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0069 CARLETON LANE - Health
69 Carleton Lane, Centerville IN N 12534 o.2 R `bsrcoc+s o- NASTING9.UN No. ' F/I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitatlon for Misposal *pstem ConstrUttion permit Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) XCompleteSystem ❑Individual Components Location Address or Lot No. ( A-RL-M,.) (;,Auer,LLOwner's Name,Address,and Tel.No. Vf(Assessor's Map/Parcel �9b LA+JG CePTG6W 1"Je Installer's Name,Address,and Tel.No.5'09 Z-V77 Designer's Name,Address,and Tel.No. 50$-.173-d3'7°7 Type of Building: Dwelling No.of Bedrooms Lot Size a0l i t 4p_ sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -3 2e) gpd Design flow provided 3�-9,4 gpd Plan Date y-30 _1;L0(5j )Number of sheets l r Revision Date Title Size of Septic Tank ,®Ord {,L.D Id /Type of S.A.S. G&U-b&/ Description of Soil SAM 00 a , / A(FZ--cco gr, _.;dAm (b> aq l� 5,155 T( 1.] Nature of Repairs or Alterations(Answer when applicable).. iJ5 C� ee`(,(She IL.��s�`(Ooe> �/� 6L� �np-rcL TAA��` � � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si ed Date 2-0 l� Application Approved by "- Date `+ cJ Application Disapproved by Date for the following reasons Permit No. ��� `� Date Issued 614!,lZV15- ' No. �(J 6( :3�- �r_-.;�, Fee w' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS �. Zipplicatlon for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) Complete System ❑Individual Components 7 J Location Address or Lot No. (Pq G1 A61Z prL)e- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel C�D I ck' R-l7 VIE 0R.A C Installer's Name,Address,fand T 1.No.5'Qg-q7-7�E;'S77 Designer's Name,Address,and Tel.No. 50$'yi3'03?`l C�P�ca�Cb6 AK5S-i.Lc. , - C. i EscxJ U 4��t`aC- Type of Building: 5 Dwelling No.of Bedrooms 3 Lot Size iR0,4i((O sq.ft. Garbage Grinder( ) Other Type of Building p=--CDCXt N-1 `{l. - No.of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow(min.required) gpd Design flow provided .34�9,4 gpd Plan Date � Number of sheets Revision Date Title L Size of Septic Tank; ,'[boo (�;rA4-AZ Type of S.A.S. W (,j� �.�,��ti,/ a[�cwX-ra �K(btR5 Description of Soil L01 A" 15,61Q OD « -C �� �J t Nature of Repairs or Alterations(Answer when applicable) J5 E ej(S-G� (Q0 -0 E .Z �j '�G• TALK' n--AO)c Cad :506 idt) (EACA10G. 1 -xzc GolrA Fes' rjV (R-art CgAQZ a Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si ed Date f , Application Approved by Date y Zoi Application Disapproved by Date for the following reasons Permit No. ZO[ 16 ( Date Issued 6&17v15 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS CPrtifkate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by C A?Lw(bE bJ Z.,(.c_ at GSj A��, � 41,3 E l ��L� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No - — 16( dated G Installer AQ o)1 ®/l J$��L` Designer ;TC.. E)�j &/t,jl #bedrooms 3 Approved desi flo 3 gpd The issuance of his :ermit shall not be construed as a guarani ee that the system wil nc as d se i d. Date (Q 3 ( Inspector / ------------------------------------------------------------..-------------------------------------------------------------------------- No. 15 — 1 W Feet �, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal .pstem (Construction Permit Permission is hereby granted toConstruct( ) Repair(, Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her du to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permi Date���— Approved by 93998 N. 00-1/UV 1 �06/04/2015 08 :29 5082730367 Tovvn of Barnstable Regulatory Services g, Thomas F.Geller,Director Public Health Division NAM tb�o Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790.6304 Date: �O"y" -� Sewage Permit# L.01 r Assessor's Map/Parcel l 9 Q l z 3. Installer&)Dtsianer Certification Form Designer: 5c- rlh�t�ee`in�� , Tr�C Installer: Gc�rrw�de �r►Eerfcises Address: Z95 y UwSoe-cry4- Ir►w — Address: I G 3 Comm arcl'a( Strut ra,k uuafe.M6m 51,4 0153 h zc-273•,0377 On (c -; -01,�! G��ewcd� G'n�zc rises was issued a permit to install a . (date) (installer) septic system at 6 9 Ce c,(e ka n 1--41 e- based on a design drawn by (address) 'I C En5zoee_cioc) , Tic- dated May 80i, t (designer) i I certify that the septic system refbrenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system rei'erenced 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. Stripout (if required) ' s ected and the soils were found satisfactory. 'A Of JOHN L. CHURCHILL a JR. I t ler's ature) ML Itoo fASE signer s Signature (Affix Deg Here) P RETURN TO ARNSTABLIE PUBLIC HEAL DIVISIO —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. gAoflice forrnsldesignereertifieation form.doc . a TOWN OF BARNSTABLE LOCATION �� �� C i�l�l L 4 w E SEWAGE# XLLAGE Eo1mZ%qt( i C AAS�� E� E l��I NSESSOR'S MAP&PARCEL (� INSTALLER'S NAME&PHONE NO.�tPC0GVeises( ri-98", SEPTIC TANK CAPACITY l4�® LEACHING FACILITY:(type) (Z) Scg> at oUg c3c7,S (size) X a5 NO.OF BEDROOMS OWNER 'Rt My(ab 1 PERMIT DATE: (©—CJ—a0J COMPLIANCE DATE: 3 --.©C 1 Separation Distance Between the: tic) Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility QJtD 4w Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) NJ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) isk 4 Feet A FURNISHED BY ��t✓�f� l.�t'e6�Q1� r Ca r J-dv^ IU ON e- f P RCAR 41.E A-z Town of Barnshable P# d (o Department of Regulatory Services >u Public Health Division Date y 3 o 15- �Af 1e39.A� 200 Main Street,Hyannis MA 02601 . ��aq,. Ftr ntat / ' G Date Scheduled Fee Pd. Tithe— _c> Soil Suitability Assessmentf foe- Sewage isposal Performed By: Cy h, 8 uW a ( L I G 5 6 Witnessed By: ✓ 10� Location Addres LOCATION& GENERAL M-OBMATION s � CI�A 0A�t.E'�?