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Home My WebLink About0020 CHILDS STREET - Health 1. 20 Childs Street Centerville P A = 248 015 IN i S//// aaECYC��CO J yA UPC 10259 No.H� 163ORq � oa HASTINOS, MN Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Childs St. Property Address Jim Scovil Owner Owner's Name information is Centerville MA_ 02632 _ 4-16-13 required for every _ page. Cityrrown 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. Implimo out s A. General Information filling out forms utt�unuuip on the computer, ��``t�(tt OF•ft�q`S'S' use only the tab ��y�4�.• q key to move your 1. Inspector: cursor-do not Ln DAMES James D.Sears _ :m_ use the return --• - -+� key. Name of Inspector. o RS -:Cl)= - �� CapewideEnterprises,LLC �-, �Il,�, ►I Company Name 4 � '••..Ni" 153 Commercial St. 1',�i111 . U��a``�� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number . B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-16-13 pector's Signature Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be senq to then system, and copies sent to the buyer, if applicable, and the approving authority. kkAlr'T'iiiss, report only describes conditions at the time of Inspection and under the conditions of use at thattime. This inspection do*s not adds- s�lhv",; iiii sjf44r;ii; iriii fiviiviii1 i/rG lui.fre under the same or different conditions of use. Sins•3113 Tiile 5 011ioial Ins ri ofm Subsurface Sewage Disposal Sysle.n•Page 1 of'.7 ' Apr 1713 09:06p p.2 r Commonwealth of Massachusetts - Title 5 Official Inspection Form . - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Childs St. Property Address Owner Jim Scovil Owners Name . --_—__....—..._----._.._._..---------•- information is Centerville MA 02632 4-16-13. required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltratiion cr tank failure is ini inenL. _System will r;as inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. rielGi Gepiic 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): ,Sins•3M3 TAIs 5Official Inspection.Fonrc Subsuface Sewage Disposal System•Page 2 of 17 Apr 1713 09:06p p.3 Commonwealth of Massachusetts lug"! Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Childs St. Property Address ---" --- Jim Scovil Owner Owner's Name information is Centerville MA 02632 4-16-13 required for every __ 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 pumpsialarms 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 fleet of a bordering vegetated wetland or a salt marsh 15im-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Apr 17 13 09:07p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Childs St. Property Address Jim Scovil _ Owner Owner's Name information is required for every Centerville MA 02632 4-16-13 page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) 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 colisorm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal I o 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ' ❑ ® or clogged SAS or cesspool ❑ Liquid depth in angft is less than 6'below invert or available volume is less than'/day flow 1—F1I cN/iL1 G ,sins.W 13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 4 of 17 Apr 1713 09:07p p,5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Childs St. UV . Property Address Jim Scovil Owner . Owner's Name --- information is required for every Centerville MA 02632 4-16-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 10 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. ❑ 9 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_ FSirts•3113 Title 5 Ofrcial Inspection Form:Subxwrace Sevrage Disposal System-Page 5 of 17 Apr.1713 09:07p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Childs St Property Address Jim Scovil _ Owner Owner's Name information is required for every Centerville MA 02632 4-16-13 page. Cityfrown 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? 