerville
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms the
computer,
r,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. DOUGLAS A BROWN INC
Company Name
VQ P.O. BOX 145
Ale Company Address
CENTERVILLE MA 02632
Bd0" Citylrown 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
7-30-13
Inspector ignature 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.
(d NY
t5ins-3/13 Title 5 Official Inspection Form: su ce Sewage Disposal System•Page 1 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w„ 1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
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:
AT TIME OF INSPECTION SYSTEM SHOWED NO SIGNS OF FAILURE
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-3113 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
1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owners Name
information is CENTERVILLE MA 02632 7-30-13
required for
every page. Citylrown 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 '/2 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 1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
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.
[:j ® 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. tilhis
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.]
El 0 The system is a cesspool serving a facility with a design flow of 2000 d-
9 9p
10 000 gpd.
❑ ® 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
wM , 1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
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): 4 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5Official 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
1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owners Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON SEPTIC TANK D-
BOX AND 3050 INFILTRATORS IN A 11X40X2 AREA
Number of current residents: 3
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:
2011-------303 2012----------297
Sump pump? ❑ Yes ❑ No
Last date of occupancy: CURRENT
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per dayd
(gP )
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2002 ACCORDING TO AS-BUILT
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: 2
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:
1500
Sludge depth: VARYING LIGHT TO MODERATE
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. Citylrown 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 LIGHT
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._):
WOODEN POLE
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
, y 1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. Cityrrown 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
1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
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 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.):
BOX LEVEL NO LEAKAGE OR SIGNS OF FAILURE
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 PORTS FOUND
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5-3050s
❑ leaching galleries number:
❑ leaching trenches number,, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
NO EVIDENCE OF FAILURE IN AREA OF S.A.S NO OBSERVATION PORTS FOUND SO I COULD
NOT DETERMINE LEVEL OF PONDING/STAINING
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
I
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.' 1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of pondirq 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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. Cityrrown 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17
•
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
,M 5. 1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
every page. CitylTown 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: AT LEAST 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 3
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
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1257 BUMPS RIVER RD
Property Address
JOHNSON
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-30-13
j
every page. Cityfrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Assessing As-Built Cards Page 1 of 2
—� TOWN OF B STABLE
LOCATION �� 1 J�Lt1�S �� SEWAGE
vII LADE 'ik., GEi �Ur ASS 'S MAP&LOT_Xk_") 7-7
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACrrY t
LEACHING FACUMT:(type) ��irl�T(Ir�(size)
NO.OF BEDROOMS—_4_
BUILDER OR OWNER
PERWMATE: /1-0-01- COMPLIANCE DATE: /i z
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
http://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappat=18 8077&seq=l .7/3 0/2013
No. Q00?-SlS FEE -570
COMMONWLALT14 OF MASSACHUSETTS
Board of Health, IWnS-'&bk , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon( >(Complete System ❑Individual Components
Location ' U�, ,� Owner's Name
Map/Parcel# OCCP—\ 4 Addresslas
Lot# Telephone#
Installer's Name _ ` G __ _, Designer's Name 5 J,� ,� e-1
Address � R Address F. MA
Telephone# Sb - uA _ 63\p Telephone# SAIR_O L da 36
Type of Building eFi\1 4\ Lot Size Q- 8 ACPES sq.ft.
Dwelling-No.of Bedrooms ^Fw7 P, (4,)` Garbage grinder 44
Other-Type of Building � k,u{`-\cQ 6 oZ Coc QjC-C r.4R. No.of persons Showers (v�Cafeteria (V)
Other Fixtures Lao 6._ *&a^ 5i n-h AT.
Design Flow (min.required) A4b gpd Calculated design flow� Design flow prodded �36gpd
Plan: Date N 1a`ca Number of sheets Revision Date
Title "?i S� "
Description of Soil(s)
Soil Evaluator Form No. �� �`�_ Name of Soil Evaluator CE c,,NY Date of Evaluation IoZI� I�
DESCRIPTION OF REPAIRS OR ALTERATIONS ?
