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HomeMy WebLinkAbout0066 CAP'N JAC'S ROAD - Health 66 Cap'n Jac's Road,Centerville A= UPC 12534 No.2-153_L0,R HASTINGS, MN No. Fee U� THE COMMONWEALTH OF MASSACHUSETTS Entered in. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplit tion for Disposal 6pstem Construction permit . Application for a Permit to Construct( ) Repair(14up grade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. W. dA-P 1� z"/}C.S A14 6591. Owner's Name,Address,and Tel.No. Kok—mN -t cNRI S NLE—fZ_ Assessor's Map/Parcel iq4159 C.40,;P'A JI_'AC.S KI C MT0eV1c.Q1E' Installer's Name,Address,anA Tel.No. 50$—4 Z Designer's Name,Address,and Tel.No. S0'9—A73 Cbkt9416;kC4(4-c_.S7r MASf4P65 854 C "Wq Type of Building: ���; ! M rN p� /�'��r Dwelling No.of Bedrooms � 'Zot Size 1 �6(��� sq.ft. Garbagi der( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided `f""i and Plan Date (2—3-4 O t(;z Number of sheets I Revision Date Title 04, 0A VAC`S kjDAQ CLMX.1 IU1- Size of Septic Tank 100c)c i Type of S.A.S. Description of Soil Xie Na -Sers,- DCA4 Nature of Repairs or Alterations(Answer when applicable) O SC QU-(TI f.7G L,000 (2,AC bO l C__TAN� uvITLt Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date —01XI —A O L Ia Application Approved by Date 06 - Application Disapproved by Q bAl Date for the following reasons Permit No. 6 6 2 Date Issued { No. 2 2 '' Fee UU THE COMMONWEALTH OF MASSACHUSETTS Enteredin-compttter: Yes PUBLIC HEALTH DIVISION_-:TOWN OF BARNSTABLE, MASSACHUSETTS 01pptiLation for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair( /Upgrade( ) Abandon( )i ❑Complete System �dvidual Components Location Address or Lot No. Wo 'mp 1 ! Z-A s RD GENT. Owner's Name,Address,and Tel.No. KA-rtt`I -t CH R t 5 �'lirT?_ ` Assessor's Map/Parcel 19 4 /5 8 6(p CA-P rN �„$ C 7 VIL 5_� Installer's Name,Address,ang Tel.No. S02-471 -8817 Designer'sName,Address,and Tel.No. 50'9-a73 -031-7 CAGEk.XDE E ASES LLC.. .7G CNEtr��C3C„l u�E, SNG 3 C-D 9t �R�et c. ST tKAStI 85(f C laW%4 E. W 4��N(� if Type of Building: (L.,.n r cl FY 3 7 V 3 3 Dwelling No.of Bedrooms 3 til tN PEtt tTCtL Size 5,LyU-.. sq.ft. Garbage Gr der( ) Other Type of Building No.of Persons Showers( ) Cafeteria( Other Fixtures y� a ,_Design Flow(min.required) gpd Design flow provided ? c4, r gpd Plan Date -]4 _2 a �T—Number of sheets Revision Date h Title (oG CAENJAC5 DA E ;a Size of Septic Tank I.ooc7 --o&1 Type of S.A.S. C�, 500 !Fz4L 0Q c+_4y4l4 R& j Description of Soil R§iz S k lV?j 9 PL.4A Nature of Repairs or Alterations(Answer when applicable) L)_�G— C-W_(T J 1JCz 11 00O Gi U40 SC- TI G Td41�1,� New D-z ok W /;Li Soo 6►��AA H-ao t,c-`xc � GN'4� W 1 T bt 4 F&5" !)r l�G&"6g,k6 Sy i x WI06r- 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. Signe / Date Application Approved by Date�� 2 S' Application Disapproved Q Date for the following reasons Permit No. (3 r Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ����, , r�, ✓ � �P d BARNSTABLE,MASSACHUSETTS 3 7`/ d f)A, � Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by (APCLv 1 o E G j-r( p* js-4n C.C.C. at �y� 0, ?-ij _TAc rS A-b d t y has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. � b��� dated Installer CAPEwI-46 JENT�pR�S LCC Designer #bedrooms ;;k. Approved design flow ��(� gpd The issuance of this pe it shall not be construed as a guarantee that the system will mctio s design . D Date -7 a '(g Inspector --------------------------------------------------------------------------------------------------------------------------------------- No. G 6 ?)5- Fee 6 v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(k) Upgrade( ) Abandon( ) System located at K){/O CA-P tN ��S KJ) 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 mrist be cpmpleted within three years of the date of this permit. Date a °l J �_ Approved by II�1 v t 1 Town of Barnstable Regulatory Services I► BAIWBTABL6, 1 Richard V. Scali, Interim Director ' ?AAWPublic Health Division Thomas McXean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: � Sewage Permit# Ito UP a-15 Assessor's MaplParcel_ , C 9Y 1'58 Designer: __SC En, tcoeertn �;' ,nG Installer: Cae._,wt'de. t=nk�c�ris� Address: 2$5y Gc'anbecrX Vigh�_ Address: 1-�13 Commuc(a( S4(-YeA Bask warr.4►�+r►, N A a253 $ Hoskpe-e, H ft 6 2 6 y 9 On _CQQe"4,& Frrhrp septic at al-a-5 was issued a permit to install a (date) (installer) se s �nta Ca Tad-5a[t Rd � p Y !? n based on a design drawn by (address) SC t4)Alnc.e.ci0 :ril dated / (designer) V T 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. Strip out (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 certified as-built by designer to follow, Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was construe nce with the terms of the IAA approval letters (if applicable) JOHN L, CHUR ILL JR. -' ( N Insta11 ' ignature) viL A .41 �p G PL/ signer's Signat (Affix igne s St mp Here) ASERETU 7l'O BAR STABLE PUBLIC lEI]a;A H D S N. CERTIFICATE OF COMPLIaCE WILL NOT BE ISSUED UNTIL BOT11 TMS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PP MC HEALTH DIVISION. THANE YOU. QASeptickDesisner Certification Porm Rev 8-14-13.doc TOWN OF BARNSTABLE LOCATION P At S t y SEWAGE# ,�O I(®�vZ2�✓ VILLAGE (2aJraLVJ GC67 ASSESSOR'S MAPP&PARCEL Iq INSTALLER'S NAME&PHONE NO. CAP&Wl DF 6k)T&_RA_4U5C9 C�� SEPTIC TANK CAPACITY I i600 �' ,ot LEACHING FACILITY:(type)(4 5@Q - Ld#"size) (ot ,% r X o`L5 NO.OF BEDROOMS 3 fl A OWNER�7d&_-,6AJ 9 eL_i LffJA/U G�'167?