HomeMy WebLinkAbout0250 CAP'N CROSBY ROAD - Health 250 Cap'n Crosby Road
Centerville
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7E
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M y< 250 Cap'n Crosby
Property Address P
Waskiewicz ='
Owner
Owner's Name ^�9
information is r..•
required for Centerville MA 02632 10-1-17 3M
every page. City/Town State Zip Code Date of Inspection QD
&5
�n -
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.
WheImportant: A. General Information
When filling out / 2�^---
forms on the C54 �taT d
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not use the return Name of Inspector
key. D.A.BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
'Ed01 Cityrrown State Zip Code
508-420-4534 S14297
Telephone Number License Number
8.,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
10-1-17
I ns—pectorA 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.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
, 6), a VS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owners Name
information is required for Centerville MA 02632 10-1-17
every page. Citylrown 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 this system was functioning properly and met all passing requirements
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
every page. Citylrown 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 Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M r� 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
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 1/2 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
, 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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
250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
every page. Citylrown 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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3113 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
t 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owners Name
information is required for Centerville MA 02632 10-1-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
This system consists of a septic tank d-box and 2 500 gallon chambers with 4 ft of stone. The original
leach pit is also present.
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 ears usage d N.a at time of
g ( y g (gp )) inspection
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
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: owner stated pumping in 2016
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: maintenance
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
M s 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
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:
s.a.s was installed in 2014
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: 1000 gallon
Sludge depth: light
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
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? wooden pole
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was functioning properly at time of inspection. Owner stated pumping in 2016. 1 recommend
pumping at least every 2-3 yrs depending on usage for maintenance.
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•3113 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
250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
every page. City/Town 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 was functioning properly at time of inspection.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number:
2
❑ 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.):
At time of inspection there was 4 inches of liquid in the chambers with no signs of failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Assessing As-Built Cards Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
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 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: 9-2017
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=193176&seq=1 �10/1/2017
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 250 Cap'n Crosby
Property Address
Waskiewicz
Owner Owner's Name
information is required for Centerville MA 02632 10-1-17
every page. Citylrown 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
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Assessing As-Built Cards Page 1 of 2
TOWN OF BAMSTABLE
LOCATION (a n'.V t�rc=�ri�t SEWAGE#JLQ 11.219i
VILLAGE(P� 1g,11 ASSESSOR'S MAP&PARCEL/Q' (�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Eli-4 o
LEACHING FACILITY:(type) i ymM n (size)
NO.OF BEDROOMS
OWNER 1�1,4 V t d W;C--z
PERMIT DATE: 8 -1 S1 y COMPLIANCE DATE:
Separation Distance Between the: /VvA' z P•%ULrrre.',1d
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Of f r,C 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 Of any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BYQ),13� T�
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2-`I 7- 2 3 3
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http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=193176&seq=1 10/1/2017
i
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No. O�� d Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipphration for Disposal *pstrm Construrtion 3pPrmit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. .Z O Cap`no C<°jasle� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel j y 3 j 7 G10a s'<i e Lo i s z.
IInsstaller's Name,AAd�dress,and Tel.No. r Designer's Name,Address,and Tel.No.
Y
Type of Building: J
Dwelling No.of Bedrooms Lot Size 1`�,G 3 4 sq.ft. Garbage Grinder( )
Other Type of Building f Ps%3 e"3�x \ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3-!�c) gpd Design flow provided a y F,-7 gpd
Plan Date 7- 2 2 I-f Number of sheets 12 Revision Date
Title
Size of Septic Tank Type of S.A.S. 2 9-Co Cyr.Vck-j a.n bec w 'i 5iGN�
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) -2 5oo roc j1 t)
Lf ` o f-dNm, e�--d
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed , i- Date f S y
Application Approved by Date /
Application Disapproved by Date
for the following reasons
Permit No. �( ] �� Date Issued
( Yy{ I
No. D( d Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer ---
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplication for Disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair($.) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. .;.SV Cc to").0 iosl Owner's Name,Address,and Tel.No.
