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Home My WebLink About0048 CHILDS STREET - Health 48 CHILDS STREET, CENTERVILLE A= 249 009 1 I I mead. �J��ECYUFp(,o� UPC 12543 Now HASTINGS, MN. a�9-009 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 48 Childs Street M �sv= Property Address Beatrice Smith Owner Owner's Name information is 7� required for every Centerville Ma 02632 10/4/2017 page. City/Town State Zip Code Date of Inspectidd I'%� 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. Imngoutforms A. General Information S/# filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 Cltyrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number (f 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 10/4/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal p g System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e''yr 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is Centerville Ma 02632 10/4/2017 required for every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 48 Childs St Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 10 Hi Cap Infiltrators. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Citylrown State Zip Code Date of Inspection B. Certification (coot.) Yes No 0 ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °y 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information.For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Tito 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .'� 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. City(rown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system repaired 9/17/2013 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: .5 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 gallons Sludge depth: 0" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 4' Scum thickness 0' Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? opened covers, took measurements 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 was recently pumped and should be done again every 2-3 years for proper maintenance. Water level was even with outlet invert, tank was structurally sound and not leaking, outlet tee:intact. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal _❑ fiberglass ._❑ polyethylene ❑.other(explain): Dimensions: Capacity: gallons Design Flow: gallons-per-day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments..(condition.of alarm and float switches., etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments fi 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 026a2 10/4/2017 page. Cityfrown 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 was video inspected from septic tank and found in good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ' If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 10 Hi Cap Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 10 Hi Cap Infiltrators in a 63'x3'xl 1"trench. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately veP07— I � DES S3 0 3 2 f' Al �s W 3� "�Z 3y A 3 ,S t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Childs Street Property Address Beatrice Smith Owner Owner's Name information is required for every Centerville Ma 02632 10/4/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 'y 48 Childs Street Property Address Beatrice Smith Owner Owners Name information is required for every Centerville Ma 02632 10/4/2017 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. V /// Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Tipplitation for Misposal 6pstrut Construction VErmit Application for a Permit to Construct( ) Repair a Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ! g-C�,(�dS S'�" C.