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0052 CARRIE LEE'S WAY - Health
52 Carri e Lee's Way i Centerville P A = 168, 008 L No. 42101/3 ©RA O ® 0 0 No. �C'� FeeTHE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppliLation for MispoBal 6pstent Construction 3pPrmit Application for a Permit to Construct( ) Repair(tf Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. &Pr o�Ci,��s Cz�� Owner's Name,Address,and Tel.No. 4 3 S" Assessor's Map/Parcel �(,� Ei 05-4 36 Installer's Name,Address,and Tel.No. 57OfcS- ��I -��z / Designer's Name,Address,and Tel.No. u`�O`6- `yam{/ Type of Building: Dwelling No.of Bedrooms J Lot Size Sl — sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures a Design Flow(min.required) 30 U gpd Design flow provided 7 gpd Plan Date AAA 114L ) ) Number of sheets Revision Date Title e,S _&�Sa _ rho.¢ Size of Septic Tank f-1C i s l GCxjC P Type of S.A.S. a - i4.?D G_x djyr1 .w 1a•83 x L Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment ode not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt Si Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 4�; Date Issued l y C7 ._...- No. / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Mi posal *pStem Construction Permit . application for a Permit to Construct( ) Repair&,Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. �P��,� t Owner's Name,Address,and Tel.No.5,.C)a-"� a Cw � l fa.p. X Assessor's Map/Parcel g( 5 �E I a` r� O-x 3Cr Installer's Name,Address,and Tel.No. 50 LS ��)E.,= yDesigner's Name,Address,and Tel.No. _50_�f-,.714�` /Sy/ P U la u t, �Olr�a'�Pt��iClri, ►�f �/ GCd J ' 1 cl ,.C�►2C¢�L€r> °lI111M n" as"l A of 4 Qom.t,r< Type of Building: Dwelling No.of Bedrooms .3 Lot Size 074., Z� -- sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) q'3 0 gpd Design flow provided � �� gpd Plan, Date R i A I,A lls��jS Number of sheets ! Revision Date Title}; I . S Aa l l 04 �� OaA/t^t 9" ( C. � n V;k16 Size of Septic Tank e-Xt cL e)ny,vc,,t7 Type of S.A.S. c - }¢�jl 14",ol&& da 3-3 X 2si Description of Soil 4_'V2,. CMl. n-.I Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described oh-site sew"a eAi's"osal s stem in gn i'x g P .,Y . accordance with the provisions of Title 5 of the Environmental•Cod' d not to place the systemperation until a Certificate of Compliance has been issued by this Board of Health Signed Date A ' �Applica"tion Approved by t - Date 11 1AIo li Application Disapproved by Date for the following reasons Qe i Permit No. )R Date Issued THE COMMONWEALTH OF MASSACHUSETTS ' BARNSTABLE,MASSACHUSETTS _ - Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded'( .Abandoned( )by�(�j 7r�►r'�e,/b !t)rr a.a [__r�, y_Q,,_U_c has been constructed in accordance - - I with the provisions of Title 5 and the for Disposal System Construction Permit Norte,!/ ~/J� �datted Installer f}u?TUi(fit i �r�r�S t'1 t l _f`t CR^ . �C' Designer A J� a�Y�Crf ,o r y 'A #bedrooms `� Approved design flow `3 gpd The issuance of this permit shall not be construed as a guarantee that the system wilLf inetio as designed. Date C /p �/ Inspector_ t - 9-- _\_ No. f p `v Fee �J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS - ;Disposal 6pstem Construction Permit r Permission is hereby granted to Construct( ) Repair(V Upgrade( ) Abandon( ) { System located at ,.> l ICI.rr P i Lea "`S Ct,� , �j.p�.t (� .J>�,"`Ct:_�c+ J and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co/mplet d within three years of the date of this pe4t. Date ll 11/0 Approved by f i I F Town of Barnstable o Regulatory Services �P : Thomas F.Geller,Director +� &ARNSTABL�, ]Public Health Division I Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&1Desiguer Certification Form Date: 2 14 I q Sewage Permit## �4 U Assessor's MapTarcel 1 S 8`5 Designer: DOWN CAPr; E&6JK l tJ6 l[nstaller: { l-D�T"l C�f�l(f��C ON Address: 139 MAIN %(lZb_ZjE�_ Address: . 4�j JWbU�M PD Kk?=Wtn P-o9E. UA OM W7 titM.5-, MA 0208 On 11 L !% eJor f jGv"tt� AtN 7(yywas issued a permit to install a .(date) (installer) septic system at552 Carrie (.,.ee(s Wa Qn-Fervi 11e based on a design drawn by (addre s) (Nnie( A.01ala,EX, PL . dated 10119 /fe designer) - I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral reiocation of the distribution box and/or septic tank. L._ 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 y )but in accordance with State&Local Regulations. Plan revision or eqt eda�builtbyy designer te-€ 49w. As 8viLT Samr- -5v5T rat 'PLAN, 211411q, le, -Xr ACIR4 H OF Mgsp�C ' D-NIELA. o 0jALA- (Installer's Signature) " CIVIL Iva 46502 � kG/sTe��Oa`O ^ L O_ -19 ION AL tiNG L (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE ]PUBLIC HEALTH D '1CV7 SION. CERT30FICA.TB OF COYRUA NCE WJ LL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-)BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU Q:Health/Septic/Designer Cer ificationForm 3-26-04.doe I i LOT 22 , 26,402 S.Ft •A DECK I i9 EXISTING �\ DWELLING TOF = 45.8 E Z 3j \ V1 m \ \\ PAVED �• c \\ DRIVE G-1 \ R30.00 � C AggIE L� AS BUILT SEPTIC SYSTEM PLAN JOB #18-273 LOCATION : #52 CARRIE LEE'S WAY PREPARED FOR: CENTERVILLE, MA B OR T OL 0 T TI SCALE : 1" = 30' DATE 211412019 CONSTRUCTION/ JAMES ROCERS off 508-362-4541 fax 508-362-9880 �N OF V,4 downcope.com © `'� qoy dOWN cope eftgineeriag, iac. =,r : ; N civil engineers ' ° ID i land surveyors �� F_ 939 Main Street ( Rte 6A) ' SuR\{EA_ YARMOUTHPORT MA 02675 DATE DANIEL A. UJALA, P.E., P.L.S. L TOWN OF BARNSTABLE LOCATION �r��ttZi2�� ��1= � `� SEWAGE# VILLAGE C-j,—JL�e ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY hoc i P-.