e 1
Assessor's Map/Parcel 7Ga (AJr,S.c_le W
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
t7o„5�li s A 11,r ouwN T Nc So$-i-/oo-y/9'y ENS"N p LJ Mr S
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 19,6S4 sq.ft. Garbage Grinder( )
Other Type of Building t e5,JPA3 iu� No.of Persons 3- Showers( ) Cafeteria'( )
Other Fixtures
t
Design Flow(min.required) 110
gpd Design flow provided `;y R,'' gpd '
Plan Date - 2 Z — ! '
� �/ Number of sheets '2, Revision Date
Title
Size of Septic Tank iCY Type of S.A.S. 2 SGo S tw 4 5+6Ne
'Description of Soil
Nature of Repairs orAlterations(Answer when applicable) 9 S oc) rn %)'i
4 ' o 5 t o Ay C r,-y C , "17 -AUX
i
Date last inspected: - ,
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed-
" C/ I ---- Date
Application Approved by Date.. ., <
Application Disapproved by Datej
for the following reasons
tr.
Permit No. '� t� I Date Issued
-------------------------------------------------------------------------------------------- -----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance �
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned 0o-s A ns r
at ''� S C? c� P/V C i 0(,`0l has been const "iacce
with the provisions of Title 5 and the for Disposal System Construction Permit No. 5ted
Installer.D0 V e)u-, A i?, (f",JZ. c Designer T ry s ti r,?+f .0 f 1j p r tr -K`
#bedrooms 2S Approved design flow '3-5 J gpd '
The issuance of this perpi s all n be c nstrued as a guarantee that the system w D ctio ;a�sesi ne&� 0,�, �Date Inspector 1-------------------- ------------------------- ----------------------------- /
No. aV/4— f Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *Pstet Construction Permit
Permission is hereby granted to Construct( ) Repair(✓) Upgrade/( ) Abandon( )
System located at 2- 50 C r e',V rro S )::)ti Rd
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. -
Provided:Construction must b�a/co_mpleted within three years of the date of this permit. i
Date Approved by G f
Town of Barnstable
Retry Service
Thomas F. Ceiler,Director
t PD= ? DIV1D
Thomas,MvKeau,Director
200 Matn'Street, Hyannis,MA 020.01
Office: 5084624W Fax: 5108-7904304
Date: L t. 1 Sewage Permit# ` _
� COI J� A,ss�essor s 1klap/Farciel
Ittsta,ler_&,I esifgner.C€rtAc—Ation.Form
Designer: t o n-e,�n� Wor)As, nc , Installer: ' W
Address: z W. Cra (el 2d. Address: ex- �c
C was issued a permit to install a
(date) (installer)
septic system at 256 C �� �` �� based on a design drawn by
v�S dated � 1�)
(designer) VL`
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the-septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system);but in accordance with State & Local Regulations. Plan revision or
oft-fed as-built by designer to follow. Stripout(if required) w ; ,ted and the soils
were found satisfactory. T"kM,gs
PETER T.
Er's Signature) CI 1uCc V y.
VILL
9 NA:3b109'0
(Des;gtter's ignature) ( ix Design .
PLEASE=TURN TO BARI\TSTAI#i;F )E'T�BL�,IC EA:LTH DI'YIS Oi�1. C 2T) ATE
JN
Qr t,Ona1MLIANCEyyiLL NOT BE ISSUEJD� TIL BOTH THIS FOBIt AI�rD AS
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK Y.OU.
t
gAoffice fwmsldesiperuardflcadon form.doc
TOWN OF BARNSTABLE
LOCATION JV cyc� SEWAGE# �ZQiy
`AULAGW,&"r 0L-J%`V ASSESSOR'S MAP.&PARCEL/°y_` �
INSTALLER'S NAME&PHONE NO.Qoje_t A 2fauji,11 j
SEPTIC TANK CAPACITY E �
LEACHING FACILITY,(type) (size)
NO.OF BEDROOMS !3
OWNER [Aa" e j -;
PERMIT DATE: --/,..I of COMPLIANCE DATE: ;v/y��
Separation Distance Between the: NCrN2 e.-c,,^Ae and
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Q f pe tC Feet
Private Water Supply Well and Leaching Facility(If any wells exist ori`
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility-
) Feet
\FURNISHED B aL) r0-,0`�
i -�to 31- 30
_ � 3p5-3
S Ll
- r
7T
?'��-
Town of Barnstable P#
l
. Department of Regulatory Services
Public Health Division Date
to�
0. 200 Main Street,Hyannis MA 02601
Date Scheduled ' J`-1 2 1 LC Time d Fee Pd. (o O-Z
Soil Suitability Assessment for Se e i o a a 0
Performed By: �e Jr t `r-16� Witnessed By: 1
O
LOCATION&GENERAL INFORMATION .
