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HomeMy WebLinkAbout0195 CAP'N LIJAH'S ROAD - Health 195 Cap'n Lijah's Road Centerville P A = 193 087 No. 4210 1/3 ORA Pendaflex' 10% � 1C� too- 4T) ✓vl } •���:�� 1 � �� � ice, '�, , i � 3 Commonwealth of Massachusetts Title 5 Official Inspection Form 10-® 87 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owners Name information is required for every 306 Capn Lijahs Road Centerville MA 02632 June 2, 2011 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information on the computer, (� use only the tab 1. Inspector: key to move your cursor-do not Troy Williams lX use the return key. Name of Inspector Troy Williams Septic Inspections ap Company Name 19 Hummel Drive Company Address South Dennis MA 02660 Cityrrown State Zip Code (508)385- 1300 S1682 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this addre s' nd'that u information reported below is true, accurate and complete as of the time of the inspection. Thip�spergon was performed based on my training and experience in the proper function and maintenance 69on site sewage disposal systems. I am a DEP approved system inspector pursuant to�Stction 15.340 0 Title 5(310 CMR 15.000).The system: -'j ® Passes ❑ Conditional) Passes y ❑ Fails' 7-11 ElNeeds Further Evaluation by the Local Approving Authority �0 r �.s &eA�' June 2, 2011 Inspectors Signatur6 Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board 4 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. l t5ins•11/10 Lo Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste •Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is required for every 306 Capn Lijahs Road, Centerville MA 02632 June 2, 2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. 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): N/A t5ins•11/10 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 ye 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is required for every 306 Capn Li1 ahs Road, Centerville MA 02632 June 2, 2011 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 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): N/A ❑ 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): N/A 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is required for every 306 Capn Lijahs Road, Centerville MA 02632 June 2, 2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is required for every 306 Capn Lijahs Road, Centerville MA 02632 June 2, 2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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•11/10 Title 5 Official Inspection Forth: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 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is required for every 1 Lin 306 Ca1� ahs Road, Centerville MA 02632 June 2, 2011 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-11/10 Title 5 Official Ins pection 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 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is 1 required for every 306 Capn Li ahs Road, Centerville MA 02632 June 2, 2011 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 10=49,000 gals. g ( y g (gpd))' 09=48,000 gals. Detail Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/AGallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "( 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is required for every 306 Capn Lijahs Road, Centerville MA 02632 June 2, 2011 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): General Information Pumping Records: Source of information: Last pumped on 5/24/05 per info from BOH. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of.the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Forth: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 °< 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is required for every 306 CapriLijahs Road Centerville MA 02632 June 2, 2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank is original from 4/21/76. D-box and leaching were installed on 5/25/05 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): ' Depth below grade: 1 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: 5'X9'X6' 1000 gallon Sludge depth: 4" t5ins•11/10 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Capn Lijahs Road, Centerville l — Property Address Alan Hidenfelter Owner Owner's Name formation is every 306 Capn Li ah required for eve 1 s Road,- Centerville MA 02632 June 2, 2011 page. City/Town 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 2' 811 Scum thickness Thin layer 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 14" How were dimensions