HomeMy WebLinkAbout0017 CEDAR POINT CIRCLE - Health 17 CEDAR POINT CIRCLE
CENTERVILLE
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1 p Title 5 Official Inspection Form
lIb Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V �,
„�' 17 Cedar Point Cir. �
Property Address
Joseph Gentile
Owner Owner's Name
information is
required for every Centerville ✓ Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection '
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information I z is W 2—
,
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites Path
Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
{elan 508-477-8877 S114430
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
P�-�H OF
2. ❑ Conditionally Passes
may: MICHAEL '.N
3. ❑ Needs Further Evaluation by the Local Approving Authority _o: SEARS
* No.SI14430
4. ❑ Fails ;�•°FR �o.o�
pISI1q��G```````
12-2-20
Inspector's Signatur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.VM2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
I
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments,
e / 17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is
required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 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:
1500 gal tank, D Box 2 Drywells
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y., N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*,or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial.infiltration_or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is
required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑. Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
\ ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s).are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.0oc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Cedar Point Cir.
u
Property Address
Joseph Gentile
Owner Owner's Name
information is required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other.
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system'component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
�A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is
required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '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.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate,nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
El10,000 gpd.
❑ ® 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.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section C.4.
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
r
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Cedar Point Cir.
u
Property Address
Joseph Gentile
Owner Owner's Name
information is Centerville Ma. 02632 12-2-20
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components,pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A) ,
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
• ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Cedar Point Cir.
u
Property Address
Joseph Gentile
Owner Owner's Name
information is
required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
2018-34000 gal
Water meter readings, if available (last 2 years usage (gpd)): 2019- 18000 gal
Detail:
Sump pump? ❑ Yes ® No
NA
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
I� Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is Centerville Ma. 02632 12-2-20
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: May 2019
Was system pumped as part of the inspection? ❑ Yes Z No ,
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form r
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is Centerville Ma. 02632 12-2-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
5-18-16 #2016-165
Were sewage odors detected when arriving at the site? ❑ Yes ® No .
5. Building Sewer(locate on site plan):
34„
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
J
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection form
�I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is Ma. 02632 12-2-20
required for every Centerville
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 24
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gal
, k `
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth: 1„
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
8"
Distance from top of scum to top of outlet tee.or baffle
18„
Distance from bottom of.scum to bottom of outlet tee or baffle
Sludge judge tape
How'were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage; etc.):
1500 gal tank with in and out tees in place, inlet cover 24" below grade, outlet cover 12" below grade
-t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18.
I
Commonwealth of Massachusetts
,l�? Title 5 Official Inspection Form
- �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is
required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Cedar Point Cir.
V�
Property Address
Joseph Gentile
Owner Owner's Name
information is required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16x16 with 2 outlet pipes cover at 17" below grade
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
w ,? Title 5 Official Inspection Form
�0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is
required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.1/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
>r;
17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is
required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 2 Dry wells Wells are clean and dry with no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer "
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
C Commonwealth of Massachusetts
�u Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is
required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids -
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):'
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
w ,, Subsurface Sewage Disposal System Form Not for Voluntary Title 5 Official Inspection Form
- Assessments
I� y
a / 17 Cedar Point Cir.
Property Address
Joseph Gentile
Owner Owner's Name
information is Centerville Ma. 02632 12-2-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below-.
® hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
Commonwealth of Massachusetts
19.2 _ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Cedar Point Cir.
V�
Property Address
Joseph Gentile
Owner Owner's Name
information is
required for every Centerville Ma. 02632 12-2-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
10+
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:
Hand augered 10' no ground water
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
L,5,nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
4
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c� 17 Cedar Point Cir.
u—
Property Address
Joseph Gentile
Owner Owner's Name
information is required for every Centerville Ma. 02632 12-2-20
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
L_
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No. ./ [Y A Fee 16-0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for 33isp' osar 6pstem Construttion i3Prmit
Application for a Permit to Construct( ) Repair()o Upgrade( ) Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. 11 CC-1>AZ POWTGIP-C.0 6 Owner's Name,Address,a�Tel.To.
CfVILL�, :�'G�S�� -r- n14ez —aVT(C-tf
Assessor's Map/Parcel v2 as �45�3 dWAK 20 L21 Uk.
Installer's Name,Address,and Tel.do.SO$—d477— $`i'l Designer's Name,Address,and Tel.No.56 8—X7 3—03T 7
CAJ961i/D 6; L4..-- :q c- 7 Nc
C! S Os ��S e�AulZ3� �U
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size �/;w,6 -t sq.ft. Garbage Grinder( )
Other Type of Building RI S No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) `3_3 t) gpd Design flow provided 349 gpd
Plan Date O(42 Number of sheets Revision Date
Title (°I c,c- �i A - pat o-" <2 I giC LAE9 GGuT w_y i i C
Size of Septic Tank 1;0 y Type of S.A.S. (/;z) Sup m Eel &j 46C�2�
s
Description of Soil C[v Aasc- .6A-&jb ,30'1
Nature of Repairs or Alterations(Answer when applicable) (V 0t)
7D 14-10 D-6o K Mp l9) �r uD CF.A-u-O,\J -N'-!® L0(60c& � S
CW c r BELT dr6— L� f,�4-iT Sy l u� �C•r'
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Heal
Signed Date j_1 Q nil—
Application Approved by Date O
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
No. /W `" ti Fee /
! THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplicatlon for MIsposal 6pstem (Construction Permit
t.
