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0067 CARRIE LEE'S WAY - Health
67 CAE LEE'S WAS', Centerville A = 168 - 008 - 011 i I S M E A D No.2-153LOR UPC 12534 smead-com • Made in USA i w WUSMNiNSPBODM NE WWWNFROGRAMAW SFImmsmsouRmoffammalys CERTIFlED SOURCING No. "�'1 • FEE COMMONWEALTH OF MASSACHUSETTS Board of Health,RA rv%.S}- e— , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgraded, Abandon( ) - ❑Complete System 09Individual Components Location 67 Ca Mi e- L6es W a Owner's Name 15 t 0 Dev-e I OP rVLerl,-y-- Map/Parcel# L 6 s T-0019—O 1) Address l?a. %C M y 54-f ome 04 OZ+(4o Lot# Telephone# Installer's Designer's Name �Jel `K Address )C Address Telephone#��" l 't ��'�� Telephone# 08r—L0 7—5'3-)3 Type of Building �S YP g � �°at / Lot,Size/? ,$��� �sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) 3l9 gpd Calculated design flow '3 3 U Design flow provided --3v-M gpd Plan: Date /o l Z41/3 Number of sheets 2- Revision Date p Title ! miBQIa �d�s y 5 Ue`p lit GHQ Ll 67 Ca eyi L-w S w, &rl.+ce V e Description of Soils) - _6—if s-A/ �c /4� /3L �j_ ,S�-��2 C� 4'2 -5A At f�o Soil Evaluator Form No. le Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The underswned agrees to install the described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ees ton t to place in o eration until a Certificate of Compliancg has been issued by the Board of Health. Signed s"` Date,&1a/ r Inspections No. 001 .. qq e , 'J, FEE�I0�. �,. �,- LV COMMONWEALTH ,OF,MASSAC14USETTS Board of Health, aS APPLICATION-FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(R'Abandon( ) - 0 Complete System 19Individual Components Location &7 Cc, r ,,e Le.e f W a,, Owner's Name 1?j pip ri O wLe'l I- Map/Parcel# 0/) Address !?d, 1-3b; 28 L( J`Gi c�kc I'V74 Lot# Telephone# Installer's Name �' V�L;,- L L e Designer's Name >� / fG1=vt t e F IA Address /_j � Address w C�aS E 1�kew fg;,C�g&,q l' ft#1 Telephone# - Cl/ ���_ Telephone# SOS- 9 7-7 -5-3-) 3 U Z(o-I I/ Type of Building ��S /< u Lot Size /7. S LO +/-sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder ( ) Other-Type of Building /V /}a No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) 3 30 gpd Calculated design flow 3 3 0 Design flow provided �✓-s� gpd Plan: Date /0 /Z c)//3 Number of sheets �} 2 Revision Date Title ��o�o b d S P� c Y 5+e✓"t U,o a rc I G �t (7 �r r r Y e 1-��'s l.V �F✓a i-C V,]I Le Description of Soil(s) -�/ � , 13, L)S- / - i C fJA N� Soil Evaluator Form No. Name of Soil Evaluator P l vi 1-0 Date of Evaluation �-y✓ram , - "DESCRIPTION OF REPAIRS OR ALTERATIONS ��S l� ✓!�v+/ S f�S U_S, i-Cy,:a ' .. /�,`c,r.✓'• f'�u �-e%J l'I-zrI ci y+d (�fv1 -fi-�.c.�' The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further gees toot to place the,-system in operation until a Certificate of Compliance has been issued by the Board of Health. Sig ned4 1 // / f Date AI U s r Inspections No. FEE #0 COMMONWEALTH Of MASSAC14USETTS Board of Health, �3 t��l i S f e, b MA. CERTIFICATE OF COMPLIANCE Description of Work: 0 Individual Component(s) ❑Complete System The undersigned h•reby c�errtify that the Sewa�g/e Dis ,os/aI System; ,Coonstruucteed p(,.),Repaired (Upgraded ( ),Abandoned ( ) by: � !� ��,r �X�,�i� Ault, i l at � has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application�No.aI. -mayy-$ �/�ydatt�ed{1( (N 7413 Approved Design Flow il'JO (gpd) Installer_P &A/ AA//�/l f'� (/ Designer: J s Inspector: 1 /l/ . f, 9ate: J -- r The issuance of this permit shall not be construed as a guarantee that the system will function as-designed. No. Zoe 3- 114 1 g FEE (' COMMONWEALTH OF MASSAC14USETTS Board of Health, 33 ri S J-r,_�Le ,MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(/ Upgrade( ) Abandon( ) an individual sewage disposal system at 67 CAfeit Ly1 S WA-1 �'`JlJT�1ZUtuc= as described in the application for Disposal System Construction Permit No.2011, ,dated I1 11412C,13 Provided: Construction shall be completed within three years of the date of th' ermit! 1 cal conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Chades own,MA Date I I `)I20► Board of Health G/ ToWn of Barnstable z"E r �o Regulatory Services Richard V. Scali, Interim Director * IARNSMLE, .: 9� MAM Public Health Division ''Fa rase a Thomas McKean, Director NO Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: I 1 �(3 Sewage Permit# Assessor's Map\Parcel 16 d613�_6 11 Designer: .. �� ��,�s—�� Installer: �•�C�Ma.,. Address: p 2 .C.