`V� O neerr's Name,Address,and Tel.No. -Assessor's Map/Parcel ® Installer'sName,Address,and Yel. o. Designer's Nam�e,,Address,and /Tel.No. ` i Type of Building: /� / Dwelling No.of Bedrooms Lot Size o 0 sq.ft. Garbage Grinde (1 � Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided ��n b gpd Plan Date �'' �'a, 3 Number of sheets Revision Date Title Size of Septic Tank ,t!Q Type of S.A.S. `Vt C c,,p \ 4rr,. Cl 10 Description of Soil Nature of Repairs,or Alterations(Answer when applicable) ('`_ S tl\ 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 Boar f Health. Signed- Date Application Approved by Date �� `—i. Application Disapproved by Date for the following reasons Permit No. go 1 Date Issued y No. V Fee THE COMMONWEAL TH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Misposal �&pstem Construction J)ermit Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Lf8-C (( S C.ut O ner's Name,Address,and Tel.No. Assessor's Map/Parcel I1 CIAr <"C.?- SM c Installer's Name,Address,and el.No. Designer's Name,Address,and Tel.No. Sco\c GC-"V,— 5`o& a9 y c O cocl � �-�v e Rv\c, S 57A- Type of Building: �} q � Dwelling No.of Bedrooms 6 Lot Size o sq.ft. Garbage Grindei(�V Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) � (Z> gpd Design flow provided d gpd Plan Date \ 3 Number of sheets Revision Date Title ` Size of Septic Tank k SD O Type of S.A.S. �A� C cep _(� \ -}�.�U�1 10 Description of Soil Nature of Repairs or Alterations(Answer when applicable) kb \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 Boar Health. Sin Date r r� 1 Application Approved by Date — f Application Disapproved by Date for the following reasons �� r Permit No. d 0 > / Date Issued --------------------------------------------------------------------------------------------------------------------------------------- TFi E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired V) Upgraded( ) Abandoned( )by S Co`� �Ml^-�� at L C has been constructed in accordance (� with the provisions of Title 5 and the for Disposal System Construction Permit No. Oa , / dated Installer C O ��c,./�V�' Designer \A 6, S #bedrooms Approved design fl _ gpd The issuance of this permit shal of a co e a guarantee that the system will i 'ti tt as designed a Date Inspector ----------------------------------------------------------------------------- C --------Fee------------------- No. P0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction 3permit Permission is hereby granted to Construct( )` Repair`( 4" Upgrade `( ) Abandon( ) System located at C\e�l i 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. I Provided:Construction must be completed within three years of the date of this permit Date Z Approved by - t Town of Barnstable Regulatory Services o� Richard V. Scali,Interim Director B"R Public Health Division 9 1639- Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Fax: 508-790-6304 Office: 508-862-4644 Installer & Designer Certification Form Date: 7 t 13 Sewage Permit# O\ — Assessor's Map\Parcei (Q awl Designer: 51MIR'"t-ro A• I+A.AS PE- Installer: 37rc,,` Address. 9 2 3 �v Cod Address: c��r1 �,{ S"in -4-40 0rs�A&Ar H,4. ae GT; "\c, , On C) 3 �� was issued a permit to install a (dare) (installer) septic system at C66 based on a design drawn by (address) ^CA-,4s, P4' dated �7 ► b (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation.of any-component of the septic system) but in accordance with State &Local Regulations,', Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in pompliance with the terms of the I\A approval letters (if applicable) a (Installer's i e) . Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OM AND- AS- OF COMPLIANCE VVIIED Y THE BARNSTABLE PUBLI HEAL DIVISION. BUILT CARD ARE REC THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.dvc r Town of Barnstable °FIHE ram, Regulatory Services Richard V. Scali, Interim Director STAB . # Public Health Division 9 MASS. �► Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Systems Property Address: // 9 r 1,i J s S4 C ry t 1.V Assessor's Map\Parcel: a (1C l o0 5! Property Owners Name: ! - �a� In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an 'Y' in the applicable box next to each line certifying the information. Yes N\A ftQ ❑ I have been provided a copy of the Title 5 I/A technology Approval letters. (15 page Standard Conditions letter and the specific technology letter) ❑ I have been provided with the Owner's Manual