— PERMIT DATE: (,p s�q " `� COMPLIANCE DATE: Separation Distance Between the: L Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility A/ Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) 'VIA Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) /vM Feet FURNISHEDBY k : 42.cz` 'Ro r AM G A-3' �1•�c P ' A•5= 11 .2` (ow p -2 o Lo �-3 =as.s y s a-y z1.0 Q-5 z 19,E &i p 34 �` Town of Barnstable . P# Departinent of Regulatory Services s muwar�►et�q a Public Health Division Date » �p �e3p� 200 Main Street,Hyannis MA 02601 -C rEo next Date Scheduled 3 V Time Fee Pd. _ 1 I" s Soil Suitability Assessment for Sew. 'ge Disposal Performed By:_ 144, ,,A.(�te Pik) -04e-1 LTXSE Witnessed By: ,:%V1 LOCATION&.GENERAL INFORMATION Location Address Owner's Name < T1 t (off OAP r N TAC!5 P!7 r f �N�tS Nrc?Z CCF rrjajZVl L(C Address 6(te CIA P IJ T4C 5 P-V C V1 LC y O AP6W(05 � s Assessor's Map/Parcel: 19C. 5� Engineer's Name:T OE fzlR C�GfI�KYru NEW CONSTRUCTION(r_� REPAIR _ Telephone# c5U73—Lt'7`j — e��5.7 50£�-273-d 3-77 Lund Use SiVl4�E _U VM;lY du_diA sto % 1—'Z � —�— Pes( ) Surface Stones Distances from: Open Water Body — ft Possible Wet-Area ft Drinking Water Well — ft Drainage Way ft Property Line _ ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) . i Parent material(geologic) 0 f W G S k Depth to Bedrock=��t I q u" 5l yy" Depth to Oroundwater. Standing Water in Hole: `�/Uy �5 Weeping from Pit Face hV Estimated Seasonal High Oroundwater `7I�1 DETERMINATION FOR SEASONALMIGH WATER TABLE Method Used: 0ir-e-A Qhter•Vra+nM Depth Observed standing in obs.hole: 7 (41�_ In, Depth to soil mottles: Depth to weeping from side of obs.hole: — In, Groundwater Adjustment Index Well-# Reading Date: — Index Well level. Adj,factor. Adj.droundwaterLevel„v PERCOLATION TEST bate,.._.,,.,., Thne. Observation Hole# 'lime at 9" Depth of Pero Time at 6" Start Pre-soak Time® 'time(9"41 End Pre-soak Per- 5a 1 1 o{ (AC,4M Sinn. I g IN Rate Min./Inch Site Suitability Assessment: Site Passed_�� Site Failed: Additional Testing Needed(Y/N) 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:ISEPTfC1PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# 1 + 2- Depth from Soil Horizon Soil Texture Sdil Color Soil. Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones;Boulders. Consistency. %'Gravel) 6 6 (a L S i©YY 3/) — - �� o (3 s +to Yr �• cfs / 1/ J-� 0 C-1 SDI+ �.bGvvt 2.0 T 4/1 - -q 6 C-Z L 5 110Yr 5/6 - • q��I�u c-3 M s 2.5 `C �16 - _ • w DEEP OBSERVATION HOLE LOG `--Hole# Depth from Soil Horizon} Soil Texture Soil Color Soil Other Surface(iu.) (USDA) (Munsell)' Mottling . (Structure,Stones,Boulders. en DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Scopes;Boulders, Consistency, layll) Flood Insurance Rate Man: Above 500 year flood boundary No— Yes Within 500 year boundary No✓+ Yes Within 100 year Flood boundary No.✓ Yes Death of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervious mtiterial exist in all areas observed throughout the area proposed for the soil absorption system? Ve S If not,what is the depth of naturally occurring pervious material? Certification I certify that on �D ?�" 9. 9 (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 training,expertise and a erience described in�10 CMR_15.017. Signature 4 Date �"Z y-/6 Q:WBPnLVERCPORM.DOC f 4 .00 No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprtcatton for Miopooal *pgtem Conquatton Vermtt Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 66 Captain Jac ' s Road Thomas .George Centerville ,Mass. 17 Thacher Shore Road Y-Port Installer's Name,Address,and Tel.No. Desi ner' Name,A dress an Tel.No. 508-775-3338 J.P.Macomber Jr.. J.Y. Iacom`�er r. Box 66 Centerville,Mass . 02632 Box 66 Centerville,Mass . 02632 Type of Building: Dwelling XXXNo.of Bedrooms? Garbage Grinder(NO) Other Type of Building RES No. of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 0 gallons per day. Calculated daily flow 3/1 1 0 gallons. Plan Date Number of sheets Revision Date Title Description of Soil Sand & Gravel Nature of Repairs or Alterations(Answer when applicable) Adding 1—1 000 gallon leaching nit to qn Pxi g .;ng tank & nit. 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 apid not to place the system in operation until a Certifi- cate of Compliance has been issueo by this oarj f lth. Signed A J Date 3/2 9/9 6 Application Approved by Application Disapproved for the following reasons Permit No. 94411'"11,_1 Date Issued ��� 40-00 No. #ON / Fee s � THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS n 0(pprication for 0igpoq;a1 *pgtem Con!5truction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 66 Captain '&ac' s Road Thomas George Centerville,Mass. 17 Thacher Shore Road Y-Port I to er' ame,Ad ress,andTel.No. F.�l� D si er' ame,A dress an Tel.No. 5Q$-775-3338 . .SMr'acom� sr--�Jr. j acom�er Jr. Box 66 Centerville,Mass. 2h32 `` Bo-x11_66*.Centerville,Mass . 