��Q��— C',rc�ss�'( e (ck L10 Address: 1S S�ecj", On /,/y/n ' ^`` �xc�/a�, as issued a permit to install a (date) (installer) septic system at 67 L ee's wwj &., k rv,JLC based on a design drawn by (address) C4 ncj; n�2r1 n 5 WW�.�-, �4. _ dated l° Z`� 3 (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 relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the. septic system) but.in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. o� I certify that the system referenced above was constru with the terms of "((Inst AA approv lit s (if applicable) - 4� PETER T. WENTEE CIVIL No.35109 er's Si )` A.3$1 S��ONAL (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO.BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE .ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:1Septic0esiper Certification Form Rev 8-14-13.doc r e Town of Barnstable �FWE 1pN, Regulatory Services ti 0* Richard V. Scali, Interim Director l HszAB . i Public Health Division 9�A1639. �`� Thomas McKean, Director rEo MA'S a 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Systems Property Address: -7 Carr,-e Le `f Assessor's Map\Parcel: / 6 T— 06 S-6 ik Property Owners Name: 1: k 6 ia P L L G In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an 'Y' in the applicable box next to each line certifying the information. Yes N\A ❑ I have been provided a copy of the Title 5 I/A technology Approval letters. (15 page Standard Conditions letter and the specific technology letter). ❑ ® I have been provided with the Owner's Manual ❑ F- I have been provided with the Operation and Maintenance Manual ❑ R For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10) and the Approval ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) ❑ If the design does not provide for the use of garbage grinders, the restriction is understood and accepted ❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the enviro t, as defined in 310 CMR 15.303 I pe't/. agree to comply with all terms and conditions above. 'Drop 0 s rinted name J r f-j-c Co a l l Property Owners Signatdre Date Note: This form must be submitted along with the septic system disposal works permit application for all IRA systems including new construction, repairs\upgrades, with and without aggregate (stone) and with conventional design criteria or credited design criteria. Q:\Septic\IA homeowner certification.doc TOWN OF BARNSTABLE LOCATION 62CArU?fEG6�S f,-,A: SEWAGE # Zo/S- WR VILLAGE Coff AJ %�? tli c.c.�� ASSESSOR'S MAP & LOT L13 -ccoo'/ INSTALLER'S NAME&PHONE NO. DOW A. 5&1eY ^—) SEPTIC TANK CAPACITY ',1000 C„ LEACHING FACILITY: (type) �/� rcS size NO.OF BEDROOMS B UILDER OR OWNER 0E L d,'° /� r PERMITDATE: I/�/Y//3 COMPLIANCE DATE: r� - Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Al f 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 f �U✓9 within 300 feet of leaching facility) Feet Furnished by A. �� �' u / pt ,f0 � I� �. � � � � ZZ .9�i � ° , I , � �?.'� psi. 1 S3,P/06/2013M I 07:52 Am C.0.M.M. Fire Dept FAX No. 508-7 60-2385 P. 002 ,,64 t W- 'C'940-:5 J 44// to 66 Y blr -vJ 14, 'J X'*" The Comvnortwealth of Massachusetts 1de�partnwnt of Pubtte Sgety �3LA_tc 527 CUR 4.00 7;wk Ob Farm 1 Application for permit, ]permit., and certificate of Completion for the Instacllation or Alteration of y sing Equipment and the Storage of Fuel oil Cel itervill , Qsterville,Marstons Mills (city or Town) (Date) 01920 Permit #'s: FD Elec. FDID #: _ Fee Paid: $ �9Y e Owner/Occupant Name: � AAaA�26Tel.#• Installation Address: S fit! Serviced Floor or Unit #: l CJ Heating Unit ❑Domestic Water Heater d Power Vent Q Other Burner: p New 10 Existing IN Location: &"4Vr_ Trade Name: Mfg: Type: -- Model# or Size: Nozzle Size: ❑Fuel Oil __.._.... LI Kerosene ._ . ... C]Wasfie O 1 Storage Tank: ❑New Exlstin . Location: ' A 6" � g Wt'> Type:— G - _. Capacity: 7� gallons No. of Tanks: Special udreme s or additional safety devices)I&AW s ,alb (k Al_ Q OSV Valve®Oil Line Protected Sheet Rock ©Sprinkler AFUE: ❑yes❑no EF:p yes©no (Furnace and Boilers) (Water.heater) Co. Name: 14Lc ;f Tel.