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HomeMy WebLinkAbout0241 CAP'N LIJAH'S ROAD - Health 241 Cap'n Lijah Centerville A == 193 - 132 0- 1S3L0 o.2 �! F ,vt I� t Commonwealth of Massachusetts 93 /3-p— �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�'Y 241 Capin Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt ' Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 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. Inspector Information on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Jim the inspector man use the return Company Name key. P.O. Box 784 ,Q Company Address West Yarmouth Ma. 02673 City/Town State Zip Code 508-364-4398 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes � N OF t r�SY//��i 2. ❑ Conditionally Passes `�`y� :••'""•••.sgco,� rR— MICHAEL`. 3. ❑ Needs Further Evaluation by the Local Approving Authority ?o; SEARS -m * No.SI14430 :ca 4. ❑ Fails 4-8-20 Inspector's Sigi6ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts � Title 5 Official Inspection ection Form1 I1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cti u � 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts �n ,� Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ !% 241 Cap'n Lijahs Rd u Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments U 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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? El ® 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I. ............. 241 Capin Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5i nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 241 Cap'n Lijahs Rd u Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� 241 Cap'n Lijahs Rd u� Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 28"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1500 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑. Yes ❑ No Dimensions: 1500 gal Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 2„ Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge gudge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gal tank with baffle in, tee out Inlet cover under cement patio, outlet cover at 11" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ........... 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x16 with 2 outlet pipes, Box at 34"cover at 7" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �� _ � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 2-500 gal dry wells Wells are at 41" cover at 16" below grade Wells are clean and dry, no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v— 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments �w ........... 241 Cap'n Lijahs Rd u— Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 Rear a. eI O 3 B A 1-19 61- 18-6 a•_ay.8 ��a� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts n Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .......... 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: House set high up on hill, no ground water problem i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 F , Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 241 Cap'n Lijahs Rd Property Address S Chris Callahaan Kathleen A Uggerholt Owner Owner's Name information is required for every Centerville Ma. 02632 4-8-20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included Gard, 6 elf S S10 t� t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Town of Barnstable PM Department of Regulatory Services .BARMAELF.: Public Health Division Date KJOV Z I , W1 Z s� i 39.��� 200 Main Street;Hyannis MA 02601 Date Scheduled / Time /0 Fee Pd.