02632 Type of Building: Dwelling XXXNo.of Bedrooms_ 2 Garbage Grinder(NO) Other N Type of Building RES No. of Persons 2 Showers( ) Cafeteria( ) Other Fixtures, Design Flow 3 3 0�y` '! gallons per day. Calculated daily flow 3 11 1 0 gallons. Plan Date . Number of sheets ,Revision Date Title Description of Soil Sand & Gravel Nature of Repairs or Alterations(Answer when applicable) Adding 1-1000, gallon leaching nit to an existing tank & bit Date last inspected: " f ` Agreement: The undersigned agree'sto 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 d not to place the system in operation until a Certifi- cate of Compliance has been issue by this 'oar 16f lth. Signed /v ' Date 3/29/96 Application Approved by' "` Application Disapproved for the follow g reasons Y Permit No. ! ° / Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS T , Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced�. X on 1 by J. P. Macomber Jr. for Thomas George as 66 Captain Jac t s Road Centerville,Mass* has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated ' Use of this system is conditioned on compliance with the provisions et forth below: ✓, No. Fee THE COMMONWEALTH OF MASSACHUSETTS 1 PUBLIC HEALTH DIVISION BARNSTABLE; MASSACHUSETTS igoaf *pgtem ow6truction Permit Permission is hereby granted to J.P.Macomber Jr. to construct( )re air N)i an On-site Sewage System located at 6 Captain Jac ' s Road Centervi le, ass . and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: Approvedy �r TOWN OF BARNSTABLE 1 L X-ATION (0(' CA jai- -TIP C.(CS f SEWAGE # -,q LLAOE Cek l�erL 1 ASSESSOR'S"MAP& LOT/9! ,4&" INSTALLER'S NAME&PHONE NO. T 7 VhAC&»6 e/' Seh ZTInC SEPTIC TANK CAPACITY J o 00 LEACHING FACILITY: (type) a- ���`S (size) rao a NO.OF BEDROOMS RUffOM OR OWNER PERMITDATE: m% '�'�/'"' .7�� COMPLIANCE DATE: ����"J� Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 \� \ ej / y� \ 4�3 03� 60 b CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL, WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) d I Joseph P. Macomber Jr; hereby certify that the application for disposal works construction permit signed by me dated 4/1 /96 , concerning the property located at 66 Captain Jac I s Road Centerville meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is �4 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : d _ DATE: _4/1 /96 LICE D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. I /Trt r • 38o' k1o4t5G� i� 'cl.. . .ALL Ae.ca. • LZ� S F . _. ''r a LZ2 ? a�'SF j5 � �}-�D •6oTTOAA AIZMA ! �13 5 I .I •Y! I 1 v'I�JAC(� ri �L.C�w 1 a•'� Cs1� C� J, py SATIC)W %?-A"T -- Irelu 14 I4 w o2 LFfh; ! : : : . ': : � : ; . I.7 � .l � � • ; ; ; ; I i ' -- I — III ? �� _ . .. ,: ,•, , . : _. .•� , •r�•'::•` - - _ : � . . . .. .Irk ; : ; • ' + •: '� _{;,.� . : . � .t�•0 . ' •O �LyI{a,IAM. .^� !. ( . . Q (TIIULIN... •He. 10314-• {fit 0/3T V- T F' uot.b' •� ng- c�n�r• yr;►... �• 7m ; �i.•5 ' 8d I ern =7�1 .. 4' 77.�4ILjv s u 9 II,. I s�'�P� ID15r TAU I ItJJ t K. l cr�o 1 14„6 I Iu ' u'w ' 1-A16 .._..'. _ . PIT : I WITtd� Toutos4., , PL-a I"i rl I i , ;:72o FI C-L.00A.T"CO►J ; �� ..t. 'Uj 44o SG4tls 1 --►✓{ , K 1 lY•�� i r p r Pt- r� 2cF'�.�c-�C- CloCTIF''/ ; T"AT T►4U .IC GVI.J S�IoA �J a2.Eo►r ' Com PL-Y S W I TH Tt.4E riltvGt+1"ea. " T I1 1w, evarvACIL R6gIJ1E.-M6►uT5 OF THE , !._.•iv r 7t�+� of ('Sb.?W'-) 9P LC- XWZ> IS, (�-�r-�`� �-A� 3 ` 1 ��' fVCATE3� WITW W ' TI-1e P*LootO ?LAIW. 4�IsTc Qt� L4tJD Crt,eVEypt; PLAU Ie. 'UOT 8A.5ED OIJ LU 11,14T WT O4rT�KVItC•( TN6 OsrFS4T� "S410u1D UOT- 1S6 Se.P i ►.M ,/ Ci w � � r ' Existing 1000 gallon tank. Proposed 1000 gallon leach Existing Distri g bution box. ing pit. Existing 1000 gallon leach ing pit/ � �ayz �C's �itad DATE:_"3/`j/•96 . PROPERTY ADDRESS' 66 aptain Jac ' s 'Road F���/J � � Centerville , • V Mass . 0263.2 i I On the above date, 1 Inspected the septic system at the above Address. This system consists of the following: 1 . -1 -1, 000. gallon septic tank. •2. 1 -Distribution box. 3 . .1 -1000 gallon leaching pit . Based on my Ins.naction, 11 certify the following conditions: 1 . This is a ..title five septic sytem. (­ 8 coda, ) . 2. T,he .S'eptic system is in failure . 3 . Water -is over outlet invert of th, distribution bq : 4. Water is over. th(5 invert . pip.e entering the .lqachp . 5 . •Syystem mu`ls.� bey upgraded. . 51GNATUR!7-: ` Name: J_P_M_acomber Jr_.� _�____ Company:J.P.Macon)ber- & Son•_Iac . Address:_Z4;,x—b6------= ------ Cent_erville .Mass__0.2.632 ' ` Phone'---S48 77.S_333a------- . i qR .. ��9 , 6' t, THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. 'ranks-Cess pool&-LeachfIa]ds Pumped & Inst:Iled Hangm Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 77.5.3338 775-b412 Commonweafth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WUIIun F.Weld Trudy Coxe GOAMor B-Mtwy A��r Paul Celluoal a David B.Struhs • C4mm4s{or»r • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 66 Captain Jac ' s Road Centerville Address of Owner. Date of Inspeotion:2/2 8/9 6 (If different) Name of Inapector.Joseph P. Macomber Jr, Company Name,Address and Telephone Number. J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 508-175-3338 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority �Faila Inspector's signature: 6 J ��ty�' 1 /� Date: x-;W —l� The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional ofMce of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: . A] SYSTEM PASSES: .__Ald I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,..