Location Address C�\ Owner's Name W q S l il'L,,J i C S�-►V\
ZSo n Cr�sh\�
2tn ti{t/`ft t /� Address Z 50 Clke'e% LCbS; JQ( 94 CQ.t,+-
Assessor's Map/Parcel: 1 3 l0 Engineer's Name?,L4kJ-'MLC^
NEW CONSTRUCTION REPAIR �L Telephone# 50'9-73-)-4-7 g
Land Use J Z!J t \-tl,+ 1 Slopes(%a) _ A
Surface Stones Distances from: Open Water Body.—1 U ft P.-ble Wet Arta N A-ft. Disking Water Well ! r✓ R
Drainage Way ft Property Line Z1D ft�Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)
V
i
c>
CD
co
w
C3\s+��n� V Ac A Ile,
Parent material(geologic) Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_
PERCOLATION TEST Date Time
Observation
Hole# rune at 9"
Depth of Perc -2 S� �'���RA'�Y`^` Time at 6"
Start Pre-soak Time Qa G z u A Time
End Pre-soak �— � {
Rate MinAnch
Site Suitability Assessment: Site Passed OC Site Failed Additional Testing Needed(Y/N)
,Original:Public Health Division Observation Hole Data To Be Completed on Back-
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTI0PERCF0RM.D0C
DEEP OBSERVATION HOLE LOG Hole# .
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.)' (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistencv.° Gravel)
5� �6 41
d 1(Zs
z -i32- L -DY 7
DEEP OBSERVATION HOI E LOG Hole# 'L_.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsen) Molding (Structure,Stones,Boulders.
On isten
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
el
DEEP OBSERVATION HOLE:LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
C ns' Gravel)
Flood Insurance Rate May;
Above 500 year flood boundary No_ Yes
Within 500 year boundary No_& Yes_ ,
Within 100 year flood boundary No-6- Yes—
Depth
V P of Natural) Occurrin 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?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on � (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required tra' ' g,expertise and experience described in 310 CMR 15..017.
Signature Date (7 zf (L/
Q:\SEPTIC\PERCFORM.DOC
COMMONWEALTH OF MASSACHUSETTS
TV04 OF r'ARHSTABLE
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTALRCEG1'IOsI*I �0
C11VIS10I4
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 250 Cap'n Crosby Road
Centerville, MA 02632
Owner's Name: Martha Jane McDonald
Owner's.Address:
f�
Date of Inspection: June 7, 2005
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of 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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: June 12, 2005
The system inspector shall subm' copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 250 Cap'n Crosby Road
Centerville, MA
Owner: Martha Jane McDonald
Date of Inspection: June 7, 2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
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
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 250 Cap'n Crosby Road
Centerville, MA
Owner: Martha Jane McDonald
Date of Inspection: June 7, 2005
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.
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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 250 Cy2'n Crosby Road
Centerville, MA
Owner: Martha Jane McDonald
Date of Inspection: June 7, 2005.
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 250 Cap'n Crosby Road
Centerville, MA
Owner: Martha Jane McDonald
Date of Inspection: June 7, 2005
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:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 250 Cap'n Crosby Road
Centerville, MA
Owner: Martha Jane McDonald
Date of Inspection: June 7, 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): epd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable-Pumped after the insi2ection for maintenance
Was system pumped as part of the inspection(yes or no): 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:
Installed on 315182-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 250 Cgo'n Crosby Road
Centerville, MA
Owner: Martha Jane McDonald
Date of Inspection: June 7, 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: _ Measuring stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage
The tank was pumped for maintenance after the inspection. Note:A large bush is over the tank-recommend removing
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 250 Cann Crosby Road
Centerville, MA
Owner: Martha Jane McDonald
Date of Inspection: June 7, 2005
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Continents(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: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 250 Cap'n Crosby Road
Centerville, MA
Owner: Martha Jane McDonald
Date of Inspection: June 7, 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -6'x 6'(1000 gal.)
leaching chambers,number:
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.):
The nit had 6"ofliauid on the bottom. The scum line was approximately Pup from the bottom There does not appear to be any
slQns of failure. The cover was 20"below Qrade.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 250 Can'n Crosby Road
Centerville, MA
Owner: Martha Jane McDonald
Date of Inspection: June 7, 2005
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.