-T a te, JCVZ5 4,tt-- LEACHING FACILITY. (type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: 1 I--,4 i COMPLIANCE DATE: `off Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 43 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Y4 Ik Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 0 Feet FURNISHED BY e2 A s'3 _ rO i O �o d J �dl/1 (c,)�Y, I Cdlb Nate Town of Barnstable Barnstable Regulatory Services Department 1 V M104STABM ' I Public Health Division �Arf°"'pY• 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#7015 1730 0001 4987 9989 June 6, 2018 ROGERS,JAMES M PO BOX 843 BARNSTABLE, MA 02630 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 52 Carrie Lee's Way, Centerville, MA was inspected on 05/10/2018 by Frank Nunes III, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Backup of sewage into the house due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty (60) days 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 Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\52,Carrie Lees Way Centerville.doc �THEr Town of Barnstable XKMRegulatory Services Department Public Health Division 200 Main Street,Hyannis MA'02601 Ofcc: 508-8624644 Richard Scab,Dircctnr FAX 508-790-6304 'homas A McKean,CEO Feb 6,2007 Rev. 5111116 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 I ❑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. :. Wackup 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 Ile 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 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water qualitg analysis.'(This system passes if the water analysis indicates the well is free from pollution). TWO (2)YFAR DEADLINE CRITERIA q SingleCesspool o Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a diiveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER A 4 Repair deadline: _ Q:ISEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts 8 r608^ 00S— Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments x. M ' 52 Carrie Lee's way ; Property Address t.w Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 32 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. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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 5/10/18 Inspec Sig at re 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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M s 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6/16 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 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 City(rown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number f m i n : 3 Number f b bedrooms(actual): 3 o bedrooms (design): o e ( ) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 CitylTown 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: No.recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,a' 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1979 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain). H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: undetermined t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityrrown 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 >12" , Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 years to prolong the life of the system 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Over invert 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 flooded 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: ❑ 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.): Leach pit is full above its leaching capacity 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.doc-rev.6/16 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 s 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Q � O Lea $ � 3S G�3 CiZv`� -"Ro SC&L_6 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for Centerville MA 02632 5/10/18 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells >12' Estimated depth to high ground water: 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: per elevation of site Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 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 52 Carrie Lee's way Property Address Rodgers Owner information Owner's Name is required for every page. Centerville MA 02632 5/10/18 Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable Barnstable ��`�r� End Regulatory Services Department 04mericaC'I MSTAUM 6 q ,m Public Health Division 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#7015 1730 0001 4990 6999 October 15, 2018 — SECOND NOTICE ROGERS, JAMES M PO BOX 843 BARNSTABLE, MA 02630 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 52 Carrie Lee's Way, Centerville, MA was inspected on 05/10/2018 by Frank Nunes III, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Backup of sewage into the house due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year, on or before June 6, 2019. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH ean, .S., Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\52 Carrie Lees Way Centerville Second Notice.doc •n �73 �oF,IKE rod; Town of Efarmstable P# Department of Regulatory Services HARNSTAHLE, Public Health Division Date `~ v MASS. �p ie.9• 200 Main Street,Hyannis MA 02601 rFo rnp�t n 7•� /� t.: Date Scheduled Time Fee]Pd. ' Soil Suitability Assessment for Se e .Dlsp®sal zf` Performed By:(i(cct tE �� � ,�g Witnessed By: Location Address LOCATION&GENERAL INFORMATION ATIO �e�� B �� Owner's Name o? � Address Assessor's Map/Parcel: �6d���� Engineer's Name NEW CONSTRUCTION 'REPAIR Telephone# I- 36:L® �` Land Use 11;d"Pz \0t Y Slopes(%) '"`C • Sur J}y, ' face Stones Distances from: Open Water Body——�ft Possible Wet Area�ft Drinking Water Well !,160 Drainage Way t� e--f ft Property Line �ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) :,A) N �°" Parent material(geologic) i 48-�t'� t s6 � Depth to Bedrock y� Depth to Groundwater: Standing Water in Hole: 9 ` Weeping from Pit Face m' Estimated Seasonal High Groundwater DETERR INATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs,hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: iin. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level• Observation PE RCOLATION�TI+8T Date Time � f Hole# Time at 9" Depth ofPerc PP Time at 6" Start Pre-soak Time @ Wry Time(9"-6") End Pre-soak Rate Min,/Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. F Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth ffpm Soil Horizon Soil Texture Soil Color Soil Other nrcdin.),. (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Loei1 DEEP OBSERVATION HOLE LOCH Hole# �. h .-. n n ya--�q . Depth from SbMOi-i on^ Soil Texture SoiltCdlbr' ni>< Otha,er Surface(in.) (USDA) (Munsell) 1v wliNng'-!i;$t Utijrp;Stones,Boulders. wy �t nn Consistency.%Gravel) �4' c4^'•.iti:�:.•a...., ./�r'�'ti ti n, � ; ��. �� �,by.���$�tt',B ..•;, �"A DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stricture,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. Consistency.%Gravel) Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No 'A� Yes Within 100 year flood boundary No Ye Yes Depth of Naturally Occurrinl?Pervious Material Does at least four feet of naturally occurring pervio . aterial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pe vious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of EnvirO mental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. gn 4� Si afore Date,�� Q:\SEPTIC\PERCFORM.DOC tg-273 �oa�o�vm�>'oc��-s Town of Barnstable P# 15 oF��ram, Department of Regulatory Services * Public Health Division ld 3 BARNSTABLE, * Date ' y MASS. �p 1639. �e`�s 200 Main Street,Hyannis MA 02601 ren r,��t Date Scheduled Time Fee Pd. �/00 , Soil,Suitability Assessment for Se e Disposal Performed By: 1 Witnessed By: -' t; LOCATION & GENERAL INFORMATION Location Address '5?_arr 1el �t5 VV' Owner's Name 01 ��Ce,nCJ +erV.l`Iei' MA Address Assessor's Map/Parcel: �����j'l�I Engineer's Name"PpwN NV aQM"OrNe, NEW CONSTRUCTION REPAIR Telephone# Laud Use -! G� A� Slopes(%) Surface Stones Distances from: Open Water Body � - ft Possible Wet Area 5m ft Drinking Water Well !r_ ft Drainage Way 106 + ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) oz �`` �•• O 4 mJ w1!y Parent material(geologic) a �!- Depth to Bedrock. 1 Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole; in. Groundwater Adjustment ft, Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date Time Observation ` Hole# �/�'� c, ,,���� Time at 9" Depth of Pere - J�—�- Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N) , Original: Public Health Division Observation Hole Data To Be Completed on Back-----------. ***If percolation test is to be conducted within.100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFORM.DOC 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. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistent %Gravel �1 M� � 'ice.► Q ` 4Y.� p� a��d� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones,Boulders. Consistency.