� E f Owner's Name �9 Address Assessor's Map/Parcel �� la�3 tom. Engineer's Name (t6862oeoe t'-. iq e.,•e..t._ ° 6 NEW CONSTRUCTION ITC Ch5ttieer611S REPAIR TeJ.epbbne# 5,0 a C,7'1 o 8'2•-?'1 Land Use _5(45U4oro�t Aw�tlt:vl 50 8-273-0 37 7 y S Slopes(%) ►' 3 Surface Stones .. Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Dralnage Way - ft Property Line /t> _f[ Other ft it SKETCH:(Street name,dimensions of lot,exact locations of test holes&)?erc tests,locate wetlands i,t n proximity, to holes) Sze- Parent material(geologic) 0Ukwc Depth to Bedroclt Depth to Groundwater. Standing Water in Hole: Weeping from Pit Foce Estimated Seasonal High Groundwater 7 DETERAIINATION FOR SEASONAL-E (GI WATER TABLE Method Used: Vireo obs e j.+ror, Depth Observed standing in obs.hole: 2 13.2 In, Depth to soil mottled: Depth to weeping from side of obs,hole: ltt' Index Well#: — Itt. Groundwater Adjuattnent ft. Reading Date: — Index Well leY01 _ Adj.factor _ A,Q Groundwater Level PERCOLATION TEST bate 5-20-i5 J huo F -�----. Time at 9" _ m 3lo-5`� Time at G" \ Start Pre-soak Time @ )U:G U Time(9"-6") End Pre-soak 10 Rate Min./Iuch 1-2. Site Suitabili Assessment: Site Passed y�S 1 J . h' Site Failed: _ Additional Testing Needed(Y/N) N .►"� Original: Public Health Division Observation Hole Data To Be Completed on Back--------- ***If percolation test is to be conducted within 100 of wetland, must first notify the. Barnstable Conservation Division at least one(1)week;prior to beginning. Q:\S EPrIC\PERCFORM.DOC DEEP.OBSERVATION]BOLE LOG Mole Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. onsistency,%Y3rayell • �-3� 6 LS /wy� �l6 ' � ' 34- V8 G- I 6.5 /UYrsly y8 - $o G-2 /I-05 2.5`( 5/6 5% sr go. 13 Z G-3 rtS 2 5. 6/3 DEEP OBSERVATION HOLE'LOG hole# Depth from Soil Horizon Soil Texturc' Soil Color Soil Other Surface(in-) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. on i en %(3rayell DEEP OBSERVATION BOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil` Other Surface(in.) (USDA) (Muosell) Mottling (Structure,Stones,Boulders. Consistcnev. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. I+lood Insurance Rate Map: Above 500 year flood boundary No_ Yes Wi►liln 500 year boundary No Yes Within 100 year flood boundary No-. Yes _ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? YES If not,what is the depth of naturally occurring pervious material? Certification I certify that on 0� U (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and,e"erience d cribed in�10 CMR 15.017. Signature V Z Date 6 Q:\SEM0PERCPORM.DOC THE T Town of Barnstable -Barnstable �.�.~ Regulatory Services Department jmicaCfty BARNSfABM `"�: Public Health Division rfD"" a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7014 1200 0001 0358 0338 May 14, 2015 Richard Pereira 69 Carleton Lane Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 69 Carlton Lane, Centerville, MA was last inspected on • April 25, 2015,by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Back up of sewage into facility or system component due to overloaded or clogged SAS or cesspool. • Leaching pit or cesspool with high liquid level,<12" below pit (per Town Code 360-9.1) You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH <:=Uasl-ela"n, R.S., CHO Agent of the Board of Health • QASEPTIC\Letters Septic Inspection Failures or Future Evl\69 Carlton Ln Cen May 2015.doc f Town o 7 Barnstable • anxivsrnHr.e. "59 1639. Regulatory Services Department �0 ptfQ MA'S A Public Health Division 200 Main Stre(;t, Hyannis MA 02601 Office: 508-8624644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/28/15 DEADLINES TO REPAIR, FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone l to a public well ❑ Any portion of a cesspool within 50`feet of a�private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) �eaching pit or cesspool with high liquid leveil, <1.2" below pit (per Town Code §360-9.1) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc r r. Commonwealth of Massachusetts Title 5 Official Inspe ;tion Form uv Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;2c 69 Carleton Lane Property Address �r Richard Pereira �-e Owner Owner's Name information is required for every Centerville MA 02632 4-25-15 page. Cityrrown State Zip Code Date of Inspection 'N;a 4� 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 ngout forms A. General Information �r on l the computer, / �o� �j\A OFr '91%p use only the tab 1. Inspector: key to move your JAMES G cursor-do not James D.Sears use the return SPARS key. Name of Inspector CapewideEnterprises,LLC I� Company Name .,�i�'�F.,R;rF •�G�Q\�: 153 Commercial Street i�����151 iN Sp�"`����� Company Address Mashpee _ MA 02649 Cityrrown State Zip Code 508-477-8877 _ S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority _ 4-25-15 spectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not addre;ss how the system will perform in the fut r I under the same or different conditions of use. �1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is required for every Centerville NIA 02632 4-25-15 page. Cityrrown :3tate Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.301 exist. Any failure criteria not evaluated are indicated below. Comments: The system is failed. The system is a 1000 Gal. Tank D Box and pit. 