Application for a Permit to Construct( ) Repair()o Upgrade( ) Abandon( ) ,Complete System ❑Individual Components
Location Address or Lot No. I CGJ>AR PO(NTGttZC(-C Owner's Name,Address TOCiI;T
Z'G756
Assessor's Map/Parcel oZ ClJ3 (Z Q[UT CAR . Ill1`r�
Installer's Name,Address,and Tel. 7-o.J09 59"t`j Designer's Name,Address,and Tel.No.$08-X73—0377
( A
Y
Type of Building:
Dwelling No.of Bedrooms .3 Lot Size 51 a�lw t sq.ft. Garbage Grinder( )
Other Type of Building E2ES I D'6)Qrt o(4— No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flo(min.required) 3,30 gpd Design flow provided 349, 4 gpd
Plan Date ((2 p((p Number of sheets t Revision Date
Title f!I c!c(:).4P, PO JOT a r,9Le.c.lc:!r G&.17Wt�..V r[.c,<;;,Z'
Size of Septic Tank 15 0 Q Type of S.A.S.C1Q jU o 6.l C, L4 CA �
Description of Soil CV A R55 S'hAA 0 -3 !! Se7_— p C.-Xf
Nature of Repairs or Alterations(Answer when applicable) «U(] 6ag��J t4—i(o
TO Ns[) 14-10 Q-&K TO lal 5'00 H-[U CEACOI&A=
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Heal ti
Signed Date
Application Approved by Date ,/g-
Application Disapproved by Date
for the following reasons
r_ p
Permit No. Ll_ 'U L Date Issued p
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(A/\A) Upgraded( )
Abandoned( )by 0A0!5k21 1)15 G1J Tr>{PR&5es L.L r—
at 1 T CcnAk Nm;—tt C(QGLC (v l"Z has been constructed in accordance `/I
with the provisions of Title 5 and the for Disposal System Construction Permit No,.}C/(� - (n 5 dated
InstallerQAP6 J1 a E (✓x� pQ+S �.,(,C, Designer �TC C-1wj&lam EFRULJC-,,r See.
#bedrooms Approved design flow 3,1Q gpd
The issuance of this permit shall not be co sstrrued as a guarantee that the system w'. functi a ned.
Date /K� Inspector
---- -- ---------------------------------------------------------------------------------------------- -------------------
No.cl Fee
- �(o G G
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repai ) Upgrade( ) Abandon( )
System located at I r7 Cemit- L— t&,r Ct&GC-6
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 mfist be completed within three years of the date of this pe, it. --
Date 5 �// Approved by
1
1
Town of Barnstable
Fr►+F, Regulatory Services
Thomas F. Geiler,Director
AARNSTABMAM NA68. Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: 20— , (a Sewage Permit# Assessor's Map/Parcel 2 2 8 �o
Installer& Designer Certification Form
Designer: 5C EnAtoe.ecigl, 7,1C Installer: Caeewide C-otereU.Se_S, 2-4-G
Address: 2&511 Cco,berr)e His Address: l53 Go.Wnerec-i 5{ree+
L�as� woreharn. HA- oz:38 Nastifee, N DZlo 'Y 9
On 5 Cgewide. Erg ue(lses was issued a permit to install a
(date) (installer)
septic system at 17 Cedar Coo if Uccl C based on a design drawn by
(address)
5C 1rn9tr)eercilC L Zy1G, dated Har 1(0.201 b
/ (designer)
Y 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. Stripout (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. Stripout (if req ' 'nspected and the soils
were found satisfactory. �.�N°F
JOHN L. �
JR.
(In t Iler's Sig a Lire) No l41e07
AL
esigner's Signatur (Affix esi 's e rnp Here)
PLEASE RETURN O 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\m11cc i'orm.;Jc;igncrccni(i�aiinn lonwdoc
TOWN OF(BIARNSTABLE
LOCATION `45DAR. `O«T %tR• SEWAGE# ;tO`(0 ' 1
VILLAGE C�t.(-����t ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ,5®c C—,ku
LEACHING FACILITY:(type)(;Q 500 GA(_N& (size) ci 5 X!01 ,R
NO.OF BEDROOMS 3
OWNER q 05CQ(, 4� MAC- 6e0TtC.G:-
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N 1Q Feet
Private Water Supply Well and Leaching Facility(If any wells exist on qq
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) tJ /A Feet
FURNISHED BY 0,AP&w r A 6 &Ili 1 WAJ L CC
(edor Ic
a-I a�.3` BACK
ig-2 ' 19•b`
Q-4 = 41.2 ' - - -
I pj
C i
Town of Barnstable P# fD 3
. dFtt161Uy,,
Department of Regulatory Services
s ,ta,,m a Public Health Division Date 2 �p
200 Main Street,Hyannis MA 02601
�AlEU MA't t' �
Date Scheduled o Time /0 #M Fee Pd.
s '
Soil, Suitability Assessment for Sewage Dispos't
Performed By:,- M lc�l l C til1/l�dl��k El_-f, CS E Witnessed By: \I Iry �- J �^✓1 �^� �S _
all
LOCATION&.GENERAL INFORMATION
Location Address Cy/p�� Owner's Name _j dSEVH ev C '7 f LC?