L� ❑ I have been provided with the Operation and Maintenance Manual [IR For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10) and the Approval V ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) ❑ If the design does not provide for the use of garbage grinders, the restriction is understood and accepted �J ❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303 Le- srn ah agree to comply with all terms and conditions above. Property Owners printed name A / /j roperty Owners Signature Date Note: This form must be submitted along with the septic system ,disposal works permit application for all I\A systems including new construction, repairs\upgrades, with and without aggreLyate (stone) and with conventional design criteria or credited design criteria. Q:\Septic\IA homeowner certification.doc I _ F. TRANS. NO.: CITY/TOWN: APPLICANT: 6&-,4--sAq e.4F -SA4 1774 - ADDRESS: 'f6 CH-ie b S 5 j DESIGN FLOW: 3 gpa . REVIEWED BY: DATE: 7a Za 3 N/A. OK NO GENERAL �y i' Y F t y ,; -a,4 S4 J � , 'k y Ji � p 4 Y } ✓ Legal boundaries denoted [310 CMR 15.220(4)(a)] Street,Lot, tax parcel number and lot number noted on.plan [310 CMR 15.220(4)(u)] - Locus Provided'[310 CMR 15.2204(t)] Plan proper scale?(1"=40'for plot plans, 1"=20' or fewer for components) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(l)(a) for upgrades]-*if not, a variance is required [310 CMR 15.412(4)] . Location of impervious surfaces (driveways,parking areas etc.) [MO CMR 15220(4)(d)] Location all.buildings existing and proposed 310 CMR 15220(4)(c)) J Location and dimensions of system-components and reserve areas: [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)(f)] daily flow septic tank capacity(required and provided) soil absorption system(required andprovided) whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)j Existing and ro osed contours 31.0 CMR.15.220(4) P [ (g)j Location and log of deep observation holes(existing grade el. on each test), [3.10 CMR 15220(4)(h)] Names of soil evaluator and-BOH representative [310 CMR F 15220(4).(h) and(i)] Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)j Percolation test results match loading rate?'[310 CMR 15.2421 Certification statement by Soil Evaluator[310 CMR 15.220(4)0)] Observed and Adjusted'groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Address ` z`f4� Sheet 1 of 7 i I N/A OK NO Location of every water supply,public and private, [310 CMR / 15.220(4)(k)] J within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water,supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case / of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins / located within 50 ft. [310 CMR 15.220(4)(1)] ✓ Water lines..and other subsurface utilities located [310 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) Profile.of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(o)] ✓ Stamp of designer [310 CMR 15.220(1) and 310 CMR.15.220(2) ;/ Stamp ofRegistered.Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15:102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)]` ✓. Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm-adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75'of system [310 CMR 15.220(4)(q)] . Materials specifications noted? [various sections of 310 CMR 15.000] System components not>36" deep (unless Local Upgrade j Approval or LUA re nested)[310 CMR 15.405(1(b)] I Address 2�g� Sheet 2 of 7 �sT `N/A OK NO -. � � :F *r# n7�.*• s f� > 7 ' �c f � � r:`�,'S`w s � �,3^ 42r a'tr; s�:.1` s �.�`�..�;-� a, asa-�bz z+r. :1:3��:z`�ia"#'�x�. �".u�:�.2"��.N.ah sF 4`p� !��. �f•. fi;z_p; '� �:?