determined? probe/measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete inlet baffle and outlet tee were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °< 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner owners Name information is 306 Capn Lijahs Road Centerville MA 02632 June 2 2011 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: N/A gallons Design Flow: N/A 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.): N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "f 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is 306 Capn Lijahs Road Centerville MA 02632 June 2 2011 required for every � , page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level 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.): D-box was found level and in working order with equal distribution to outlet lines through speed levelers. No evidence of solid carry-over or backup in the past were found at the 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.): N/A Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 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 't 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is 306 Capn Lijahs Road Centerville MA 02632 June 2 2011 required for every � , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal. withstone ❑ leaching galleries number: 29'X 10'X 2' ❑ 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.): Chambers were found with a low water level. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 195 Capn Lijahs Road Centerville Property Address Alan Hidenfelter Owner Owner's Name information is required for every 306 Capn Lijahs Road Centerville MA 02632 June 2, 2011 page. Cityfrown 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.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is 306 Capn Lijahs Road Centerville MA 02632 June 2, 2011 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately o L 6 0 i �3 . �5' t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'e 195 Capn Lijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is required for every 306 Capn Lijahs Road Centerville MA 02632 June 2, 2011 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: 13.0'+ 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: 5/2/05 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: SDW 252 Zone C 46.8' 1.8'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 10.0'. Groundwater adjustment at the time of inspection was 1.8'. Bottom of leaching at 6.0'was found not to be located in the high groundwater elevation at the time of inspection. USGS maps estimate groundwater at 35 0' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ug 195 CapriLijahs Road, Centerville Property Address Alan Hidenfelter Owner Owner's Name information is 306 Capn Lijahs Road Centerville MA 02632 June 2 2011 required for every � , page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 p { j , j - t 1 Ao OR , _ ri 65 _.......t_-. � _. - _`- �L_--+ _-,..�_... _--T —•)'F i-TI-->0-- ..._.�-...�.�.--.—_r+�. .__1...._..�-....._:._�yy--.,..-4�-...-,.w:...:......ten.-__.__--_"-.-.<.-.r,.,.. +..-`-"'---...+-.� i , , 111 t r j i i �1V elo4 rjr !! r LY Doi If f f - -- t III , E IN Alm- 45 ——----+ - -r - t No. ' I/l FeeL THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migogal Opgtem Con5truction Permit Application for a Permit to Construct( . )Repair(><)Upgrade( )Abandon( ) ❑Complete System >4ndividual Components Location Address or Lot No. Oct 6 CAP I N L aAWS—v?<& Owner's Name,Address and Tel.No. ►1�e lit GP-M\d Lof�2c—ne,n Assessor's Map/Parcel 1q3 �P►QC6L O$ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Co�46- 5310 3�- Type of Building: Dwelling No.of Bedrooms Lot Size 15 ja00 sq.ft. Garbage Grinder(� Other Type of Building 1 No.of Persons o2 Showers( ) Cafeteria( ) Other Fixtures L A u t-Ta V_Y , 1c1-T-"CA Sl ni k , LAOC4 CQ9 Design Flow 3 gallons per day. Calculated daily flow -gallons. Plan Date S I'D4 o5 Number of sheets A Revision Date Title '�— S Size of Septic Tank C 4rnbe Type of S.A.S. CC tq0M\NQr__1. Description of Soil: , `-b�� l , Xr7��1 a Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been issued b this B It Sign d "� o Date - \4 S Application Approved by Date Application Disapproved for the following re o s Permit No. A Date Issued v -••, � r`� Fee — �50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer; Ve ° PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplicatton for 30t5pozat Opotem Congtruction Permit a Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon(� ) O Complete System ><Individual Components Location Address or Lot No. kci S ,C AP'N Li