# Address; City; / l Zip: 0 26 VC1 Completion Date: Combustion Test: Grose Stack Temp.; Net Stack Temp: _ CO2 Test -- Breech Draft:. Smoke: Overilre Draft:_ Efficlency Rating %: I,the underslgned cer*that the installation of fuel burning equipment has been made in.accordance with M,G.L. e. 148 and 527 CMR 4.00 currently in effect. Furthermore,this installation has been tested in arccyrdance with such requirements,is now in proper operating condition and complete rtt ns as to its use and maintenance have been furnished to the person-for whom the instaliafiian.(or altera was e: Installer• OL Prtrit lVame Cert of Comp. 0 l9 re(no stet . Address: : max 2-7 lty; once 8 aed by the epartment, is a PEirMIT a storage and tune.of oil burning equipment. Approved by: FP6 11kib Date: " REFER TO CHECKLIST ON RE ERSE BIDE Form Distribution:White: pre Dept. (Application) Yellow: Inctallatien(Permit To Store) Pink:itrstalior(Permit To install) . This iorFn swoved by 11196tM Fire Marshal and provided mudesy o}the Mace.M Heat Council. Form design in NCR by Cotw and comm Rre Depts: July 1,Im PERMIT EXPIRES 60 DAYS AFTER ISSUE DATE. L t� t VE Town.of Barnsfable P# Departiment of Regulatory Services . WRr"LK Public Health Division Date /0 — M.AH9 200 Main Street,Hyannis MA 02601 . rfl>NIP'1 k ,�w Date Scheduled— t) Time to� Fee Pd.�_ Soil ► uitabilio Assessmentfor ,sew �e Disposal c , Performed By: 2 Witnessed By: J' �. ✓ M�1!/� LOCATION dui GENERAL MOIIIVIATION Location Address Owner's Name O fl PW j,.O Mere')" td7 CvJ'�'1e- Leer u+v_Y Y Address t'� `ko p1p.tv\T fl—J'�,^� 20 ea✓t l i 2 �i� l�1��• © 1 Assessor's Map/Parcel: Q V Engineer's Name Al �Pcp-T�r 1tV1��T<� NEW CONSTRUCTION REPAIR Telephone# r�o` 73 7 - y 7 6.p Land Use....1`ne to l�� t a' es Slo 96 2- P ( ) Surface Stones n una Distances from: Open WaterBody _ft Possible Wet Area one ft Drinking Water Well (ions` ft Drainage Way A ft Property Line eft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) VO- t-=1 �3 � 2 Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: ��A— Weeping ft'om Plt Rape Af j Estimated Seasonal High Groundwater DETE1 ARNATION FOR SEASONAL IIIIIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to soil mottles: Itt, Det±th to weeping fern side cf obs.lisle: III, Oro undwnWar Adj;isIi-ownl f[. Index Well# Reading Date: index Weli level......_.___. Adj,fdetor— A(U.Cil'ouildwpter Levei n �, -PERCOLATION TEST Uate� Time_ Observation Hole# Time at h" Depth of Pere Time at 6" Start Pre-soak Time @ GN t ` ` 11l Time(9"-6") J ,End Pre-soak 7Cc s yS$k5 Rate Miii.flnch 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. QNS EPTICPERC-FO RM.DOC DEEP—OBSERVATION HOLE LOG Mole# � Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in•) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. onsistency.?6 arayell 0 —11LO � ,5' L to `f:rC31 ga '- 3z cam. pl- s� n 2� 5`C W 3 DEEP OBSERVATION DOLT;LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten % ravel r4 2:_$7Y6I(4 gv -)3z Gv ir1 c 5q td 2 5-77)3 DEEP OBSERVATION MOLE LOG Mole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION BOLE LOG: Mole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Cons' ten a i IF,lood Insurance Date Maw Above 500 year flood boundary No— Yes ___ Within 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? If not,what is the depth of naturally occurring pervi us material? Certification Ok I certify that on �" (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was perforated by me consistent with . the required training,expertise /and experience described in 10 CMR 15.017. Signature Date Q:\SEPTIC\PERCPORM.DOC *Town of Barnstable Barnstable Regulatory Services Department ;e`cac 1 ''M`A Mr Public Health Division I �• i639 A E�MpI 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard Scali,Acting Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 0978 November 7, 2013 David J. & Patricia A. McCarthy % E&B Development, LLC 1020 Plain Street, Suite 170 Marshfield, MA 02050 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE. TITLE 5 The septic system located at 67 Carrie Lee's Way, Centerville, MA was last inspected on 10/01/2013 by Sean Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • System is in hydraulic failure. You are ordered to repair/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 omas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\67 Carrie Lee's Way Cent Nov 2013.doc Commonwealth of Massachusetts W Title 5 Official Inspection FormY Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /(V Zoo rCcl wM 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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: 1-j 0 ❑ Passes ❑ Conditionally Passes ® FWs Ca C- .