�.r, Size OK? [310 CMR 15.223(1)] Inlet'tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth[310 CIVM 15.227(6)] Outlet tee with gas baffle or approved filter[310 CMR 1.5.227(4)] ✓ - Note regarding installation on stable compacted base [310 CMR 15.228(1)] a/ Separation between inlet and outlet.tees (no less than liquid depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5))or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9"must have risers on all openings and on the d-box) [3`10 CMR 15.2228(1)and 310 CMR 15.232(3)(fl] T,hreer access covers (inlet and outlet must be 20"'or greater) - / middle access at least 8" (by 7/07) [310 CMR 15.228(2)] % Access to within 6 " of grade one port for systems<1000gpd / two for systems>1000 gpd [310 CUR 15.228(2)]; All at-grade covers secured to:unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done[310-CMR 15.221(8)] H-20.Where appropriate? [310 CMR 15;226(3)] Setbacks fiom resources [310 CMR 15.211J Required.when other than single-family dwelling or flow>1000 gpd[310 CMR 15.223(1)(b)] First compartment 200%daily flow;Second"compartment 100% dailyow [310R 15.24(2) d(3)]M r. "U"pipe through or over baffle, outlet of each compartment with gas baffle or approved filter:[310 CMR 15:224(4)] Address. Z`fg��i Sheet 3 of 7 N/A OK NO L1I�D�1�'G��S�V,4�ER�t��Q,�HE2P�PItY� Located at least ten feet from any water line? [310 CMR 15.222(2)] .Disposal piping at least 18"below water line(when water and sewer cross, see 310 CMR 15.211(1)[1]) Cleanouts required/provided? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable / [310 CMR 15222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)) Siphon problem/(leachfield below pump chamber) Endca s or,vent manifold specified? Size and orientation of discharge holes specified?(not smaller than 3/8`' not.larger than 5/8").[310 CMR 15.251(8)and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe. types allowed) - Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided?(when pressure sewer to d-box or steep,pitch of gravity sewer] [310 /. CMR 15.323(3)(a)) ✓ Riser if deeper than 9" [310 CMR 15.232(3)(f)] . Inside minimum.dimension 12" [310 CMR 15.232(2)(b)] Minimum sump 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd);;waterproof manhole'if>2000gpd j [310 CMR 15.232(3)(d)] Capacity(emergency storage above working=design flow)?,[310 CMR 231(2)] Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in miniuri access manhole at least 20"MUST BE TO GRADE[310 CMR 15.231(5)] Service.components accessible(not.too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in-lead-lag mode. [310 CMR 15.231(6)and(8)] V Stable Compacted Base-[310 CMR 15.221(2 Buoyancy calculations needed? Provided? 310 CMR 15.221(8)] Address Z`f g,S Sheet 4 of 7 N/A OK NO Calculations correct? ^ 4 feet of naturally occurring material demonstrated? [310 CMR f 15.240(1)] ✓ Required separation to groundwater? [31:0 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided?.(system under driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation. within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] GALLERIES,PITS,CIIMl3 �2S310C1VI�Z15 Chambers and.Gal. in trench configuration,supplied with inlet every 20 ft. 1310 CMR 15.253'(6)] Each structure.with one inspection manhole(if>2000°gpd must be to grade) [310 CMR 15.253(2)] Aggregate 1'minimum-4'maximum. [31.0 CMR 15.253(1)(b)] . 2' sidewall credit maximum{310 CMR 15.253(1)(a)] .' In bed configuration,inlet every 40 sq. ft. [310 CMR 15.253(6`) - Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)j 100 feet-maximum length[310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches).[310 CMR 2.51(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(l)[4] and Guidance Document] minimum 2 distribution lines[310 CMR 15.252(2)(a)] Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310` CMR 15.252(2)(e)] y Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10'`minimum. [310 CMR 15:252(2)(f)] Bottom area used in calculations only[310 CMR 15.252(2)(i)] Address Sheet 5 of 7 I N/A OK -NO M4 mat'-'z U Y 'rt'� ' dY,rl",�xa +h .r..�...,...#'�,`�7�`�s. ��:'r ;, Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems>: M00gpd or alternative systems under remedial approval [310 CMR 15.254(2)and UA Remedial Use Approvalsl If used in gravelless system -make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly (>2000gpd) good to.note on plan[310 CMR 15.254(2)(d)] Construction in fill -Did the plan specifythat the fill shall meet / the specification of 310 CMR 15.255(3)? v Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed,by Registered Professional Engineer [310'CMR 15.255(2)(a)] Side slope not exceed 3:1 ?'