{o,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain-why not) A The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street 9 Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-SM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) PropertyAddrem 66 Captain Jac ' s Road Centerville ,Mass . Owner. Thomas George Date of Inspeotlon: 2/2 8 9 6 B)SYSTEM CONDITIONALLY PASSES (continued) s N� Sewage backup or breakout or hA static water level observed in the distribution boot is due to broken or obstructed pipe(s) or due to a broken,settlad or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed distribution box is levelled or replaced A9 The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(g)are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _/0 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: &•A Cesspool or privy is within 60 feet of a surface water a 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Q� The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. a$ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. AM The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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 6 ppm. 9) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 66 Captain Jac ' s Road Centerville ,Mass . Owner. Thomas George Date of Inspection:2/2 g/9 6 D) SYSTEM FAILS: • I have determined that the system violates one or more of the following failure criteria as defined in 310 CMft 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. AD 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 U2 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. ,wARr Q� Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 7- Any portion of a or privy is within a Zone I of a public well. le.3cto Any portion of a or privy is within 50 feet of a private water supply well. �c.b dr 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. If the well has been analysed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: PThe system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 49 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 dLI' 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddr w 66 Captain Jaci ' s Road Centerville ,Mass . Owner. Thomas George • Date of Inspection: 2/2 8/9 6 • Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. ,None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ,ZAs built plans have been obtained and examined. Note if they are not available with N/A The facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow ZThe site was inspected for signs of breakout. ZAll system components,itcluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. , The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. , The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM P?SRT C SYSTEM INFORMATION Property Address: 66 Captain Jac Road Centerville ,Mass . Owner. Thomas George Date of Inspeotion:2/2 8/9 6. e FLOW CONDITIONS RESIDENTIAL- Design s flow-. as X4441 s Number of bedrooms: Number of current residents:62 . Garbage grinder(yes or no):iUb - Laundry connected to system(yes or no): Seasonal use(yes or no):/� Water meter readings,if available' iIV 7. )! Last date of occupancy:) E COMMERCIAL NDUSTRIAL: Type of establishment: AA Design 1low:-12fl—gaIlons/day Grease trap present: (yes or no)1± Industrial Waste Holding Tank present: (yes or no)ALIQ Non-sanitary waste discharged to the Title 5 system: (yes or no)16y) Water meter readings,if available: 117� Last date of occupancy:_ OTHER:(Describe) 11j Last date of oocupancy: GENERAL INFORMATION PUMPING RIPCORDS d sQ f informa�ipn: /� 6 System pumped as part of inspection:(yes or no) S If yes,volume pumped:of 920 gallons 4 a ReWn for um ing� s °' L �� L° '7" D ��S/�7 � D� IW�� x �7?,- Q 7'4'0C11 V j W 1 VX,4-!5 4 A,' i(V44--^ r TYPE 0 SYSTEM Septic tank/distribution box/soil absorption system kO Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPRO)aXATE AGE of all components,date ' ed(if known) and source of information: 102 Sewage odors detected when arriving at the site: (yes or no)a (revised 11/03/95) 5 or BoTToM A¢cA-! :113 5>r ` 11 ' _ � i 3. x o; �%5F t � 'I ' . • ; � ; ; � trytip , t _ I � E>�Got_.dT l o►-t �dTL' I I N h4tJ oQ'0LI:. , '_ ��.� q..;�,•,��....,,«•.,��.•...,*..� D71VI17' ti , , ram:•=%- Y • i 29976.* Na. 403 �d i9tE Cwv 'T"tzsT _ . :_: : i -_ ::. . ...;_• I I . . �^ l l�l�Z =11 ToP Fuv 1�1►5 0 r S4 u r r c ��l.. s �� yr:,•.� 'yip. 4 Iwv • �jL r PG ,uu 4aL. lNV•0 ��, �,L SuA IL: . , • I �15L old jjkV C &AL. LAIle N FIT .. I , t � • : ; : ; �tz o F I l_.E- �/� � l•.�aG A.T 10 f,.1 ; (,-(� �1/�, t ' uo sGA c L6,' - .' D aT'�- '•4•Z u - , C GLCrI Fes( : T"AT T►•+E �C •I=G V t�A S�t�v� sa2_Eot4 - e_0mp Y'S A W D `5i aTT'V A G K. R IJ I t2�M�u-�- OF T W E. of C3p, St7p.( .e ANC is ?l� Lv(::.o,TEz) wlTui IJ T►-1E P-LAoo PLAIW. jC.14 V I EF >z�Isr� czc� ��.,e ,vev�oec TNIS ?LAW Vr '$ASED OLI AU 1047 E."T OerTEi-RV1I fir- AAko �. SUevr•/ TWr- OFFS¢T;: •5WC,ULv LICIT ks6 SeA APPLIC.AW ^/` t5% To �.o T LI W 154. PERMIT AGE ; :. 17 dj LO CA.T I0y Y I l LA G E ...�e C, KA E i ADDRESS 1NST A ILER'S �J5 i ao —R OR OWNER LDE DATE PERMIT ISSUED ISSUED DATE C O M P L I A N t� �01 SUBSURFACE SEWAGE DI9"c `.1, SYSTEM INSPECTION FORM SYSTEM INFO,.:,:,MON (continued) P,rop.rty,ddr.a: 66 Captain Jac Is Road Centerville ,Mass . Owner. Thomas George Date of Inspection:2/2 8 9 6 SEPTIC TV :Ll04a9'91j.ost3 /A. C' e• . (locate on site plan) Depth below grade: ld Material of construction:Zncrete_metal_FRP_other(e:;, .. ) Dimensions. '� xw 7 lc/_W , . Sludge depth.- Distance from top of sludge to bottom of outlet tee or baffle:s� Scum thickness:f_ Distance from tap of scum to top of outlet tee or balne:, Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or bRT' e, depth of liquid level in relation to outlet invert,structural integrity, evidence ofleakage,etc.)• Pump septic tank annually,Inlet & outlet tees are in place , Septic tank is structurally sound^No .repairs are needed at this time. GREASE TRAP:y1tff (locate on site plan) Depth below grade: A Material of construction:ILA ncrete_metal_FRP_other(espini„) AN Dimensions: Scum thic]mess: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:" Comments: (recommendation for pump,condition of inlet and outlet tees or baPles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.)