�. � T❑ Needs Further Ev luati by the Local Approving Authority „ ;t Iv ► ' I 10-1-13 Inspector's Signature Date 0 M 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 address how the system will perform in the future under the same or different conditions of use. lit a C)/�� %I 1 t5ins•3113 Title 5 Official Ins n orm:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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: II 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 c 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. 4. . ❑ 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 -Not for Voluntary Assessments M 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the.SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 cesspool 99 SAS or V Discharge or ponding of effluent to the surface of the ground or surface waters El ® due to an overloaded or clogged SAS or cesspool 4 ® ❑ 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 Y/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts , W Title 5 Official Inspection Form 5-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts , W Title 5 Official Inspection Form ' o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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: 8-2013Date 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-3/13 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 M 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town 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: N/A 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-3/13 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 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1970's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 48"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 40"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 Sludge depth: 12" t5ins-3113 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 ,M 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 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 20" Scum thickness 4" " Distance from top of scum to top of outlet tee or baffle 4. Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? 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.): Tank is in good condition with baffles installed and 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 it --- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 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 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town 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 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 in poor condition with stain lines above th outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in workingorder: Yes No* ❑ ❑ Comments note condition of um chamber, condition of pumps and appurtenances, etc.): ( pump P p Pp ) * 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ Teaching 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 was empty at inspection with clear evidence that it had been operating above capacity and backing up into d-box. 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 W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ',M s 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town 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•3t13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. CityTrown 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 J 4 6 OOC . 3g;c .. OY 4' 5,6 1 t5ins•3/13 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 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town 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: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) lain: Accessed USGS database-explain: ® P You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts , W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 67 Carrie Lee's Way Property Address Bob Brady Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i TOW OF BAMS ALE ICION ��":r r e L e e �f:'�'v earl e. Pf ONE c TAN c: 7 . 