�� Soil Suitability Assessment or Se a Dis ty f posal Performed By: Witnessed By: LOCATION&GENERAL INFORMATION Location Address GZ C ��^n S Owner's Name F I t"yT40 bore c(yl � � `J'M ) 1 I p � (' y Address Z1..,1 (�i'r e;l. ��b�p Assessor'sMap/Parcel: 1q. �� �+`�l�' Engineer's Name, C.t&�Us -y1 ( J 4J�01 yt�/1�l0. �� �(�SOnI C. NEW CONSTRUCTION REPAIR / Telephone#�J^ o^ 'LA Land Use RE,S11�i•+?t�C_ Slopes(%) G I O/Q Surface Stones Distances from: Open Water Body I Ck'4— ft Possible Wet Area (dam,'{`ft Drinking Water Well NIA ft Drainage Way 6'4t* ft Property Line (`J, ft Other ft .SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Parent material(geologic) fk-0(rL,A1— O v1-V#A(-* Depth to Bedrock IA Depth to Groundwater: Standing Water in Hole: 0�-. Weeping from Pit Face lJ Estimated Seasonal High Groundwater N PN DE ERMINATION FOR SEASONAL HIGH WATER T ABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Datel 18 Time IQ:OD � f=a Observation ` r`d Hole# Time at 9" Depth of Perc 26" Time at 6" Start Pre-soak Time Q 0:00 Time(9"-6") Q lJ! Ci.3 End Pre-soak <'I•' IS:�Oa =`' ::V Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: _0 Additional Testing Needed(Y/N) d t17 Original: Public Health Division Observation Hole Data To Be Completed on Back---------- [ t ***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:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. — Consistenr,y%Cavel) A Loa,,%rt SAvD 10`1,01Z Nta t2(0� t- meo1.4 9 r'1 t LppsE DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency-%Gravel) to,, A �.5. 10ti YZ A)(A R L S 10k►L�& Ij(A G DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. --- Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con i temy%Gravel) Flood Insurance Rate May: Above 500 year flood boundary No_ Yes JZ Within 500 year boundary No .�/Yes Within 100 year flood boundary No +' Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughoutthe area proposed for the soil absorption system? -- If not,what is the depth of naturdly occurring pervious material? Certification I certify that on (date)I have passed the sod evaluator examination approved by the Department of Envlron n 1 Protection and that the above analysis was performed by me consistent with the required training, xpe a and experience described in 310 CMR 15.017. Sign ure Date Q:\SEPTIC\PERCFORM.DOC No. Fee - THE COMMONWEALTROF MASSACHUSEYTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zfppliration for 30i5po0al 6potem Conotruction Permit Application for a Permit to Construct( . )Repair(P4pgrade( )Abandon( ) El Complete System llndividual Components Location Address or Lot No. 2 y L A h `�r�a ti� Owner's Name,Address and Tel.No. Assessor's Map/Parcel f:Gf�,.�Qit(n Lw lift �Qr�l1-v� Ig /3 3 L Installer's Name,Address,and Tel.No. j D���f 0'��+30 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size �' 97desq.ft. Garbage Grinder K� Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow 3 3 v gallons per day. Calculated daily flow y a 3 gallons. Plan Date a�Zo 4/0 G Number of sheets Revision Date Title Size of Septic Tank IS x /6-Trt) ,�� S Type of S.A.S. Description of Soil; S!e id t&,-I Nature of Re airs or Alterations(Answer when applicable) I e�0(aGC •(�o�( /tom w 29tK/I�X � 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 Bo d of Health. Si ed Date Application Approve by Date Application Disapproved for the following reasons Permit No. '� Date Issued �' i No. �C� � �... i� � Fee THE COMMONWEALTH�OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Oigponl bpo'tem ctCon!5truction Permit