_A. j CAMM&-V-`S (revised 11/03/95) 6 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 66 Captain Jac ' s Road Owner. Thomas George Date of Inspection: 2 2 g 9 6 TIGHT OR HOLDING TANI{:&)Q • (locate on site platy • ., a;c Depth below grade: other(�p> ) Material of cos t:ua =i 4)flooncreu m A etal RP_ Dimensions: AM Cale malons Design flow: no/day Alarm level: Comments: - (condition of inlet tee;condition of alarm and float switches,etc.) ih nev7" U DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above cutlet invert I Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into solids f box, carry t ) over,.no istribution e o repairs are needed at this time . I PUMP CHAMBER;A&e_' (locate on site plan) Pumps in working order:(yes or no)_4Zd . i Comments: (note con of pump chamber,condition of pumps and appurtenances,etc.) I ! (revised.11/03/95) i r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i,.._ SYST�.. ... .......:JN (continued) P:opertyAddress: . 66 Captain Jac ' s Road Centerville ,Mass . Ownen Thomas George Date of Inspections 2/2 8/9 6 SOIL ABSORPTION SYSTEM(SA9h�l8o0 e (locate on site plan,if poss ;excavation not required,but may be arpr=imatad by non-intrusive methods) If not determined to be present,explain: Type • leaching pits,number: umberkullIn galleries, leaching trenches,number,length: leaching fields,number, ions_��-- overflow cesspool,number Comments:(note condition of soil,signs of hydraulic failur-, ��,; ! c'M�? ��, condition of vegetation,etc.) Cam;►{.,Cat s9c1171nnnS Sin n�2�o . gn s...__Qf_-H. All vegetation i orma . Pit is fille to capacity and has wa ers an ing in collars of 777777hing Lit. The leaching nit h s failed . System has to be�Yupgraded: CESSPOOLS:LfQN� .. (locate on site plan) I Number and configuration: N0 Depth-top of liquid to inlet invert' OR Depth of solids layer. n1A Depth of scum layer. ASA i Dimensions of cesspool: IUA Materials of construction: ni ja Indication of groundwater. • inflow(cesspool must be pumped as part of iva condition of etc. � Commenb•���noottee condition of soil,signs of hydraulic tailt�re, �,,.�..! ,.r� -'�^^ vegetation, ) PRIVY: (locate on site plan) , Materials of oonstructioa i1J/1 _ _ ——-- Dimensions. i11r9 Depth of solids: 4,-W . Comments:(note condition of soil,signs of bydraulic failu:.,; :cn of vegetation,etc.) W* In�v ss7F�.�rJ7"�i I ' (revised 11/03M)� e i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: e SKETCH OF SEWAGE DISPOSAL SYSTEM: inch"I ties to at least two permanent references landmarks or benchmarks locate all wells within 100- DEPTH To GROUNDWATER Depth to groundwater.�feet method of determination or approximatio 7 Z \ `7 ljo -IV (revised 11/03/95) 9 . --r..r...r.r.:•:r.-•.r�r:m•-.—r.er.—zr^•rc.:.-.: ._ . .. .._ .._. .. .. .-. _... .ar--r..�-.r�.rn-r-:r-r..r. .r.:-.... M:r.-rnr•se-rt•rr--rr-zrjr:.-.r.•r.rrr._ . 1• TOWN OF a rn s t.a hla BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CF,RTIFICATION •-r.ssn••.-:-nr.r-n•r.:pas—srr..-esr.rr•--rs'r-•sr:.--e::esr-r-t--snr*r*r rr._•�r..r-sz n�nn•rmr�rrzse�Trrrtrr�r.•..:rrr•r.•-s••-..� -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 66 Captain Jac ' s Centerville ,Mass . 02632 ASSESSORS MAP , BLOCK AND ARCEL # OWNER' s NAME Thomas George PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME J.P.Macomber & Son Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( ) - - 1^1R 7 FAX ( [ p �'7(� C�'7Q ���^�a�-..tee J 0 O ! 7 0 � J /v m CERTIFICATION STATEMENT I certify that I have personally inspected the sewage dispostj system at this address and that the inforination reported is true , accurate , and complete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . XXXXXXXXSystem FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance - with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date311I96 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF 1IErAL7'1I. * If the inspection FAILED, the owner or"" Aerator shall upgrade ' the eyotem within one gear of the date of the inspection , unless allowed or required nfhrarvian na nrnvi rip el in 'iln ( LIn _I5 . ,IOr C V 1 THE COMMONWEALTHOF MASS.ACHUSETTS DEPARTM ENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. .e Has satisfied the. Department's qualifications . as required and.is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided i a 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June S. 1995 T Acting Director of the ' ion of Water Pollution Control i < API FOR PERCOLATION TEST AND OBSERVATs . n LOCATION o t GtI1` Ou� + NO. � 7 ' �� VILLAGE �n p Lj t ��e_ _ DATE APPLICANT �Z5 aft)e/o FEE _ (Non-refundable) ADDRESS 13 Aq o n i s TELEPHONE NO:-j 144 1 1 ,° ENGINEER GU( K^ }. �j Wc_.- _TELEPHONE NO. 13 DATE SCHEDULED cA X4 _ f (Applicant' s signature ) • • • • • • o 0 0 0 0 0 0 • o • o 0 0 0 0 • e • • • • • e e o • o o • • • • • • • o • • • • • e • • • • • • o • • • • • • • • e • o • o • • • e • • o • • • • • • SOIL LOG SUB-DIVISION NAME tLZ-/, DATE- - 4 TIME EXPANSION AREA: YES ✓NO� s ^(- hl J otier, I gJ ENGINEER TOWN WATER '�'PRIVATE WELL J (,- v0 e. I BOARD OF HEALTH �I t3rmtt.1 a EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes ) NOTES: 1 PERCOLATION RATE: "tQ -� I U� 012. rj TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 2 2 3 _ 3 4 4 __-- 5 D/-/ 5 6 6 - r4 ✓- — 8 9 10 � � 10 ------- 11 11 12 12 13 13 14 14 15 15 16 16 Q S7a�Jr3 A A A FIELD _L A NG PITS STcS'tM S !aJ SUITABLE FOR SUB—SURFACE SEWAGE: LEACHING FIE _ E I LEACHING TRENCHES �pv�-- AvZ3 UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: wy ,NOTE : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P . E . AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT y .. NoTL ._.. Fps..5... .:.