ZAK'S � Owner's Name,Address and Tel.No. (� Assessor's Map/Parcel `-�c M(l� GerQ\C\ Lavnp-c-co- CO-) �Fls2CEL O Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel No. Type of Building: t Dwelling No.of Bedrooms _ Lot Size�_sq.ft. Garbage Grinder(N�, Other Type of Building t��r\o No.of Persons_ Showers( ) Cafeteria( ) Other Fixtures I-d ��Q r_�, =_0 C., , (-aw a Cg� Design Flow gallons per day. Calculated daily flow ?,n --gallons. Plan Date r'��� s{ InP� Number of sheets 1 Revision Date Title t��-``?2 --- —`-�, �-�-P c�5��rfl Size of Septic Tank . V Type of S.A.S. a- am Description of Soil "'� ` ,g (-_i,r� 18 KrX 3L, .Nature of Repairs or Alterations(Answer when applicable) n 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 Certifi- cate of Compliance has been issued by this Board of Health. Sign Date - Application Approved by f� /��a'.t Date Application Disapprove fdr/the following re a s V L Permit No W t5__ nd Date Issued g ") THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded Abandoned( )by `'� _1 . _�-}-� G�',e ��- at }��� �,r,�•' � {-c -Z e �� has been constructed in accordance with the provisions of Title and the for Disposal System Construction Permit No. _—Q Wdated---S,I CA Instalier 4 Designer � s The issuance of this permit s p all not be construed as a guarantee that the sste wihrf ncti on as designed.' Date �� Inspector . - - . - —.--n.---- ---_----- --------_—.-----_---.----- -- No. f/ �� Fee „i- v THE COMMONWEALTH OF MASSACHUSETTS q ,0 PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS 10i5tlogal *pgtem (Zonztruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(.)'Abandon(� ) `/ �-- System located at C�! /. �_�p�1 �//l/ , Oc'.oll�/ � 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. Provided:Construc on st be completed within three years of the date of this permit. " Date: , Approved by 1 / / v TQWN OF BARNSTABLE LOCH- ION / �:J C19ATN 4-237144�5 SEWAGE # Irl _LACE �. ASSESSOR'S MAP & LOT — 7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY -V--p dab LEACHING FACILITY: (type) cA. u,,'-'_<- 1<t9-1 -NO.OF BEDROOMS BUILDEKOR'OWNER tl t�1t�y'�vn/L� PERMITDATE: 7 �� � COMPLIANCE DATE: 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 c0c+ f Z a-A. T.4WN OF BARNSTABLE r' LOCATION l�iTN� i�K��-tiS SEWAGE # VILLAGE � Ny ASSESSOR'S MAP & LoTJ—t5. ---0ff7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK'CAPACITY Q t3 PO4C4& LEACHING FACILITY: (type) Cs`nL (size) NO.OF BEDROOMS� _ . BUILDER OR OWNER 11 0Q V''An,AA—,? 100, PERMTTDATE: '64Z5 COMPLIANCE DATE: 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 J c0 � Qo, V J#36 s—+ Z oZ. �-` 3e � Town of Barnstable �FtHE ley, Regulatory Services �O Thomas F. Geiler,Director + BARNSPABM MASS, Public Health Division prFo �A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 5/26/05 Designer: _Shay Environmental Services, Inc. Installer: Robert Septic Services. Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street MA 02536 Yarmouth, MA On 5/24/05 Robert Septic Service was issued a permit to install a (date) (installer) septic system at#195 CAP'N LIJAH'S ROAD, CENTERVILLE, MA based on a design drawn by (address) Shay Environmental Services, Inc. dated 05/24/05 (designer) XX 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. 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. VZH OF MgSc, --- o� BARMEN E. Nm,, nstall is ignature) SHAY C No. 1181 1pFG I s-r V?_ 0 SgNITAR\P� esigner's 1gnature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form f 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM i hereby certify that the engineered plan signed by me dated I, ;� j concerning the property located at lot a meets. all of the following criteria: • This failed system is connected to A residential dwelling only. There.are.no,commercial or business uses.associated with the.dwelling. • The soil is.classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or.may conduct deep test holes and percolation tests.at the site without a health agent present. • There is no.increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will-be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) , o B) G.W. Elevation +adjustment for high G.W. DIFFERENCE BETWEEN A and B ) . n SIGNED : �. DATE: 4e�( NOTICE Based upon the above information;a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. q ASepdc\percexemp.doc Permit Number Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: Lot No. lB Owner: Address: iCaL L Contractor; ��� nay, Address:_ '41 �-AaP, Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. .............................. ' 6� � ................................................ .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well..................•.............. .............. 2 OWater level range zone ..................................................... � STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... - m mnth/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 26) determine water level adjustment STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .............•.............,•,,,,, • - T .............. f; Figure 13.--Reproducible computation form, 15 Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street'Boston,Ma. 02108 .John Septic D.C.P. Title V Septic Inspector P.O. Box 2119 Teatieket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI I�_I _ ♦ 3 Lt.Governor A* . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO FARM PART A CERTIFICATION �i,J ' iG CAI f Property Address: 195 Capt'Lijahs Rd.Centerville Map 193 Par.87 Lot 18 Address of Owner,, ti9y0� dQ Date of Inspection: 718/98 (If different) Name of Inspector: John Graci Julianne Van Os � I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: 1 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: x Passes This Inspection Is based on criteria defined In Title V Conditional) P sses code 310 CMR 16.303.My findings are of how the system is Y performing at the time of the inspection.My Inspection does _ Needs Fu he Evaluation By the Local Approving Authority not Imply any warranty,or guarantee ofthelongevltyofthe Falls septic system and any of Its components useful life. Inspector's Signature: Date: vsm The System Inspector shall s bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 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: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 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, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is 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 conforming septic tank as approved by the Board of Health. (revised OMP97) One Winter Street • Boston,Massachusetts 02108 . FAX(617)556-1049 0 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 195 capr Li)ahs Rd.Centerville Map 193 Paz.87 Lot 18 Owner: Julianne Van Os Date of Inspection:719199 _ Sew.a4e backup or.hreakout or hiah.static water level observed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _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(s)are replaced obstruction is removed 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 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: 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. 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 the SAS 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 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. Yes• No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to llle surface of the yround or surface wutors duo t0 r 11 ov0110ad0d 01 ci099ed cesspool. SAS is in hydraulic failure. (revised 0427)97) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 195 Cape Lijahs Rd.Centerville Map 193 Par.87 Lot 18 Owner: Julianne Van Os Date of Inspection:719198 D]SYSTEM FAILS(continued) Yes No 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. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. — — Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The 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: 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) 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 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 195 Capr Lijahs Rd.Centerville Map 193 Par.87 Lot 18 Owner: Julianne Van Os Date of Inspection:71erg8 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x — As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x 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. x The size and location of the Soil Absorption System on the site has been determined based on — The facility owner(and occupants, If different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)) (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 195 Capr Lgahs Rd.Centerville Map 193 Par.87 Lot 18 Owner: Julianne Van Os Date of Inspection:719198 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 1 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): rJa Sump Pump(yes or no): No Last date of occupancy: nia COMMERCIAL/INDUSTRIAL: Type of establishment: nia Design flow:U gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nia Last date of occupancy: nra OTHER:(Describe) nfa Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was lent pumped on Nov.161995 System