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 oldi*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Noi t for Voluntary Assessments '< 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is Centerville MA 02632 4-25-15 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operafonal. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break cut or high static water level in the distribution box due to broken or obstructed pipe(s)or due to E broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ , obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not funcl ionmg 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments t 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is required for every Centerville MA 02632 4-25-15 page. Cityfrown 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 tribL!tary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cessl')ool ® ❑ Liquid depth in is less than 6" below invert or available volume is less than 1/day flow (7. - t5ins-3113 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is required for every Centerville NIA 02632 4-25-15 page. City/Town ;sate Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping mout 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 Hiell water analysis,performed at a DEP certified laboratory,for fecal caliform 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 rust 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 fleet of a tributary to a surface drinking water supply ❑ ❑ the system is located in -cI 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 1 ection 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 Suction 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 '�CN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 69 Carleton Lane Property Address Richard Pereira Owner owner's Name information is Centerville MA 02632 4-25-15 required for every page. Cityrrown c)tate Zip Code Date of Inspection C. Checklist Check if the following have been done. You irrrwst 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 NIA) ® ❑ 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): NA — Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I - Commonwealth of Massachusetts Title 5 Official Inspecition Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is Centerville MBA 02632 4-25-15 required for every _ page. Citylrown St€ate Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal Tank D Box and Pit. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2013-34,000Gals g ( y g (gp )) 2014-32,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: PresentDate 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.fL, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 sy>tem? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspecttion Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 69 Carleton Lane Property Address Richard Pereira Owner owner's Name information is Centerville MA 02632 4-25-15 required for every _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 2007-2010 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 oti'tained from system owner)and a copy of latest inspection of the 1/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-No#for Voluntary Assessments 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is Centerville MA 02632 4-25-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1977 Permit#77-404. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"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.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 10"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 or 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 69 Carleton Lane Property Address Richard Pereira Owner Owners Name information is required for every Centerville _NIA 02632 4-25-15 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 27" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and cover's at 10" below grade. In and outlet baffles. No sign of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspecytion Form Subsurface Sewage Disposal System Form-N()t for Voluntary Assessments 'f 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is Centerville NJA 02632 4-25-15 required for every _ page. Cityrrown Slate 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, evident:of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 official Inspection Form:Subsurface pecti Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is Centerville MA 02632 4-25-15 required for every _ page. Cityrrown Stab, Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x21"-20" Below Grade. Wall's are gone on box w/one line out. Need to replace D Box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Y Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is Centerville MA 02632 4-25-15 required for every _ page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal Precast Pit. Pit at 18"below grade w/cover at 6". Level in pit is less then 12" below inlet line w/stain line at 6"below inlet. Pit not leaching. Need to replace leaching. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is required for every Centerville MA 02632 4-25-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 a Commonwealth of Massachusetts Title 5 Official Inspecti':)n Form d Subsurface Sewage Disposal System Form-Not four Voluntary Assessments r 69 Carleton Lane Property Address Richard Pereira Owner owner's Name information is required for every Centerville MA _ 02632 4-25-15 page. Cityrrown State Zip Code Date of Inspection D. System information (cant.) 