0 ❑ 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? IM El 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 015dal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Apr 17 13 09:08p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Childs St. Property Address Jim Scovil Owner .Owner's Name information is required for every Centerville MA 02632 4-16-13 page_ CityfTown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal Tank D Box and four cultec chambers ' Number of current residents: 2 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 ears usage d 2011-86,000Gais g ( y g (gp ))' 2012-38,000Gat's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: P resentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gattons 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: Mm-3113 Title 5 Official Inspection Form'Subsurface Se-age Di"sal System-Page 7 of 17 Apr 1713 09:08p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Childs St. Property Address Jim Scovil Owner Owner's Name information is required for every Centerville MA 02632 4-16-13 . page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 0-8112 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 l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3f13 TiVe 5 Official Inspection Fomr Subsurrace Sewage oisposel system•Page a of 17 Apr 1713 09:08p p,9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Childs St. Property Address Jim Scovil Owner Owner's Name --- information is required for every. Centerville MA 02632 4-16-13 page. Cityf rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components; date.installed(if known)and source of information: 2002 Permit#2002-143 Were sewage odors detected when arriving at the site? ❑ Yes ® .No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 14"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: 1500 Gal Precast 1, Sludge depth: 15ins-3n3 Title 5 Official Inspeaor.Form:Subsurface Sewage Disposal System-Page 9 of 17 Apr 1713 09:09p p.10 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 20 Childs St. Property Address Jim Scovil Owner Owner's Name information is required for every Centerville MA 02632 4-16-13 page. Cityrrown State Zip Code Date of Inspedion D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 1 T How were dimensions determined? Asbuilt-Plan-Tape Slunge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and cover's at 14" below grade w/out let tee No sign of leakage or over loading. 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 (Sins-3113 T.tlo s Official Inspacdon Form:Sa.bs.,.taee 6owogc Di.yosel Syalem-Paga 10 d 17 Apr 1713 09:09p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Childs St. Property Address Jim Scovil Owner Owner's Name information is required for every Centerville MA 02632 4-16-13 page. Citylrown State Zip Code Dale 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•3113 We 5 0rridai Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Apr 1713 09:09p p.12 CommonweaM of Massachusetts 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Childs St. Property Address Jim Scovil Owner owner's Name information is required for every Centerville MA 02632 4-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-2'below grade w/two outlets. Box is clean and solid . No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•2113 Title 5 Ofri iel Inspection Form:S:ibsurtace Sewage Disposal System•Page 12 of 17 Apr 1713 09:10p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form si Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Childs St. Property Address Jim Scovil Owner Owner's Name - information is required for every Centerville NIA 02632 4-16-13 page. Ci rfcywn State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology. Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is four cultec chambers ,4'stone sides, 3' stone ends, 1'stone below per plan. Camera out line's and ck. D Box. No sign of over loading or solid carry over. No sign of holding water. 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•3113 Rig 5 O(Fdal Inspection Fomr Subsurface Sewage Disposal System-Paae 13 ar 17 Apr 1713 09:10p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 20 Childs St. Property Address Jim Scovil Owner owner's Name information is required for every Centerville MA 02632 4-16-13 page, Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Prwy (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•3r13 - Tide 5 octal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Apr 1713 09:10p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Childs St. Propefty Address Jim Scovil Owner Owner's Name information