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i C7..W .N...--....OF.....�.U�'.11..-s...T.��� .`�.--............... Apli iration for DiipnsFai larks Tonstrnr#inn thrum# Application is hereby made for a Permit to Construct (%,­ror Repair ( ) an Individual Sewage Disposal System at d �-. k ._7 - Location Address Lot No.................................................... VerJ............ er A--------------------------------- --- Installer Address � � Type of Building Size Lot.. 5®�..a........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ({�� aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures -------------------------------- - W Design Flow........... .....................gallons per person per day. Total daily flow------------- ................gallons. WSeptic Tank—Liquid*capacityV Ogallons 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 ( ) Dosing tank ( t p Percolation Test Results Performed by..... — .......... Date ._-. :5 !1 aTest Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water-.-._-_-_____-___-_-_--. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ....................................................... ---............. -----------....---.-.............................................................. O Description of Soil....�-�=--•--JA C��'YN- ' �]b-.S..%��------------------- x -------------------------- . .... 1 � .. .cam-- ----------------------- �W-?-�---------------�-- ------.....------------------------------ - - ----------- UW --•-------•--------- ------------------------•-----------•. ----------------------------•-......------.V.......................................................................................... 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 TITIL- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igned---- ....... ---------• ApplicationAPPr e ---•..............=------------------------------------------------------------------- Date Application Disapproved t e following reasons:............................................................................................................. -----•---...--•------------------------------•--------------....---......--------............------....-- Date PermitNo......................................................... Issued....................................................... Date 3 1..� Fo p.................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....OF...... Glr n.. . fc�.... .. 9. -,-: Appliratiun for Disposal Works Tonstrurtion tirrutif Application is hereby made for a Permit to Construct Ce or Repair ( ) an Individual Sewage Disposal System at: . ..._ .�J.�. ..... �. �e. ...............•... ............................... ......................................... Lot No. Location-Address .. s...._...... :..... rn..�_._.... . -- fi•n s ��.1_...... .............. .._. .�- ner dress Installer Address Type of Building Size Lot_..... �_°......Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (p Garbage Grinder ((� aOther—Type of Building ............................ No. of persons................_........... Showers ( ) — Cafeteria ( ) Otherfixtures ------•------------•-----------••--••---•••••••-•---•-............................................................................................... . W Design Flow.......... .......'......................gallons per person per day. Total daily flow........... -3____�---�.--._......._....gallons. WSeptic Tank—Liquid capacity���-O.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 ( ) Dosin tank ( ) ~' Percolation Test Results Performed by._. _� _. '..._.... .__ !.._...._.... Date .-a. _~__44............... �7 Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••--'•--•--------------------------••--•-'-•••-�••--- ...•�•'• ...----- D Description of Soil...'. ... U v C:IM..:n.... �.2 ?.`+.* ? a_..... rW V ...................................:) .:...V' ......_._n rim. ....... `' w 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed--- �Y Application APP ........................... Date Application Disapproved r e following reasons:.......................................................... .......................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........�. .�........... 0.r� s C. .p l _ O F............. ................................. ? 1..4- -............... Tntifiratr of TompliFana `T�V IS IS TO CERTIF That the Individual Sewage Disposal System constructed (4<or Repaired ( ) by..... ............ :�--......"......'----------- ------•---------------------•-'-------•----•-'-'---------•---•. (� k Installer . N. -- .................................... ...gin has been installed in accordance with the provisions of )IT "F 5 o The State Sanitary Co e- ribed in the application for Disposal Works Construction Permit No.. _. .... date .......................... THE ISSUA CE F THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE SYSTEM V//IIIL U TION SATISFACTORY. DATE._...f�-•�� --••-•-----•--•------------------------------- Inspector....-- •. •......_..........................................................•.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,. ........ .............O F..........�..1 C_ f 1:l(lr0 �-r��^-�- NIP....................... FER( ................. Disposal Works Tontr ion rrntit Permission is hereby granted....__... Ap n __. . . ._.._.