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: Z hand-sketch in the area below drawing attached separately w 7-3 aW ER ,r U f, Lj 't) 2 C�- f is 7 I b e 6t J,e Ej 03 t5ins•3f93 Title 5 Qt6"KVe' -Form:S-t--ace Sewage Disposal System•Page 15 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 69 Carleton Lane Property Address Richard Pereira Owner Owners Name information is Centerville MA 02632 4-25-15 required for every _ page. Cityfrown 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. 42' 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: U.S.G.S. Well SDW 252 at46' You must describe how you established the high ground water elevation: U.S.G.S, Well SDW 252 at 46'w/4'adj Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 69 Carleton Lane Property Address Richard Pereira Owner Owner's Name information is required for every Centerville MA _ 02632 4-25-15 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 �X 10 Lill COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVXRONMENTAL PRO T11 ONE WINTER STREET. BOSTON• MA 02108 617-292-5500 l0 7 19 9T C N�a(Tyo pjTAB[� W'ILLIAM F.WELD 49 TRUDYiCOXE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Judy McVarish 503 Commodore Ct Property Address: 69 jganr-1'fT?+4' Ln, Centerville Address of Owner: Spinnaker Island Date of Inspection: rG—r -d—9/7 (if different) ' Hull, MA 02045 Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Service Mailing Address: PO Box 1089 , Centerville , MA 02632 Telephone Number 5 0 8 7 7 5—8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving; Authority _ Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional 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: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] STEM 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. Indicat 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 Compliance (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 04/25/97) Page 1 of 10 DEP on the World Wide Web: htta:1twww.magnet.state.ma.usldep Printed on Recycled Paper �+. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r ( PART A t ` CERTIFICATION (continued) Property Address: 69 Carlton Ln, Centerville Owner: McVarish Date of Inspection: %U OZ a—4 7 SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a 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 levelled 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) URTHER 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. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (con;tinued) Property Address: 69 Carlton Ln; Centerville Owner: Mc Varish Date of Inspection: /0—XO-9 �7 YSTEM FAILS: You ust indicate er; ,er "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 into facility or system component due to an 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 lit day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. 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 I 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] RGE SYSTEM FAILS: Y must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: 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 req irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 69 Carlton Lin, Centerville Owner: MCVari sh Date of Inspection:Check if if the following have been done: You must indicate either "Yes" or "No" as to each of the following: es No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or / as part of this inspection. _ V _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. V _ 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. Ll —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) s: (revised 04/2S/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 69 -Carlton Ln, Centerville Owner: McVarish Date of Inspection: It> -;,0 7 FLOW CONDITIONS RESIDENTIAL: Design flow:3,70 g.p.d./bedroom for S.A.S. Number of bedrooms:_ Number of current residents: Garbage grinder (yes or no):-±:G Laundry connected to system (yes or no):-,y'-'3 Seasonal use (yes or no): Water meter readings, if available (last two (2) year usage (gpd): 19 9 5 - 13, 000g Sump Pump (yes or no): 1 9 9 6 - 2 7, 0 0 0 g Last date of occupancy: CO ERCIAUINDUSTRIAL: Type establishment: Design ow:_gallons/day Grease t ap present: (yes or no)_ Industria Waste Holding Tank present: (yes or no)_ Non-san tary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last LR: of occupancy: OTH (Describe)Lastof occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)�d If yes, volume pumped: gallons Reasori for pumping: TYPE O 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) I/A Technology etc. Copy of up to date contract? Other ' APPROXIMATE AGE of all components, date installed (if known) and source of informations O .S Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 0 Carlton Ln, Centerville Owner: McVarish Date of Inspection: /(>—Xe B ING SEWER: (Locat on site plan) Dept below grade: ntin Mate al of construction: _cast iron _40 PVC _other (explain) Dist nce from private water supply well or suction line Di eter C . ments: (condition of joints, v a g, evidence of leakage, etc.) SEPTIC TANK: (locate on ¢ite plan) Depth below grade: /O Material of construction: _ oncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: `� �, °1` 10 0--e-2 qA ' Sludge depth: 3^±i ' Distance from top of sludge to bottom of outlet tee or baffle:4/o Scum thickness: (5—/ ► 1 Distance from top of scum to top of outlet tee or baffle:_ , Distance from bottom of scum to bottom of outlet tees or�baffle: How dimensions were determined: a 4 Comments: (recommendation for pumping, condition of inlet a d outle tees or baffl s, depth of,lliquid level inrelation to outlet invert, structural integrity, evidence of leakage, etc.) A.