%Gravel) Flood Insurance Rate Map: Above 500 year flood boundary No— Yes ' Within 500 year boundary No Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurrina Pervious Material Does at least four feet of naturally occurring pervious aterial exist in all areas observed throughout the area proposed for the soil absorption,, — -_ If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Envirofimental Protection and that the above analysis was performed by me consistent with the required training,expertis,.,and experience described in 310 CMR 15.017. Signature Dated T Q:\SEPTIC\PERCFORM.DOC COMMONWEALTH OF MASSACHUSETTS z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m + d DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP0W 350 MAIN STREET PARCEL WEST YARMOUTH,MA 508-775-2800 LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE ADRT DISPOSAL SYSTEM FORM JAi'ta � �' ZQ04 CERTIFICATION TOWN MAP 168 PAR 008 OF 6.4REtSTAB�� H��LTh DEP Property Address: 52 CARRIE LEES WAY r CENTERVILLE,MA 02632 Owner's Name: ROGERS,JIM Owner's Address: 52 CARRIE LEES WAY CENTERVILLE,MA 02632 Date of Inspection DECEMBER 8,2003 Name of Inspector: (please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yannouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT 1 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 perfonmed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: /�— p-0 3 7 The system inspector shall s it 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 52 CARRIE LEES WAY CENTERVILLE,MA 02632 Owner: ROGERS,JIM Date of Inspection: DECEMBER 8,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: .( I have not found any infonnation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the . for the following statements.,If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 52 CARRIE LEES WAY CENTERVILLE,MA 02632 Owner: ROGERS,JIM Date of Inspection: DECEMBER 8,2003 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system.(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 52 CARRIE LEES WAY CENTERVILLE,MA 026362 Owner: ROGERS,JIM Date of Inspection: DECEMBER 8,2003 D. System Failure Criteria applicable to all systems: N/A 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 J 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'h 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have detennined 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system.is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 li Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 52 CARRIE LEES WAY CENTERVILLE,MA 02632 Owner: ROGERS,JIM Date of Inspection: DECEMBER 8,2003 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received nonnal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ✓ Was the facility owner(and occupants if different from owner)provided with infonnation on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 52 CARRIE LEES WAY CENTERVILLE,MA 02632 Owner: ROGERS,JIM Date of Inspection: DECEMBER 8,2003 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms: 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: TO BE PUMPED AFTER INSPECTION Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1978 NEW DISTRIBUTION BOX DECEMBER 2003 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 CARRIE LEES WAY CENTERVILLE,MA 02632 Owner: ROGERS,JIM Date of Inspection: DECEMBER 8,2003 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 101, Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 12" Material of construction: ./ concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON Sludge depth: 3" Distance from top of sludge to the bottom of outlet tee or baffle: 27" Scum thickness: 3" 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: 15" How were dimensions detennined: ASBUILT AND 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.): MAIN TANK AT WORKING LEVEL.TANK AND COVERS 12"BELOW GRADE.INLET TEE,OUTLET BAFFLE.NO SIGN OF OVERLOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address: 52 CARRIE LEES WAY CENTERVILLE,MA 02632 Owner: ROGERS,JIM Date of Inspection: DECEMBER 8,2003 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alann level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alann and float switches,etc.): 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.,): DISTRIBUTION BOX IS 16"x16", 16"BELOW GRADE WITH COVER AT 6".DISTRIBUTION BOX IS NEW DECEMBER 2003.ONE LINE IN,ONE LINE OUT. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 CARRIE LEES WAY CENTERVILLE,MA 02632 Owner: ROGERS,JIM Date of Inspection: DECEMBER 8,2003 SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required) If SAS not located explain why: 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 ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER AT 20".STAIN LINE AT 2'.6"WATER IN PIT.NO HIGHER STAIN.WALLS CLEAN.NO SIGN OF OVERLOADING OR SOLID CARRYOVER. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 52 CARRIE LEES WAY CENTERVILLE,MA 02632 Owner: ROGERS,JIM Date of Inspection: DECEMBER 8,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I 1 1 i 1 C Title 5 Inspection Form 6/15/2000 10 Page I I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 52 CARRIE LEES WAY CENTERVILLE,MA 02632 Owner: ROGERS,JIM Date of Inspection: DECEMBER 8,2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 12 feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole within 150 feet of SAS). Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation V Accessed USGS database-explain: You must describe how you established the high ground water elevation: Title 5 Inspection Form 6/15/2000 11 J TOWN OF BARNSTABLE LOCATION - Clhff/g 4ily �/jf'` SEWAGE # /ti i` ViI.LAGE -/ ASSESSOR'S MAP & LOT _. ...INSR S NAME&PHONE NOG SEPTIC TANK'CAPACITY LEACHING FACILITY: (type) (size) , NO.OF-BEDROOMS BUILDER OR OWNER /G!c- PERMTTDATE: C@b5*&kN4-0E DATE: Separation Distance Between the: Maximum Adjusted Groungwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by } F Fr 0 IPA _3 W P �T 3� ^�No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zi pprication for Mizpogal *p5tem Conotruction Permit Application for a Permit to Construct( )Repair( 1-116pgrade( )Abandon( ) ❑Complete System I GI'fndtvidual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 3-4r- Z6A- 9�ss .3-� CA/'1�1c kay w Y, �r�n /Po g £/PS A e�Cso 's aQ/P� 1 co C F A-7— pO d 41 B X O Y3 401al,,(, Installer's Na eAddress,and Tel.No. 5-D 8' ° *7 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) C F_ ------------------------ 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 i stiSd by this Board of Health. igne Date Application Approve Date I P- 2 Application Disapproved for the following reasons Permit No. 0 t Date Issued Q f� �4��+� �No. Q'`�'" 3 60 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[pprication for Migool *p! tem Congtruction Perini Application for a Permit to Construct( .)Repair(krupgrade( )Abandon( ) El Complete System A'rx;dividual Components Location Address or Lot No. , Owner's Name,Address and Tel.No. sar= ���- 9jss .S5o CA/t'/'j lc )..Ff57 14oA i� Seri d g £'iP,7 AyeV a8C1 el co 5 t C -E X-7-� 00 .1 'B 11 x p yj Q/4/P� Installer's Name,,Address, OTel.No. ,5_4 Y ' / r�I� �Q° Designer's Name,Address and Tel.No. Type of Building: J. Dwelling N f Bedrooms Lot Size sGarbage rinder Dwel g o o d q ft. G ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures - Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7) ------------------------- 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 q8ty by this Board of Health. �igne Date • Application Approve—y_ Date J �I 7 Application Disapproved for the following reasons Permit No. r+C7Cy "' (04 Date Issued -------- -------- -------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired 'TUpgraded( ) Abandoned( )by r 4 ti("10 13,o t 41 A- S T u at 0 P / E £F T Lv,4 C A- r- has been constructed in accordance with the pr sions of Title 5 and t:244-442:= Disposal System Construction Permit No.200 Z--0 01 dated 6� k_10 3 Installer A 2 Designer The iss5ncel1 of this permit shall not be construed as a guarantee that the symem will unc n as designed. Date I 0 Inspector //s,�/ , i � a No. O 3 (00 1 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS =Iigpogar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( grade( )Abandon( ) System located at .S a 04 if IP/ F, )LE FT iv 4 Lr C 7 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: Construc7-710 n must be completed within three years of the date of this Date: �' Approved 'ID �� one .TOWN OF BARNSTABLE �' LOCATION, -a QAIl 1?/ E )-ET-3 ivA V SEWAGE # °~ 7- 0 j VILLAGE c A.,rCC ASSESSOR'S MAP & LOT !� --00 ©� c- i INSTALLER'S NAME&PHONE NO. fit. ( 0-4,V C G SEPTIC TANK CAPACITY £ C £ LEACHING FACMITY: (size) NO. OF BEDROOMS BUILDER OR OWNER k U Fye.s -,7--,L PERMIT DATE: o 3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and I-caching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by j 4V TOWN OF BARNSTABLE �' LOCATION eAA'�'/ SEWAGE # '2 0 o VILLAGE C 1:A.,7-Cel// ASSESSOR'S MAP & LOT I i LQOLQos� INSTALLER'S NAME& PHONE NO. y t tl� (-31#ti C U SEPTIC TANK CAPACITY 9P f Oi w C £ �r .60 LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNERS PERMIT DATE: I ' t - o-3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by rIrc�✓T o f � y 3 e No........ ... FE01K NY $....�.!��... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 770.W.-N-............O F.......I31-QR-N-5_T-f1131--G=.-----------------._.......-------- Appliratiun for Dispaii al Works Tonarnrtiun ramit Application is hereby made for a Permit to Construct (V/Or Repair ( ) an Individual Sewage Disposal System at: .C,f. ARL. iV-.t9-z.::..