pumped as part of inspection:(yes or no)Ne If yes,volume pumped:0 gallons Reason for pumping: rva TYPE OF SYSTEM x Septic tank/distribution box/'soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date Installed(if known)and source Information: System Is 22 yeere old. Sewage odors detected when arriving at the site: (yes or no) No (revised 0427197) t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 195 Capt'Lliahs Rd.Centerville Map 193 Par.87 Lot 18 Owner: Julianne Van Cis Date of Inspection:718198 SEPTIC TANK: x (locate on site plan) Depth below grade: t' Material of construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age nis . Is age confirmed by Certificate of Compliance No ('Yes/No) Dimensions: Le'e^h5'r'w4-10- Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness:3' Distance from top of scum to top of outlet tee or baffle:S" Distance form bottom of scum to bottom of outlet tee or baffle: 16" How dimensions were determined: Measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound.Recommend pumping system now and then maintained every one to two years. GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nra Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:nra Distance from bottom of scum to bottom of outlet tee or baffle: nra Date of last pumpingn* Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Na BUILDING SEWER: (Locate on site plan) Depth below grade: v6- Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction IineJto- Diameter: We mments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04127197) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 195 Capr Lijahs Rd.Centerville Map 193 Par.87 Lot 18 Owner: Julianne Van Os Date of Inspection:719199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rde Capacity: rda gallons Design flow: rda gallonstday Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nia Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_yes Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) rds (revised=V97) I� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 195 Capt'Lijahs Rd.Centerville Map 193 Par.87 Lot 18 Owner: Julianne Van Os Date of Inspection:718198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: n1a Type: leaching pits, number: 1000 gallon leach pit leaching chambers,number:nla leaching galleries,number: n1a leaching trenches, number,length: rda leaching fields,number,dimensions:rda overflow cesspool,number:n1a Alternate system: Na Name of Technology._rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leach pit Is structurally sound and functioning properly.The leach pit had T of water In IL Recommend pumping pit every one to two years. CESSPOOLS: (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: rda Depth of solids layer: rda Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: rya Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) rda Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) roa PRIVY:_ (locate on site plan) Materials of construction: rda Dimensions: rda Depth of solids: rva Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Ma (revlsed 04127)97i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 195 Capr Lijahs Rd.Centerville Map 199 Par.87 Lot 18 Julianne Van Os 718198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) A AA ��r! Q (revtned04m197) ,• Page ! of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contlnued) 195 Capt'Lijahs Rd.Centerville Map 193 Par.87 Lot 18 Julianne Van Os 718199 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) f USGS Maps and Charts k 2 (rev1sed04127197) Pays 10 of 19 LOC&TION : SEW CZE P T O: VILLAGE V L L IMSTQLLER�S t. &ME DDRESS 15UILDER 5- Q &MF- ADDRESS DATE PERt,� T ISSUED =- LIV2 - - - DATE COMPLI &MCE ISSUED : = � FmoOT .13 A gl�Nr� C2 3 .'Box l No..__ 3.tr—..... Ficu......./ ............... THE COMMONWEALTH OF LASSACHUSETTS BOARD OF HEALTH - � ppliration -fur Utipn0al Works Towitrnrtinn Prrntit J� A tcation is hereby made for a Permit to Construct (�) or Repair ( } an Individual Sewage Disposal em at• � Locatio A_4dqlo6s or Lot No. Wn%W---••- ,fner Address W ---il�z ___ � Installer Address Q Type of Building �� Size Lot_...l� �Sq. feet Dwelling—No. of Bedrooms_______________ ..... Expansion Attic ( ) Garbage Grinder ...-•--.------ No. of persons....... ................... p., Other—Type of Building _�... p - � Showers ( ) — Cafeteria ( ) p' Other fixtures --____________________________ __ W Design Flow------------5_1z.......................gallons per person per day. Total daily flow......... ✓ ---------------------gallons. fy Septic Tank—Liquid ca pacit __O9Z� allons Length Width-__-- -._------ Diameter................ Depth--_.--.__.__---- 1 q 1 . --- g` g W Disposal Trench—No. ...........I _ _`A Width`_._._....-- Total>Length ..... ....... Total leaching area....................sq. ft. / / `iG+t' •�5 � ' a/� Svc'/ Z, Seepage Pit No. (� me ¢ "!`� ' ept below inlet Total leaching area. sq. it. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------------------------------------------------------------ ............. Date........................... ----------- Test Pit No. 1................minutes per inch Depth of Test Pit_-._-_._.___..__-_-- Depth to ground water..._____-_---._.-_.-_--- (_, Test Pit No. 2----------------minutes per inch Depth of Test Pit.-______-..______-_. Depth to ground water.-._...--__----.------_. -------------------------- L .I..•--------•------------------ ; ; ----------/�-------------------------------------- Description of Soil. ._ 1�'� --- ----------------------- ----------- / ---------------------------------------------------------------------------------------- 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 Article 1I of the State Sanitary Code— The undersigned fur ees not to place the system in operation until a Certificate of Compliance has be:42s2�11", e boa ealth Signal..... . ..Z a �1)) Date Application Approved By.---' _.__.._..... "i. __,_ lz . ate Application Disapproved for the following reasons-------------------- -----............. _.____________._..._..____....._____._________...._.._____.__._... --------•------------•---------------•----•---------•-----•------•------__.....------------•----------•----------•------------•-••----••-•---•----------------------------------•-------..---- Date Permit No......................................................... Issued----- `Z 7--74.-•-••---'•-•--•---••"-•--'- Date ---- ----------�Z'----------------------- - - J vy �v No..... Fa$............................. THE COMMONWEALTH OF MASSACHUSETTS _._ BOARD OF HEALTH ��i,•.Jir...a/ r �S /ice. OF........ .... ...................................... Appliratinn -for M_gpviitt1 Workii Tonfitrnrtinn Vrrmff Application is hereby-made for a Permit to Construct (/-<Or Repair ( ) an Individual Sewage Disposal System at �.� Locatiorl� or Lot.No. ..... ................•----••-•---------------- S ..... — ......-----•......••-•--------------------- Q ner Address Installer Address // DUUf UType of Building Size Lot_.___ .............Sq. feet �-, Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder (A16 aOther—Type of Building ______________ No. of persons........ Showers ( ) — Cafeteria ( ) Otherfixtures -----------------------------------------••••--------- ............................_---....--- W Design Flow--------------!!rp......................gallons per person per day. Total daily flow....... ©__.___._-_.._..__-.-gallons. WSeptic Tank—Liquid capacityl��GGgallons Length................ Width....... .._.._._ Diameter_-.------------- Depth........... x Disposal Trench—N . _______../&me� idt ..._.._.___ tal e h __._.. Total leaching lrca____________________s ft. Seepage Pit No• � g q .-------- pt e ow•In et-------------------- Total leacllillg area t_.__-----------__.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--------------•---.---------------........................................ Date-----.-.-.---.---------------_.--------. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_-_-__._--._..__-_-- fzq Test Pit No. 2----------------minutes per inch Depth of Test Pit----------------- . Depth to ground water............--.-___----- ------------------� ,: O Description of So _ 6, ... D ;----- ---------- -- ------ , x � .--- -•-• ------- -- ---- ------------ ------ ----------------------- 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 Article tI of the State Sanitary Code— The undersigned fur ees not to place the system in operation until a Certificate of Compliance has been iss b the boa -pf ealthSign - 'f''""' ' - '" ` Application Approved BY-------- -- ---- i:_/ vl_ !1. --- .....-.. ---- -� Date Application Disapproved for the following reasons:-------•---•---•-----------------------••---------_-------------------•--•-------------------------------------- -•--•---••---•-•------------•-------•----.....--••------------•---•------•••------•-•-------•------------•----------------•-------•-----•--------•----•-------•---• ------•----------.---•---------•--- Date PermitNo......................................................... Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... 