Application for a Permit to Construct( . )Repair(grade( )Abandon( ) ❑Complete System f5'Individual Components Location Address or Lot No..Z y �' l� 'r 'L �A b� 1264 Owner's Name,Address and Tel.No. Assessor's Map/Parcel j / 3 2 94-i0 V, /w . (,Ci Ft vI Installer's Name,Address,and Tel.No.YOE-q2 0`,?700 Designer's Name,Address and Tel.No. ' Type of Building: Dwelling No.of Bedrooms 3 Lot Size2 0, 9 V sq.ft. Garbage Grinder KeID Other Type of Building No.of Persons Showers( ) Cafeteria( ) '� Other`Fixtures Design Flow\ 30 gallons per day. Calculated daily flow zf 0 3 gallons. Plan Date =:!,�Z o IV G Number of sheets Revision Date �r Title Size of Septic Tank Fx /-T 0 Q S c / S T Type of S.A.S. Description of Soil fee.. ,d lx,— Nature of Repairs or Alterations(Answer when applicable) rW6z;P Date last inspected: r, + 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 Bo d of Health. SW ed Date /- Application Approved by Date Application Disapproved for the following reasons Permit No. 114co l0 '0 ' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the�0 -site ewage Disposal System Constructed ( ) Repaired (4--�-Upgraded( ) Abandoned( )by Jd3f/�� at T14.Ca 4 C4VT,/"✓1 M/5 has been construc a&oidance with the provisions of Title 5 and the for Disposal System_ Construction Permit No.'c���-0 dated / lQ Installer .'t- 1- 0 yf',.S l Designer The issuance of this ne sh not be construed as a guarantee that the ysteif �ion designed.Date Y) Inspector 1 `4 P � r No. goo(0 ^'z7a 7 ----------------.--.-------- —Fee � .. ,' 3\THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Iigpont *proem Conn;truction Permit Permission is hereby granted to Construct( )Repair p de( )Abandon/( /) System located at .2 11V1/ ��d�/✓ L-% 1 ��S fc�1 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:Construction ust be co pl three years leted within of the da e of this s t. Date: C � �" 7 Approved by ��� 4/6/2020 ShowAsbuilt(1700x2800) I TOWN OF BARNSTABLE LOCATION 24/6$jd Z m'9 k,/ SEWAGE# 2eoG-0?4 - VILLAGE- lfxnThrw/lh ASSFSSOR''S MAP&LOT ZZ9=✓-r2 INSTALLER'S NAME&PHONE NO, fOT-Y204n,?c/tsePl��lZ,Q.Vi+�t SEPTIC TANK CAPACITY /Soo LEACHING FACILITY:(type) 2 S00 I1.0 wI29I'S (sim) /S X 2-5-- NO.OF BEDROOMS .3 BUILDER OR OWNER ,q"k.,/ • i .I PERhIITDATE: /-27OL 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 feetof leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist _ wft ais bin 300 feet of Icae6ing facjlity i Feet Furnished by a '•"(_ .. :fJ i s �r patio n' ; -Yvg a Ax, L;J*9,J a https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=193132&sq=1 1/1 r Towp of Baristable Regulatory Services 'Thomas F. Geiler, Director • swatvsrAat& Public Health Division + � Thoma&McKean,Director 200 Main Street;Hyannis, 1d9A 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: / Sewage Permit# --- - — _ Assessor's Map\Parcel /7 /3L Designer: �j- 1�, - l'�'! Q�� Installer: Address: _9 l�o�Q �p/� �N — -- Address: BI -------__. /�o���►J/Yf.'lI i��oZGy� �._�. ��- DEG �"� On was issued a permit to install a (date) (installer} septic system at Z C GI �`i -jCe 1�� r,{Qfy.�� based on a design drawn by - n (address) _ - -- �&I IIC S dated(desig _ /_P/P --/ J Y ✓ 1 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. A OF MgSs9c GLEN yc.. -- - -- "z �� ERIC nstaller s Signature) HA4RRINGTON No.1070 0 (Designer's g- -e) G� -- (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSfABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTII. BOTII THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q, I1eatth/Septicll)esigner Certification form 3-26-04.doc TOWN OF:BARNS'I'ABLE k0,V0 SEWAGE # Z000-QQ7 VILLAGE- (!