�4A1.ZZAWAL4G............... - --Q.T....... ............................................. .Address or Lot No. ----------------------------------------------- ----------•____-Q.1�,1Ai3�.............................................. Owner Address a .EToQl>u� ��'F•]E2S ---------------- R 13�T.b�--�'�....-•-----••-•-•-•----•--------'-----__-•- --._--- - ---- ---- Installer Address � S Type of Building Size Lot�.�.Y0.o�-- q• feet U Dwelling—No. of Bedrooms........2_.............................Expansion Attic ()O) Garbage Grinder (Nd) p, Other—Type of Building ...NIA......... No. of persons____________________________ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------•... W Design Flow.........//.,0........................gallons perq$=P Mday. Total daily flow._._...._7..3.0................gallons. WSeptic Tank—Liquid capacity/O.O.O.gallons Length...6._°_ Width.Y.�/--m_"' Diameter................ Depth.,$....&"' x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......,/..•.......... Diameter----(6__ ...._ Depth below inlet---6_.' ......... Total leaching area.a_ZX> ?.sq. ft. Z Other Distribution box (L4 Dosing tank ( ) aPercolation Test Results Performed byA?.0.Wfl4Ll......4....._(5.- ff0Ab..R'_5_! Date____ a Test Pit No. 1...4_;-....minutes per inch Depth of Test Pit...12...._....... Depth to ground water........................ Test Pit No. 2__4;:.3r...minutes per inch Depth of Test Pit---4Z_---------- Depth to ground water........................ Pd ................................ -••----••------•----------•---................--•-••---------.............-•---•-------....---•---••...--•---.....----__••-- O Description of Soil...----- -----�-1v.46------ C/��0/.fir. • ! `�-L.`��1 �.............. x ........... __....._�/_8s1iD...................------- - - • . . . --•----•-------•--------------------------------•---------------------•-------. W ---•----- —-------Sot 1.C.-------QYV_,?.lT/-,0.,V 5..__.../M----8jZW- .......;SST---- Qs ................. 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.L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. S' ned ... _:_. .. --------------------- ------------ ---------- /� Dat Application Approved BY { -•CS.-• !!Ill ,7 1d T--� --..---•------ - •-•-- Date Application Disapproved.f or the following reasons:-------•-----------------------•-----------------------------------------------•----------............••--•----- .................•••---••------•--...•--••----•••-••••-•-•••.......--•••-------•----------•-•••••.....---•-•--••-•--••••--••--•-•••- -------- --- ------ Date PermitNo......................................................... Issued_--- - \ .-----•--------._...--•---- Date No.. -- .... Fims... .��.......... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Applirtation for Disposal Works, Tontrurtton rrani# Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: R.R! ._.. ��..._ arv/_y.--. iT Rv{c .. 1...c 7 .- .. -------------------------------------------- ................................... R M Lo tion-Address or Lot No. --- Owner ddress w VEzcaczl ivn ©-tjICRS F12► S_rP,e.E -----------------------------------------------------------------------------------•-•--•......-•- -------•--------------------.....------------•••-••---------------•............................_.. Installer Address d Type of Building Size Lots2�A.'5tQ9,,,_._Sq. feet V Dwelling—No. of Bedrooms....__.______________________________Expansion Attic alp) Garbage Grinder) p-, Other—Type of Building ._ S�/AO.9........_. No, of persons............................ Showers ( ) — Cafeteria ( ) Q, Other fixtures --------------------------------- 00 w Design Flow........ 0........................gallons pei per fssmi per day. Total daily flow...........-3.4..............._gallon. WSeptic Tank—Liquid capacit/PAI _.gallons Length'�_.._g..... Width 3f_.�'�.n_ Diameter................ Depth_-+`"_.."a..... Disposal Trench No.......... ......... Width.................... Total Length.........._......... Total leaching area-___-_---_--------sq. ft. Seepage Pit No..._:,e�...____._. Diameter----... ...... Depth below inlet.--l�-.:+......... Total leaching area_Q,0.0..sq. ft. Z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by_-XPIV&4_0....14.r..__.GRe450,0!z 0..84- Date... "_ .. p__^-V ..... ,.a Test Pit No. 1..��__;• ....minutes per inch Depth of Test Pit.. ........ Depth to ground water........................ ,.. .s Nest Pit No. 2.' .An....minutes per inch Depth of Test Pit__?!Z-........... Depth to ground water........................ a O Desc iption of Soil........0:'-- --Y-�� C�/? --•--�".V..6----• �/ .�' VNature 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 TITI.sj. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ned--•-- ----------------......................•....-----------•-•--------------..---- Application Approved B Date Application Disapproved-.,for.the following reasons----------------•--------•--••------------------------=--------•-----------------------------•------------------- --------------------------------------I.