- .............. to Construct el_<Or�Repair ( ) an Individual Se 'age Disposal Syst at No. �" ... ;? .. Street. �.`...•-•-_...._'�--• -+` �•-l....\.f :::.. as shown on the application for Disposal Works Construction Permit No..-.,,.,' .__ ._ ated.......................................... ......................... • ....................................... -------- � _ / S Board of Health DATE---�--='----------------------t�-=............................................... FORM 1255 A. M. SULKIN, INC., BOSTON 4p�ntit DA L ,4 F`L o•�/ 1 t o .c 3 = $ O 6.P.1� SRG T��.t�C'a 330 k,15�'/0•� 4ri V � �. i .� 'LZ`i?C � �� .�fsF._.� i ��5�:•��•. i� .. '� 1 , x. ''I' 1 ''BOT'ToAA gtZCA ! a l 3 'S F i h _ •[�IR.t? : . : i i ' N 1 06 pf p t...dT 10 61•• Q4TC-.' l"I u htw 02(.FfJrs. - '-�• �-J,, M_ .�., .;. '- ..: .'1-. ...`,.,: •, ,. , , "Eat j - � , I � � , �,� � .. . i `S . ,.•� ... , ; a•a• 1 ;.•. .°`�P�'t11�►.�4lgs I_.I i.� I' I �- I '�---•-- �_ .,.I Ctp c� aVo 199Z'6 c r I N.Y .No. 19394- ' �C1STEP�O�• •rat . .." A cI •1 i.i. ,.I i . , ,.i .,.y >��•,,�:... _ ,hp r,0 L rr.�4 •'y,Pe �:, 11� rL, su1! I� �'wc ID15r �uu .'4AILL. i T , •, ,• ;11V. �� �.IK. �r;. 2.• . �` .: bay. 114 .'_:•'.. «►� �. t'FV 06-40 A • w/, I I I I :rr,'C Ir�C.T l{=t �.D DI._oT pL A t+J 4• ZUIra i . � i p�o.I�1 QCF-"E�..�c-_►.Icy . I C¢KTt�Y , T"AT T GL vC .�,Vup 5�-tower t-4B2E.o►-1 ' CAMPS-`(I WtTH TU G- A WD yar-VAGK R64J1¢�.M6�►-1TS OF -rWr-- � 1` . �Uw�.J of C3D,`,Z1.)Sr �e Ati1D ' 76 is t-x'��T K A1..) ' µ , . i Loc.4-rEx:�. <,vev -%foet Tu15 P�� I-er -WOT IWED OLA Xu IQ4T ZT O�TE Vtu.� MATNr► OFFSf4'T; -5WC>ULD LIOT 16S S0 AppLIGAu" ' To 'DaTe �►.JE, _ a •tOC 'AT 10 llilll//'�� ZAGE PERAAIT , NO. VILLAGE O 431NSTA LLER'S NA E i ADDRESS _ �I B U I L D E R ON OWNER DATE PERMIT ISSUED o N ,_U DAT E COMPLIANCE ISSUED �o �- D l 3 � o i 4 _T PROPOSED VENT WITH CHARCOAL PROVIDE EXTENSION RISER T.O.F. EL.= 120.3�± INISH GRADE OVER D-BOX= 119.6�± FINISH GRADE OVER CHAMBERS = 1 10,60' - 120.50' FILTER TO ABOVE GRADE GENERAL NOTES � SLOPE @ 2°!o MIN. OVER SYSTEM WITH COVER OVER INLET& REMOVABLE WATER-TIGHT COVER OVER 3/4"TO 1-1/2" DOUBLE WASHED STONE TO 1. UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE OUTLET TO WITHIN 6"OF F.G. 4"SCHEDULE 40 PVC MIN SLOPE 1% RISER TO WITHIN 6"OF FINISHED GRADE ACCESS BOX WITH COVER TO GRADE CROWN OF PIPE @ FND. EL.= 119.2'± F.G. OVER TANK EL. =119.4'-�2Q,Q'± (SEE NOTE#21) METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL -5"DIA. OUTLET(S) 2" OF 1/8"TO 1/2" DOUBLE WASHED STONE CODE AND ANY APPLICABLE LOCAL RULES, PLACE RISERS ON ALL 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE I TOP OF SAS = 1 16.50' CHAMBERS WITH DESIGN ENGINEER. PROPOSED 4" 9"MIN. 4.00'MAX OF 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL PVC SEWER PIPE 36"MAX. 115.50' SEE NOTE 23 BREAKOUT EL = ' INLET TO ` 3" DROP MAX I 116.00 SYSTEM UNLESS OTHERWISE NOTED. 6" 3" 2" DROP MIN 3" 9" L = 16't PROVIDE WATERTIGHT ! � 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN M'" SLOPE, JOINTS (TYP.) o ELEVATION = 116.00' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A 13'" } 4" PVC IN FROM O L_� �� (� J I 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF f 1 �-1 r--1 I--� t-J �`eo ��----;; 0 14" SEPTIC TANK 4"PVC OUT TO I__1 Lu_1 �� 0 o L� O u t--I THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. CONTRACTOR TO PROVIDE O LEACHING FACILITY oo oo oo 0 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. SPECIFIED DROP BETWEEN o 0 0 O THIS SYSTEM ° INLET AND OUTLET CONTRACTOR CONTRACTOR SHALL OUTLET TEE 115.90' MIN. 6 115.73' 2 00 6. S EM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. SHALL VERIFY SIZE 48" VERIFY CONDITION OF �\ 00 0 o 0 AND CONDITION OF EXISTING TEES GAS BAFFLE o 0 00 � 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR T 6"CRUSHED STONE I l 0 0 o i O BACK EXISTING SEPTIC AND REPLACE AS OVER MECHANICALLY o� !-1 0 0 0 , 0 p i i FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION.SYSTEM IS TANK NECESSARY NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH COMPACTED BASE I - 5 OUTLET DISTRIBUTION BOX 4 0 8.5 (TYP) ( 4.0' 4 0 4 0 AND DESIGN ENGINEER. 4.83' 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 118.10' TO BE INSTALLED ON A LEVEL STABLE 25.0' (TYP.) BASE. FIRST TWO FEET OF OUTLET < 107.60' ESTABLISHED ON THE CORNER OF A CATCH BASIN AS SHOWN ON PLAN. EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK PIPES To BE LAID LEVEL. 113.50' GROUND WATER ELEV.= 2 83' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION 2 - 500 GALLON H-20 CHAMBERS THROUGH DIG SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT .` e v i.. V i I_ti it CROSS SECTION VIEW 5'MIN. "` " """'i'` 1 -888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES `CONTRACTOR TO VERIFY EXISTING ELEVATION PRIOR SEPTIC TANK PROFILE F`)l � C�IRI ITIONI R(`))( DETi TYPICAL CHAMBER PROFILE L1 -20 CPA �11171�-0 DETAILS TO THE DESIGN ENGINEER, TO ANY WORK& NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE I NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. �- TEST PIT DATI`'1_ 11 REGULATIONS.TOWNER/APPLICANT ION HAS BEEN EI TO OBTA AS TO IN SUCH DLIANCE ETERMINATION NATION FROM TH DEEDED OR NING ,° •' PERC NO_ 'S059 APPROPRIATE AUTHORITY. Benchmark R a tg rl 1 1` >�`' INSPECTOR: David W. Stanton, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED Tower's Comer C.B. � ,;� :�; �` #� � =�% 6 Comer = 118.10' UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT, DRIVES, OR Elev. EVALUATOR: Michael Pimentel, E.I.T. TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING. Approx. M.S.L. ,i