The unde igned agrees to install the above described Individual Sewage Disposal System in TI11%�,aad
further a es to no to place th in opera' n until a Certificate of Compliance has 1V4p-Ti9shkd by the Bggd otp"ta .WRITING
Signed Date if/3�- T '� S'. ' .-'a INSTALLED IN STRICT
ACCC, i J PLAN.
Inspections
-No-0?0Q S 1 FEE
• , M
COMMONWEALTH OF MASSAC14USETTS
+ ,�\ -"Board of Health, tr c rt S�C.b�t , MA.
APPLICATION FOR.DISPOSAL SYSTEM CONSTRUCTION PERMIT
Applicati6>1 for a Permit to Construct( ) Repair>< Upgrade( ) Abandon( '>(Complete System ❑Individual Components
Location°\ r a� � DS pS d, {�-Q.cUt ��e Owner's Name (-),5CC!C U n
Map/Parcel# M A p 1 4 Ct Cam' (� Address V�(A Ce
Lot# Telephone#
Installer's Name C�Q �C cJ QCv\ Designer's Name J C,5
Address Address "T,I>X
Telephone# S C,- _ (,A fo S \p Telephone# 5-A ' -O 9l. �� 3L.
Type of Building �s\ C` Lot Size o7• AC91:S sq.ft.
Dwelling-No.of Bedrooms Wit'0U P., (4)- Garbage grinder VGA
Other-Type of Building Qe k `r ('V,0 6 r3 C--C1. G No.of persons oa Showers (v),Cafeteria (✓)
Other Fixtures La.oc,
Design Flow (min.required) �'�rD gpd Calculated design flow 4�1 D Design flow provided 49•3b gpd
Plan: Date a OQ Number of sheets Revision Date
Title `\��TJt .C� CA O-soC�C C-p SR \J\ ,�C1Cc1:�
Description of Soil(s) 4e-r -�n C)'�'�'t C'.C y\0 r-( c S(� \ e\\CA\�l(-
Soil �lCX�
Evaluator Form No. �` Name of Soil Evaluator l _ <. A't' Date of Evaluation � 'C)d
DESCRIPTION OF REPAIRS OR ALTERATIONS C A-b G._C�C A '7 mr,-�C>zP C� -D
The unde l iened agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees
s^t�oJ�not
Dto place the,,ssysteJmf in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 1 l(iT//,t.�Ci�� - ll t`! !/CX/ /� Date 11-13-00-
Inspections
No. Q03L_5 7 5- FEE 570100
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ���?, 7 �P MA.
CERTIFICATE OF COMPLIANCE
>
Description of Work: ❑Individual Component(s) Complete System
The undersigned
Jhereby certify that/tth}e�Sewage Disposal System; Constructed ( ),Repaired' Upgraded ( ),Abandoned
J ( )
at �-� �7 1 .W�9,�01 �1 r—tl-0911 fry yl _VVI 1��
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 NS, fdateda Approved Design Flow (gpd)
Installer mot/ i& -'L N r,
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.oCO
n So+
S 1. FEE
C®MMONWEAOf �'ASSACHUSETTS
Board of Health, /Z)- tK rl�IP MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(�,l) Repair'(/; Upgrade( ) Abandon( ) an individual sewage disposal system
at 10� q l"1��Moc) �f 1% K f Y o It ( ,a-)6,4 1'r as described in the application for
Disposal System Construction Permit No.Aocg-SS/.S, dated 1/'13-0a.
Provided: Construction shall be completed within three years of the date of this permit.N
Allocal conditions must be met.