Address
C C_1Ai'CS.ZJtbto tom` GQ?&5 e-"—
Assessor's Map/Parcel: ` Itp a o o Engineer's Name SC-SET 106FE) Lltsr Z VC.
NEW CONSTRUCTION REPAIR Telephone# J_Q 8--"-7—a% 77 . P 9-7-7 3.0377
Land Use.- `(14R. �, ly 'Dr%-,,lntIIt Slopes(%) Surface Stones
Distances from: Open Water Body ) 1 V0 ft Possible Wet Area /10� ft Drinking Water Well d ft
Drainage Way G ft Property Line 1 ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands{n proximity to holes)
See
Parent material(geologic) �ud S� Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
�Z7 NATION FOR SEASONAL HIGH WATER TABLE
Method Used: i tPC Q( �iISV\
Depth Observed standing in obs.hole: ,3 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,fector Adj.Groundwater Level
PERCOLATION TEST bate .._.�_, Titne.Y�,
Observation
Hole# Time at 9"
Depth of Pere Time at 6"
Start Pre-soak Time® Time(9"-6")
End Pre-soak , ems �Q�L �f�S� La4j6e_�
Rate MiiaJlnch . C V O-kAA cr S _
Site Suitability Assessment: Site Passed Ve.) Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division 6� Observation Hole Data To Be Completed on Back--------
I
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one (1) week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
nd V
DEEP-OBSERVATION HOLE LOG Hole# _
Depth from Soil Horizon Soil Texture Soil Color Soil- Other
Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders.
onsistency.%,Gravel)
%0 A Loom S,,,)
coo_rge &1rj
DEEP OBSERVATION HOLE LOG Hole#
Depth from '+ Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
onsistency.%
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Con i to Gravel)
1
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders,
Consistency, QGvel)
Flood Insurance Rate Map: /
Above Soo 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? Y e-S
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on 10-7 7 .g% (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required train' exp rVseanexpe " ce described in�10 CNM 15.017.
Date 5-1-5-1
Signature
Q:\S.EfrnCVERCFORM.DOC
,No :�.-..�. ��•.. , Fxs..............................
THE COMMONWEALTH OF MASSA-ZHUSETTS
BOAR® OF HEALTH
/ 7 w................OF...... W4% ...._----•---------------...---.............
Appliratilan for U44pu,ial Workii Toustrurtiun ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
J--, .RZI M z .�- !v u . -••---------------------------•-•-I. -r...C. ...----•---..._.._.._......._.........•
y� ,s Loca�t�opn. Address {f,��j����/ per ° ,your Lot jN'`.
�o�3 ..F: I F.R• _� �__i r"'- 4+cad ll.I.a7 ms74_1._...$ F l fsr� •••••...••....
Owner • Address
a ........................................................................ .4............. ..... -•----...... ...._._.........._._..----....•---......
Installer Address
UType of Building Size Lot.....,0 ....Sq. feet
., Dwelling—No. of Bedrooms.......................................Expansion Attic (qA) Garbage Grinder (WA)
Other—Type of Buildiug ------NIA............ No. of persons......... .............. Showers ( ( ) — Cafeteria (ujA)
P4 Other fixtures •-----------�IA••--•-••-•-•-----------------•...---•-------
Design Flow...........A!$.........................gallons per person per day. Total daily flow......A4.40_..............._......gallons.
0� Septic Tank—Liquid capacity 1 ..gallons Length_A.R..._.. Width....-.._Q.__. Diameter.-.A_....... Depth_A_a._....
W
x Disposal Trench—No...NM___..___. Width...NIA......... Total Length.._a1.16.__..___ Total leaching area...� „�!� .......sq. ft.
Seepage Pit No......A............. Diameter......1_0....... Depth below inlet.....Am.......... Total leaching area..� ....sq. ft.
Z Other Distribution box (V< Dosing tank (NAP)
t
Percolation Test Results Performed by.... ���e�� -1'r�.,.-.�� �� ...... Date--- AP..'A.�....__....
,aa Test Pit No. 1. _...minutes per inch Depth of Test Pit-..-- ........ Depth to ground water.. _........
Test Pit No. 2_4."°...minutes per inch Depth of Test Pit.....�n-°__-___.- Depth to ground water.�OR97...--..
a --•---••-•••-----------------•-•--••------•--•-----•••-•----•-•-••--------------•-----•---•--.----...........................................................
Description of Soil......._... °T _!®1'..................._.�_.'�P�JsL..
x ----
V ' '�..— Irti fZS_.N1 1M_°.3� --- ..�+R/'C�....---------------------------------
� ----•------•----------- •-----------•--•-----------------------•-----------------------------------
U Nature of Repairs or Alterations—Answer when applicable_..N1A..................................................................................