(3,ac�c
A
Q
g aq
C
10
f
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 250 Cap'n Crosby Road
Centerville, MA
Owner: Martha Jane McDonald
Date of Inspection: June 7, 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topogral2hic and water contours maps, the maps were showing approximately 40'+/-to ground water at this
site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report.
11
T WN OF BARNSTABLE "N.
1 ATION ��S--� Cro SEWAGE #
\PILLAGE Cke; "06- ASSESSOR'S MAP & LOT 2z 1 to
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY an
LEACHING FACILITY: (type) P+ x (size)
NO. OF BEDROOMS 3 ^^ J J
BUILDER OR OWNER ` ' !L c•O�l�'`
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin facility) —�-- ) Feet
Furnished by��/19�C V�)D^
A
� o
�g ac
a-
F3NO. .......... ..C.. x$...... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
oF... `!Q��..s.� .c .. -----------------------------------------------
Appliration f nr Dispaii al Works Tonlitratrtiun rantit
Application is hereby made for a Permit to Construct (1) or Repair ( ) an Individual Sewage Disposal s;
System at:
....zoo .sa.:..... r�.o!'....�' y....!�Q........--•-------... .4t.......�z.,?................................................
Location-Address A or Lot No.
..........QPr. !V................................... ...6,�(!tc.. t...— �lPs�flfl�f!�V �� ��= .._.....
Owner ° Address
W Pj?,e1.j9Z,&:ewiLd..............•.....
Installer Address
Type of Building Size Lot_.1.9s.fe jY._.......Sq. feet
U Dwelling—No. of Bedrooms...z.Q.g?.e.........................Expansion Attic ( ) Garbage Grinder (Aee)
pa,, Other—Type of Building ............................ No. of persons---T4E'P_e---.______- Showers (aw) — Cafeteria ( )
04 Other fixtures ......•••.....................
W Design Flow..Y19....X..3.....................gallons per person per day. Total daily flow_-______----__a.R..Q.................gallons.
WSeptic Tank—Liquid capacity/aoo-...gallons Length................ Width................ Diameter__.---__-__--_. Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-_----------------- Diameter............. Depth below inlet..._................ Total leaching area..................sq. ft.
Z Other Distribution box (✓j Dosing tank ( )
aPercolation Test Results Performed by....t4RY-t0.C..._. .............................. Date..a?t.,4%.$J....._.----------.
Test Pit No. 1.........1..~_minutes per inch Depth of Test Pit-------!a....... Depth to ground waterN e-... K-t
Test Pit No. 2................minutes per inch 'Depth of Test Pit.................... Depth to ground water........................
0 ------------------•------•----------------•----------------------------............-----------------.........................................................
O Description of Soil.......d-' ............ --sv_,g_so."4.
x a;6- r , a. 5`;�-a
v ...............•-•• - --•••••••••••-.........................................
W
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
-------------------------------•......----...-----------------------•--------------------------------------------------------------------------------------------------•----•-•••••••••••--•-•••••-•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT f.;:. 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 bo d of health.
Signed.._...-J.�.,...
Date
Application Approved BY ' - -te Z-------------------------
- Date
APPlieation Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------••..
..----•-•--•--•-•-••---•-•-•...............................................................................................-•-•----••••----------------•-••-•--•-••-------•......•--....•--
Date
t No: f:.... _._.. Issued.....................................................
�a
Date
a
Fn$......;Y._��..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'...:......... ...... .....................................................................
Appliration for Uiopooal Works Tonotrurtion 1hrmit
Application is hereby made for a_Permit to Construct (6''•') or Repair ( ) an Individual Sewage Disposal
System at:
............................. ... ,.f........ ....................