Form 1255 Rev.5/96 A.M.Solkin Co.Boston,MA Date 11-13OZ Board of HealthC
S
TOWN OF B STABLE
LOCATION (J SEWAGE # 2-0�-S yS
VILLAGE ��+�,����\`�—�� ASS 7,'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)NO,OF BEDROOMS
BUILDER OR OWNER {�(�-� r7�rCny�J
PERMIT DATE: 'I COMPLIANCE DATE: 1/ 2
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
' o
i A �, v
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#1257 Bumps River Road Owners Name: Mr. Oscar Johnson
Centerville,MA Address and #1257 Bumps River Road,Centerville
Lot# (Map— 188,Parcel 77) Telephone Number:
New Construction : X Repair :
r
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 a Yes ❑
Within 100 Year Flood Boundary: Nog 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 7 Below Normal El
Other References Reviewed: USGS Topographic Map
DEP APPROVED FORM 12/7/95
FORM 11 — SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No.: #1257 Bumps River Road, Centerville, MA
On -Site Review
Deep Hole Number: #1 Date: 10/28/02 Time: 11:00 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, 101/6
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 EVALUATOR FORM
Page 3 of 3
Location Address or Lot No.: #1257 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: 1 1-') Oc-)•
r
FORM 12 - PERCOLATION TEST
Location Address or Lot No.: #1257 Bumps River Road
COMMONWEALTH OF MASSACHUSETTS
Centerville , Massachusetts
Percolation Test
Date: 10/28/02 Time: 11 :30 AM
Observation Hole #: #1
Depth of Perc 40" — 58
Start Pre-soak 11 :28 AM
End Pre-soak 11 :38 AM
Time at 12" Would Not Hold 24 Gallon
Presoak
Time at 9
Time at 6"
Time (9-6")
Rate Min./inch < 2MP1
* 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
Sep- 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 P • 02
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
PERCOL,aTIO:N 'PEST AND SOIL EVALUATION EXEMPTION
FORM
hereby certify that the engineered plan signed by me
dated 11 %0'-k concerning the property located at
5; z � meets all of the
tCl:own; c�,terla
• This failed system is connected to a residential dwelling only. There are no
-or.u-nercia! or business uses associated with the dwelling.
• TE.e soil is ciassi5ed as.CLASS I and the percolation rate is less than or equai to
-n:nuces per inch. The applicant may use historical data to conclude this fact or may
_onduct pre!tm,:far% tests at the sire without a health agent present.
• There :s no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leachin, facility will not be located less than fourteen
1 Y) '.et aoove the maximum adjusted groundwater table elevation. ,Adjust the
;:-nundwwer table using the Frimptor method when applicable)
Pease complete the following:
�. "fop of Ground Surface E!zvation (using GIS informations
B: C, W E;ev31.011. _ cd;ustmen( for high C.W.S.--Le = 3'_�e —
I
),TT .kEi\CF. S.ETWEEN A and B
:GVED DATE: Il
...-- ----------...._.._.— :NOTICE
3asec jpori t,ne abo4e :rformacion, a repair permit wil! be issued for beds^ems
T.2?.Ir'.uT. \;r ,dc ucnil bedrooms are authorized to t�e future without engmeerec
i
ep� c s_�stem plans. _. _-----
1-_sin!r,:dci puccam9
Permit Number: Date:
Completed by:
i
I
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: Ia6} 3,rriQ-.5 gwer . LQV-AC%]skk? Lot No.
Owner: ���z�'�Q �p(1 Address: Lo�rJ� �yPN�S
i Contracto(: 9nut,1rQnC9' nk*o k Address: X (o��i �- �QJVNNA \
Notes.
i
i
i
STEP I Measure depth to water table to nearest 1/10 h. ............. III
elm Q....................... Date III m V
.......................................... month)I;.y yrar
I
STEP 2 Using Water-Level Range Zone j
and Index Well Map locate
site and determine:
OA Appropriate index well.................................................... „1IW
OWater-level range zone.....................................................
i
i
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...........................
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), j
and water level zone (STEP 28)
determine water level adjustment ....................................'......................................................
I
STEP 5 Estimate depth to high water
by subtracting the water• j
level adjustment (STEP 4) i
from measured depth to water I
Ilevel at site (STEP 1) .............................................................................................................
I
i
i
i
' I
' I
L �
Cape Cod Commission: USGS 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 last 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
>< SGS Site
Departure from Number****
Location Well No. Fate* Record Record Average** (links to L1SGS
Level High LowMonthly 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 !! -3.01 -3.4 JI 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 ZIS2 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 WNW 12.4 7.3 12.8 -1.4 -2.0 415353069585401
http://www.capecodcommission.org/wells.htm 11/8/2002
!, ... - t
1 8-2 0 0 2 01 :37 PM P. 01
r
TRANSACTION REPORT }sae-0796
CARMEN Ee SHAY - - P M
* P.O.Box 627,East Falmoutb,MA 02536qVUiV1"'A_INC.