--------•-------------------•-----....---------------------•------------------------•-••--•-•---•---•-•-----•--•------•-•---•-•--•---•••----•-••------•-••---•-.-:..---•---••--•-•••••-•-•--•-•-----••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL is 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 bwkhle board of health.
Signed ----•• -------------------------•--•••••--• --...S.—l.9....oe
�C Date
rt, Application Approved By...... -- -----•-•--•-•........ .... ................................................
Date
Application Disapproved for the following reasons:.............................................................,..............................
.....................•-----•-•---•-•-----...-------------------•-•-•-•----.._.._......-•---•------------•--------------------•-•-•--
Date
PermitNo.--- -�=....... `V............................. Issued--------- ...... .� ........--•---•-•--•--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`... ---------------OF...... h �1C .._...
.. . •. Appliratilau for IlWpoli al Works Toustrurtinu ramit
Application is hereby made for a Permit to Construct (•4010or Repair ( ) an Individual Sewage Disposal
System at:
!� v I LL ................................... -= �► ______
- ...................... ..
Location Address or Lot No. .+..
--
W 2 , Address
----...... .......-•-•••............................ •-•--•-••--•---•••--.................--------.••------••-----•-•.....••-------..._...--Q.---....
Installer Address -w
�
U Type of Building Size Lot___________�................S feet
U Dwelling—No. of Bedrooms.............3............................Expansion Attic Garbage Grinder (t4�
aOther—Type
of Building -------ShA............ No. of persons..........`In............. Showers ( ( ) — Cafeteria (tio)
dOther fixtures ............. A....--•----•--••••••••--•--•-••---••--•---••-••-•---••••••••••••----••--•-•-••-••••••••••••-•••-••-•-••......-•...............
W Design Flow............--'_A.......:................gallons per person per day. Total daily jfiow....._." .�_______._..__......._ allons.
WSeptic Tank- Liquid„capacity_3_ .gallons Length__$__.__._ Width....... ?_... Diameter----�_------ Depth_.�_Y_._..
x Disposal Trench-No. _ ....... Width.... ._...... Total Length....W.:.�J., . !IJA ......_ Total leaching area___!``JJJ -------sq. ft.
Seepage Pit No.......1------------ Diameter....___f.0...... Depth below inlet...... "....... Total leaching area.._ ..___sq. ft.
Z Other Distribution box (v< Dosing tank (+� 6 j
`" Percolation Test Results Performed by.........................................................................., is�t"�.........�__!.............: ................ Date.... .'.3q'.6.1..._..__.
Test Pit No. 1_. _.______.minutes per inch Depth of Test Pit...... ......... Depth to ground water..NOW�-------
Test Pit Now UE,
o. 2..�..� ..minutes per inch Depth of Test Pit......j .___._.. Depth to ground water......................
-------,--•••-• :•......----•••-••••-•••---•---•---•--•-••••......-•--•••.....•--.
ODescription of Soil............ , 16" 1A a -1- P-_.6► .Z.- --------------------------------------------- ------------------------
--•••-----------
.._.......--•-•---•-------------------••......--•----•••.
W
x .......................... ........•--•---•---•-•-----•-•••----•--••---••••••......--•----••-••......--••---••---•--•-•••------•-••--•---•--•••--•••---••-----••......----••......-
U Nature of Repairs or Alterations—Answer when applicable.____-�41A.................................................................................
-------•••••••-••••••---•-•--••---•••-••••...----•--•--•--•-••--•----••-•-•--•-•--------------••••••--•:...-----•-••-•--•-------•-•-••-----•---•••---•••••••-•-••-•-•---•••--•-•----•-•-...•-•••---•--•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss ed by tkie board of health.
Signed----... ----••--` t�:..�v
Application Approved B I� Date
Date
Application Disapproved for the following reasons:--------•-•---••-----------------------------•--....---------•------------------•--------------------...._•••---
...........-•••-••••----•--•-•---•---•••------•----•-•---••--------•-•••••••--•------•_•-----•----•-•-••_..----------•••-•-----•••-----••--•--•---••••-•---•------•••-•-•---•-------•......•--...._....
Date
Permit No.--. ............................. Issued......... s- `� �-.......................
Date
A"
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Wrttftratr of TvntV1i aatrv,,
I \
THIS I$*Q,,CERT,�FZ,1-That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...............................•••••••••-•--•------••-••--........--•-----•---•-•-•••...--•---•--•-••••••----•--•-•-••-••---•••••--...:.....
Installer/
at........4.4i.jc.:•--•••6--------- ---........•=-•Cr...erh-----..J...4'�..-..--..-- f-..-�:
has been installed in accordance with the provisions of„TI T LE 5 of The State Sanitary Code ape deny bed in the
application for Disposal Works Construction Permit No..-.. � __ _____________________ dated__..._._' . . .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
-SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................. ;,.
.:................ ..........I_bl).i�.._........ Inspector-=--------- ....................................................
a, THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF-, HEALTH
................... r.............OF.............�i/r/•Jrkdrtc............................._.................