is required for every Centerville MA 02632 4-16-13 page. City/Town 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 -r = 3 <sins-an 3 Titre 5 Official 1-speotion Form.Subsurface Sewage Disposal System•Page'5 of 1.7 Apr 17 13 09:11 p p.16 o Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Childs St. Property Address Jim Sc_ovil Owner Owner's Name — Information Is require every Centerville required for eve MA 02632 4-16-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells -N Estimated depth tofhigh ground water: 10, 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: 3-13-02 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: T.H.on Design Plan 3-13-02. No G.W. at 10' bottom of leaching at 3'. Bottom of leaching at 7' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3l13 Title 5 official In spection Form:Subsurtace Sewage Disposal System-Page 16 0117 I Apr 1713 09:1 1 p p.17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k 20 Childs St. Property Address Jim Scovil Owner Owner's Name information is required for every Centerville MA 02632 4-16-13 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A. 8, C, 0, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Tile 5 Official Inspection Form Subsur`ace Sewage Disposal System-Page 17 of 17 No. G Z 1 FEECOMMONWEALTH OF MASSAC14USETTS Board of Health, ARNS Lz MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade>< Abandon( ) - )(Complete System ❑Individual Components Location Owner's Name Map/Parcel# a - ®�� Address 0 G f t L-0515-; Ce4- :, Lot# R Telephone# sob- a 1. (Q Installer's Name ,� Designer's Name 5'"4l 1 Y &0%r %) GV" Address Address '-P,30X a < re LmO 00% Telephone# Telephone# O _0-.9 Type of Building Sid ��o.� Lot Size 19 4P L- sq.ft. Dwelling-No.of Bedrooms ��,,,, �n:22� 4Garbage grindere'(/J`A Other-Type of Building No.of persons *>? Showers (&-?,Cafeteria (�? Other Fixtures 1+Atl22A"�Oiz`�, Design Flow (min.required) iJ 30 gpd Calculated design flow Desiggflow provided 340 i gpd Plan: Date J /a 10a Number of sheets 1 Revision Date Title Description of Soils) O. C�c�sz� J ' 'CL\N30. ' Soil Evaluator Form No. 1, s� Name of Soil Evaluator�f eM SyAP`T Date of Evalua i-on 13:1 0 '1 1 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further 7ag#reetoo to place a tem in operation until a Certificate of-Comp fiance has been issued by the Board of Health. Signed �' f1A � DateD / DESIGNING ENGINEER MUST SUPERVISE p c �- - DESIGNING INSTALLATION AND CERTIFY IN WRITING THE SYSTEM WAS INSTALLED IN STRICT Inspections ACCORDANCETot AN. t` No. 0 y i�- .,.. ;• - FEE } ,. s. ♦ COMMONWEALTH OF MASSAC14USETTS r. Board of Health, -BA(ZNS'p'P'4tZ , MA. APPLICATION FOR,DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) UpgradeX Abandon( ) ->(Complete System ❑Individual Components Location ZQ ''64-( * I P A1-,.C6 f- Owner's Name Map/Parcel# MAP (3Z LA w5 Address ao GA I L()5 S\• Lot# a R Telephone# Sob -:r+ — (p SS Installer's Name Designer's Name 5%4R v &U170r)- .7dCS Address Address ?Q•'3cw O oZ C_• l"A U+Ot O 3/a 1, Telephone# Telephone# � 5%AjS-0'}96 r 'Type of Building �S�e��-��Q� Lot Size` • l 191 L4RL sq:ft. i i Dwelling-No.of Becl �yr rooms C--�.�QQ� i 't Garbage grinder (t- J'A 'Other-Type of Building lWISF CC No.of persons ,G" _Showers (Cafeteria (j)- ��r Other Fixtures LAUi�Tbe i Design Flow (min.required) :Jy gpd Calculated design flow �bo Design flow provided 340 t gpd J )10 ICQ Number of sheets �s Plan: Date � Revision Date Title DDes`crip nofSoil(s) -co coteQ& Soo .)��uck�cc� lu ,y6 Soil Evaluator Form No. Name of Soil EvaluatorCAZMQ-1 Stkq`l Date of Evalua ion 3-113 joa 1 , DESCRIPTION OF REPAIRS OR ALTERATIONS The Undersined agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further afire a to no to place a system m operation until a Certificate of Co pjiance has been issued by the Board of Health. Signed Date v Inspections No. 00) ' I y3 .. FEE Board of Health,,&W,51 z4 C , ' MA. CERTIFICATE OF COMPLIANCE' Description of Work: ❑Individual Component(s) 9-ro—m-plete System The undersigped hereby certify at the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded)dl Abandoned ( ) at �,26 Chl U.Sitlx V l l t' has been installed in accordance with the pro .s.o s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. ( 900 l2-I Ll3, date y / U 't . Approved Design Flow (gpd) Installer ( ' / Designer: Inspector:— i �P`' „�/ Date: �'� 1 o d" Y ` V � µ The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. �� -J/ FEE C®MMONWFLAA OF MAC ACHUSETTS Board of Health, fT�7. MA.461 ' e DISPOSAL SYSTEM CONSTRUCTION PIRMIT Permission is hereby ranted to; Construct( ) Repair( ) Upgrade V Abandon( ) an indiN idual sewage disposal system at d V as described in the application for Disposal System Construction Permit No. �W o2- fl3, dated U 2 . Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date t� U 7• Board of Health c/ �"�'Gf �N Z- C) A �-' OWN OF BARNSTABLE LOCATION �o SEWAGE # VILLAGE (---f ASSESSOR'S MAP & LOT 2 INSTALLER'S NAME&PHONE NO. v SEPTIC TANK CAPACITY �GU nJ LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE:4 c U 1- COMPLIANCE DATE: O Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i �Q 12 i - i Tom; ' n:::...::.::::..::.. :::.: ::::.::::,:: Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. %Gravel) b—f0 S.L !pymt3/ PIA C a� NJO a-2a ::: :::;::::. :::::::::::::x0 #.. . .. EP::.QB:SERVATZQIII:;H.lQ:LE.;LO< :::::<::;::: :::>:>::>::::<:::;::>::::.:::::::.::.. Depth from Soil Horizon Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency %Grayell ore 3 q % -A- S'L v-ye,51e. Fr i ..:::.::.:::::.::D .Q..::..:::::.::.:::::::::::::::::::::: :.::::::::::::.::.:::..:.:::::.::::::::::::,:::::::.:::::::.::...:.::.: .....................::::::::.::::::::.::::.::..:..... . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° AT .4�:H ( :.::.::.; Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. °° e R Flood Insurance Rate Map: Above 500 year flood boundary No Aell Yes Within 500 year boundary No v Yes Within 100 year flood boundary No 1� 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? S If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of EnvirolimeAtal Protection and that the above analysis was performed b me c s' ent with the required training,expertise and experience described in 310 CMR 15.017. 'Town of Barnstable P# D Department of Regulatory Services oF,KE Public Health Division Date 3 D ` per 200 Main Street,Hyannis MA 02601 r BARNSTABLE, '♦' NAM OiEt639^. Date Scheduled d Time 2Fee Pd. U `� Soil Suitability Assessment for Sewage Disposal Performed By: ^ h u Witnessed By: t RM Location Address !r'' CU1�jj �W�JJ�. S //I�� Owners Name a V ; hbTr�?� �tddress i Assessor's Map/Parcel: L//Y 0 S Engineer's Name CG PNIVI skw NEW CO NSTRUCTION (REPAIR Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) +4o05e f� `1T P 1 Parent material(geologic) !nQ Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Nth nbS. Weeping from Pit Face ovz om . Estimated Seasonal High Groundwater r. q S SO1DnQ a Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level— 'EC£1LATCN'T 11 . , .,.... Observation .*1 `\ Time at 9" Hole# Depth of Perc Time at 6" Start Pre-soak Time® I&M Time(9"-6'1 End Pre-soak Rate Min./Inch �011 � l� t� (�� Ir10�G� oZ� ` l t1 15 frlu�• Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/I) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- Q:HEALTH/WP/PERCFORM FORM 11 - SOIL 'EVALUATOR FORN ' Page 1 of No.: Date: 3/13/02 COMMONWEALTH OF MASSACHUSETTS Plymouth , Massachusetts Performed By: Carmen E. Shay Date: 3/13/02 Witnessed By: David Stanton Location Address or#16 Bullrush Lane Owners Name: Mr.James Scovil Plymouth, MA Address and #20 Childs Street,Mashpee, MA Lot 4 (Map—248, Parcel 015) Telephone Number: (508)-778-6557 New Construction : X Repair : OFFICE REVIEW: Published Soil Survey Available: No ❑ Yes ❑ Year Published: Publication Scale: Soil Map Unit: Drainage Class: Soil Limitations: Surficial Geologic Report Available: No❑ Yes❑ Year Published: Publication Scale: Geologic Material: (Map Unit): Landform: Glacial Outwash Flood Insurance Rate Map: Above 500 Year Flood Boundary: No ❑ Yes 1 Within 500 Year Flood Boundary: No ❑ Yes ❑ Within 100 Year Flood Boundary: No 1 7X Yes ❑ Wetland Area: None National Wetland Inventory Map (map Unit): Wetlands Conservancy Program Map (map unit): Current Water Resource Conditions (USGS): Month Range: Above Normal El Normal [il Below Normal ❑ Other References Reviewed: USGS Topographic Map DEP APPROVED FORM 12/7/95 I FORM 11 — SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No.: #20 Childs Street, Centerville, MA On -Sete Review Deep Hole Number: #1 Date: 3/13/02 Time: 10:00 AM Weather: Sunny, Cool Location (identify on site plan): Refer to Sketch Landform: Outwash Plane Position on Landscape (sketch on back): Refer to Sketch Distances From: Open Water Body N/A feet Drainage Way N/A feet Possible Wet Area N/A feet Property Line 25' feet Drinking Water Well N/A feet Other DEEP OBSERVATION HOLE LOG Depth From Soil Soil Soil Soil Other Surface Horizon Texture Color Mottling Structure, Stones, (inches) (USDA) (Munsel) Boulders, Consistency, ` % Gravel 0" — loll AB Loamy 10 YR 3/2 None <5% Gravel, Friable Sand Friable 10" — 36" BW Loamy 10 Y/R None <5% Gravel, Friable Sand 5/6 Friable 36" — 120" C' Medium 2.5 Y 7/4 None Medium Sand, 10% Sand gravel, Loose Parent Material (Geologic): Glacial Outwash Depth to Bedrock:None encountered Depth to Groundwater: Standing Water in the Hole: None Weeping From Face: None Estimated Seasonal High Water Table 120" Assumed — No groundwater Observed DEP APPROVED FORM 12/7/95 FORM 11 — SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No.: #20 Childs Street, Centerville, MA On -Site Review Deep Hole Number: #2 Date: 3/13/02 Time: 10:00 AM Weather: Sunny, Cool Location (identify on site plan):. Refer to Sketch Landform: Outwash Plane Position on Landscape (sketch on back): Refer to Sketch Distances From: Open Water Body N/A feet Drainage Way N/A feet Possible Wet Area N/A feet Property Line 25' feet Drinking Water Well N/A feet Other DEEP OBSERVATION HOLE LOG Depth From Soil Soil Soil Soil Other Surface Horizon Texture Color Mottling Structure, Stones, (inches) (USDA) (Munsel) Boulders, Consistency, % Gravel 0" — 11" As Loamy 10 YR 3/2 None <5% Gravel, Friable Sand Friable 14" — 34" BW Loamy 10 Y/R None <5% Gravel, Friable Sand 5/6 Friable I 34" — 120" C' Medium 2.5 Y 7/4 None Medium Sand, 10% Sand gravel, Loose Parent Material (Geologic): Glacial Outwash Depth to Bedrock:None encountered Depth to Groundwater: Standing Water in the Hole: None Weeping From Face: None Estimated Seasonal High Water Table 120" Assumed — No groundwater Observed DEP APPROVED FORM 12/7/95 f FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No.: #20 Childs Street, Centerville MA Determination of Seasonal F/i_gh Water Table Method Used: ❑ Depth observed standing in Observation Hole: N/A inches ❑ Depth weeping from side of Observation Hole: 120 inches (assumed) ❑ Depth to Soil Mottles: None inches ❑ Groundwater Adjustment: None feet Index Well Number: Reading Date: Index Well Level: Adjustment Factor: Adjusted Groundwater Level: N/A DEPTH OF NATURALLY OCCURING PERVIOUS MATERIAL: Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system: Yes CERTIFICATION: I Certify That on September 17, 2000, (date), I have passed the soil evaluators examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. i Signature: Date: �� FORM 12 - PERCOLATION TEST Location Address or Lot No.: #20 Childs Street COMMONWEALTH OF MASSACHUSETTS Centerville , Massachusetts Percolation Test Date: 3/13/02 Time: 10:30 AM Observation Hole #: #1 Depth of Perc 48" — 64" Start Pre-soak 10:28 AM End Pre-soak 10:38 AM Time at 12" Would Not Hold 24 Gallon Presoak Time at 9 Time at 6" Time (9-6") Rate Min./inch < 2MPI * Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Performed By: Carmen E. Shay Witnessed By: David Stanton Comments: Would Not Hold 24 Gallon Presoak - <2 MPI Site Passed X Site Failed DEP APPROVED FORM 12/7/95 SKETCH OF PERC TEST & DEEP HOLE LOCATION Property Address: #20 Childs Street Centerville,MA Owner: James Scovil Date of Perc Test: 3/13/02 h i 1 d t r e e t Existing House Asphalt Driveway Test Hole #1 25' Test Hole #2 I OWN OF BARNSTAI!�.E LOCATION z S �J%fz•�✓ SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 42 INSTALLER'S NAME&PHONE Ni;. �{--�w SEPTIC TANK CAPACITY LEACHING FACILITY: (size) NO. OF BEDROOMS BUILDER OR OWNER 'PERMITDATE: i U ;L COMPLIANCE DATE: O Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I { 2 One't Commonwealth of Massachusetts OWN ��ECEIv� Executive Office of Environmental Affairs MAY 6 1997 Department of 1114 TOWN OFBARNSTABLE Environmental Protection HEALTHDEPT. . William F.Weld Governor Trudy Coxe Secretary,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: t�` j Address of'Owner: Of'1ic�. Date of Inspection: 7 (If different) Name of Inspector—C,Qsc.