7 rtk.obi t 19M.l2 �XT ft�l _.COl�1?1�l A CE DATE' ntaor��lsta,s��c;Y#c�tw�eta ti�a I"e4ti um ) � � tputhcfwacet'lAt3te tc�filar k�aua ul LaaGhin 17�uility ' ato Supply�ldull wld,Leui; Py.�{el9s c�sti �7rcr�s site,ac:wlthio 200�edt of ls�cfiir► facility) 11)f,VeIbri.9 mid t..esal969f9cWtY X OY wetland xist kill ►5co feet of weblo8 lucilsry? " c �7& r L00io 0� 41�1' f i -IC y w o c �- r ��J V �l � �- y 1 ��� C �/ � No. 0 7d ---- FEB....2 d THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............fawm......:......OF................B.,fi.P_.N..S.'rA_84.C....... Applir�ation for Dispoii al lark, Tvustrnrtirrn .erttt� A lication is hereb made for a Permit to Construct or Repair an Individual pp y ( � p ( ) al Sewage Disposal PA System at: - VENT&RWLLE Location-Address or Lot No. Owner Address a o �C � Installer Address UType of Building Size Lot.,.75-_41......Sq. feet �-, Dwelling—No. of Bedrooms......................... ..._.._.._Expansion Attic (jo) Garbage Grinder (No) '4 Other—Type T e of Building /4._._.... No. of persons............................ Showers p,., yp g .-----Ih..1-.-- p ( ) — Cafeteria ( ) 04 Other d fixtures -----------•______________________ ---------------------------------------------------------- ------ WW n per day. Total daily flow............�30.................gallons. Design Flow.........14a........................gallons per Se tic Tank—Liquid ca acit 10Q. allons Length Width..4.24.` Diameter---------------- De th --_- �Y.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft. 3 Seepage Pit No........�_.-_-__-- Diameter.....a.......... Depth below i t......6.......... Total leaching area.; O b.....sq. ft. Z Other Distribution box (� Dosing tank ( ) " *+y J/ - 7 &-' '-' Percolation Test Results Performed by....JZ0MA_cb......A:.... A Sw_-• Date.....HAY_.. :$ Test Pit No. 1...._!�.2-minutes per inch Depth of Test Pit.... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••-•-•••••-•----------------•----••••--•--•------••--•••---••.......-••-•-..................._------......................................................... O Description of Soil............0- ..2-'I" ...4.Q.A/.►?---•------.4-,.v..O............sl fd,&.1014--------------------------•---•-•----------------- v -••••••-••-•---.......................... _`.!-..._.6j`..._....1.`1"19M-------.54,,Vb---------------------..................................................... VW ....................-.....................60 -----...4`Z111,6.............S IV-a---------------------------------------------------...-•-------------...----- 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 TI'i U 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. Sied.••--_. .... •••••••...................:........•-••-------•----•-•--••......-•-•-• ............Da••••......__.... nn �j,, _ Date Application Approved B ------e...._•L..lM1 .... L}..'...i;-=Z_.-_�..a..-- PP PP Y Date Application Disapproved for the following reasons--------------------------------•----•....................................................................... ..................••..........•••------•-••------•-••---••--------•••-----...-•••--------••--•-••--....•.--•••••••-•-••--•--•---••------•-••----•••--•--••-------------•--•••••-----------••••••-•-•-••- Date )/ ........ Permit No......................................................... Issued..-d Date ....... F�s...2`�_.. .._ THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH .............OF...............113AC.N.51t.. 2.-4-6•-_...._..._..._........... x 'Applira#inn for Rapos al Works Tontitrur#inn pram# : Application is,hereby made for a Permit to Construct 'Disposalo> Re air an Individual Sewa a System at: .t ...... ..' ... ccNrr2vicc� Locat on-Address or Lot No. .................................................... �t�ME S SMi Q13,ET 1sLe .... x •- .................................................. ..---------•----•------------_...... ...........----...--•-•-....--•••-............ •-. Owner Address U�Toc�►No ,(2os t� Ns R3►.e ........ = ... Installer Address Type of Building Size Lot _. __.._._Sq. feet Dwelling—No. of Bedrooms... _.._......Expansion Attic ,NO) Garbage Grinder (00) - aOther—Type of Building ..... _. ........... No. of persons............................ ShowersCafeteria ( ) Other fixtures --_-------- -------- ZWWV4....- W Destgn Flow........ ...o....................... gallons per person der flay. Total daily flow_______ . � gallons. WSeptic Tank=Liquid capacity00A!??_gallons Lengthd.W__s.._. Width_1.1/4°O' Diameter_______________ Depths_vd.'.'4.. x Disposal Trench—No...................... Width..................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No....... ......... Diameter----45.......... Depth below i t..... ._____._._ Total leaching arear .9.©......sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed b ... 9_NR4A...._ '__ � Qh ___ t Date____ y_. � � Y ..- --- Test Pit No. I.....4. -.minutes per inch Depth of Test Pit--- ..-_._.__.. Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit...:................ Depth to ground water........................ o Description of Soil.------.... .:!. . '!�.........L.�9&•--_-----AN- ------------Sw S!t64.•--••••-••-••••-•-•-------------•.....---------•- U ------. 6�..ry �� ",.... / YY�� �)lK� ` 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 TITTLE 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. Sied . .--• ....-•-•--•---•-•------•-•--••--------•---------------• ------- ..Da e.......-- �� � ............. ,, Date Application Approved BY is t• ......'" '�--..• -- .. ____.e________________________ Date Application Disapproved for the following reasons:............................................................................................................. ...................................................... ----••...•-•--•--••-----................•............... •------•----------------------......------..................---.... ------........ Date PermitNo....................................................... Issued-....................................................... Date THE COMMONWEALTH OF,MASSACHUSETTS BOARD OF HEALTH lw ..................OF...... fl �-a. :.A$.LC.................................. Tnrtifiratr of ToutpliFatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by......... T.4 1_NQ- QS. :--------------------------------------------------------------•-----------------------...............-------••................--•- Installer at............LO--T-...i C- Q 6 C._..1.� .-�� J .'----------------•-----••--------------------------...---------------------.....--------------- has been installed in accordance with the provisions of5 of The State Sanitaryade asescr e in the application for Disposal Works Construction Permit Now. -........................................ dated------- -- -- _...._.�____--- ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector_-•----.....-------------------•--••---•----= .................................... THE COMMONWEALTH OF MAS,SACHUSETTS BOARD OF FiEA'LTH , p ......... ow..I)...............OF.... .. �, , No.-••--••••--••----•-..... --•. FEE-••---••- fit.... Disposal Workii m5ono#rudion "unfit Permission ishereby granted......k.:t_TQ(?_1 zo-•----. 0.5------------------------------•--------------.......•-•-•-......_-••_.. ......... to Construct ( ) or Repair ( ) as/n�Individual Sewage Disposal System l��t f atNo..............6..�7�... 1.1..........�•'-1"7f�-' A.r_' 4—EE 5..._... Street... �7.�. U.1. L.l. ................................... as shown on the application for Disposal Works Construction P it N ._...,....__ Dated..................... !-----.-.... DATE................ ...................................................................•._.•.......-_-'........ Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �'7_�� Z�70 LOCATION SEYYAGE PERMIT NO. G of 4 r VILLAGE f 7ke 0 A e aoA a INSTALLER'S NAME & ADDRESS L/= ?j%-ram BUILDER R OWNER M1•krbt^b DATE PERMIT ISSUED 0 DATE COMPLIANCE ISSI ED� e��- p r / o t LOCATION- , J z7 G�)l l _ SEWAGE P VILLAGE �� � c �.. ERMiT No. � ,� r INSTA LLER'S lJ( � NAME i ADDRESS I BUILDER bR OWNER DA T E PERMIT ISSUED �,'//.�. . �DATE . � COMPLIANCE ISSd - iv j I i r LEE 1� 8•s +5 PROP A Y // ;9 7 8 E UJArER s INE :LOT 17 TES T 76'' .