- GREAS TRAP: (locate n site plan) Depth low grade: Material f construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum t ickness: Dista a from top of scum to top of outlet tee or baffle: Distan from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Comme ts: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integri , evidence of leakage, etc.) (=evieed 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 69 Carlton Ln, Centerville Owner: MCVarish Date of Inspection: /(9_ - TIG T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (local on site plan) Depth low grade: Materia of construction: _concrete _metal _Fiberglass _Polyethylene __other(explain) Dimen ions: Caps ty: gallons Desig flow: gallons/day Alarm vel: Alarm in working order_Yes; _ No Date of revious pumping: Comme ts: (conditi of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_/ (locate on site plan) pp�� Depth of liquid level above outlet invert: V Comments: (note if level and distribution is equal, evident of solids carryover, evidence of leakage into or out of box, etc.)_( L G -j6 9�i G PUMP C AMBER:_ (locate o site plan) Pumps ' working order: (Yes or No) Alarm in working order (Yes or No) Comme ts: (note con ition of pump chamber, condition of pumps and appurtenances, etc.) 14 (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART C SYSTEM INFORMATION (continued) Property Address: 69 Carlton Ln, Centerville Owner: 1�cVari sh.., Date of Inspection: /D 7 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) / p AT 3 ' CESS O15: _ (locate n site plan) Number d configuration: Depth-top f liquid to inlet invert: Depth of s ids layer: Depth of sc m layer: Dimensions of cesspool: Materials of onstruction: Indication o groundwater: inf aw (cesspool must be pumped as part of inspection) Comments. (note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on sit plan) Materials o construction: _ Dimensions: Depth of lids- Comments: (note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: .69 Carlton Ln, Centerville Owner: McVari h Date of Inspection: /G—oZ o.may 7 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) 3 � 4 ` l lL 1 _ (revised 04/25/97) Page 9 of 10 1` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 69 Carlton Ln, Centerville Owner: McVari sh Date of Inspection: `O^;k-e— <j x Depth to Groundwater d O Feet Please indicate all the methods used to determine High Groundwater Elevation.. /Obtained from Design Plans on record f/ 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 Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) tizi�7 (revinqd 04/2S/97) Page 10 of 10 Fizx THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE'=ALTH �p T.QWN...... oF.........BARNSTABLE -�����irttt�nn��fux �i,��nstt1 .>�rk,� Cnl�n��r�rttuYt �(rr�it Applications hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: q s Carleton Lane Lot<:.�14 -----------------------------------------•---- ........................ ........................................._......... ............................................ L m on ddress or Lot No. ---- .............. . ......................... ••--------..-••-•••--•--••--------•----.....--•---......--------•---.............................. e O e Address ................•-•---•-------. .•. Installer Address 2 0 816+ q Type of Buil ing Size Lot..-.---.i------------------S feet Dwelling—No. of Bedrooms--------- .................................Expansion Attic ( ) Garbage Grinder (Iff) aOther—Type of Building ---------------------------- No. of persons_...__---_--__-__---_--_-__ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow------3.3.0..............................gallons. WSeptic Tank—Liquid capacityl_000gallons Length..$_'.-.6". Width4-1_.-10'..'Diameter---------------- Depth---5'-4'_.' x Disposal Trench—No. .................... Width-------------------- Total Leqgth.................... Total leaching area..-.-------_._._----sq. ft. Seepage Pit No.........I--_-__--__ Diameterl.01_-0"__.. Depth below inlet52.7.7"...... Total leaching area---2-52-------sq. ft. Z Other Distribution box (X ) Dosing tank ( ) aPercolation Test Results Performed by....Cape-..Cod...Sur ey.._r-Qns-ul.tari-tote...June...29......19.7.7 .a Test Pit No. 1...... --------minutes per inch Depth of "Pest Pit......12__'------- Depth to ground water.... fZA Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wate ��PySN-OF_,ta q P4 •--------•---------------------------------------------------- d' O Description of Soil_..._._.._.0.'-.-0 -5 woo d loam 7 .07-12. 0 Cleari WfiIt --WI •-• RENWICK--- G x 0.5 3.0 subsoil--•-------•---------- ----- ---- ----------------sand--- ----- o a: U -----------•--------------------------------- r----•-.........................i ..................... •CNAPNTAN--- W 3 .0 -7.0 coarse sand & graver ti x - - -------------------------------------------------------------------------------- ---------------------------------------- A ao:�tss U Nature of Repairs or Alterations—Answer when applicable..