=-- Company Name, Address and Telephone Number: CERTIFICATION•STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: — �tsses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signal re: i t Date: tj -'I ( _X4 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of i0,000 gpd or greater, the inspector and the system owner shall submit the repot, to the appropriate regional office of the Department of Environmental Protection. The original should be sen: to !ne system owner and copies sem to the buyer, if applicable and the appro\'ing authority. INSPECTION SUMMARY: Check A, B, C,:or D A) SYSTE PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: y One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiitration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02106 • FAX(617)556-1049 • Telephone(617)292-5500 `~S Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properly Address:0-0 C �v Owner: ►-t` ry tic;n Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven';distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _YX4 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. .. -1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE E.NXIRONAIENT: _ l he system hd,, a septic tanK anu soil abSurpuufi syDieni and i5 will"', i06 foci iu a �uifa�C vo Ci pp: or tributary t0 d surface water supply. _ The system hat a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The systen-i I;as a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp_m D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 c... ._.. -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM__. — PART A CERTIFICATION (continued) Property Address: a0 G-�; `' C c"' Owner: Date of Inspection: D] SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. 1`4 Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. r Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 'Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. /- Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a.surface water supply. Any portion of a cesspool or privy-is within a Zone I of a public well. Ly Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool.or..privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is v,ithin 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 suppiy well' The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:` av G�'��5 ST• C-e.�T, Owner: Date of Inspection: Check if the following have been done: ✓Pumping information was requested of the owner, occupant, and Board of Health. one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. built plans have been obtained and examined. Note,if they are not available with N/A. ✓The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow —The site was inspected for signs of breakout. TII system components, excluding the Soil Absorption System, have been located on the site. c _.(he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,,material of construction,_'dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. d;..'em^ f nm. ovmcr;• were provided with information on the proper maintenance of Sub- Surface Disposal System. ,3. ti (revised 8/15/95' 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: G 0" Sr C Owner: Vk�^-�e,-9 Date of Inspection: FLOW CONDITIONS RESIDENTIAL- Design flow: g3D Qa! ns _ —"—Number of bedrooms: -- Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or Seasonal use (yes or no): /Y Water meter readings, if available: `J I& Last date of occupancy: �Sc'a-i COMMERCIAUINDUSTRIAL• Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)= Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last data of occupancy: OTHER: (Describe) Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)_ If yes, volume pumped gallons Reason for pumping: TYPE 9PSYSTEM t/ 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 7`l✓s 7— Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95). S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 0 CAN I`�S �' C f':T. Owner: l-\lAwb0v0 Date of Inspection: SEPTIC TANK: (� (locate on site plan) fi . (t , Depth below grade: �d / Material of construction: vconcrete _metal _FRP —other(explain) Dimensions: Sludge depth: f Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: %jf art Distance from top of scum to top of outlet tee or baffle: 1 Distance from bottom of scum to bottom of outlet tee or baffle. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete metal _FRP _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom - crjnn v, hot!nm of outtpl tee o• banie- Comments: (recommendation for pumping, condition.of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '` SYSTEM INFORMATION (continued) Property Address:-�O C-\h,\Q 5 S\•C-V7:*: Owner: la v�n��c v1 Date of InspectiorJ: TIGHT OR HOLDING TANK:(-/ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: - Comments: � ` (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:. (locate on site plant Depth of liquid level above outlet invert: /y41U� Comments mote ii ievei and distnbutwl, o t,lyuo., e�.UcflCe Of surd: La,i)u.ei, evidence of leakage into or out of boy., etc.) PUMP CHAMBER: f` __ '.,.., •.• ... .\...,:.::.,.:,..,...,_,_.w:._:�.�__.._,....._._..._.... .. _.... ... . (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of-pump chamber, condition'of pumps and appurtenances, etc.) (revised 8/15/95) 7 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (( SYSTEM INFORMATION (continued) Property Address: r6 G V-- ,W Owner: %A-Nl-Suv✓ Date of Inspection: 7 i SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non intrusive methods) If not determined to be present, explain: ' Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: (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 ground%%ate . inflow (cesspool must be pump ij;as part of inspection) 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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION (continued) Property Address: RC)G I"j;`PS' STr-eeT Cc�a TT✓v��e Owner: j-�Vuv So1�J Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' f 7' t 1. 1 f:• — -DEATH TO GROUNDWATER �U wYttY,r Depth to groundwater: `a feet method of determination or approximation: �� ( � �, S r� / 12 (revised 6/15/95) 9 L SECTION A -A 11 = 2000' ALL OUTLET PIPES FROM THE house' in. from tIc took 'NOTE: ALL PIPES ARE TO 13E 4' SCHEDULE 40 P.V.C. r " DISSET LEVEL FOR X SHALL 12. _ co�FF PROFILE VIEW OF ADDITION TO LrH'AC81NC SYSTEM orsltdeullal sox I Existing Foundation tank covers rnwt W 3 of 1/8 1/2 Washed Peastoa t tF�44r 2 FT. 6 in. of finished gross SAS- as.ao /4" to 1 1/2 ' Noshed crushed stone 3- Or OUTLET 2 ROUTE 28 • Graded.arse Septic Tank- 90 80 Grade o- as de over so:- oo wwcxouTs over -- , as• otnLET tr WET s . 0.02 3 HOLE H-20 3 wmar,>um cover ,e6• °•. SIT a 4�PS� 44 NEW s-arn DIST. Box Tap of SAS- rev. -Qe.Oo EXI T. PIPE �' 1,500 GAL. s•- solo' per root • 4' - SCH. 40 T t.78' �1Q�h FROM EXIST, FOUNDATMN N SEPTICITANK 35' EHectiv�Depth PLAN SECTION CRO55-SECTION ro s�hPP 0.ft inh vj CONCRETE FULL FaUNDA 'u i °f ��, 1 PINE STREET h o a' M 4 STONE e D = z4- 3 HOLE H-10 DISTRIBUTION BOX a SYSTEM PROFILE 6 In.of 3/4•-1 1/2` 11 a A 1' �, 3, 1 STONE LIMBER CHAMBERS 3' > compacted Stan. o i M 4• NOT TO SCALE Not to Scale _ 4' 4' o 10- LOCUS MAP Effective Length 6 In of 3/4--1 1/2` - 10 aotw stun. EPPectivr vidth m° SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES Bp�pms(Test y� 1_Elves-tt4.25 _ CULTEC MODEL 125 (H-20 LQADING)/ $H[]REY PRECASTE � (OR EQUIVALENT)Not to Scale 1. Contractor is responsible for Digsafe notification NOTE: OVERALL HEIGHT Of INFILTRATOR is 1 a /EFFECTIVE HEIGHT IS 12" and protection of all underground utilities and pipes. 2. The septic"tank a I diWi ution box shall be set O O level on 6 of 3�4 -1 1/2" stone. O S 87d 52' 10" li w 3. Backfill should be clean sand or gravel with no stones over 3" in size. 130.00' i 4. This system is subject to inspection during installation 3-2e DIM+. ACCESS MANHOLES � i j by Carmen E. Shay - Environmental Services, Inc. I 1 I 5. The contractor shall install this system in accordance i PROJECT BENCH MARK i with Title V of the Massachusetts state code, the approved pion I TOP OF FOUNDATION and Local Regulations. ELEV. = 100.00 1(Assumed) 1 6. If, during installation the contractor encounters any 1r- �•\ `R „ I soil conditions or site conditions that are different e = 1 1 from those shown on the soil log or in our design nscr _ /FF i< �l;: CUT ; I i installation must halt & immediate notification be INLETsees THE ACCESS COVERS FOR THE SEPTIC TANK, I 1 made to Carmen E. Shay - Environmental Services, Inc. DISTRIBUTION Brno AND LEACHING COMPONENT ice- I 1 7. No vehicle or heavy machinery shall drive over the SHALL BE RAISED TO VATHIN 8' OF r•- i I p p •�"-"--.