* S U 8 8 T I T U.'1'L. R X November 12, 2002
DATE START SENDER LADES TIME NOTE
* ,�__ �.��'.._�.._,.o�r:�L.v c��c�®t •++ IiLtsllat on:
* N 0V- jtesi4"tSj f roper
ity-1257 Bumps River Road,Certerville, 910575 NO PAPER
Dear Sir or Madam:
On November 9,'2002, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at
1257 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,
CA AMEN E. SHAY
EN VIRONMENTAI.SERVICES,INC. q
LSH OF Mq'�.
CA EN
SHAY
Carmen . Shay, R.S., C.S. No. 1181
President �Fc/s T E¢�o
,S4NI.r R�
j
TOWN OF BAESTABLE
LOCATION .—� J SEWAGE # .20e;t_S yS�
VII.L �G E- `� ASS S MAP & LOT
t
INSTALLER'S NAME&PHONE NO. [l
SEPTIC TANK CAPACITY I m CAA\fir
LEACHING FACILITY: (type) ��Q�n s ���r��U1�I� (size)
NO.OF BEDROOMS
BUILDER OR OWNER �L�ri�, c�
PERMTTDATE: COMPLIANCE DATE: // 2
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
Ilk
age
No.....*15,9�.- Fs$.....sr ..........
THEoALT C OF
TS �
I �Sr� 0
BOAffiiD 7
1� —
n...-----...OF.......... ..................................
Apphratiun -fur M!ipuiitt1 lVorks Tuui#rurtiutt Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair -(61<an Individual Sewage Disposal
System at:
. o.
tion-Address ... or Lot ....
Own 0. dreg
W
a
Installer Address
Q Type of uilding Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms__w3--------------------------------------Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ____________________________ No. of pei-sons,l— Showers ( ) Cafeteria ( )
a' Other fixtures --------------------------------- -
W Design Flow--------------------------------------------gallons per person per day. Total daily flow----------------------------------------.---.gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter____-...._.____- Depth----------------
x Disposal Trench—No- ____________________ Width---- -------------- Total Length........... _ Total leaching arer._.____._____..._____sq. ft.
Seepage Pit No.__.�............ Diameter__-__4®__-----_-_. Depth below inlet..�t..�......... 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._.__-___-__.__._-._----
Gz, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water__._______________-__---
a -• ------------ -----------------------------------------------------•-••-•---------------------------•--------------•------------------------------------
0 Description of Soil__________ _______
V -•--•••---•----•-•----•--••-----------•---------------•-----------------------------------------•-•----••-•----•-•---•--------•----•-------•----•------------------------•------•----•----•------------
•---•-••------------------------------- -----------------------------------•-•-•--••----------•---•-------------.--..-----•--•---------•---------- --- -- -----
U Nature of RV <•r or Altera 'ons—Answer when applicable-------- _._._....
----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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.
ned l r-l--
} Pate
Application Approved BY •-_----------- -•--- ✓ .""l�' 7.� Date
Application Disapproved for the following reasons--------------------•---•------ (-------------•-•--••--•-•-•-•--•------•----------------------•-----•----------- ..
---------------------------------------•------------------------•---•---••-------------------------------••--•------------------------------------------------------------------------•.-------•--.-----
Date
Permit No. Issued �1 -----
Date
4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD fiDF HEALTH
--- -------OF.......... .Girl �---......... .................
Appliratintt -for Di-spoiial Works Cnowitrurtiin jjrruli#
Applicationlis hereby made for a Permit to Construct ( ) or Repair (fr�an Individual Sewage Disposal
System at:
L tion-Address or Lot No.
•--------!!._i.'t_5!!41�1 Le_ . ---•.............................. ••-- ---•-------------- -------------•------...----.....--------•--.............................
x _ _._._
Own � �r-/ dre6
Installer Address
d Type of Building Size Lot_---_-_:_-_---•-:_____-__-Sq. feet
U Dwelling—No. of Bedrooms---3--------------------------------------Expansiqon Attic ( ) Garbage Grinder
pi Other—Type of Building ---------------------------- No. of persons_et...................... Showers ( ) Cafeteria ( )
aOther fixtures --•------------------------------------ -
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.,
P4 Septic Tank—Liquid capacity.------:___gallons Length_______________ Width..= Diameter---------------- Depth.__---._:.-----
x Disposal Trench—No..................... Width
� ------- Total Length...........�
Total leaching area--------------------sq. ft.