No........... _ - , 4/ FEE................
DWpotiFal Works Tonotrurtivit fautit
Permission is hereby granted_.____.__.__ �...___"f�_..0_....._A If R'
•-------------------------•........... ..................................
to Construct ( )Xor Repair ( ) an Individual Sewage Disposal System �� , tr;O-
at No.. w / � ...... t3 �y .. .
%ah /G I f//i4 c
•-- •.
T - Street 1/ � l
as shown on the application for Disposal Works Construction Permit" No...................... Dated..........................................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS''. ^
t
LOCATION LG?T C d ...• G� PAR?.lT. G(�C ,"� NO. d 2
VILLAGE O � Ll.. .. DATE. zl��.
.APPLICANT .J O L LF_ FEE!' !-5
ADDRESS (Non-refundable
TELEPHONE NO. 2�
ENGINEER DC__- +.SZ� TELEPH E NO' -15-124q
DATE SCHEDULED'. 1' �50 ICI g 1
(Applicant' s signature
SOIL :DA�TE
SUB-DIVISION NAME G�pv( PCB 1 "7 q 30. I TIME 10 -'
EXPANSION AREA: YES �NO C Q wr3 Red ENGINEER :k,
TOWN WATER �RIVATE WELL 01o� (sotpsopb BOARD OF HEALTH
024 %C=ILL_- EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES:
�oe
o �
38't-
o
PERCOLATION RATE: I�SSSa `r�+Ar.1 2 Ant,.J ��iJ
TEST HOLE NO: ELEVATION: TEST HOLE NO: . "tW0 ELEVATION:
2 ro€�scI 2
3 3
4 4
5 t►4ye-P-S 5
7 ►f 12` S�ta� 7 = Al
8 8 Ojai
9 .9
10 10
11 11
12 KW W A•`t'E-A, . 12 vC1 w-offe�-
13 e !2' 13 i2
14 14
i
15 15
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: LEAf-..3"'_NG FIELD LEACHING PITS
LEA"'i: NG TRENCHES /
UNSUITABLE FOR SUB-SURFACE SEWAGE. REA-33 NS: ►--�
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON TEST APPLICATION
ORIGINAL: _COMPLETED IN ENTIRETY BY _P, E. AND RETURNED TO BOARD OF HEALTH
copy!: , RETAINED BY APPLICANT
m
Pit \�
i�,00 co 1 l ca.i sew_
1K m �.
T� Q ^
0
,Ay ..
r
- m
0
.d�
1 .II
_ 2i3 toSSIN 1.
5 + J
;z• / 15,OorJ s F
to
F.S,,B,. p
.45
2E qF Rw✓Eenr
OF
SU
LESEND
0111ITINO"' SPOT ELEVATION OF Mq CERTIFIED PLOT FLAN
EXISTING CONTOUR
o ALBERT ( -T -_ CpA� ` f�t►�,rn C Pit
fINlSMEQ' 810OT ELEVATION e
No.'10951
�'PRQVEa! SOAR0. OF HEALTH 9 Fc,srE�
Y+ oFFsSIONA� � AIMS 1A.GLit, Asse
1`_ M1 •• w
1'.
�r L
i AT$ 'AGENT SCALES' I' = 4v' GATE ArPf 30;82
EDf� N INEEMINQ CQ l MA�ue air a
CLIENT. I CERTIFY THAT THE PROPOSED
REdISfiIElfED Oa 'NC. ' 8 DUILDINA SHOWN ON THIS PL AN
CIVIL LAND, CONFORMS TO THE ZONIN® LAW$
" 7t"2; '1 +A�I N STREET b CN.`SY
wYaaN I g : M•Ass. r4�
A ,` $NEET-L OF 2 DATE (RE A. LAND SURVEYOR
t
ED FP M/N /1/OTF /F E/Ti'/ER THE SEPT/G TAN. OR
3 �E.4GSI/ivG P/T ARE IVORE TifA:"/ /2==BEL0.V I
/O:PT•�►�/N. 1RAOE' A 24'O/AM ETER COiyCR ETE COVER
4�PYC 0/P1r 'SHALL B.E BROUGHT TO
GI�AOE.�.;.Y EXTRA
GONCRCTC �y/IV, P/TCN HEAVY CA ST ES
1=L IOSA COVERS �B PFiQ FT /F//V OR/VEWA Y,
a
TE
2 • MiN. CONCRE
A _ G AoE CO YER CL EA/V .SAND
LEVEL �.i
4"'CAST� - �. 2"LAYER
"IRON P_/PE o e o P 1/8"_J/9
`
P/rGN _ • a . . . . • , , . o aF " -
`< SEPTIC TANK D/ST. • • • • • • • • • • a WA St/FO Srz�NE i
BOX
• a
ti 2 y rt t` M •, f
• (EFFECT/✓E ' • , 314��-
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•
/NrLET,,A. .SE'PT/F r4NK l02`.3 FT 10 FJ O/.4M. C SEE 7A4&1"7
Ot/TLE�'`-O 'PTIC,TANK 102: I FT
/NLET;O/STR%46//T/ON BQX 10I .9 GROLINO WATER HALE
OV7ZAE7D/STRIB&lT/GN BQX lO t c7 'FT_
SECT/ON OF
lNL:Er LE.vcN/A/G P/T:.: SOWAGAS O/S.400JAJ. SYSTE/�'f
LEACHIIVCr pl.T TABUL.4TlON
SCALE S/ON A 2 5 F T.