[310 CMR`15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious.barrier to edge of SAS (10 ft. / reconvneuded) [310 CMR 15.255 (2)(e)] ;� 1�"�,.3^� :..� �-jv n6i#' �,.fi,+ ,.�� ✓ �i,�r,�r ,s.-k �'i�,S,t" �h-�y,�,yy Cy w.. . S'y- ..`�^ *r . Y :� �ZeSs S�Steili:�' �I�IYOlI[IteYS �� s °�� si Asa ; °Iz 4i Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to.scour soil interface.P�.�.�.„Y� Was DEP Approval Letter provided and/or have you / reviewed the letter for conditions? Is the technology being properly applied arid.does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance,agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant-submitted a copy of a maintenance �h ".� �' r F `.�u Z"tP w.°A 7 '+^ it .�sr.nPe43'i.4 �.3 sv Nn Are the variances,listed.on the plan?{310 CMR 15-:220 / (4)( )] RLS Stamp necessary onplan.if acomponent is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.414] Address 2 g h Sheet 6 of 7 - __ . 4 : _-------- _.:__......._.__..._: ....... ---- I N/A OK NO j i � �;. y, ru. rx`d�t"k.-`:-r t, y.p3'h•iJ a.G"R-,�r .,r '1�' +"�,.r.,�3`�-.� Yx wx.�a.N ,{ to r 7,-s`" q Is the system in a Designated Nitrogen.Sensitive Area(Zone II for a public supply well)? [310 CMR 15.214, 310 CNM 15.215 and 310 CMR 15.216 -also refer to Policy regarding upgrades of such existing systems] ✓ Is the system proposed on the same.lot as served by private well? / .[310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] Pumping to septic tank ? [ 310 CMR 15.229] . Shared System [310 CMR.15.290] F Address Z`f Sheet 7 of 7` i Commonwealth of Massachusetts Executive Office of Energy &Environmental Affairs Department of Environmental Protection One Winger Street Boston, MA 02108. 17-292-5 00 OEVAL L PATRICK RICHARD IC,SULLIVAN JR. Governor Secretary T IMCFrHY P.MURRAY KENNETH L,KIMMELL Lieutenant Governor Commissioner APPROX'AL FOR GENERAL USE Pursuant.to Title 5, 310 CMR 15.000 Name and Address of Applicant: Infiltrator Svstenls, Inc. P.O.Box 768 6 Btisiriess Park Road Old Saybrook, CT 06475 Trade name of technology and model: High Capacity chamber, Quick4 High Capacity chamber, Quick4 Plus High Capacity chamber (8-inch invert), Quick4 Plus High Capacity chamber (13-inch invert), Standard chamber, Quick4 Standard chamber, Quick4 Plus Standard chamber (5.3-inch invert), Quick4 Plus Standard chamber (8.0-inch invert), Quick4 Plus Standard LP (Loiv Profile) chamber (3.3-inch invert), Quick4 Plus Standard LP (Low Profile) chamber(8-inch invert),Infiltrator 3050 (St.olYn Tech SC- 740) chamber, Equalizer 24 chamber, Quick4 Equalizer 24 chamber, Equalizer 36 chamber, Quick-4 Equalizer 36 chamber, Quick, Equalizer 24 LP (Loiv Profile) chamber (6 inch invert), and Quick-4- Equalizer 24 LP (Low Profile) chamber (2 inch invert) (hereinafter the "System"). Schematic drawings of the System and a design and installation manual are a part of this Certification. Transmittal Number: 'X228042 Date of Issuance: Tune 6. 2013 Date of Revision: August -2, 2013 Authorihr for Issuance Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000,the Department of Environmental Protection hereby issues this Certification to: Infiltrator Systems, Inc., P.O. Box 768, 6 Business Park- Road. Old Saybrook, CT 06475 (hereinafter "the Company"), for General Use of the System described herein.The sale, design, installation, and use of the Systein are conditioned on compliance by the Company, the Designer, the Installer and the System Owner witli the terms and conditions set fortli below. Am, noncompliance with the teens or conditions of this Approval constitiites a ,riolation of310 CMR 15.000. August 22 2013 David Ferris.Director Date Wastewater Management.Program Bureau of Resource Protection This information is available in alternate format Call Mchelle Waters-Ekanem..Diversity Director,at617 292.6751.TDD� 1866b397622 or 1-617-574-GM MassDEF