1 ......... �...... �tprtifiratle of f�nnt�rltttnrr TH IS O CE fI Y, That the Individual Sewage Disposal System constructed ( �r Repaired ( ) by....... .. I '',,// //��jj t -------- ------- --------- -- atf/' ( r✓ •— - ` C-`••�•- .. ngtaller /1 /� ��=� f b �✓i�`�- ^.- , has been installed in accordance with the provisions of Arti e I of The State Sanitary C de as described to the application for Disposal Works Construction Permit No---- _P611ATS- dated....____-...-�:S____--7 G THE ISSUANCE OF THIS (CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------ { '-_4..7------7-Y-....------------------------•--- Inspector--------------------------------...-----------------------------................... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTG�'� �J Z!/1. ►..........OF........ ........ .................................................. No..... •••• FEE----� ............ Bi-sp g kq� nitrnrtinn rrnttt Permission reb ranted :-- --•------- -----------------­------------------------ pwag g to Cons t t '") or R �tr ( ) n I vidual S wage o. Syst at Street as shown on the application for Disposal Works Construction Per o...._.._ ated__.._'t�'_�_S{ 7� ... L Board of Health DATE-------------------------------------- ----------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS X 74 /.OT �o• ,F? ".. f � o I - ;A,p�. 1 /U 9. 7c? C 3 (fAlID;V Z X--,/- 1 �5 2P S/L L EL-E 1✓' '- FF�T.4430✓E POAZ7 PL. O r PL. A A/ L O CA T/OAI _ S CA L.E _/ "=l QZZOA T& )PLAN 2E FL-ZL-NC,& : $1EIIAVG 407 W iR A5 sNa,".IAl a v /I4 AN Doe- _ z-7.4, r->ACcrter, ; �• ,--W-o'r,; I NEXzEBY CEQ7'iFY T14A T 71.1E EX/ST- iNG FOUMDA7/ON LOCATION /502?Z i45 5WOWIV COit/FOZI-f W17.q Tf•/E 8G//LD1NG SETl3.4C�.L�EQI�iPEMc=M OF 7-A16 TOWN OF AL569• L.d-A/S Oz✓L YCO� C Uo wez e- + T.a Y4402 CIO 81 G! 1440W ST. X`4,0"Ot/77/PVZ'7 MA. 19 LOCL�,T10N SEW&C,E PER _ T O. 6-4-6- 70� VILLAGE IMST^QLLER 5 U&NlE ADDRESS BUILDER 5 1J-&VAF-- �. _ADDRESS _ ro DINTE PERMVT ISSUED Plv2e- Dt%,'TE COMPLI WACE ISSUED .- Q,3 C. 1 � i i l� yn *r 8'F4i% 4 inches tall VENT PIPE O Least 2 n s SECTION .� Filter TI A A w h r I Odor to 4( PVC C a aoo ., . >'Schedule D i NOTE. ALL PIPES ARE TO BE 4 SCHEDULE 40 P.V.C. � ALL ounEr PIPES FROM THE - 10 min. from I V DISTRIBUTION BOX SHALL BE PR FILE VIEW OF 'LEACHING SYSTEM a Existing Foundation . .house to septic tank Septic .tank covers must be CHAMBERcovermust be 0 EM t2 CONCRETE COVER � P SET LEVEL FOR AT LEAST 2 FT. r . • D-BOX cover must grade _ s , ` -grade - within 6 In. of finished rode 3 �•`within 6 in. of finished g " 9 TOE LEV 100.00 Ew/m 6 of finished grade .+ , .• ,�u+ r �;y-,. 1 - _ - ode over SAS - ELEV- 98,50 3 5' OUTLET ���..r ..r..+, 2 } Grade over Septic Tank 99.00 Grade over D Box 9880 P /. _ ,. / -`< KNOCKOUTS ,.... •.. �� TMs s f sawn$ �,.,,•"'•-a^-""^.f4.. far�•'"' % � b t I/s raM.a-C�udW 3w+w al r/A t/s rorrd P...eo�. y r INSPECTION cover must be - -t - i 5 5 OUTLET 12 IN it S s w/in 6 of finished grade ) r 0.02 3 HOLE H 10 8 'i• 3' Maximum Cover T of SAS-EIPv.=96.25 ng Pce> s DIST. BOX :•,..' T, a n 2 " _7_ +Ofi Capa L44sr,#d H 10 EXIST. S 0.o1 or Greater S- 0.010 per foot f/ �1�- EXTSTPIPE N :.....1,��� GAL. + / .. J. 15.5 • tl 0 '� ��,`. _ x cv o SO o o O p o a o 4 SCH. 40 Te 1.79' �' ` `", J +".n" FROM EXIST. f DUNDATIDN w ^ SEPTIC TANK O C7 -C� C7 C7 = C7 f� �y., u ; O.iu ,,,. Ce 20 0 o Effective Depth I 11 e„,,*, o PLAN SECTION CROSS-SECTION j' _ tP s'1 ' j ry H-10 o 0 2 Units 2 65' w/2 stone in betwee = 19 mm, m CONCRETE FULL FOUNCA710N y '-` • ' r �' ar) 2.5' S'- 2.5' .. �' 6 i ° 3 HOLE H-10 DISTRIBUTION BOX al 6 h.ot 3 4'--1 1 Z• � j j' , � t a I 11 �� rT e�, � SYSTEM PROFILE / / z9' Q compacted stone - - 1 G' II. -I t64 a t d> _ Effective Length NOT TO SCALE p ai Not to.Scale - Effective Width I. 59UA - j j y @Rand dAl6+�vE�ip' ®MM L. a > SOIL ABSORPTION SYSTEM (SAS) 5' PROVIDED � C 6 In.of 3/4'-1 1/2" 0 500 - C H-20 LEACHING UNITS / WIGGINS PRECAST GENERAL NOTES compacted stone m NOTE: ALL COMPONENTS MUST HAVE RISERS TO W IN 6"' OF GRADE Bottom of Test Hole 1 Elev.- 86.50 Not to Scale 1. Contractor is responsible for Digsafe notification -------------------------------------- and protection of all underground utilities and .pipes. Obs. Groundwater - Test Hole 1 Elev.