"DES/6/�! CRtTER/fit• o/MEiv
OI'bfR'V.S/O N'
1VlJM4jE1q:Qf'BEDROOMS:.: 3 4, DI�yENS/ON C.
FT.-�M I►J
s
CsARQAGED/SP0.5.4L.U/V/P ONE
SOlL. LOG -
TOTAL EST/M-iTEO FLOW 33o GAL./DAY sO I L TES.T; / SO/L T.FSTZ: SO/L TEST.
NVMBER QF`tE.4cwtnrG. P/Ts_ t` f^Ece►Y 105.0 -El.Ar 103.S ,DATE OF SOIL TEST ' gl 6'
SIDE';L,L-AGH/KG AER-Rlr t88 SCR PT" RESULTS iv/TNESSED 8Y J �NG� Q0
90TTOMslFa4Cl//NG P6R P/T -7S r Lo1'tN� �/
�•, RT , 7' AeIVCOLATNATE,/ EA
TOT.4C BEACH/NG 4R AT/ON RATE2 I M/N�IlNCK
MIw. l/INCH
.RESERVEGEA4C/J/N6.AREA /L�aCo $Q, ,FT,.
tN of �N o F,y r- 'r MEDwM AS 1
sue ► �ss9� 18 .i1 sA�►p lo�C Ca - C� Q i NT c►PcLE
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as a 6R ItUJ KE /e
296J�`O, No.10951 O
• 9F El-DREDG&ENG/AIAZR/NG CO,/NC.
�..
E L= 9 I S � 7/2 "Ally S T , H
ND G/TO[JNO 4TER ENCOUNTERED' YA,vNiS; M.g ss,
Np.SUS"" FS570,A��`� ® yNi
CL/EevT; n g it DRTE : OQ '�4 g2
Q GROUIVO JPVATE.? AT:ELE{/
r . r ✓OB ND: SHEET 2 OF 2
LO•CAT10 _ SEWAGE PE,RVIT N0.
II LPL A G E r—
- ej"
�JNSTA L R'S NAME & ADDRESS
� 3D U
UILDER OR OWNER
DATE PERMIT ISSUED l �z�
DATE COMPLIANCE ISSUED �c��/
�y-
TOWN OF BARNSTABLE6,9( 3
LocAT oOP V- 6 Ca%:�--*r 9 Ciro SEWAGE # ��
VILLAGE-_( J f���- ASSESSOR'S MAP & LOT ZZ8 113.COb
INSTALLER'S NAME & PHONE NO. ,
SEPTIC TANK CAPACITY iQC)Q
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
i / ��
FINISH GRADE OVER D-BOX= 48.3'± FINISH GRADE OVER CHAMBERS= 48.2' 5'- 48.
T.O.F. EL.= 50.6�± 3/4"TO 1-1/2" DOUBLE WASHED
PROVIDE EXTENSION RISER REMOVABLE WATER-TIGHT COVER OVER SLOPE @ 2% MIN. OVER SYSTEM STONE TO CROWN OF PIPE
WITH COVER OVER INLET& FINISH GRADE OVER TANK EL.= RISER TO WITHIN 6"OF FINISHED GRADE 1� UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION
OUTLET TO WITHIN 6"OF F.G. 4" SCHEDULE 40 PVC INSPECTION PORT WITH ACCESS BOX METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
FINISHED GRADE 0 2" OF 1/8"TO 1/2"DOUBLE WASHED
@ FOUNDATION = 49.0'± 48•8± r-5" DIA. OUTLET(S) MIN SLOPE 1 /o TO F.G. (SEE GENERAL NOTE#21) STONE OR GEOTEXTILE FILTER FABRIC CODE AND ANY APPLICABLE LOCAL RULES.
2 0" MIN.ACCESS -___._.___ 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
COVER(3 TYP.} 9"MIN. t , PLACE RISERS ON ALL DESIGN ENGINEER.
36"MAX. 9"MIN TOP OF SAS= 46.18 CHAMBERS WITH
PROP. SCH. 40 9"MIN. 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
PVC SEWER PROP. SCH. 40 I 36"MAX. 45.35' 36"MAX. BREAKOUT EL= 45.85' INLET PIPES TO 6"OF SYSTEM UNLESS OTHERWISE NOTED.