-...---------------.....---- Date PermitNo_..................................................... Issued-........................................................ Date i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH —Io w - ,era�-r ,....c........................... Tnrtifirtatr of Tontplitanrle TH 111 TO CERTIF , That the Individual Sewage Disposal System constructed (Y ) or Repaired ( ) e �`©Z.�a a�r NE B.....--••-•-------•-----•--•----------------------------- � +K `Q K. `.. � t staler at----------------•-------•---------------------------------•-- . ---------------- . • `..---3--•--- .-- -1-EZ 111 C.LC: ............................... has been installed in accordance with the provisions. of T r of The State Sanitary odes described in the application for Disposal Works Construction Permit No____________............................. dated__..__.__.._.__8..... ` '_"_.._...______.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. c DATE................................................................................ Inspector,-........................................... •=.................................. THE COMMONWEALTH OF MASSACHUSETTS : BOARD OF HEALTH 7� .............�O.W taJ.........OF..........k.?t') .' :;?."T(NZ.C:................----•-.....--- No.......-:°'.�...._ FEE..- .- ............. Disposal Works 0-Fono#rudion anti# Permission o hereby granted---------UUqfi:I. ----.-�ex�'T�.............................. to Construct (V ) or Repair ( ) an Individual Sewage Disposal System at No LOT------....----fir��C�1� f-4�._5....... F3� 4Y WTE 2..w4 i St-------------------------------------- Street j as shown on the application for Disposal Works Construction Per ' No.. _ _._ _____ Dated. "_' ............... l; �--- lT +---------------------------------- DATE 1 Board of Health . -•- --------------------------•---- K FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS , LOCATION SEWV PERMIT NO. VILLAGE I N S T A LLER'S NAME i ADDRESS 19 UILDER /Olt OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 7P, _ . C r � QJ \Y .��%/.J ����,7,, ��I J � C� ��� �,i --` - � � - - v 1:111,11,11,11''I'l T, - V� ' IP 7 `dam "T -K4 k6q m OR 2 L07- zj �-w /Y LOT 0 A '\lD j #0 S a 501 > �u t l� �iV A All 41 '3 �LO VF, X .0 r (b L,SAC# mbtm -lot 7 TOWN WA T�C_g ' Is A-Yq 4-A iff i__5 A41 A-f 1%4 U A,-1 .40 ' 15 u 1_0 6 ET,0ACIL-_ A2�i�VI,2,e_^-�&,AU7Z5 "100,V 7- �Sl.t74 A;2,1 S 4 7a Pep X;:Po SFZ), SEPTIC 5 Y:5 7-&A-4 CoOA45 oct T/OAJ SA4 A 4-1- A-? 70 .MASS ICU&5 If Ai -336 GALIZ OAY I- COOS T/77Z_L Aj VIe OAJ,-YC.,V 7A '2- 1 Z-,E 2L x - Z?6 'BA RN,S 7A U4- lr__ 4. :kFo'6 97-ACov. -v /.3 g A,�EA 4:7-/-7' )2.- 7T A 7-/O.IVS, OF N ao. on V,/O.U.5, (:_�o,V61e �1'lAA/140,L6.JCoV6lz2 70 CK 7-9 AtZ:) TO VEA17 4 0-S M TA-1/A/ P OF 7A -IZ-7,oe,4 7_/AAF, IrZ 0 I-le 1AAC 0 :5710Af4E D1577 aox I5"A4,IAJ 4 CA p 6-Mrs! 4"-Z)IA. A — —— 3'14-41 AJ Pr WA' ,Z:>/7r- /0 A/ .. . .Ems-C, - ' P. IO."A41AI A z. eAl /�,/rc.Al 7 V2",DIA. T 14" A4 'A lef _Y_ A41AJ' IF40 7- Q, WA 5 H,E 6 1000 zoo t�0,5 7-0 . + I - (:�0 A z-.(-GALLON/ /.A/VAer /A/V�e_T- C,4 )c>A C/ 7- R 0 4�Ao(D 7-A AI& ;-: (WA 7- 4Z 5 45C)71-OA 4 OF /,V v C-z r /Yo GAe5A6E_ Gr-?IAjZ)4,'---P_ C- 4- 7,1 C� V r) IA4UA4 i?0' Aj/A/ 51 TE PL A-A/ P)?oP40 .SjED 5JCb�� - C F LOCA 7-/O/V CCRN. ViLL 9 �iAss, EC 12 1-=Af C F_ a UEIN s LOT Ill An' .5e_r_>7-1C -rAAl.0`A::f BoxIN P-L#9 N .',4"Z:> Z_ A C 4-11A10 7 7 )70A2 ARTMIli OE' OF .LEiA/F0:2CED CO.vG.tzGTE T A.A. 1T' 5000 1 H 20000 M E 7 0 OA D/A/<!�� A COE E))EV VF_ WA Y A,/O 7- 7-0 43E Z_0 G4 D Y_4 4?A-1 0 Le 7-2,1 A-_C5 B.7-' A,�',4AS 0 Vee vi 14'OF S/GAY /S -1 CERTIFY TkAT THE FOUNDA T lON :5h`OtON 0 N O 74'0 OW THE CrROUNi 0 T.N.15 RL N IS -L. CA 7 GEORGE _5904 ,,V IIER60N AJVL) /7 D06-5 CONAORM TO THE 2L)ILD IN& S*673RCA, 17 E 0 U R 6 Plll;w r4 10 1 . I e 44; 6,C_ 31401-5 T, 777 0 by DATE 7_�E AIE4 Z_77-/ 40zEA17. A FW->)e 0 V,4 Z_ E UAll,'P,1778 L --- ---- SYSTEM DESIGN: SYSTEM PROFILE 4CHARCOAL" SCH4o VENT WITH Al LEGENDMARKED WITH OR BE SHOWN PLANLVIEWAS '`��-T-Ec+ COMPARABLE MEANS FOR FUTURE LOCATION. PITCH BACK TO SAS, i7 l PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) NO LOW POINTS. 1. DATUM IS NAVD 88 rn - 99 '- EXISTING CONTOUR GARBAGE DISPOSER IS NOT ALLOWED ACCESS COVERS TO WITHIN 6 OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE �6� Q o 2" PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING X EXIST. SPOT ELEV. EXISTING 3 BEDROOM DWELLING \ TOP FOUND. EL. 45.8 FILTER FABRIC OVER STONE DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. — 99]— PROPOSED CONTOUR _ MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 41 '-42.5' USE A 330 GPD DESIGN FLOW PRECAST FI-10 NOTE: 2" MIN. WALL BLOCKS OR 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS SS REQUIRED Route 28 �98.4) PROPOSED SPOT EL. THICKNESS TO BE AASHO H-20 RISERS (TYP.) PRECAST RISERS TH1 2'0 4"bSCH40 PVC MORTAR ALL o 6" MIN. SUMP PIPES LEVEL 1ST 2' COMPONENTS H-20 5. PIPE JOINTS TO BE MADE WATERTIGHT. Route 28 TEST HOLE SEPTIC TANK: 330 GPD 2 = 660 12" MIN. INT. DIM. �4D (TYP.) INV'S EL. 37.0 4' ( NS Locus SLOPE OF GROUND **USE EXISTING 1000 GAL. SEPTIC TANK 10" 14" EE °SIDES DETAILS TO BE IN ACCORDANCE WITH 38.0' 6 CONSTRUCTION TEE o � oo � 000 o°000 0000 " EXISTING p ° ° ° ° 310 CMR 15.000 (TITLE 5..) 