Location-Address or Lot No.
Ii! ter.✓� .r t' 'os l . Veo s.,,g 7tt+;Y
................... �1............................
[ g Owners +� Address
Y..`..�.. .-.....!_-p---t-'-+_t!S:'! t..................... .........................G_...........
-.....................................................
Installer Address
Type of Building Size Lot--- ........Sq. feet
aU Dwelling—No. of Bedrooms-__?� . . �? p ( ) g (. )
...........................Ex Expansion A Attic Garbage Grinder
p, Other—Type of Building ............................ No. of persons... Showers (-") Cafeteria._( )
a' Other fixtures ................ .................
W -Design Flow... Z!�...._1`___3.....................gallons per person per day. Total daily flow__._.........._2 a_.n.........._......gallons.
f� Septic Tank—Liquid capacity&::^_q...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 (41 Dosing tank ( )
'~ Percolation Test Results Performed by..... F' _T: _._. .. `,V.e.............................. `Date..�?!._.,O..
Test Pit No. I.........P-----minutes per inch Depth of Test Pit........! _..... Depth to ground water_-".5�...t_° " w"
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' •-•••-....-••••---------•....•••--•••-•••-••--•--•••-•-•..........•-•••.....................•-•••-•..................................•.......................
Description of Soil------. = -------------. n.__...
--------------•---------------------------------------......------.......---...__.
°`.•-•-•-•-----•ram';. . ..`^r; `..Z.)..................................................................................................
W
---------------- -- - ------- ..........................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.____.........................•....._..........._....._....._._......................_......._..
.................................-..............................................
Agreement: t� N., - -
The undersigned l,agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE y g g p y
5 of the—State Code— The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the bo of health.
Si gned < c r'' -':' -
v
.._..- ....................................... .......
ate
Application Approved By...... . .......................•. -------------- -^ ...............
Date
Application Disapproved for the following reasons---------------------------•---------•---------------------------------------------------------------------.._...
------------------------------------------------------------------••••••.....•-•------•----•-••--•-•-----
-----------------------
Date
PermitNo--------------------------------------------------------- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS pcM P
BOARD OF HEALTH
..........................................OF.....................................................................................
(Irrtifirate of Tuntplianrr
THIS—IS TO CERTIF , Th IndivAiTl Sewage Disposal System constructed ( Pj or Repairedby...._..........-•-• -- ---. ..•-•-•-••-•-----. ...... ........c------------------------------------------------------------------------------------------------
Installer
---------------------------------------------------------------------------------------•--............---•-••--••-.....
has been installed in accordance with the provisions of TITr j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. .. ..................... dated................................................
THE ISSUJ CE OF THIS CERTIFICATE SHALL NOT BE fCONSED AS A GUJARANTEE THAT THE
.SYSTEM WI � CTION SATISFACTORY.
DATE..3. S..... .Z .------ -- -----•------•--._......--•----•-------•-------. Inspector. ----------------........----..._....----._...--•---••----.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................OF..................................................................................... �y
No._':.............. FEE.row�l..................
Eiiposal Works, Ton#r"n �erntit
Permission is hereby granted...........................
-- ---- !2lLt,"" ........................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System %
4'of f' . r
at No.... `� .. .F ,..�..r ------ --------�--£--"-'-----------�- -`----------------------------
Street
as shown on the application for Disposal Works Constructio t Noo...................... Dated..........................................
..........-......
----
) B;�w orHealth
DATE...............................V' Y/
...
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS J
VAI
133,al . .
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t.10 GAtZBAG� 6RI +T1 -t' ; ; A
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PAM ur.c0 TO DMTceMl%4t= LOT -•t,_Iwa,; --�AV1 �Au V-0
o ;0- �—�r
0 CAT ION SEWAGE PERMIT NO.
SLAG E
s,, / 7
INSTALLER'S NAME i AD-DRESS
n\ a rr��,,5 w� a►xy
GUILDERf. OR OWNER j
Witt E' P EItM-IT ISS-U E D 1
DATE COMPLIANCE ISS.UE.D
a
��
L2CAT10N SEWAGE PERMIT NO.