� 6 r - ELEV.. l 5 460 RECEIPV 0- �4 LOAM A NZ , 5U..5o/4 F SEPf 1C , TANK , j a fir' - 60 MEDJuM 5,qN �lCI vy S l N i 60 - W r. FINE 5RN D i 5t POUI' DAT101V 48' � a f Qa' 95 1 i ELEV 46 - LOT / (a TOUJN WA ?Er> 15 AYA%LABLE 11541 s /3[J/LD/n/G S ET6,gC/c ,2Z C_ U/)2E-MEA/7� SCQ L E / = 40 C'1001V T S/DY ,,'( 14OZE472 G20,a0 SE2� 4 f3F_D��o/�15 SEPTIC 5Y57-�M CONST2UCT/ON SHA u. CONFO/2M TO. MASS DES/G nJ FLOW � ' � � GALL L�.y ENV/,e 0i_//NEN T�(L CODE. Ti T'L L: IT j s �- L LEA C A/ 2 A TE � � IAIC<,/,� s REVISED 7--/- ?7' � LEA FPNIS 1 � LE. � n,t "i, ;V , .�EC,aU/ C-I� LE ICN �1�F4i C-/ l.s TOP OF .yEAL T/-/ GI LA TIONS.. ,o20F�O E U L EACH'-/' A2�A ' j9 ._-_ .... -.. ---.-n-...._ -wi...-.a.rr++•-r.._.-.....r E.�t S7•a/tiE . 90.00 (;'�9 �SZ�I ' Aif/10LE #Go i/E,2 � ✓/OU5 co VEQ0' TO-.a2E✓ENT sr/A/G5 !P E-D. 0JZA D LE �/2oM /iVF/LTi2.4 T/i1lFi a3 *. - -4 �� f Z4„co✓ i25 —= �:� D/57. I moo✓ 2% G ,C4DE ° 4.,C4 T . , 7 I BOX F"tiger 4 DI A.. �/T `t ` , FOOT /D N M2- P/7-�4 Face C0010DO S,O/ OALLO,\ EDO/,a. + /,VVEe7- 6 � 4L4.- 3 //vVEe-r -CA AG/ TY A20Un/O — �WATG�T/GNT� OF,. = : '� //VVE2T */ Crz p A/r 4 //V VEI&T NO GA,e5A6E C� 02SURNILAC-ILE (CENTERV, L LE ) MASSs �EFE2�nlC� a4:", 6' LOT i6 5 " 10A k `xr 3a.p PaG 9 3 �'�>` r �'. EDT TA /G n/K, 4D/,57-s2 d U OA/T/ 80x P� .t',� .3�R� F'tr�l t_ � .OUTLETS AND LE<1CAIIA.110 .a/T ' _ on/c2�rE ST,2EAJ0771 . 15000 ps/ Men/ �t /.1 MC (\ _J t T ��5'�' �sgh,'j TEEL 20000 /3Y � C't� f f Ltd,. COOP _ �'ii f/- /O LOAD//vG s D)CI VE WAY NOT TO B� LOCATED .. r Y,4-'2/NI0CJ.7'A:/�R7"" Oi/F2 'Sy5TEnit UNLEs5 hl- 20 r /PLtiN Gr k E S/G/V L OA`CMA.10 /S 06E_Z>. I. CFRT 1 FY THAT rla E -FDUNDATION _5#6,ik N ��� ON rH15 PLAN /S LOC'A T ED ON THE G ?.aVkD GEo;aGE f�S GjVtWLJ1V HERE0N AND lT DOES CONFORM �''� LOW, A, TO Th'E 13))I I INCY <e rt.W ACK RE Or` i f! T�i,_-.-?t�l OF c�sr�4 �� DATE. /-/E.AL77-/ AOZ=� 7- D H T n, A piD20 V,4 Z_ tiles t5`J� LEGEND N cu z -- 9 g --. EXISTING CONTOUR mye� Toom Rd �� X 100.98 EXISTING SPOT GRADE w W EXISTING WATER SERVICE Route 28 G EXISTING GAS SERVICE TEST PIT Q Westmms er a (p � c�eh �D Go 4A m e LOCUS � v G� \ WA LEES Y OCUS MAP CARRIEL NOT TO SCALE pavement 97.99 96,75 101.30 .100.97 100.16 edge °t -- AN `oo - f S 86'02'59" W W D TP 2 10v99.0 GS 9,8.74 x 96.40 --�\ 100, 0 iO3.30- _-_ 1' TP-1 101.17. ; X 96.55 104.52-�� 102,9 _ X �2 101,f� 9 �$ 1,05.97 `�: ` S"RIPOUT AS REQUIRED WAVED, \ (SE��NOTE 11-SHEET 2) DR( 0 7.0 3.. :.: ...:.. ..... WA 10516 x 1� \ x 100.30 PROPbSED S.A.S. EXISTING LEACH PIT r ��' \ � TO BE PUMPED, FILLED WITH r--__ 1 ' �\ �,'r� INSPECTION 'PORT SAND AND ABANDONED '110- 0 �5 �� �4 ` 39' ---- (SEE NOTE 11-SHEET 2) �xQ 11 x 111,44 l �Y� 1�ij8;51S `\ X 104 71 EXISTING SEPTIC TANK TOP OF TANK, EL.=110.20 ------ ---I INV.(0UT)=108.87f w�� - WNT �� X 112.82 2,87� WALK 113.4 Benchmark Set OUTSIDE COR./STEPBM v- EL.=114.88 (Assumed).. . _ 113.77 114.88 t�. \��� � 107,8� o z `113,09. INSTAL A 40 4 POLY LIN TOP OF LINER, EL`-105.5 EXISTING SPLIT LEI/EL BOTTOM\OF LINER, 103.0 /\\ HOUSE(#67) x 113.55 .- _coo 113,78 T.O.F.=114.5f// �\ CELLAR FLOOR, EL.=111.2f ��\\ �� \ Z 113.78 DECK 114.57 Z_xi�11 ,89 ` 114.15 114.35 X 114.47 x EXIS77NG HOUSE L- x 114.88 x 1L4.81 X 117,22 FRONT + 116.94 S � x 116.87 117.60 N' LOT 16 x 17,541f S.F. T MBLU 168-008-011 117,44X 4`\ \ ; x 117,39 x 117.86 A_ I f 1 $ / CONVENTIONAL S.A.S. �I�STEP EACH FOR ILLUSTRATION ONLY-DO NOT INSTALL -� ROW IN 1.0' 6`L 2-500 GALLON CHAMBERS W/4' STONE \A 13.2' x 25.0 S.A.S. FOOTPRINT ~j BOTTOM SIDEWALL TOTAL AREA AREA AREA S.A.S. LAYOUT 330 SF 152 SF 482 SF TOTAL CAPACITY = 0.74 GPD/SF(482 SF) = 357 GPD ��P``� of MgsSq�yG PROPOSED SEPTIC SYSTEM UPGRADE PLAN PETER! T_ g McENTEE 67 CARRIE LEE'S WAY, CENTERVILLE, MA o CIVIL "' Prepared for: E & B Development, P.O. Box 284, Scituate, MA 02066 o. 35109 P P OWNER OF RECORD F�/STER Engineering by: SCALE DRAWN JOB. NO. E & B DEVELOPMENT, LLC Engineering Works, Inc. 1"=20' P.T.M. 240-13 120 PLAIN STREET, SUITE 170 ` 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. MARSHFIELD, MA 02050 (508) 477-5313 10/29/13 P.T.M. 1 Of 2 sJ 4 NOTE: TO PREVENT BREAKOUT, INSTALL A 40 MIL POLY LINER AS SHOWN ON SHEET 1. TOP OF LINER, EL.=105.5 BOTTOM OF LINER, EL.=103.0 SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT INSTALL INSPECTION PORT OVER END UNIT T.O.F. OUTLET AND SET TO 6' OF FINISH GRADE COVER SET TO 6" OF GRADE CHARCOAL EXISTING F.G. EL.