�.sxrz;rw ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY _Ls00 LEACHING FACILITY: (type) 2`s'Da ��i�tii /"S (size) NO.OF BEDROOMS 3 / �\ BUILDER OR OWNER R,/, �1 PERMITDATE: 9-27-OG 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 fac' 'ty) Feet_ Furnished by r d , PIV ;r&g a r Notice: This Form Is To Be Used For the Repair Of Failed 3=rt < Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, G-J ^ AF• hereby certify that the engineered plan signed by me dated L� O ,concerning theproperty located at Z Y l Cas,H L eTAI �f/�`T C yot meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering) and two percolation tests shall be conducted. • 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. • 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) '70 B) G.W. Elevation 3 7 +adjustment for high G.W. DIFFERENCE BETWEEN A and B 30*: SIGNED : DATE: 112, D NOTICE Based upon the above information,a repair permit will be issued f r --� edrooms maximum. No additional bedrooms are authorized in the future wi out engineered septic system plans. gASeptic\percexemp.doc i t C� 1 No... .1. ....... Fss......J.r .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. 0/�©© .....................". .........O F..........................._..-..........._...... 1 � Appliration for Disposal larks (�nnstrnrtion . mit 01 pplication is hereby made-for a Permit to Construct ( ) pair ( ) an Individual Sewage Disposal System at: ¢l 4 � ... •.�:.....•.....--.. ...................•._.. ... - o n Address � r�Lot N` - ------------------ ----------............... -------- . . C� ......��.- .� ' r Address a ... .... ... ...................................... ............................-...................-----------------------------------�._....--- Installer Address Type of Building' Size Lot......_?®_0._..Sq. feet U Dwelling—No. of Bedrooms----.._.` .. .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- - ... _______ ___I................ Design Flow.................�®........•..........gallons per person per day. Total daily flow_.__...._= �._® gallons. WSO® �••--••-----.•--- WSeptic Tank—Liquid capacity-__..._.-___gallons Length____./ _..._. Width. . ........ Diameter__�r ------- Depth._.,fc____.._. x Disposal Trench—No. ................. Width.................... Total Length .......... Total leaching area....................sq. ft. Seepage Pit No./!:Vt1,1.__. er.................... Depth below inlet.................... Total 1 ch• g area 7.....0....__..__s . Z Other Distribution box ( Dosing tank ( ) -d a"7 7- XG /�d'�y• '`A Percolation Test Results Performed by......" , -... . ........................... Date........................................ Test Pit No. 1.....'.�...minutes per inch Depth of Test Pi ................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---••.......................... ........ 1 N-- ....-- .. ..... O y- 2escr Description of Soil --•---. `� x P..� . = --- s W UNature 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 undersig d further agrees not to place the system in operation until a Certificate of Compliance has been iss by ar of heal h. Signe •... . .......... �' ----- - -----rr-------�0_- ----------------•--- -...---•--.._.........--------•- i . 4" Date Application Approved B ,.F ��� 7 .7..•--••- PP PP Y .ct --•- •.. ------- Date--------•----- Application Disapproved for the following reasons:........................................ easons:......................................... --•----•-----•-------• ------ ----------------------------------------------------- ---------------------------------------------------------------------------------------------- ••-------- Date PermitNo...................................................----- Issued_....................................................... Date . Tr;P tJi- FOUNDATION s CONCRETE COVER t CONCRETE COVERS 9I` ,,r,.,. ., ry7TTJTT✓7 s , . e 4 CAST IRON 10"MAX. 10"MAX. PIPE (OR 4"ORANGESURG(OR EQUIV.) EQUIV).— MiN. PIPE- MIN. LEACH PITCH I/4"PER. PITCH 1/4-PER.FT PIT PRECAST ; NVERT t o~ Q LEACHING ERT INVERT . ® . PIT OR a SEPTIC >CAIVK DIST. EQUIV. ,w g: EL. pi- BOX ELE�Q,2S. , >s INVERT F Q " e; EL VERT GAL. INVERT C� 3 va •., u EL.mo.¢.i INVERT ww O i6. /4 T011/2 , ® � WASHED w. STONE DIA;I ' 6i, ° t v_ n PROFILE OF - GROUND"WATER TABLE F , ;, • -.SEW.A E DISPOSAL. SYSTEM _ .. :.. v NO. SCALE SOIL LOG AVITNESSED BY C. ._Dc;tk46( .ASS. r1\c rll.r.42E BOARD OF HEALTH DATE ..�./3d Z:7.. TIME. . ; TEST HOLE I TEST HOLE Z ENGINEER pp t IAic�o�LaAn� DESIGN ®ATH _. wo NUMBER OF. BEDROOMS A TOTAL ESTIMATED FLOWN. . GALLONS/DAY . _ . . BOTTOM LEACHING AREA ! O. .. SQ.FT./PIT. SIDE LEACHING AREAS :. I�8,�.0 SQ.FT./ PIT Go-po's � GARBAGE DISPOSAL _iL'0. . :_(50% AREA INCREASE) TOTAL LEACHING AREA % SQ'.FT PERCOLATION RATE �.� ).o , , . , MIN/INCH LEACHING AREA PER PERCOLATION RATE . SO.FT. Mo. .WATER ENCOUNTERED —� �, . NUMBER OF LEACHING PITS . . .0.�. . . . . . . APPROVED A)S 1615 BOARD OF HEALTH DATE . . . . . . . . AGENT OR INSPECTOR -• . O F G � rn o EY �s TH( ;,e� -r'x-� 1f o.2426p O en C.iT f?� 1� S, [- �'T �'J 1_� �1 EN�•$'� Zi."vi1vR fi,€ TE�k��a�� W Q �-.�-• !.`I.G. f�l Y."t (G I Q 34 i Ol ry_'QiN 3 r"'t`�'_t17. DRIVE � ESS/dtdALF�6\ Z .i ��•t �3'cAic�li'TH>02664 7-C—m lk\ 85,.29 'r Tv ARav N� � T.�SE�+�'C— ��T�>S�rfx*a•�d,U 7r�iS 20,1`fe) j } 119 CAPE /\N_k) \1tN REYA. D °- ELN�G. GO• I_i\ ss lEw-" Q ;01iAS E.KELLT- co. RS S'71 25,+ cTr:crxs --svRvac� I 346 LONG PU=vD DRi\ �27 C4a/JG6 SOUj-• i YARNIOUTH.,MASS' SLaF� a 02664 FuDo R e , 26 � + k?��µ 6F tiAr� L�DF �J �z +� THOUAS ' v Ex rtdp�FarE ice} . ` fit ,o F of noru�a¢� 1 suR�c� ssr0ol NA L GZ4 63,4. •x , 41' CERTIFIED PLOT PLAN Q L-OCATION Q 39 Go,B 6 E SCALE . ��` 3<?. . . DATE. .. . . . i ./\ " 77.00 ,`t PLAN REFERENCE V..T. v. NJ.RP X\0 � ( 4 0' �-AY sS.Z �3�2►{tR'(�,. �.���,��.�.��:..'��. �:N. Pam,a►�. . I CERTIFY THAT THE W."J " `i e�. •. . SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE C NA61t Ewa F S� ANL6`( SETBACK REQUIREMENTS OF THE TOWN OF ►1_ h S.T.h[ ikp I,. . . : . . WHEN CONSTRUCTED. Ro�.c-LNG H►-rcK Elan..'➢ CF_NTt3RviL-LE, DATE cam. �t•l2.�� (s!� -• j i PETITIONER: O2�a,� -REGISTERED LA D SURVE;'P'IIR `/ - No------------------------ r Fss.._........._.. THE COMMONWEALTH OF MASSACHUSETTS n. BOARD OF HEALTH -------. -- .........................OF.................................._._.. Apphratiun for Diipuual Works Ton,itrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy em at, Xq a OV -----•-- -------- --•_.._. .-- - ---- .. (1 L �ion �Addres-_r_ o �Lo No. . Y.. ...•-• ....................................•...._...... ........ ........ ._........ ._ i er Address W Installer Address ..�,.._.. oo Type of Building Size Lot_____:___-t-----------------Sq. feet Dwelling—No. of Bedrooms________ ________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building _______________ No. of ersons___..__.._______.___.______. Showers — Cafeteria a YP g ------------- P ( ) ( ) alOther fixtures - ----------------------------------------------------------------•-•--------•------------------------ d - Design Flow.............. :__ ` ��__.gallons per person per day. Total ily flow............... lons. W , WSeptic Tank—Liquid'capac y____________gallons Length___.,�__. _ Widt f_.