Website:)ivwvw.rnass.gcn Uep Printpri nn Prr,%xlpri Panpr s t Infiltrator-chamber-Infiltrator Lie, Approval for General Use August 22,2013 Page 2 of 9 I. Design Standards 1. The models listed iil Table 1 are covered under thus Certification. Table 1. Chamber Dimensions Dimensions Ins=ert Model W x L x H Height Inches Inches Equalizer 24 15 x 100 x 11 6 uick4 E ualizer 24 16 x 48 x 11 6 1lick4 E ualizer 24 LP(6-111ch invert) 16 x 48 x 8 6 1uck4 Equalizer 24 LP 2-inch invert` 16 x 48 x 8 Equalizer 36 22 x 100 x 13.5 6 Quick-4 Ec ualizer 36 22 x 48 x 12 6 Standard Chamber 34 x 5 x 12 6.5 Quick-4 Standard 34 x 48 x L' 8 Qiuck4 Plus Standard(5.3-inch invert) 34 x 48 x 12 5.3 Quick4 Plus Standard(8-inch ill-Vert) 34 x 48 x 12 8 Q11ick4 Plus Standard LP(3.3-inch il1<<ell) 34 x 48 x 8 3.3 11ick4 Plus Standard LP(8-inch invert) 34 x 48 x 8 8 Infiltrator 3050 or StorinTech SC-140 51 x 85.4 x 30 22.25 High Capacity Chamber 34 x i 5 x 16 11 Quick-4 High Capacity, 34 x 48 x 16 11.5 Quick-4 Plus High Capacity( 8-inch invert. 34 x 48 x 14 8 2ick4 Plus High Ca aci , 13-inch invert) 34 x 48 x 1L__L 13 r Includes Infiltrator Multipolfm invert adapter attached to the side of die end cap. 2l11cludes Quick-4 Plus Periscope adapter attached to the top.of the Quick4 Plus A11-ii1- One 8 Endcap. 3 Chlly�ysttems installed with this invert height shall be allowed to use the effective leaching area associated with this model in Table 2 4Includes Quick-4 Plus Periscope adapter attached to the top of the Quick4 Plus A11-111- One 12 Endcap. ?. The System is all open-bottoln leaclung lllllt molded fi-oin polyoletin resul. It call be installed without. aggregate or distriblltioll pipe as all absor�ptioll trellchl in accordance with the requireniellts ill 310 CMR 15.251 or as a bed or field in accordance with the requirements in 310 CMR 15,252. 3, The total effective leaching area for any Cllaillber Model shall be calculated by multiplying the Effective Leachung Area per square foot of cllalllber times the total length of chamber from eild cap to end cap includulg end caps. 4. For new collsti-uction,the applicant can size the System ill a trench coilfigura.tion without aggregate,llsillg the effective leaching areas presented in Table 2. ' • L f Lifilhrator-chainber-Lifiltrator Lic, Approval for General Use Au,ust 22,2013 Pa'e 3 of9 Table 2. Effective Leaching Area in Trench._Configuration for New Construction and Remedial Sites Effective Effective Model Leachingg Leaching? Area Area SF/LF SF/LF Equalizer 24 3.76 NA Quick-4 Equalizer 2.4 3.90 NA 1ick4 Equalizer 24 LP 6-i11ch invert 3.90 NA tuck4 Ec ualizer 24 LP(2-inch illveltt) 2,75 NA Equalizer 36 4.73 NA Quick-4 Equalizer 36 4.73 NA Standard Chamber 6.53 NA Q11lick4 Standard 6.96 NA Qiuck4 Plus Standard(5.3-inch invert) 6.20 NA l ick4 Plus Standard(S-inch in1Tert) 6.96 NA tuck4 Plus Standard LP(3.3-inch inverk) 5.65 NA uick4 Plus Stalldard LP(S-inch invert) 6.96 NA Infiltrator 3050 or StorinTech SC-740 NA 6.718 High Capacity Chamber 7.79 NA 111'ck4 High Capacity 7.93 NA Quick-4 Plus High Capacity• (8-inch Ill-vert) 6.96 NA Quick4 Plus High Capacity (13-inch ilivert) 7.93 EL 5. Effective April 21 2006, 310 CIVIR 15.251(1)(b)inaxilnuni trench width is 3 feet. 6.Effective leacliina area is equal to 1.67 (bottom width+ (2x invert height))for Systenls 3 feet,or less in width. 7.Effective leaching area is equal-to 1.0 (3 + (2x invert Height))for Systems with a width greater than 3 feet. 8. The maximum trench width allowed to calculate effective leashing area is 3 feet. 5. Systems installed oil remedial sites shall be allowed to utilize the effective leaching areas presented in Table-2 above or additional reductions ill soil absorption leaching area.approved by the approving authority in accordance with 310 CMR 15.254. In 110 instance shall the reduction ill the soil absoll)tion system required in 310 CMR 15.242 exceed the maxilniun reduction allowed for alternative systems approved ill accordance with 310 C'MR 15.254. 