Seepage Pit No.___ __-___ Diameter......6 Depth below inlet_. Total leaching area.. sq. tt.
Z Other Distribution box ( .„) Dosing tank
Percolation Test Results :i Performed by------- ----------------•--•-•-•-•--•---•••---••--•••.... = Date
as
a Test Pit No. 1.._.._..... !.minutes per inch Depth of Test Pit.................... Depth to ground water....__.:__:_._.__._....
Gz, Test Pit No. 2...........:....minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--.--__---_-------_-
--'------------ ---- -------------------------------•---------- •- ----
----
-------------•------•-•----•-•- •-------------- --
p
Description of Soil------.. ._� -�-u--- --- - -------------••--------•--------------- ,
xt F
_______________________________________________________ ._ 1' __ a _.._..___...__.._.____.__.____-_____-_-____------_-_--•--_ -..
\./ .................... ___ ._
U
W --------- --��?•y-t�-
_______________________________________________ �_______ _ _.. __.. _.____ i�y"' ___.____.___ --.-- _ _ __----
�C
V Nature of Re r or Alte a 'ons—Answer when-applcable._......1 -Q -�" ...
' .
----- .. _ --•-••----------------•-••----•-----_------------•-•-------------•-------------------------------
Agreement: ^
The undersigned agrees toi'nstall the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation'°until.a Certificate of Compliance'has been i s d by e board of eal h.
...........................7 l,,�'
q 1 ` nedj
1 �. �....<., ate
Application Approved BY _ � . . •-• --• --• ''K� f " ��•
r' Date
Application Disapproved for the following reasons: '=-----------•------------------------••--•--•-----••-•---
Date
PermitNo---------_--------••-•-••-•--•••-•--=='=-' Issued-•-------------------- -•----------• ......:.__.....:__
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE - H
�•. .r✓L'' OF:........ � r ............ .
err ifiratr Of - ampliaurr ,
TH I CE IIF Y at ndividual Sewage Disposal System constructed ( ) or Repaired ( )
by Z •• •••-- :- ..A- taller
------------------
has'been installed in a ordance with the provisions of .Arti XI of The State Sanitary od�s as d9cr' ed in the
application for Disposal Works Construction Permit No________________��`'._______..______. dated..1_-----_@_-_--_-----7..�.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. e
DATE............................................. .-----------------•-------------- Inspector....................................................................................
f THE COMMONWEALTH OF MASSACHUSETTS '
BOARD F HEALTikke
C f/�
i
�......
OF......
N0.......l�/' P....... FEE....-1............
ion Vprrmif
Permission is hereby grante .`'�'_.
to Construct ( ) or R air ( n Indi a!t,,Sewage saF Sys ,
at No. .........................................................
---------------••-••--• ••----. -
S;r et _ � � .r. (�
as shown on the application for Disposal Works Construction P m' No _.'D ted.... ____...
� ------...4-------------- F
.. t Board of,'Health tf
DATE. _1 '"
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r.
-LOC_QT_1.O/y�_ 5 WQCtE PERMIT QO,
F i
R-5 Q. NAl
T-1-L-D E-R-S-IJ-�.-M Ei�_A_D_D R E S S
D A--T E-GO N_�.P_L_I_&t`l __
rZc /IxX
� ---
A
.. # �.