----------------------------------------------------------------- �'p Fcr�T��`� -------------------------------------------------------------------------------------------------------------------------------------------------------------------- FsslO NG�� Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor ance wit the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bZn ue thy• and of healt . c �� -------------------------------- Date Date Application Approved By._...` 9 . P / `- ' Application Disapproved for the following reasons:___.__...____.. -------••�-------------------------•----•-------------------------.Date -•------•--•- ...............•-••--•-----------------------------.•----•-------------....•••---•--••-------•----•--- Date PermitNo........................... ...................... Issued---- ........................ Date / . FEs....... u'� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -" TOWN BARNSTABLE Appliratinn -fear Bhipaoal. Workii Tonfitrurttnn Prrmit Application isx hereby'made for a Permit to Construct ( 2� or Repair ( ) an Individual Sewage Disposal System at: Carleton Lane _ / Lc�t14 t - .. --- ....................... ... ............ - - ----------•---•------•-- j. Location-address or Lot No. r t ) .� . _ !: C/ ................ . .........-..—0 r =. Address.... -•-•............................. Wf ......... .........................•---_.._...._........--------_._...•--•-_._............................-- 911 Installer Address 2 0 6+ UType of Building Size Lot... t....._...9L„____Sq. feet ., Dwelling—No. of Bedrooms----------3_______________________________Expansion Attic Garbage Grinder ( /Y) ,:: Other—Type of Building ---------------------------- No. of persons____________________ _____ Showers ( ) — Cafeteria ( ) W Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow........3.0.............................gallons. WSeptic Tank—Liquid capacitv.10.0.(�allons Length---8_'_"6_°'vVidtti_ 1.-I.O.t'Diameter________________ Depth.... x Disposal Trench—No. .................... Width-------------------- Total Length._...,,. Total leaching area.__._.______...__-_.sq. ft. Seepage Pit No...........�.________ Diameter_.1Q.'__-.001._ Depth below inlet�'6'-$_"._... Total leaching area....25-2------sq. ft. Z Other Distribution box ( x) Dosing tank ( ) Percolation Test Results Performed by-----C_ape...C_Od..SV"t VP'-Y-._.Q11S.Ult1> a-_---June--_2_9_,_._1977 a Test Pit No. 1-------2-------minutes per inch Depth of "Pest Pit.......12._...... Depth to ground water________________________ rX4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water O Description of Soil---_._---- y 0_:3 -f_- woad--loam 7::� iZ.II clean""caFiit o=� t�ravre�c cya subsoil sand---- v ------------------------------------- t . �------------B:----- ---- m ----------- - 3-.0- -7-:i7• coarse sand & ravel------------------------ ------------ - - o VW -------------------------------------------------------------------- g -`------CHAPMAN---- v' Nature of Repairs or Alterations—Answer when applicable--------........................................................ No. 27654, --------------------------------------------------------------------------------- Agreement: NAL ENS' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor with the provisions of Article LI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bi a thard of heal r Signe . -_.... .............••---------.----• ------. ...--- -__ Date Application Approved By.__.... r., - �.._----•--------- --- ..f '*77----- Date Application Disapproved for the following reasons:---•-------- -"........ ... ..... .••-----------------------••---------------.._._---------•--........---•-- -------••---•--•---•---------------------------------------------•---•-•----•---------........._.........---._.....-------------------•-•....--•-_...__......._..-----.._._...-------------------------- 'Date Permit No----------------- `' Issued. = Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J O F........... ..... Tntifirntr of fin nplinnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..................................................................................................................................................................................................... Installer at--•-------•-------•--------------------------•-•--•••------------------------------------------------------------------------------------------------------------•--------------•---•---•------.----- has been installed in accordance with the provisions of Article )�.:I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------------------------------------------ dated----- _.--.___-_.--.-.---__.--------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................................................................... ...... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF E-ALTFL O O p ..._.................0&C.•.... �G ........... O ................................... No......................... FEE......................... Bi_rlvn.6�l1 nrk�nnni;rnrttn/B� rrntit Permission is hereby granted------------l_zll-.. ✓...................... to Construct ) or Rey it ( ) an I ivid 1 wage osaI S stem/� /J � "� at No. ~ '----"""-...•. 7. - (P.<f Lis_ Street `-- �Z as shown on the application for Disposal Works Construction Permit No___*Board ___ Dated.... ._�-_/.___..___..... _.._. �� --------------------------------- ._...