6. For new collstiaction, the applicant can size the System ill bed or field configuration without aggregate,using the effective leaclung areas presented in Table 3. f - Infiltrator-chamber-Infiltrator Lic. Appro-vil for General Use August 22,2013 Paae 4 of 7. In accordance with 310 CMR 15.240 (6) absolptioil trenches should be used whenever possible. When the Systeln is installed for new construction without aggregate ill a bed or field configuration, as defiled ill 310 CMR 15.252, the System shall be designed using the effective leaching area for the bottom width presented in Table 3. Table 3. Effective Leaching Area for Bed or Field Configuration New Construction and Remedial Sites Effective Model Leaching9 Area SF/LF Equalizer 24 2.09 Quick-4 Equalizer 24 2.23 Quick-4 Equalizer 24 LP 6-inch invert. 2.23 Quick-4 Equalizer 24 LP (2-inch invert) 2.23 Equalizer 36 3.06 Quick-4 E ualizer 36 3.06 Standard Chamber 4.73 QIUA4 Standard 4.73 Qii1'ck4 Phis Standard(5.3-111ch invent) 4.73 Quick-4 Plus Staldard(8-inch invert.) 4.73 Qiiick4 Plus Staldard LP 3.3-inch invent 4.73 u1ck4 Phis Standard LP (8-itich invert) 4.73 Infiltrator 3050 or StolinTech SC-740 7,10 High Capacity Chamber 4.73 QIU 4 High Ca acit- 4.73 Quick-4 Plus High Ca achy, (8-hic-li invert` 4.73 Quuck4 Phis High Ca pacit�- (13-ii1c11 illvert) 4.73 9.Effective Leaching area is equal to 1.6 7 times bottom width only. 6. The System,when installed in a bed or field configuration without aggregate oil remedial sites, shall utilize the effective leaching areas presented ill Table 3 above or additional reductions in soil absorption system area approved by the appro"-illg antllority i11 accordance with 310 CMR 15.1-84. In no instance shall the reduction in the loll absorption system area required ill 310 CMR 15.242 exceed the maxin1 un reduction allowed for alter ative systems approved bi accordance with 310 CMR 15.284: Lifiltrator-chamber-Infiltrator Lic, :approval for General Use August 22,2013 Page 5 of 9 II. Special Conditions 1. The System is an appro-,-ed Alteniative Chamber for use as all Alternative Soil Absorptioin System. Ill addition to the Special Conditions colltailled lin thi's Approval, the System shall comply with all file "Standard Conditions for A1teill,-e Soil Absorption Systems"("Standard Conditions'), except where stated otherwise in these Special Conditions. 2. New Conshziction This Certification is for the installation of a System to sei e new construction or aii existing facility with a proposed 'increase in flow, for which a site evaluation iih compliance with 310 CMR 15.000 has been approved by the Approving Authority and the site-meets the siting requirements for new construction, as provided in Paragraph 6 (b)in section II Design and Installation Requirements of the Standard Conditions. 3. Remedial Site This General Use Certification also applies to the installation ofa System for die upgrade or replacement of an existing failed or nonconforming system,provided that the facility meets the siting-requirements for upgrades, as provided in Paragraph I and 9 in section II Design gild Installation Requirements of the Standard Conditions 4. 1Adnen installed without aggregate,the System shall be exempt fioiii the iniiliniuin inlet spacing regiiirenieilts of 310 CMR15.253. (Systems iih,talled with aggregate are not exempt fioin this-regtuirement..). 5. Wlieil installed without aggregate,die System shall have a niiihimunn of one inspection port through the top of one of tine chambers. The inspection port.,hall be capped with a screw type cap and accessible to within three inches of finish grade. �lleih installed uvith aggregate in trench,bed, or field configuration,the System shall have a inninfli mull of one inspection port consisting of a perforated four inch pipe placed vertically down into the stone to the naturally occurring:soil or sand fill below die stone. The inspection port shall be capped with a screw type cap and accessible to witlnl three inches of finish grade. Wlien installed with aggregate iil accordance with the design specifications of 310 CMR 15.253(1)(a)(c) for Pits, Galleries, or Chambers, the System shall comply with tie in,pectioll access requirements of 310 CMR 15.753(3). 