s
- �� ��`
7
O
VENT PIPE (0 Least 24 inches to LOCUS M AP
Schedule 40 PVC w/Chorcoof Odor er
10' min. from 3-24'DIAM. ACCESS MANHOLES Q)
Existing Foundation 1_h_-�se to septic tank *NOTE. ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V,C- SECTION A —A C I I
0
T-OT. elev, 100,00 Septic to Covers must be _J
within 6 in- of finished ode Crode over SAS Vorift (1 DO 00 to 98.00) PROFILE VIEW OF LEACHING SYSTEM -�7 =7 Grodt over Septic Tank - 9&00 Grade over D-Box 99-50
Not to Scale
xz� XZ i • BUMPS RIVER RDo
3 HOLE T 4114- to I 1/Z Wwh*d crushed Sterne
002
(H-20) DIST, BOX 3' Ma-imurn cover INLET
20' S-0.01 INLET OUT.El _y SITE
EXIST. PIPE NEW 1,500 GAL 0
rn SEPTIC TAN
FROM F"DA71ON 27' 20' THE ACCESS COVERS FOR THE SEPTIC TANK,
.0010, per fool
K .2
DGTRIBUTION BOX AND LEACHING COMPONENT L
15 4)
H-10 CID Effecti�* Depth OF 0-owe. S11ALL BE RAISED TO WITHIN 6 >
CONCRETE FULL FOUNDAT FINISHED GRADE.
L6
w If 0) A 24 Effective STEEL REINFORCED PRECAST CONCRETE IKSTALL TUF-TITE GAS BAFFLES OR EOUALS
5 y. 4# 4- Sidewall ALL OUTLET TEE ENDS
SYSTEM PROFILE > 3' PLAN VIEW V 2000'
5 Units 6.25' 31.25
Not to Scale
31-25, 3-24'REMOVABLE COVERS
Effecti�& Width
GENERAL NOTES
4-
6 in.of 3/4'-1-1/2" 4)
3" min. clearance di 3"f 1wE7
compacted stone Effective Length 1 Contractor is responsible for Di sole notification
0 INLET 1-1-T fj�l 12-.min, inlet to outlet frl�.4
M and protection of all underground utilities and pipes.
Z4E�EY-OUTLET
INLE Ui 10 ,. 1::T
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE SOIL ABSORPTION SYSTEM (SAS) T 2, The septic tank and distribution box shall be set
level on 6" of 3/4"-1 1/2" stone,
INFILTRATOR MODEL 3050 (H-20 LOADING)/ SUMNER & DUNBAR 4E 5 3. Backfill should be clean sand or grovel with no
EJ 4'-0-min.
in size.
LkWW depth stones over 3
(OR EQUIVALENT) o
4, This system is subject to inspection during installation
v
by Carmen E. Shay - Environmental Services, Inc.
NOTE: OVERALL HEIGHT OF INFILTRATOR •IS 30' /EFFECTIVE HEIGHT Is 24-
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 EN 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 1500 GALLON" SEPTIC TANK
installation must halt & immediate notification be
NOT TO SCALE mode to Carmen E. Shay - Environmental Services, Inc,
7. No vehicle or heavy machinery shall drive over the
FOUNDATION 20' SEPTIC TANK 27' 0-BOX -raj0, LEACHING FACILITY (H- 10 LOADING)
septic system unless noted as H-20 septic components.
8. Install Tuf-Tite gas baffles or equals on oil 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
A PERCOLATIOW TEST Schedule 40 NSF PVC pipes with water tight joints.
11. SITE and Surrounding Properties ore not Connected
to Municipal Water.
0 20 40 50 Date of Percolation Test: OCTOBER 28, 2002 1
Test Performed By CARMEN E. SHAY- R.S., C.S.E.
Results Witnessed By WAIVER per BARNSTABLE BOH
rrI Excavator: ROBERTS SEPTIC SERVICE
0 Percolation Rote: Less Than 2 min./inch 0 3 FEET, BELOW GRADE
0 THE PROPERTY LINES ARE APPROXIMATE AND
COMPILED FROM THE SURVEY PLAN GENERATED BY
BEARSE & LAW, SURVEYORS of CENTERVILLE, MA
Q11' TI Test Hole ENTITLED " PLAN OF LAND OF JOHN H. JOHNSON",
LOT #4 0 No. 1 CENTERVILLE, MA", DATED DECEMBER 23, 1958
;10 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
> DEPTH SOILS .ELEV.
Z IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
CD 0 100.00
QP 0 rri Sandy Loom THE SEPTIC SYSTEM INSTALLATION.
01, 10 YR 3/2 99.00
9A 0,
tTJ
t. Sandy Loom
0
Failed IOYR 5/6
Cesspoolerg 12"-36" Be 97,00
Med-Coarse NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
Sand d FROM THE EXISTING SEPTIC SYSTEM TO BE DISPOSED
2.5 Y 7/4 OF AS PER BOARD OF HEALTH SPECIFICATIONS.
36--144" C, 88,00.,
EXISTING CESSPOOLS TO BE PUMPED DRY &
FILLED WITH CLEAN FILL MATERIAL.