FINISHED GRADE
PVC SEWER 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
MIN.SLOPE 1 6" 31, 2' DROP MIN. llll"'' _j I 3" DROP MAX. 3" 9�. MIN SLOPEQ 1% L=40 ± I PROVIDE WATERTIGHT o a ELEVATION =45.85' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A
4" PVC IN FROM JOINTS(TYP.) � 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF
10" 14 SEPTIC TANK 4"PVC OUT TO 0 � 0 � 0 0 0 °° � � 0 � � o
„ � THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
46.50 LEACHING FACILITY T °° C� 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
46.75' 1 r' 6° o" °°
6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
48� OUTLET TEE 45.80' MtN. 45.63' 2' 0 00 0 0 o� 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
6"CRUSHED STONE f-� r-'I (� °° C] p� FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
GAS BAFFLE OVER MECHANICALLY o� L _ _! 3-�l +---� °° _ Q NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
16.9'OFFSET TO FND COMPACTED BASE I AND DESIGN ENGINEER.
4.0 8.5'(�-�,P) 4.0 4.0' 4.0'
I 5 OUTLET DISTRIBUTION BOX 4.83' 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF 50.00'
6"CRUSHED STONE I TO BE INSTALLED ON A LEVEL STABLE 25.0' (NP.) ESTABLISHED ON CORNER OF BULKHEAD AS SHOWN ON PLAN.
OVER MECHANICALLY BASE. FIRST TWO FEET OF OUTLET GROUND WATER ELEV.= < 37.30'
COMPACTED BASE C C C C ZA3•35 12.83' 9• CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
PIPES TO BE LAID LEVEL.
PROPOSED 1 ,500 GALLON CONCRETE SEPTIC TANK 5'MIN. THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
,- „ , „ ,- „ 2 - 500 GALLON CHAMBERS CHAMBER END VIE�PV 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
LENGTH �� WIDTH 5 -8 DEPTH �.8 (Dimensions per wggin CROSS SECTION VIEW
Precast Corp.,Pocasset, MA) TYPICAL CHAMBER PROFILE TO THE DESIGN ENGINEER.
10. ALL JOINTS WHERE PIPE ENTERS AND (EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT.
NOT TO SCALE NOT TO SCALE NOT TO SCALE
11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
PLAN NOTES: SWING-TIES �- �...�- ,,.c " � • a.. • •1 T REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
` °• • j • APPROPRIATE AUTHORITY.
DESCRIPTION HC-1 HC-2 GC--1 _- '" • ` " " PERC NO. 15034
1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE • • o '
TOP EDGE OF EACH SEPTIC SYSTEM COMPONENT. : • ! �t0 ►t t:� INSPECTOR: David W. Stanton, RS _ 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED
SEPTIC COVER IN (1) 22.9' 27,2' -- ,' EVALUATOR: Michael Pimentel, EIT, CSE UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT, DRIVES, OR
I / - TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING.
2.} CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE SEPTIC COVER OUT (2) 24.3' 20.9' -- I `Beek hwo0l,' '` '� _ .g C.S.E. APPROVAL DATE: Oct. 1999
LOCATION OF THE PROPOSED LEACHING FACILITY TO ENSURE • _ 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
CONSISTENCY WITH TEST PIT DATA SHOWN ON THIS PLAN. CORNER OF STONE(3) -- 33.2' 11.8' (gym ••+ ` . . . •' r.. • DATE: May 13, 2016
REPORT TO ENGINEER AND LOCAL BOARD OF HEALTH IF •
• . ' • . . 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. MAP 228 CORNER OF STONE (4) -- 45.9' 15.8' r .,�. ,.• : , • , TEST PIT#: 1 - MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
LOT 114 "' •• + "• •% •. " f'I ELEV TOP= 48,30' _ REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
3.) ENTIRE PROPERTY IS LOCATED WITHIN THE ESTUARINE �.: CORNER OF STONE(5) -- 53.1' 38.1' `.'.: •• • '• LOCUS . ... .i . FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
+ . . . ," . :•.� ELEV WATER= < 37.30'
WATERSHEDS. ! I.�..,r , ,� • , . _� -
'��•....�„ CORNER OF STONE(6) -- 42.6' 36.7' • t,��� 4, yp 15- CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
'�""�+• _ PROPOSED INSPECTION PORT C PERC RATE _ <2 min./inch _ SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
S t,_y€ ' Cs ry ; 4.�. + ' • " +•: • DEPTH OF PERC=_ _ 16. PROPOSED PROJECT IS LOCATED WITHIN:
PROPOSED 2-500 GALLON 0 S80'45'40"E . • ;• _ ASSESSOR'S MAP 228 LOT 6
� TEXTURAL CLASS: 1
LEACHING CHAMBERS (5 2 Aa ' 11g,7p� .* . ,'" �' ; • • .