----------------'--- -7Z._ DATE. ��'-1 7 of IIealth r- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS LOkCATION SEW IT NO.. � VILLAGE INS / LLER'S A DRESS -11-1 ./ ll l B x- URDE R 0 !WNE ' DATE PERMIT ISSUED 7- DATE COMPLIANCE ISSUED � _.�- '71 s q` w r 1 I' ° SOIL LOS-7 — �,J.�ll�:10\V�Nw lih�,ri ii=fj"s.�i!�Wi)✓�� •aas - i S}/ _ 2°.PEASTONE ... LOAM d FILL 12 MAX. eaOD Lo,e,y /7`0 •.. o a p0 0l �Z. /yJ j DIST. e' BOX I�� °° 02; ono IIQ00— GAL. ,WMIN. 1000 ,t GAL. PRECAST. OR c 0 I e vbZ SEPTIC 6 �, o ° BLOCK c 0 0 � TANK ; ° o SEEPAGE PIT n o ° ° 11 GGc N ° 0 0 00 0 0 20' MINIMUM _ ' ' - FOUNDATION I, ° \ 1 1 %s WASHED STONE _ Z ELEVATION SKETCH I _ 10, \\(p', Pape. RATE I ur,r>r-Q 2rnl�r/�M�h it TEST BY : G'F :JN,Tie�CT P4-kfi 121J SCALE, I"= 4' TOWN INSPECTOR: 'Da-G BACKHOE OPERATOR AQ��''TT �'' L A , �z TEST MADE ON k2l Z5) 77 / / G,Pjp p 4 i 14 -19 jig X160 OF I' RENWICK �y 13, CHAPMAN I NO, 27654,0 U Q �F. GIST i SS7ONAL ECG ELEVATION SCHEDULE PROPOSED SITE PLAN I. INV. AT FOUNDAT°ION SEWAGE SYSTEM DESIGN IN 2. 1 NV. INTO SEPTIC TANK - — _ 3. 1 NV. OUT OF SEPTIC TANK - — CC�T s?vilt t 1-ymss , I 4. INV. INTO DISTRIBUTION BOX ,�'� SCALE: I"=.Za' 1- pY 19 77 5. .I NV. OUT OF DISTRIBUTION BOX - �� Gjp CAPE COD SURVEY CONSULTANTS 6. INV INTO SEEPAGE PIT - — ROUTE 132 11 1d?�• HYANNIS;MASS. i4 Z BOTTOM OF PIT - ` Q q A DIVISION BOSTON SURVEY CONSULTANTS, INC. B. 130TTOM OF STONE LAYER ,i FINISH GRADE OVER CHAMBERS = 53.5T.O.F. EL.= 55.0'± FINISH GRADE OVER D-BOX= 53.5''F ' - 53.9 PROP. VENT WITH CHARCOAL FILTER TO ABOVE GRADE GENERAL NOTE S 3/4"TO 1-1/2"DOUBLE WASHED REMOVABLE WATER-TIGHT COVER OVER SLOPE 2/° MIN. OVER SYSTEM STONE TO CROWN OF PIPE PROVIDE EXTENSION RISER 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION WITH COVER OVER INLET& RISER TO WITHIN 6"OF FINISHED GRADE 4"SCHEDULE 40 PVC OUTLET TO WITHIN 6"OF F.G. ° INSPECTION PORT WITH ACCESS 2"OF 1/8"TO 1/2" DOUBLE WASHED METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL FINISH GRADE �F . R TANK EL. - 54.0'± 5"DIA. OUTLET(S) MIN SLOPE 1 /o BOX TO F.G. (SEE NOTE#21) STONE OR GEOTEXTILE FILTER FABRICCODE AND ANY APPLICABLE LOCAL RULES. @ END. EL.= 54.5 ± - 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE 1 i PLACE RISERS ON ALL DESIGN ENGINEER. PROPOSED 4" 9"MIN. TOP OF SAS = 50.50' CHAMBERS WITH --EXISTING 4" „ 3.40' MAX. 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL SEWER PIPE ��� SCH. 40 PVC 36 MAX. 49.50' SEE NOTE 22 BREAKOUT EL= SO.00� INLET PIPES TO 6"OF SYSTEM UNLESS OTHERWISE NOTED. SEWER PIPE FINISHED GRADE �� 3" DROP MAX _ 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN 6 3 2"DROP MIN 3 9 L 2H ± PROVIDE WATERTIGHT ELEVATION = 50.00' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A c- MIN.SLOPE Q 1% o ce) 4" PVC IN FROM JOINTS (TYP.) ��� 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF 14" *51 .3'± SEPTIC TANK 4" PVC OUT TO O 0 0 o 0 0 0 O 0 0 o THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. CONTRACTOR TO PROVIDE -- -- (0) LEACHING FACILITY o0 00 0 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. SPECIFIED DROP BETWEEN " " oo = 0 = 0 0 = 0 D O D O INLET AND OUTLET CONTRACTOR CONTRACTOR SHALL , 12 6 , T oo � � � � � � � � � o 0 000 � � � � � o o �. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. SHALL VERIFY SIZE 48" VERIFY CONDITION OF OUTLET TEE 50.00 MIN. 49.83 0 0 0 0 0o LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK f AND CONDITION OF EXISTING TEES GAS BAFFLE 6"CRUSHED STONE FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS EXISTING SEPTIC AND REPLACE AS o 0 0 C 0 0 0 0 0 OVER MECHANICALLY o _ NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH TANK NECESSARY COMPACTED BASE , 5 4'0 8.5'(TYP) - I 4'0 4.0' 4.0' AND DESIGN ENGINEER. ��- OUTLET DISTRIBUTION BOX 4.83' 8. ELEVATIONS BASED ON APPROXIMATE M.S.L DATUM. BENCHMARK ELEVATION OF 55.00, TO BE INSTALLED ON A LEVEL STABLE 25.0' (NP.) ESTABLISHED ON THE TOP OF CORNER BULK HEAD AS SHOWN ON PLAN. BASE. FIRST TWO FEET OF OUTLET 47.50, GROUND WATER ELEV.= < 42.50' PIPES TO BE LAID LEVEL. 12.83' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK 2 - 500 GALLON H-20 CHAMBERS MIN- H-20 CHAMBER END VIEW THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT CROSS SECTION VIEW 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES . • SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL TYPICAL CHAMBER PROFILE H-20 CHAMBER DETAILS TO THE DESIGN ENGINEER. CON-1 tv�i� "OR TO VERIFY EXISTINU LL._vi-,I SUN PRIOR 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. TO ANY WORK & NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE - 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING • * . r TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM M «• " * '* •r ��` r PERC NO. 14687 APPROPRIATE AUTHORITY. • ew ' • ••s ; • ; + * ` INSPECTOR: David W.Stanton, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS • • • ' EVALUATOR: Bradley M. Bertolo, EIT, CSE LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE • • • * " r ' '+ THEY SHALL WITHSTAND H-20 LOADING. ' • ! •• ; C.S.E.APPROVAL DATE: July 2003 ' • . + '� a a DATE: May 20, 2015 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. r ' « " • • � � : 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM AND UNSUITABLE MATERIAL •W o * • * we• TEST PIT# IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. REPLACE ALL �EMiN� r ; r ! + r • ELEV TOP = 53.50' UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, FINES OR OTHER F UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). E O / . . . • r ' ELEV WATER= <42.50' N� \ EOG * 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN N LP Pal ,« • t; �a `a • ** PERC RATE _ <2 min./inch SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. '. • �r *+!. DEPTH OF PERC= 36"-54 16. PROPOSED PROJECT IS LOCATED WITHIN:• �' - �•. 