___.__.. Diameter�=___._.____ Depth___ ___________ x Disposal Trench No ............. ._ Width _._.. Total Length ................. Total leaching area___________________sq. ft. Seepage Pit No/�M ameter.............. Depth below inlet_______ Total c •ng ar ........._ t: Z Other Distribution box ( ) Dosing�ta}n•�k ( )4TestPi y r " ''°'y - '` r ~' Percolation Test Results Performed b V- -..: _�.............................. Date_.__._________.......___:__________..... 1.4 Test Pit No. 1..__.�t:_.__minutes.per inch Depth of ................ Depth to ground water______-:_.___.____:_.__. (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth_to.ground water........................ ai 7 0 % Descrip •on of Soil_.__:_ ._:�. ` _ �`t!!l-� . � . .. /? .. --- -----�.- .---" -----------------=------------------------------------------------=---------------------------------- 's 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 iITI, `5 of the State Sanitary Code=T.he undersi ed further agrees not to place the system in operation until a Certificate of Compliance has been is tti/b,-111 oa . of 1 th. Si. d - •-----•• .................... ................................ g Z d—Dt / . Application Approved B - --: a,# '1,. 7__...--- ••-•-•------•-._.._..._ PP PP Y -- ` ---•--•---------------------------------- Date Application Disapproved for 'the following reasons:............................i___._____:......._:_ _ ._......._..__ ....................•------...--...-------------------------------------•---=-•----•---...---------••---•-•-----------------=`•--------------------------------------------------.................. Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH �rr#ifirtt#�e ofZOO f�ontrfi�anrr , TH�S I I.FY, at the Individual Sewage Disposal System constructed ( ) or Repaired ( ) i R` r ..............................by ._.... Installer f has been installed in accord ce with he provisions-of . "' r o The State Sanitary od�scribed in the T __ * Xd ­ 7 application for Disposal Works Construction Permit o_____________________ _ ____._____ dated_ --._.--_______.____-____:3:............ THE ISSUANCE OF THIS CERTIFICATE SHALLNOT BE CONSTRUE®. S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ri DATE............... /..--._....... ......... _. Inspector._ - x1f,r �, THE COMMONWEALTH OF MASSA.CH TS � BOARD F HEALTH . _ ............................................. .. /f 1 k on anion rrani� ,. No.. El. Permissio hereby granted_,._ _' to Construc ) Rep ( ,fin In vldual ewage s yste �r i' at No. _ _ ` _... -.-••--- + ......... Street as shown on the application for Disposal Z/rks,ConstructionP No __.__ _.__ ated... ...____. '� Board of Health DATE. == FORM, 1255 HOBBS & WARREN, INC., PUBLISHERS SITE PLAN Design Calculations ITS SCALE: 1"=20' Number of Bedrooms: 3 Existing .0) Ln. BENCH MARK ON TOP OF CONRETE APRON AT GARAGE 0".-100.00' (ASSUMED) 1040 CA Garbage Grinder: NO, GRINDER NOT ALLOWED WITH THIS DESIGN Septic Tank Capacity Required: 330 gpd X 200% = 660 gpd Septic Tank Provided-, 1,500 gallon EXISTING le C Leaching Capacity Required: 330 Gal./Day Leaching Area Required: 330 Gal-A0.74 Gal./Sq.Ft.)=446 Sq.Ft. 4 Proposed Leaching Area Provided: 1-25' X 13' X 2' TRENCH = 477 SQ. FT. = 353 GPD Total Leaching Capacity. 353 gpd > 330 gpd. reqd. 