�1---__ 5 r "1,� �� ', , Per perc test conducted on 9-30-81 by others OWNER OF RECORD: JO5EPH J. & MAE D. GENTILE
WITH AGGREGATE 0 r- ,� •' . •• ` . .. , F;;+
. , "„ '� •' • , . • ® ' 0" 48.30' ADDRESS: 17 CEDAR POINT CIRCLE
� 4) TREE LINE
_ - w ` t' ' ° •1.k 6" Fill 47.80' CENTERVILLE,MA 02632
TP I :,r
A Loamy Sand FEMA FLOOD ZONE X
PROPOSED DISTRIBUTION BOX O _, O _ - �"
R " � , �• 10Yr3/1
22.5' N ` *. i '
10" 46.97' COMMUNITY PANEL# 25001C0564J
k.p .• 17. DEED REFERENCE: BOOK 27418 , PAGE 40
(6 ( Y M•{a 1a,`. ,, . .•° •••• B Loamy Sand 18. PLAN REFERENCE: L.C. PLAN #40754A
TP 2 > �,� 7 • k• �1 1 2.5Yr 5/6
r? % (3 lOs, 48 , . + '..0 `• 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
48x3 • ` 30" 45.80'
o $ \�' C-1 -, w `• _ ,"•;" 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY
� a k.48 �, , •, - " ° . *., ••, FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
c co *- N o •'''�!.; : FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE.
a.
N " • .��•: 21. A 4" PERFORATED SCH. 40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A
bo
J ,48 DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3"OF FINISH GRADE. A
PROPOSED 1,500 GALLON SEPTIC TANK --
GARAGECoarse Sand REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS.
2.5Y 6/6
- LOCUS PLAN
�. SCALE: 1"=1000' 132" (--- 37.30'
No Standing, Weeping or Mottling Observed
x 48.8 W
{- l --HC-2 ..J
U PERC NO. 15034 EXISTING SPOT GRADE
(2 a� 'ti NUMBER OF BEDROOMS (DESIGN) 3 INSPECTOR: David W. Stanton, RS _ EXISTING CONTOUR
US E... 0 DESIGN FLOW 110 GAUDAY/BEDROOM EVALUATOR: Michael Pimentel, EIT, CS_E
Z g C.S.E. APPROVAL DATE: Oct. 1999 _ -1 50 - PROPOSED CONTOUR
TOTAL DESIGN FLOW 330 GAUDAY
X49 1
O w DATE: May 13, 2016 50 PROPOSED SPOT GRADE
O j CL DESIGN FLOW x 200 % = 660 GAL/DAY TEST PIT#: 2
23.7' - r' - EXISTING UNDERGROUND UTILITIES
Q.v USE PROPOSED 1,500 GALLON SEPTIC TANK -
ELEV TOP= 48.30'
(1 #17 W ELEV WATER= < 37.30' _ EXISTING WATER LINE
EXISTING ' _. U EXISTING 1,000 GALLON SEPTIC TANK
3-BEDROOM i` PERC RATE _
DWELLING INSTALL 2 - 500 GAL. CHAMBERS w/ AGGREGATE DEPTH OF PERC= EXISTING LEACHING PIT
TOF = 50.6't -
MAP 228 SHED SIDEWALL CAPACITY -
TEXTURAL CLASS: 1 16 TEST PIT LOCATION
LOT 126
(LENGTH + WIDTH) (2 SIDES) (2'HIGH) (0.74 GPD/S.F.) = GAL/DAY
i VCo W (25.0' + 12.83') ( 2 ) ( 2' ) ( 0.74 GPD/ S.F.) = 112.0 GAUDAY 0„ 48.30' O O O PROPOSED 1,500 GALLON SEPTIC TANK
BUSH 3H ' Fill PROPOSED 4" SOLID SCHEDULE 40 PVC PIPE
BOTTOM CAPACITY 6" 47.80'
HC-1
a (LENGTH x WIDTH) (0.74 GPD/S.F.) = GAUDAY A Loamy Sand 13 PROPOSED DISTRIBUTION BOX
O (25.0'x 12.83') (0.74 GPD/S.F.) - 237.4 GAUDAY 10" 10Yr 3/1
46.9T
W
MAP 228 �
O l PROPOSED 500 GALLON LEACHING CHAMBER
LOT 6 a
15,246t S.F. w TOTALS:
� � B Loamy Sand
TOTAL NUMBER OF CHAMBERS 2 2.5Yr 5/6 REV. DATE BY APP'D. DESCRIPTION
TOTAL LEACHING AREA 472.2 SQ.FT. 30" 45.80' PROPOSED SEPTIC SYSTEM UPGRADE
TOTAL LEACHING CAPACITY 349.4 GAL./DAY
PREPARED FOR:
Benchmark
Corner Bulkhead CAPEWIDE ENTERPRISES
Elev. = 50.00'
Approx. M.S.L.
' C Coarse Sand LOCATED AT
I 2.5Y 6/6 17 CEDAR POINT CIRCLE
4S CENTERVILLE, MA 02632
SCALE: 1 INCH = 10 FT. DATE: MAY 16, 2016
MAP 228 132" 37,30'
0 5 10 20 40 FEET
44
LOT 5 No Standing, Weeping or Mottling Observed
S80 45'40"E /`'
�_ `� PREPARED BY:
117.77' RESERVED FOR BOARD OF HEALTH USE L JC ENGINEERING, INC.
Chu Ni u.�. 2854 CRANBERRY HIGHWAY
4+eor
EAST WAREHAM, MA 02538
SITE PLAN 1 508.273.0377
SCALE: 1"= 10' Drawn By: SJI Designed By:MCP Checked By: JLC JOB No.3473