#1257
PROJECT BENCH MARK----\ Failed
TOP OF FOUNDATION Cesspool Z cr�
C
ELEV. 100 (assumed) /</ I
EXISTING 4 1
ASSESSORS MAP - 188 PARCEL 077
BEDROOM
HOUSE '
ZONING - RESIDENTIAL
FLOOD ZONE C
Perc #1
v0 Depth to Perc: 40" to 58"
O
TOF= ELEV, 100
P
Perc Rate=<2 min./inch,
-�A�1�50 AD -
THERE- RE- Loc-ATE b wfTH'f'N-'- R TU 5'
ojg_r,; of
0 BOTTOM OF TEST 116LE Elev. 120"
ADJUSTED H20 Elev. Na Adjustment Required. OF THE PROPERTY
AA r
is
NEW 15100�1
O
Septic Tank
GARAGE 0 ALL OUTLET PPE ROM THE
LEGEND
CKSTRIBU11ION BOX SHALL 13E '2' CONCRETE SET LEvEL FOR AT LEAST 2 FT, COVER
3 5 OUTLET 2-
KNOCKOUTS
C*:) DENOTES PROPOSED
L F88xo
12' INLE
0 9�? T SPOT GRADE
C:) —90 71�A\ OUTLET
T
f
2' DENOTES EXISTING
D- OX X 104.46
SPOT GRADE
4' - SCH. 40 Te
PLAN SECTION QR0S'S—SECTI0N
PL
PROPERTY LINE
TEST H LE #1-
3
3 HOLE DISTRIBUTION BQX H-__ .EV.= 00.00 _10 LOADING PROPOSED CONTOUR
NOT TO SCALE
0
88 97— — — — — —97 EXISTING CONTOUR
0
DEEP TEST HOLE &
PERCOLATION TEST LOCATION
PERCOLATION,Calculations i
Number of Bedrooms: 4 Equivalent to 440 G o L/Day (440 Gol./Day Min- per Title V)
Garboge Grinder: No FENCE
t Leaching Capacity Proposed: 330 Col./Doy Minimum (Min, Per Title V)
i Septic Tank 2 x 440 Col./Doy = 880 USE 1,500 GAL, Septic Tank.
6 SOIL ABSORPTION AREA: Using percolation 4e of <2 min. inch
PRIVATE DRINKING WATER WELL
I Bottom Area: 0-74 of/sq. ft. x 418sq-lft. = 309.32 gallons -------
Sidewoll Area: 0.74 gal./sq. ft. x 196 s4. ft. = 145.04 gallons
Id REVISIONS
co Providing: = 4 54.36 gallons
No. DATE:
LOT B Use: (5) HIGH CAPACITY INFILTRATOR CHAMBERS, HAVING A 2' EFFECTIVE DEPTH. DEFINITION
(3' W x 6.25' L) TO BE USED WITH 3' OFiWASHE6 STONE ON THE SIDES AND
3,75' OF WASHED STONE ON THE ENDS.
2.5 ACRES.
It
It
If _ J ItJ Ii �CRoPROPOSED
PREPARED
r rSUBSURFACE SEWAGE DISPOSAL SYSTEM
OF
# 1257 BUMPS RIVER ROAD
OSCAR S . JOHNSON CENTERVILLE, MA
It 1257 BUMPS RIVER ROAD
PREPARED BY:
&AAAAA,
CENTERVILLE MA ' \,-\,r OF
r A SffA Y
E.
ENVIRONNEYTAL SERVICES, INC.
tK 0
chl- 34 THATCHERS LANE
CID
EAST FALMOUTH, MA 02536
un"i IV I TAR\
TEL/FAX 508-548-0796
SCALE. 1 "=20' DRAWN BY: CES DATE: NOVEMBER 12, 2002
0
E
5 Unit 3.5 1' N '
S OV ET
PROJECT SD FILENAME- S0356PP.DWG SHEET 1 OF 1