,�7,ao Otan-ft " �nl� . Q 1-i
V LAGE '
INSTA LLER'S NAIVE & ADDRESS
15UILDER OR OWNER
D-A. T E PERM-IT ISSUED
DATE COMPLIANCE ISSUED
—�
AF a }, ; 1-
�� 29
� ��
G(4
LEGEND
N / LOCUS
—— 18 —— EXISTING CONTOUR ® - 0 tE�
x 16.82 EXISTING SPOT GRADE o m cap'
a 04 Cro by
—W EXISTING WATER SERVICE Rd
OVERHEAD WIRES
G _=I'
TEST PIT °° yt�hi 3 Pond
AG Po Ch
BENCHMARK st g v Dr
0
0
°St 4n
EXISTING LEACH PIT
PUMP, FILLED WITH
SAND AND ABANDON Ge�c Yin a
Quo
EXISTING SEP71C TANK
TOP OF TANK, EL.=63.50 LOCUS MAP
1NV.(OUT)=62.17f NOT TO SCALE
64.28
65.56
o llk
64.01 \ SPIKE2
6A / 64.58 + + 64.19
U
62.9D' x
�. : 64.49 -----------��
+ x 64.33/
`L, S 76
K.
x 64,28
63.27
��\ 1 GARAGE
BENCHMARK
�KEv DECK 63.2
OUTSIDE COR./STEP 62:1 � x
EL.=61.09 3
63.37
W \ EX/STING 63.59 to
co
N
HOUSE(#250)
RETWALL x 6z.66 62.40 Co 62.11 T.O.F.=65.1f \
,vim qj 60, % .`.`'; : �
' `° ✓ _ RAVED'.:..
..
_ - \ 62.17_�� -rJ .�,-...•DRIVEWAY'... _ - � ,
60.55 I
60,85 2
61.30
x 61.49 ::4 .00•
60.14x :61.69`N-76: 1.07
- W
\ I N Co 61.36
\ P v
v M 61.33
+ 59.68\
• � � to
\ 11 61.15
LOT 54 $ + Q
MBL193-176 60,78 0 61.33
19,634 ±SF \ z PK SET
\ ) 60.78
,7.90 I u CAP ' N CROSBY ,
\ UP
`\0 ^ � ROAD
86.73• \
N 7`,07 ry
•I U� �\
59.90
Q��� of Mgss9�
o� l
PETER T. �� 1
McENTEE
o CIVIL
No. 35109
t
OWNR OF RECORD �'OF R£CISTER�O ��
WASKIEWICZ, JUSTIN J SSI
& NEVENS, MOLLY
250 CAP'N CROSBY ROAD �(
CENTERVILLE, MA 02632 '71 Z Z
PLAN REFERENCE: LAND COURT PLAN 38507 B, SHEET 2, LOT 52
Engineering by: SCALE DRAWN J09. NO. PROPOSED SEPTIC SYSTEM UPGRADE PLAN
Engineering Works, Inc. ,"=20' P.T.M. 185-14 250 CAP N CROSBY ROAD, CENTERVILLE, MA
12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO.
(508) 477-5313 7/22/14 P.T.M. 1 of 2 Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
w,
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL:60.5
FOR A DISTANCE OF 15' AROUND THE
SEPTIC TANK PERIMETER OF THE S.A.S.
INSTALL RISERS & COVERS OVER INLET & PROPOSED D-BOX PROPOSED S.A.S.
OUTLET AND SET TO 6" OF FINISH GRADE INSTALL RISER & COVER PROVIDE TWO ACCESS MANHOLES TO WITHIN 3"
= t
SET L 6" OF GRADE OF FINISH GRADE FOR INSPECTION PURPOSES
T.O.F. 65.1
EXISTING F.G. EL.=64.0f F.G. EL=63.8t F.G. EL.=63.8t
' f f AINTAIN 2% GRADE (MIN.) OVER S.A.S. -
< L - 10' L = 5'
® S=1% (MIN.) ® S=1% (MIN.)