q eta • ',�: > >.: �'- ; C.S.E. APPROVAL DATE: Oct. 1999 13, DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. DATE: May 31, 2016 \ H�tU i i f f TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. �,.. l -' ELEV TOP= 119.60' 200 a. _ �.'' -. ; REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, ELEV WATER= < 107.60' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). OP �� 4 �� PERC RATE _ `4 min./inch 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN �� (� � - ���►� - - fir�'I SITE CONDITIONS FROM THOSE SHOWN PRIOR T .N G�OV / / - �I an'k O CONTINUATION OF WORK. DEPTH OF PERC= GPP O,��V� LOCUS dio / r u -- 16. PROPOSED PROJECT IS LOCATED WITHIN: �y �• �- %� / -T TEXTURAL CLASS: 1 ASSESSOR'S MAP 194 PARCEL 58 m co OWNER OF RECORD: KATHLEEN M. AND CHRISTIAN A. METZ ADDRESS: 66 CAP'N JAC'S ROAD A Loamy Sand 10Yr 3/1 CENTERVILLE,MA 02632 PROPOSED INSPECTION PORT p _ 6" 119.10 �pGE a` ` �� �y •�,r,-`pUbliC B Loamy Sand - "E Xi e aivv ii_r1l�i ,ii�ti f t L.P. � -` � -, _. ,A • .l i � Landing 10Yr5/6 PROPOSED 2 500 GALLON .E TO BE PUMPED AND t� " �rsr/ C FEMA FLOOD ZONE X 0�� >< REMOVED ,YP. OF 2 �� �� . �- ' 30" 117.10' H-20 LEACHING CHAMBERS / 660 3� s� _ - -�r *_ ='�` •� ��' COMMUNITY PANEL# 25001CO561J WITH AGGREGATE N '' r� ( 17. DEED REFERENCE: BOOK 17531, PAGE 118 C 1 Silt Loam REMOVE ALL UNSUITABLE MATERIAL 119' 2 5Y 7/1 • ,/ - y 18. PLAN REFERENCE: P.B. 379, PG. 70 DOWN TO TOP OF C 3 SOIL& REPLACE wl / CLEAN COARSE SAND PER 310 CMR 255(3) �" ''�'__;`• •-/ ' �+^� 78 113 10 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. `'•' P Loam Sand 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY Y 7" bra' 0„ \ ��Z ( _" (7/t;` ` " ` j,� }ram �-` C 2 10Yr 5/6 FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY 4_. FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. �. MAP 194 �f, .i,, •1� t .\1 21. A 4"PERFORATED SCH.40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A EX. DISTRIBUTION BOX TO 2� PARCEL 57 DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3"OF FINISH GRADE. A o PE REMOVED �,,� REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS. '-o C-3 Med. Sand LOCUS PLAN 2.5Y 6/6 22. OWNER/APPLICANT/CONTRACTOR SHALL BE RESPONSIBLE TO OBTAIN ANY AND ALL • U.P.#1573/5 ; 119�c6 `� � � � -EX. TANK T�? PF !T!� !? ►� j REQUIRED PERMITS AND APPROVALS FOR THIS PROJECT. 1 = 23.ro IN THIN � .�/� -` `-�� (2) TP 2 , SCALE: 1" = 1000' 144" 23. IN ACCORDANCE WITH 310 CMR 15.401 - 15.405,THE FOLLOWING LOCAL UPGRADE 107.60 APPROVAL IS REQUESTED FROM 310 CMR 15.221 7 : No Mottling, Weeping or Standing Observed j (1.) A 1.00'WAIVER (3.00' 4.00') FOR THE MAXIMUM COVER OVER THE LEACHING SYSTEM. 120x6' -- �-,y�� DS'+• Nfi� /t� ` PER SOIL LOG DATED JAN. 25, 1984 ,� \ o (PERC No. P2994) LEGEND EXISTING SPOT GRADE NUMBER OF BEDROOMS (DESIGN) 3 (MIN PER TITLE 5) EST PIT DATA EXISTING CONTOUR PROPOSED 4' PVC VENT PIPE, i` - �`ti 1 EXACT LOCATION PER OWNER PROPOSED f DESIGN FLOW 110 GAUDAY/BEDROOM PERC NO. 15059 50 PROPOSED SPOT GRADE DISTRIBUTION BOX \ GARAGE TOTAL DESIGN FLOW 330 GALIDAY INSPECTOR: David W. Stanton, R.S. �, o= PROPOSED CONTOUR EVALUATOR: Michael Pimentel, E.I.T. DESIGN FLOW X 200 % = 660 GAL/DAY \ HC 1 C.S.E. APPROVAL DATE: Oct. 1999 EXISTING OVERHEAD UTILITIES ©� \ USE EXISTING 1,000 GALLON SEPTIC TANK DATE: May 31, 2016 EXISTING GAS LINE f \ V TEST PIT#: 2 EXISTING WATER LINE EXISTING / ELEV TOP = 120.60' 2-BEDROOM � -.� - -119 DWELLING ELEV WATER= < 107.60' 0� TEST PIT LOCATION \o TOF= 120.3t INSTALL 2 - 500 GALLON H-20 CHAMBERS C` (BASEMENT) w/ AGGREGATE PERC RATE = EXISTING 1,000 GALLON SEPTIC TANK SIDEWALL CAPACITY DEPTH OF PERC= -•-•-- .- PROPOSED 4" SOLID SCHEDULE 40 PVC PIPE (LENGTH + WIDTH) (2 SIDES) (2' HIGH) (0.74 GPD/S.F.) = GAL/DAY TEXTURAL CLASS: 1 , (25.0' + 12.83') (2 ) ( 2' ) ( 0.74 GPD/S.F.) = 112.0 GAUDAY 13 PROPOSED H 10 DISTRIBUTION BOX MAP 194 MAP 194 PARCEL 58 PARCEL 59 BOTTOM CAPACITY 0" 120.60' PROPOSED 500 GALLON H 20 LEACHING CHAMBER 15,000 SF t (LENGTH x WIDTH) (0,74 GPD/S.F.) = GAUDAY A Loamy Sand 10Yr 3/1 6" 120.10' (25.0' x 12.83') (0.74 GPD/S.F.) = 237.4 GAUDAY Loamy Sand - N B 10Yr 5/6 1 6 29-16 BJW JLC Modified SAS dimensions from 3.55'to 4.0'in profile TOTALS: 30" 118.10' REV- DATE BY APP'D. DESCRIPTION PROPOSED SEPTIC SYSTEM UPGRADE -'- � p �, ,� TOTAL NUMBER OF CHAMBERS 2 Silt Loam � �O �O C-1 PREPARED FOR: �G( y,�Q. TOTAL LEACHING AREA 472.2 SQ.FT. 2.5Y 7/1 GQO�O�yp� TOTAL LEACHING CAPACITY 349.4 GAL./DAY CAPEWIDE ENTERPRISES 78" 114.10' C Loamy Sand LOCATED AT 2 10Yr 5/6 96" - 112.60' 66 CAP'N JAC'S ROAD SWING-TIES CENTERVILLE, MA 02632 NOTES: i Med. Sand SCALE: 1 INCH = 10 FT. DATE: JUNE 24, 2016 DESCRIPTION HC 1 HC-2 1 C-3 2.5Y 6/6r � 0 5 10 20 40 FEET 1.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF THE FA CORNER OF STONE (1) 26.0' 82.1' C- �� PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST PIT DATA s° :rOHNL PREPARED BY: SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL BOARD OF HEALTH IF CORNER OF STONE (2) 38.0' 86.9' I RESERVED FOR BOARD OF HEALTH USE �' CHILL JC ENGINEERING, INC. SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. 144" 108.60' C1V►t CORNER OF STONE (3) 38.8' 65.6' No Mottling, Weeping or Standing Observed 2854 CRANBERRY HIGHWAY t i EAST WAREHAM, MA 02538 2.) A PORTION OF THE PROPERTY IS LOCATED WITHIN THE GROUNDWATER SITE PLAN CORNER OF STONE (4) 27.2' S8.9' ! _ PROTECTION OVERLAY DISTRICT(SEE PLAN ABOVE). n I 508.273.0377 SCALE: 1"= 10' Drawn By: BJW Designed By BJW Checked By: JLC JOB No.3508