0 ` ,�+ • - r , • *� * TEXTURAL CLASS: 1 ASSESSOR'S MAP 190 PARCEL 236 �6os�o a ♦ : * • O # OWNER OF RECORD: RICHARD D. PEREIRA /\ m • •• •* a •• r !a+ 0�� x 53.50' o 4 / a „• •• r • •. • , �. A Loamy Sand ADDRESS: 69 CARLETON LANE GPS. . I •� s • + * • Q, ! 6„ 10Yr 3/2 53.00' CENTERVILLE, MA 02632 Q • 7 / * ; • •• III • i Loamy Sand FEMA FLOOD ZONE X Ix 5:154 - ( / J Q + • 060 ••. . LOCUS a ' C4 ! B 10Yr 5/6 COMMUNITY PANEL# 25001C0561J -N� - 54- �(� �� \ \ ' _ } �` 4 s •�• « • �`�-�,So 36" Loamy Sand S so 50.50 17. DEED REFERENCE: DEED BOOK 11127, PAGE 14 Z ��ti r r•+ . �: • lr.. C-1 10Yr 5/4 18. PLAN REFERENCE: PLAN BOOK 237, PAGE 97 1 , I 4 0 r .. . Perc oy Z v0 Loose •,. . ' +'��`: • "' 48" 49.50' 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. ` i J • ' ' ,� 1� 54" 49.00' 20. PROPERTY LINE INFORMATION IS ONLY APPPDXIMATE. THIS PLAN IS TO BE USED ONLY ( \o \ #69 MAP 190 LL 3 , } Medium -Coarse Sand EXISTING PARCEL 236 W o i .• r C-2 FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY +► + i 2.5Y 5/5 3-BEDROOM 20,816±S.F. `* �o eech 15%gravel FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. °'tii►r „"-' '� " r 1 \ ° DWELLING K `- O , , ' •• • 0 80" 46.83' \ ,)y ' * -- 21. A 4 PERFORATED SCH. 40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A TOF = 55.0'± °D _ H .+ DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3" OF FINISH GRADE. A 1 \ K �� C-3 Medium Sand REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS. \ � LOCUS PLAN 2.5Y 6/3 22. IN ACCORDANCE WITH 310 CMR 15.401 -15.405, THE FOLLOWING LOCAL UPGRADE ON 0 EXISTING 1,000 GALLON SEPTIC TANK f� N � \f ' TO BE UTILIZED IN THIS DESIGN APPROVAL IS REQUESTED FROM 310 CMR 15.221(7): Benchmark r ° f�X� SCALE: 1" = 1000' (1.) A 0.40'WAIVER(3.00'-3.40') FOR THE MAXIMUM COVER OVER THE LEACHING FACILITY. Comer Bulk Head 132" 42.50' Elev. =55.00' �i ✓ ----EXISTING LEACHING PIT (APPROXIMATE Approx. M.S.L. \ ' / LOCATION ONLY)TO BE PUMPED, FILLED WITH No Standing, Weeping, or Mottling Observed CLEAN COARSE SAND, AND ABANDONED t I „_ 12° 53x8' DESIGN DATA w 24 PR. D-BOX LP TEST PIT DATA LEGEND o ( x5 - -- - `* 53x5' 53x5 PERC NO. 14687 50x0' EXISTING SPOT GRADE CV) I / NUMBER OF BEDROOMS (DESIGN) 3 INSPECTOR: David W.Stanton, R.S. 50 - EXISTING CONTOUR N c+'i ` o I I �p� 1, EVALUATOR: Bradley M. Bertolo, EIT, CSE , Z `TP 1 O ��3x9 E FEN X���' J/ ' DESIGN FLOW 110 GAUDAY/BEDROOM C.S.E.APPROVAL DATE: July 2003 50 PROPOSED CONTOUR MAP 190 \ `53x5' O �OCKP'�X�X TOTAL DESIGN FLOW 330 GAUDAY I 14" S�X�X DATE: May 20, 2015 50 PROPOSED SPOT GRADE PARCEL 9 , \ 1 ' __' � SWING-TIES SCALE: 1" =20' DESIGN FLOW x 200 % = 660 GAUDAY TEST PIT#: 2 GAS - - EXISTING GAS LINE 53x8' �18„ 53x6' DESCRIPTION HC-1 HC-2 USE EXISTING 1,000 GALLON SEPTIC TANK ELEV TOP= 53.50' TELE - EXISTING UNDERGROUND TELEPHONE CORNER OF STONE (1) 35.9' 85.8' ELEV WATER= <42.50' PROP. 2 -500 GAL. H-20 PERC RATE O/H/W EXISTING OVERHEAD UTILITIES LEACHING CHAMBERS CORNER OF STONE(2) 29.8' 63.6' _ (- WITH AGGREGATE = CORNER OF STONE(3) 42.5' 71.4' INSTALL 2 - 500 GALLON H-20 CHAMBERS DEPTH OF PERC -W-W - EXISTING WATER LINE / PROPOSED INSPECTION PORT CORNER OF STONE (4) 47.0' 91.6' TEXTURAL CLASS: 1 TEST PIT LOCATION � SIDEWALL CAPACITY (LENGTH + WIDTH) (2 SIDES) (2' HIGH) (0.74 GPD/S.F.) = GAUDAY EXISTING 1,000 GALLON SEPTIC TANK 9° 33 55 5 - (25.0'+ 12.83')(2 ) (2' ) (0.74 GPD/S.F.) = 112.0 GAUDAY 0„ 53.50' O a S6 3a g8 / MAP 190 A Loamy Sand #69 BOTTOM CAPACITY 6„ 10Yr 3/2 53.00' PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE PROPOSED 4" PVC VENT PIPE; PARCEL 83 EXISTING (LENGTH x WIDTH) (0.74 GPD/S.F.) = GAUDAY ❑ PROPOSED DISTRIBUTION BOX EXACT LOCATION PER OWNER 3-BEDROOM (25.0'x 12.83') (0.74 GPD/S.F.) = 237.4 GAUDAY B Loamy Sand 10Yr 5/6 DWELLING - 55.0'± HC-2 � PROPOSED 500 GALLON H-20 LEACHING CHAMBER TOF - 36" Loamy Sand 50.50' TOTALS: C-1 10Yr 5/4 TOTAL NUMBER OF CHAMBERS 2 Loo REV. DATE BY P'D. _ DESCRIPTION se N 48„ 49.50' AP TOTAL LEACHING AREA 472.2 SQ.FT. PROPOSED SEPTIC SYSTEM UPGRADE TOTAL LEACHING CAPACITY 349.4 GAL./DAY HC-1 C_2 Medium -Coarse Sand PREPARED FOR: 2.5Y 5/6 15%gravel CAPEWIDE ENTERPRISES �^ 80" 46.83' FI LOCATED AT (2 C-3 Medium Sand 69 CARLETON LANE 2.5Y 6/3 CENTERVILLE, MA 02632 N ' NOTES: O CP' � _. __ _.._ ___ -- � (1 O ��3) 132" 42.50' ' 1/►w4 SCALE: 1 INCH = 20 FT. DATE: MAY 30, 2015 1. MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF EACH SEPTIC o 10 20 40 so FEET SYSTEM COMPONENT. 25 p No Standing, Weeping, or Mottling Observed J`Jv���1H of nee r� c» PREPARED BY: z 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF THE PROPOSED (4 RESERVED FOR BOARD OF HEALTH USE CHURZZI L JR JC ENGINEERING, INC. LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST PIT DATA SHOWN ON THIS PLAN. 01VIL 2854 CRANBERRY HIGHWAY , F7 REPORT TO ENGINEER AND LOCAL BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH .418 f TEST PIT DATA. ST y EAST WAREHAM, MA 02538 SITE PLAN 508.273.0377 3.) ENTIRE PROPERTY IS LOCATED WITHIN THE ESTUARINE WATERSHEDS. 1 • SCALE: 1"=20' Drawn By: MCP Designed By:MCP Checked By:JLC JOB No.3080