^ FINISHED GRADE. septic system unless noted as H-20 septic components. STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TTTE GAS BAFFLES OR EQUALS i I EXISTiNc 8. Install Tuf-Tito gas baffles or equals On all outlet tee ends. ON ALL OUTLET TEE ENDS C I 1 Joao gal. 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. PLAN VIEW I BXISTINC Septic Tank '� 1 10. All solid piping, tees dt fittings shall be 4" diameter 8 BEDROOM 3-24'REMOVABLE co�Rs \ I I PROPOSED W Schedule 40 NSF PVC pipes with water tight joints. 1 I HOUSE INSTALL CLEAN-OUT 4• r': s i 20 ADDITION To GRADE O 11. Municipal Water is Connected to The Residence and Abutting 3 min. deoranw •+ / N • 2•nil,. kdst to outlet r - ,r .aaT i i tqtAl Properties Within 150 Feet. CUTLET ft Isr ut 5 -r i PROPOSED v' 4_a" ruin 1 1 DECK 1.72 THE PROPERTY LINES ARE APPROXIMATE AND ,�sr,,, � , I L�r+e �� "C3 COMPILED FROM THE SURVEY PLAN GENERATED BY . b " :. . ..-MtxrreiPal-allote1° I ; o CHARLES N. SAVERY, SURVEYORS. OF HYANNIS, MA ' Failed ENTITLED " RESUBDIVISION PLAN OF LOTS IN BARNSTABLE, MA" j I Leach Pit DATED AUG. 8, 1973, PLAN BOOK 279.PAGE 66 ASPHALT DRIVEWAY I I AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN CROSS SECTIQN END-SECTION i i i iT SFFOULD PE USED FOR NO PURPOSE OTHER THAN i I i THE SEPTIC SYSTEM INSTALLATION. I r 1 TYPICAL 1500 GALLON SEPTIC TANK c O , NOT TO SCALE • (H-10 LOADING) ; ; NEW 1500 gal. LEGEND i , LOT #2A 1 Septic Tank • 1" 19,406 Square Feet •/•� ' ,; PERCOLATION TEST I 1 i 104X1 DENOTES PROPOSED a it SPOT GRADE Date of Percolation Test: MARCH 13, 2002 3 1 1 1 Test Performed By. CARMEN E. SHAY, R.S., C.S.E. >z i I O X 104.46 DENOTES EXISTING Results Witnessed B)r DAVID STANTON ( for Barnstable B.O.H.) 0 1 90.00 I p� O SPOT GRADE Excavator: Roberts Septic Services 1 S 87d 52 10 1P I 6 f I i. n Percolation Rate: Less Than 2 MPI - 1 _ ; c3 w *�, PL PROPERTY LINE e� en O LATEST LE #1 a •a. ►t O ELEV.- 99.25 Ir cD� '� --1��rr PROPOSED CONTOUR Test Hole Test Hole - 0 s "� 97- - -- -97 EXISTING CONTOUR No. 1 No. 2 DEPTH saLs ELEV. a ::� DEPTH saLs ELEV. DEPTH --- DEEP TEST HOLE & 0 99.25 0 98.78 Loamy sand Loamy s«,a S' PERCOLATION TEST LOCATION to YR 3/2 to YR 3/2 V LOT #2B --- -s' -_ -99 .-- 6 FOOT STOCKADE FENCE 0'-10" Ar 99.00 0'-14" Ar 97.80 _�.- Loamy Loamy ----- Sand Sand 9 9_ - 10 Y 6^e 10 Y s/e NIF PHILIP H. GOULDINC TE HOLE2 10'- 34' Be 98.35 14'- 38' Be 95.78 = 98.7$ QQ W Coarse �� San Q P 26 C, 2 6 T 7/4 P LOT LAN 38"-1 0" C, 89.25� 36"-120' 88.78 s W 0 OPOSED SEPTIC SYSTEM UPGRADE Perc #1 " �Wof'VAss' PREPARED FOR Depth to Perc: 48 to 66 s' GiLSERT Perc Rate Less Tha 2 MPI R . J A M E S S. S C 0 V I L Groundwater Not Observed ADJUSTED H2ONo Observed SElev. None fil AT 20 CHILDS STREET Design Calculations 0 20 40 50 98--- -------- ---- PREPARED----- -98 CENTERVILLE, MA Number of Bedrooms: 3 Equivalent to 330 Gol./Day (330 Gal./Day Min. per Title V) ti . PREPARED BY: Garbage Grinder No CA R E ►' lei �l H l Leaching Capacity Proposed: .330 Gal./Day Minimum (Min. Per Title V) c� ,�; ; „-�` i J.'. Septic Tank : 3 x 330 Gol./Doy = 660 USE 1,500 GAL. Septic Tank. SCALE: 1 =20 !" 1 ENVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of Q min finch � r ciC Bottom Area: 0.74 gal/sq. ft. x 300 sq. ft. a 222 gallons -G�r T r P.O. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 160 sq. ft. - 118.40 gallons EXISTING SEPTIC TANK TO BE REMOVED do LEACH PIT TO BE PUMPED �,4rTr Ejl�cjT FALMOl1TH, MA 02536 Providing: - 340.40 gallons DRY do FILLED IN PLACE WITH CLEAN SANDY FILL. DEPTH, 52' 10� 40.00' TEL/FAX 508-548-0796 i Use: ` (4) CULTEC MODEL 135 UNITS, HAVING A 1 EFFECTIVE DEP , NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE S 87d To BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, 3' OF WASHED STONE T7�T �-•. c �-+ SCALE: 1"=20' DRAWN BY: CES DATE: MARCH 16, 2002 FROM THE EXISTING LEACH PIT TO BE DISPOSED pl �+' ,.7 ON THE ENDS AND 1' OF WASHED STONE BENEATH THE ENTIRE SAS. OF AS PER BOARD OF HEALTH SPECIFICATIONS. PROJECT#SD299 FILENAME: SD299PP.DWG SHEET 1 OF 1