'lot. ryas GENERAL NOTES "CENIE ILLE" 1. ADDRESS: #241 CAP'N 'LIJAH'S ROAD 2. ASSESSORS NUMBER: 193-132 LOCUS QX 3. DEVELOPER'S LOT. LOT 46 4. TOPOGRAPHIC INFORMATION WAS COMPILED FROM AN NO SCALE N� ON THE GROUND INSTRUMENT SURVEY. 5. TOWN WATER IS PROVIDED TO SITE & SURROUNDING PROPERTIES. 6. REFERENCE PLAN: FLAN BOOK 277 PAGE 98 REFERENCE PLAN: CERTIFIED PLOT PLAN, LOCATION: CENTERVILLE, MASS., SCALE: 1"=30'. DATE: SEPT. 12, 1977 `2 13' 2.0' BY THOMAS E. KELLEY CO. (FOUNDATION CERTIFICATION & TITLE V DESIGN PLAN). c in us* 9 H-20 tr nc 7. NO WETLANDS ARE LOCATED WITHIN 200 FEET OF SAS, 00 gal. ho be wi h 4' 8. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS. ston i bet a on & ds. 9 11010 9, THIS PLAN WAS PREPARED FOR THE SEPTIC INSTALLATION ONLY. x 16 CONSTRUCTION NOTES 1. Contractor is responsible for Digsafe notification and protection of all underground utilities and pipes. .................... 2. The septic tank op ,I distripution box shall be set ... .................. level on 6 -11/Z stone.99.W ..b�. ...... .. Or 0/ ......... 3. Backfill should be clean sand or gravel with no TEMPORARY ...... • IMW stones over 3" in size. TURN AROUND 4. This system is subject to inspection during installation by Glen E. Harrington, R.S. 5. The contractor shall install this system in accordance 0 with Title V of the Massachusetts Environmental Code 6 and the Regulations of the Town of Barnstable. 6. Provide ONE, H-10 DB-5 D-BOX and TWO Acme Precast H-10, B. 500 gal. chambers or equal. 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. 8. Install gas baffle or e ual on septic tank outlet tee and. 9. All existing inverts and conditions shall be verified by contractor. UW41 10. The existing SAS shall be pumped & removed. LAWN 9%94' ,_Mr DIM ACM MA10= PERK TEST & SOIL EVALUATIONS LAW r5. DATE OF PERK TESTS & EVALUATIONS: DECEMBER 14, 2005 TEST PERFORMED BY:GLEN E. HARRINGTON, R.S. EXCAVATED BY; JOEYS SEPTIC SERVICE PERK RATE: LESS THAN 2 MPI (ASSUMED) LOT 46 AREA 20,978± SQ.FT. 0 C3 C3 �24 PERK TES1 0 T.H. #J MW Test Hole No. 1 PERK OEPTH-36-54 (Cl) 24 gds applied within 15 min. STIM REWONIM PFEDW CONWM 2 H-10 500 gal. chambers W74 SOILS IELEV- USE PERK RATE <2 MR FOR OESM KWOSES PLANN-Y-10 ENS-SECTION -0* A LJW H-10 500 GALLON CHAMBER NOT TO SCALE U.Byuw • � USE ACME PRECAST OR EQUAL 32. 1~ 97.211 'Z cl C2 87.43' REVISE D;..3,/2/`2006. RELOCATED SAS OUT OF EASEMENT "V/3 LEGEN kk OF PROPOSED SEPTIC SYSTEM UPGRADE NO (2ROL1NDWA7R ENCOUNMtM EN- 0 ' �'ORICHARD W. CALLAHAN ET UX APPROXIMATE LOCATIONA G N EXISTING LEACH PIT .1070 AT (ro BE PUMPED & REMOVED) C o #241 CAP'N 'LIJAH'S ROAD PERCOLATION TEST LOCATION IV T BARNSTABLE (CENTERVILLE), MA 10' min. from *NOTE-. ALL PIPES ARE TO BE 4' DIA. SCHEDULE 40 P.V.C. house to septic tank PROPOSED FO-9-01 EXISTING 1500 CAL PREPARED BY: Existing House 5 HOLE H-10 H-10 SEPTIC TANK OW.WX "hod orade am wyAmm-2% slope away bdeft Grade Elm-990k DENOTES EXISTING GLEN E. HARRINGTON, R.S. Provideriserto within 6' of grade min. r of 1/a'-1/2 "-1/e Provkle-riew X 104.46 to "ft SPOT GRADE 9 L E D A ROSE LANE dotio- atom wftl!� of grod IMIGIL f 1 tevN fr r .01 99 Pagetone Say.-95.V1' -93- EXISTING CONTOUR MARSTONS MILLS, MA 02648 U EXIS1 Ce or Inv. 1500 GMNGAL 14 and wax-20.00' SEP11C TANK nv. elev.= 97.1 ' DEEP TEST HOLE TEL: 508-428-3862 --Lt 7. M-10 am nv. elev.=96.63' nc = OR W lilrenrwIftow FAX: 508-428-3862 APPROX. LOCA .1/'r to 1 11/2-wudvA &V prwAded(IV rWkvd) EXISTING WATERTI ON SERVICE Ir OF ' I 'STOW 4"e-W0*W GtOw Inv.-al LEACH TRENC Iton of TH. #1 al SCALE: 1 =20 APPROX. LOCATION SY5TEM PROFILE #I OF 3/411/r STM 6 EXISTING GAS SERVICE DATUM: ASSUMED FILE: CALLAHAN 2 SHEET 1 OF 1 Not to S00110