= NONE OBSERVED 2. The septic tank anq, ,distribution box shall be set level on 6 of 3/4 -1 1/2• stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during` installation by Carmen E. Shay - Environmental Services, Inc. `^ 5. The contractor.shah install this system in accordance with Title V of the Massachusetts state code, the approved plan and Local Regulations. ' 6. If,' during installation the contractor encounters any 1 soil conditions or site conditions"that are different from those shown 'on the soil log or in our design 40 POLYETHYLENE LINER FROM ELEV. installation must halt & immediate notification be 92.50 to 95.50 AND TO EXTEND 10 BEYOND SAS made to Carmen E. Shay - Environmental Services, Inc, 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. PERCOLATION TEST c9, 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. �\ 9. All Distribution'Lines shall be 4" diameter Schedule 40 NSF PVC pipes. ..Date of Percolation Test: MAY 20, 2005 \ Test Performed By. Carmen E. Shay. R.S., C.S.E. \ 10. All solid piping, tees & fittings shall be 4" diameter Witnessed B) WAIVER (per BARNSTABLE B.O.H) �� Schedule 40 NSF PVC pipes with water tight joints. EXCAVATOR: Shay Environmental Srvcs., Inc. �\ 11. Municipal Water is Connected to The Residence and Abutting Percolation Rate: 2 MPI ® 36" Properties Within 150 Feet. .00 Test Hole THE PROPERTY LINES ARE APPROXIMATE AND No, l \ COMPILED FROM THE SURVEY PLAN GENERATED BY L- - \ 10 CROWELL & TAYLOR CORP, LAND SURVEYOR, ENTITLED DEPTH Soii ELEV. "CERTIFIED PLOT PLAN OF LOT #18 CAPN UJAH'S ROAD II- 0 98.50 c9 �\ '-t -- -29' CENTERVILLE, MA-' DATED APRIL 12, 1975 CP } Sandy Loam 1 I I ,. ?�� �'J & THE DEED DESCRIPTION ( BOOK 16075 PAGE 036) \\ 10, 1 E4CHIN 10 vR 3/z LOT # 181.1 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN • 4" PVC THE SEPTIC'_SYSTEM INSTALLATION. 0"-9" A, 97.75I \ ti 15,135 Square Feet +/- <_ '' ° '-' Vent Sandy �� 1 -^ i ,�`J g EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE La _9 10 YR 5/6 9"- 36 Be 95.501 1 I ' NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE i 1 TEST HOt1'E #1 s _: __ -__ __ __I FR50 OM THE EXISTING LEACH PIT TO BE DISPOSED Sand 1 DEOK t LL OF AS PER BOARD OF HEALTH SPECIFICATIONS: z.5 Y 7/4 1 1t NO WETLANDS ARE PRESENT WITHIN 200` OF THE PROPERTY i 1 I � . 36"- 120 I LOT #>7 i 1 EXISTING \ ASSESSORS MAP 193 LOT 087 z,BEDROOM �t LOT 19 HOUSE # LEGEND I , M I r #195 104X1 DENOTES PROPOSED 1 PROJECT BENCH MARK SPOT GRADE r i TOP OF FOUNDATION I ELEV. 100.00 (Assumed) X'104.46 DENOTES EXISTING r , r SPOT GRADE Perc #1 1 t - rib �i :. .Depth to Perc: 36" to 56" i tt Tj � �^ Perc Rate= 2 MPi XI 10 A PL PROPERTY LINE E ST 00 GAL., ` Groundwater Not Observed 1 �r 'SEPTIC TANK 0No Observed' ESHWT -.c� °� rP PROPOSED CONTOUR ADJUSTED N20 Elev. None I' �\ v-. ��,,-� � Failed r 1 , Leach Pit , 0 r_-- - - - - - - -97 EXISTING CONTOUR _ .GRAVEL \ --------- ® DEEP TEST HOLE & - ' PERCOLATION TEST LOCATION 2-18' DAM. ACCESS MANHOLES \\ r`-�� -.--' // t ,•.DRIVEWAY i� ��\\ 8' \ r i ---------< - ;- 6 FOOT STOCKADE FENCE .. ,�. a .t•..•%1 '_i ':s.+u...:.if�'.r "- -/` ram' \ 1\ 95 0 16.00 109.78- INLET - ------ P LOT PLAN THACCESS COVERS FOR E SEPTIC TANK ----------- --------- _------- -- ..-.-L- E CCE C VE 0 THE -- - -----^ DISTRIBUTION BOX AND LEACHING COMPONENT - i CATCH H BASIN OF PROPOSED SEPTIC .SYSTEM UPGRADE SET DEEPER THAN 6 INCHES BELOW FINISHED ' GRADE SHALL BE RAISED TO WITHIN 6" OF � ,p� PREPARED FOR-' STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. C`!) ! �L l �� ,O-A MR . GERALD LONERGAN PLAN vL�1AI INSTALL TUF-TITS GAS BAFFLES OR EQUALS L.REM VV (40 FOOT RIGHT OF WAY) AT 3-24' REMOVABLE COVERS it + # 195 CAP ' N LIJAH ' S ROAD 3" min.'clearance INLET 8" mtn.T-j4_min. inlet to outlet CENTER V I t-L E 1 MA 8' min, OUTLET _fINLET Llqufd level - 10" min. 1P mn. ' }} � Design Calculation s E e } a o min. Number of Bedrooms: 2 Equivalent to 220 Gal. Da 330 Gal: Da Min. per Title V S ' PREPARED BY: eo.am. :' Ligwd depth ,M1 Y P )q / Y ( / o� .•, Garbage Grinder: No A a o LeachingGa acit Proposed: 330 Gal./DayMinimum Min. Per Title V �11 ff-F ►' E. SH Y P Y P ( ) Septic Tank 2 x 330 Gal. Da = 660 USE .EXIST 1 000 GAL Se tic Tank. 0 20 40 50 0 Cn { .. P / Y P - ' ...�.> :• <'.c .N, .. I + ..'.:...; ',-: '�'. •',. '. ... ' � ENVIRONMENTAL SERVICES,. INC. 4' -10' SOIL ABSORPTION AREA: Using percolation rate of <2 min../inch N . CROSS SECTION END-SECTION Bottom Area: 0.74 gal/sq. ft. x 290sq. ft. => 21460 gallons +� P.O. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 156 sq. ft. = 115.40 gallons fsTIE EAST FALMOUTH, " MA 02536 Providing: 330.00 gallons S PN ANI TARS . SCALE: .1 =20 TEL FAX 508-539-7966 TYPICAL 1000 GALLON SEPTIC .TANK Use. (2) PRECAST 500-C UNITS, HAVING A 2 EFFECTIVE DEPTH,.., - „ C E. 1 0 DRAWN BY: S T MAY 4 NOT TO SCALE TO BE USED.. WITH 2.5 OF WASHED STONE ON THE SIDES AND .,; SAL 2 CE DATE: M 2 2005 , 4 F WASHED N N THE N I BETWEENCHAMBERS."0 SEDSTOEO EE ENDS IN • PROJECT SD749 FILENAME.. SD749PP. -W T 1 ` F 1 # D G SNEE 0