=106.3=110.3(MAX.) VENT F.G. EL.=112.0t F.G. EL.=110.5t CONNECT MAINTAIN 29' GRADE MIN. OVER S.A.S. ALL ROWS INSPECTION L = 3' L = 14'(MAX) PORT S=1% (MIN.) ® S=1% (MIN.) 4"SCH4o PVC 4"SCH40 PVC TOP LOAD UNITS s =1 e io"i 6 14" 19" TO EXISTING 48" LIQUID INVERT LEVEL ADD INV.=108.50 GAS BAFFLE INV.=108.67 PROPOSED INV.=105.58 4 ROWS OF 4 UNITS AT 6.25'/UNIT = 25.0' INV.=108.87t D-BOX (VERIFY) EXISTING SEPTIC TANK SOIL ABSORPTION SYSTEM (PROFILE) ESTABLISH VEGETATIVE COVER BACKFILL WITH"&LEAN NATIVE OR NOTES: PERC SAND TO TOP OF CHAMBERS 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=105.58 INVERTS, PRIOR TO INSTALLATION. BRE TOPAELEV=T�05.33 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE ON A MECHANICALLY COMPACTED SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.=104.00 310 CMR 15.221(2). 2 83' 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' MIN. ABOVE BOTTOM OF 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH=11.3' AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. EXISTING SUITABLE NO G.W., EL=89.0 (TP-2) = MATERIAL USE 4 ROWS OF 4-HIGH CAPACITY ADS BIODUFUSER UNITS PLUS WEDGE WITH NO SEPARATION BETWEEN EACH ROW & NO STONE SEPTIC SYSTEM PROFILE TYPICAL SECTION N.T.S. SOIL EVALUATION Date: October 18, 2013, 10:00 am (P#14188) Performed by: Peter T. McEntee SE#1542 Witnessed by: David Stanton R.S. - Health Agent GENERAL NOTES: TEST PIT 1 (EL.=101.8) 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL DEPTH HORIZON TEXTURE COLOR BOARD OF HEALTH AND THE DESIGN ENGINEER. 0"-20" FILL 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 20"-26" A LOAMY SAND IOYR 4/2 OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 26"-45" B LOAMY SAND 10YR 5/8 LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: 45"-80" C1 F-M SAND 2.5Y 6/4 310 CMR 15.405(1)(b): 80"-132" C2 M-C SAND 2.5Y 7/3 . - _ • 1) A 3' variance-to the-3' maximum-cover--requirement, for'up � TEST 2 to 6' of cover. S.A.S. shall be vented and H-20 Rated. PIT (EL=100.0) 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR DEPTH HORIZON TEXTURE COLOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 0"-16" FILL DESIGN ENGINEER. 16"-30" A LOAMY SAND 10YR 4/2 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 30"-45" B LOAMY SAND 10YR 5/8 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 45"-80" C1 F-M SAND 2.5Y 6/4 ENGINEER BEFORE CONSTRUCTION CONTINUES. 80"-132" C2 M-C SAND 2.5Y 7/3 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. NO GROUNDWATER ENCOUNTERED, PERC ON FILE 6/11/78, < 2 MIN/INCH 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF OBSERVED SOILS ("C" HORIZON) ARE CONSISTENT WITH PERC THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 75" 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING .RINI= CONSTRUCTION. F. 76" - 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS PROFILE IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. 16" 11.2" t�34" DESIGN CRITERIA SECTION END CAP NUMBER OF BEDROOMS: 3 BEDROOMS 16" HIGH CAPACITY (H-20) BIODIFFUSER UNIT SOIL TEXTURAL CLASS: CLASS I MODEL 16" HICAP DESIGN PERCOLATION RATE: <2 MIN/IN LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT DAILY FLOW: 330 GPD EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE PRODUCT DETAIL MAY DESIGN FLOW: 330 GPD SIDE WALL HEIGHT 11.2" DIFFER SUGHTLY FROM ACTUAL PRODUCT APPEARANCE. GARBAGE GRINDER: NO OVERALL HEIGHT 16" EXISTING SEPTIC TANK: 1000 GALLON CAPACITY OVERALL WIDTH 34" 4640 TRUEMAN BLVD 13.6 CF ® HILLIARD, OHIO 43026 LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF CAPACITY (101.7 GAL) Aavavcm DRAINAGE s>rsroms, wc. • .74 GPD/SF DISTRIBUTION BOX: 4 OUTLETS (MINIMUM) PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE-4 ROWS OF 4 HIGH CAPACITY ADS BIODIFUSER 67 CARRIE LEE'S WAY, CENTERVILLE, MA H-20 UNITS WITH NO STONE ALIGNED AS SHOWN SIDEWALL AREA: NOT APPLICABLE Prepared for: E & B Development, P.O. Box 284, Scituate, MA 02066 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF) Engineering by: SCALE DRAWN JOB. NO. (BIODIFFUSERS) 16 UNITS x 6.25 LF x 4.73 SF/LF = 473.0 SF Engineering Works, Inc. n.t.s. P.T.M. 240-13 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 GPD/SF(473.0 SF) = 350.0 GPD (508) 477-5313 10/29/13 P.T.M. 2 Of 2