4"SCH40 PVC 4"SCH40 PVC
6'
10"I " 000001908300
s O 66
la" s aaaaaaa
EXISITNG as" uqulo aaaaaaa
LEVEL INV.=62.17
J BAFFLE INV.=61.57 INV.=61:40 4' 5.2' 4'
PROPOSED D-BOX EFFECTIVE WIDTH = 12.8'
:. . ._. . . .. : . . .... • INV.=60.00
EXISITNG SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS
SURROUNDED WITH STONE AS SHOWN
/ H-10 RATED 3" LAYER OF 1/8" TO 1/2-
DOUBLE WASHED STONE
TOP CONC. ELEV.=60.8t (OR APPROVED RLTER FABRIC)
BREAKOUT ELEV.=60.50
NOTES: INV. fLEV.=60.00 aa725..01
aaa6a aB6
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE ease eas
INVERTS, PRIOR TO INSTALLATION. BOTTOM ELEV.=58.00
4' 8.5'
2) D-BOX SHALL BE SET LEVEL & TRUE TO GRADE 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH =ON A MECHANICALLY COMPACTED 6" CRUSHED STONE PERVIOUS MATERIALBASE, AS SPECIFIED IN 310 CMR 15.221(2). 5' MIN. SEPARATION TO G.W. BEACHING SYSTEM SECTON
3) INSTALL INLET & OUTLET TEES AS REQUIRED. /' NO G.W., TP-1, EL.=51.5 - 3/4" TO 1-1/2" DOUBLE
J 4) CONTRACTOR SHALL INSTALL A GAS BAFFLE ON WASHED STONE
THE OUTLET TEE.
SEPTIC SYSTEM PROFILE
SOIL LOG
DATE: JULY 21, 2014 (REF#14,430)
SOIL EVALUATOR: PETER McENTEE PE(SE#1542)
WITNESS: DONNA MIORANDI R.S. HEALTH AGENT
ELEv. TP-1 DEPTH ELEv. TP-2 DEPTH
62.5 A 0" 631 A 011
SANDY LOAM SANDY LOAM
EXISTING 623 10YR 4/2 10YR 4/2
GARAGE HOUSE(#250) . B 4" 62.6 B g"
_ T.O.F..=65.lf/ SANDY LOAM L ;:SANDY LOAM . -
- - 10YR 5/8 10YR;5/8
60.5 24" 60.9 26"
C C
PERC
30"/42"
DECK '
LA MED. SAND MED. SAND
Z� A 2.5Y 7/3 2.5Y 7/3
1 0 D S.A.S.I C'i 51.5 1 132" 52.1 1 132"
PERC RATE ON FILE 2/2/82 = 2 MIN/IN.IN SAND BELOW 30"
-- __-- SOILS OBSERVED ARE CONSISTANT WITH PERC TEST
- 25'-1 NO GROUNDWATER OBSERVED
S.A.S. LAYOUT GENERAL NOTES:
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER.
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
LOCAL RULES AND REGULATIONS.
DESIGN CRITERIA 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
NUMBER OF BEDROOMS: 3 BEDROOMS 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ENGINEER BEFORE CONSTRUCTION CONTINUES.
DESIGN PERCOLATION RATE: <2 MIN/IN 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
DAILY FLOW: 330 GPD 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
DESIGN FLOW: 330 GPD THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
GARBAGE GRINDER: NO-not allowed with design `� 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S.
.74 GPD/SF 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY DIRECTED BY THE APPROVING AUTHORITIES.
PROPOSED D-BOX: 1 INLET, 3. OUTLET (MINIMUM), H-10 RATED 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
USE 2-500 GALLON LEACHING CHAMBERS IN SERIES THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
CONSTRUCTION.
SURROUNDED BY DOUBLE WASHED STONE ON. ALL SIDES 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
TOTAL AREA:.. 471.2 S.F. INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL.
..................... ...
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD NOT CONSIDERED TO BE A PROPERTY LINE SURVEY.
Engineering by: SCALE DRAWN JOB. NO' PROPOSED SEPTIC SYSTEM UPGRADE PLAN
Engineering Works, Inc. N.T.S. P.T.M. 185-14 ,
12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. 250 CAP N CROSBY ROAD, CENTERVILLE, MA
(508) 477-5313 7/22/14 P.T.M. 2 of 2 1 Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632