40 TEE *42.8' > o 0 0 0 ���� ��0� ���� � ���� �. SEPTIC TANK o 0 0 0 0 0 0 0 o••o 0 0•0 )o°o°o°o° O O O O O O O O O ,0000°o°° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO urluTY POLE LEACHING: 4' LIQ. LEVEL o000o00'000ot ERTEST D'BOX O00000000 0�����0���� '°°°°°°°°ACME OR EQUAL GAS BAFFLE ::, �_o�oo 0 0_ LEVELNESS N >0°o°0000 = o o 0 0 0 0 0 0 0 0 0 0 0 o 0 0 0 0 0 00000000 BE USED FOR.L.OT LINE STAKING OR ANY OTHER Rood° ° ° ° "-1���//\ . , o°°°°°°° ° ° ° ° PURPOSEFIRE HYDRANT ) ( / — 000 0 0 °000 0 0SIDES: 2 (25 + 12.83 2 74 — 112 GPD �.;�:: '•: 37.27 10 , ° ° ° ° °°°°° 35.0' �_ R1�et ,y. _ s C .. .:...•:.,:., c j BOTTOM 25 X 12.83 (.74) = 237 GPD 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. a. gump o NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. H-20 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. TOTAL: 472 S.F. 349 GPD ALL AROUND PRECAST STRUCTURES (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED **INSTALLER SHALL CONFIRM MINIMUM SEPTIC 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.83' WITHOUT INSPECTION BY BOARD OF HEALTH AND Q"P� Roa eq�a� USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) TANK SIZE AT 1000 GALLONS AND ITS SUITABILITY COMPACTION. (15.221 [2]) q PERMISSION OBTAINED FROM BOARD OF HEALTH. *THE INSTALLER SHALL VERIFY THE WITH 4 STONE ALL AROUND FOR RE—USE. REPLACE WITH 1500 GALLON 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING LOCATIONS OF ALL UTILITIES AND ALL SEPTIC TANK APPROPRIATE TO SITE CONDITIONS IF LOCATIOSAFEN (1 F ALL 4 UNDERGROUND AND VERIFYING THE LOCUS MAP BUILDING SEWER OUTLETS AND NOT SUITABLE � LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES ELEVATIONS PRIOR TO INSTALLING ANY 46 � 1 22.0' BOTTOM TH-2 PRIOR TO ..COMMENCEMENT OF WORK. PORTION OF SEPTIC SYSTEM MA ( SLOPE) � SLOPE) ( NO GROUNDWATER FOUND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE SCALE 1"=2000'f APPROVED DATE BOARD OF HEALTH FOUNDATION— EXIST. SEPTIC TANK 12' D' BOX LEACHING REMOVED BENEATH AND 5' AROUND THE PROPOSED 12' FACILITY LEACHING FACILITY. ASSESSORS MAP 168 PARCEL. 8-5 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY / TEST HOLE LOGS TEST HOLE LOGS BE IMMEDIATELY GRANTED BY THE BOARD OFN� HEALTH AGENT OR BY HEALTH INSPECTOR w \ ENGINEER: CRAIG J. FERRARI, SE #13871 ENGINEER: CRAIG J. FERRARI, SE #13871 PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED BY THE BOARD OF HEALTH REVISED �2 DONALD DESMARAIS DONALD DESMARAIS DURING A PUBLIC HEARING HELD ON DEC. 10, 2013 WITNESS: WITNESS: �o DATE: 8/13/2018 DATE: 10/18/2018 2) FOR ALL SYSTEMS THAT HAVE NO INCREASE IN FLOW - PERC. RATE _ < 2 MIN/INCH PERC. RATE _ < 2 MIN/INCH SYSTEM COMPONENT INSTALLATIONS PROPOSED MORE THAT THREE FEET BELOW GRADE WITH PROPER VENTING (PIPED TO �� CLASS I SOILS P# 15748 CLASS _ SOILS P# 15800 THE ATMOSPHERE) AND WITH H-20 LOADING, BUT IN NOT ��° / CASE SHALL THE SAS BE LOCATED MORE THAT SIX FEET f� �0�9 28 BELOW GRADE. - ^,� ELEV.� �°` �'`� 1 ELEV. 2 ELEV. s 0„ Q 36 0,> 4 34 0„ 4 43' ' A A .3� LS A FILL 39 o N 10YR 4/1 10YR 4/1 18 10" 12" B BA 40 �'� LS 4� � "�' LS LS J 10YR 4/1 36" 10YR 5/8 33' 42" 10YR 5/8 30.5' 24 42 B LS C C " 10YR 5/8 41 PERC 36 40, Q o N MS MS C N 44 LOT 22 J'�,� °� 10YR 7/4 10YR 7/4 26,402 S.F. M S Q 43 ' 10YR 7/4 ( 120" 26' 144" 22' '1'20" '' 33' NO GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED 45 / 0 Q DECK w � W EXISTING TITLE � DWE 0,r' ; TOFLLIN45.8 OF 46 —� W #52 CARRIE\ LEE'S WAY CENTERVILLE, TH3 0 m IN E —\ PREPARED FOR AA MOV o � Q P D BORTOLOTTI CONSTRUCT1,11CH114/ a DRIVE 43 AMES ROGER IS ' ° TH10 DATE: AUGUST 17, 2018 PROP. V NT WITH HAIR OAL ILTER � \ �' N Mq 1 AND BU SCREEN (FNAL LA MENT �2 ���NOFM�ss` � ssgc� REV.: OCTOBER 19 2018 (ADDITIONAL TESTHOLE) CONTR��TOR WITH OME WNE ' CONS LTATION) F �� DAANIEL n o DANIELA. � OJALA N E—LOC TE �, ° o OJALA CIVIL Cn G LIN IF U No.46502 z No.40980 REQ IRED 0 00 = -- "� o w� �'op o i o� `� �sTE� `� �qw ss oe ,`. Scale: 1"= 20 / F s G\ BENCHMARK: ,e^1 s CEMENT BOUND i oI f O q '� �pt ldq r �Z qS 0 10 20 30 40 50 FEET =39.5 NAVD 88 � ^� � ��`•---'-�.,ss�� � �a`',. 9C �� DANIEL DANIEL . / OJALA A. V U v/ , c� OJALA CIVIL � off 508-362-4541 r No.40950 D 45 \ NO.4h50? L£° p fax 508-362-9880 + �SURV� downcape.com IV 3� w � s I o n CdPe en hneefifi f, &C. � f � C> ��2 J'4. �-- .�...�� �, civil e ; � rs land surveyors r 939 Main Street ( Rto 65A) LICE # > 8-273 DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02575 n. t 18—273