6. Whether installed with or without aggregate,when installed in treihch configuration,the System must be installed in accordance with die trench requirements of 310 CMR 15.251, except 15.251(5)-(�)which pertain to effluent distribution piping requirements and 15.251(1)(b)which limits trench width to 3 feet ma_xililUlil. Tlie systein shall comply with these requureinents: a) Length(each trench) 100 feet maximum (310 CMR 15.251(1)(a)), r Infiltrator-chamber-Lifiltrator Inc, Approval for General Use Au,ust 22,2013 Pace 6 of9 b) Width(each trench) 2 feet muIrmIIn1 (310 CMR 15.251(1)(b)) - Clambers greater thar13 feet wide, when specifically approved, are subject to other Special Conditions and limitations; c) Effective Depth: shall be equal to the depth of the trench below the invert of the chamber inlet with a rniiiirtutull of six uiclies up to a maxirtlurn of two feet (310 CMR 15.251(1)(c)); d) The rulirliitnun separation distance between any two trer1c11es shall be two times the effective width or depth of each trench,whichever is greater, or where the area,betuveen trenches is designated as reserve area, three tines the effective width or depth of each trench,whichever is greater(310 CMR 15.251(1)(d)); e) The effective leacluillg area.shall be calculated using the bottom area and a, rliaZirnuun of two feet(per side) of side wall area for each trench(310 CMR 15.251(1)(e)); f) Trenches shall be situated,where possible,with their long dimension perpendicular to the slope of the natural soil. Where possible they shall follow the contour lines (310 CMR 15.251(2)); g) Trenches corlstnicted at different elevations :hall be designed to prevent effluent from the higher trerlchl(es) flowing into the lower henchr(es) (310 CMR 15.251(3)); Y) The area bets=eeil trenches may be designated as system reserve area only where the separation distance between the excayation sidewalls of the primary trenches is at least three times the effective width or depth of each trericll, wllicllever is greater(310 CMR 15.251(4)) - Chamber:greater than 3 feet '%ride, wheal specifically approved, shall be separated by three tine:the actual width Ruud are su�j ect.to other Special Conditions and limitations; and i) Effluent distribution lines exceeding 50 feet ill length shall be comlected and venting provided in accordance wit11310 CMR 15.241 (310 CMR 15 251(10). 7. 'When approved Alterilative Chambers are installed surromided by aggregate in trench configuration,the effective leachilig area.required by Title 5 for a. conventional system shall apply to the System and shall not be reduced, as provided in the Standard Conditions. The System shall also meet the following requirements wheii installed with aggregate 111 trench configuration: a) the malilnum effective depth shall be 2 feet,measured from the invert of the chamber inlet to the bottom elevation cif the aggregate b) the total lnayxirnuln effective width,including the width of die chamber plus . the aggregate, shall be 3 feet; and c) with the use of aggregate;the mirlinluuui inlet spacing requirements (20 feet) of 310 CMR 15.253(6) shall apply. Infiltrator-chamber-Infiltrator hie, Approval for General Use August 22,2013 Page 7 of 9 8. When installed without aggregate in trench configuration, approved Alternative Chambers greater than 3 feet wide: a) shall be installed with a milimuln separation distance between any two trenches of two tunes the actual width of the chamber, or where the area between trenches is designated as resertiTe area,three times the actual width of the chamber; and b) shall only be entitled to a.maximlun effective width of 3 feet for the purposes of calculating total effective leaching area. 9. Approved Alternative Chambers greater than 3 feet wide shall not be installed with aggregate 111 trench configuration and shall only be installed with aggregate: a) ill a,"bed or field configuration"ill accordance WIlth the Special Conditions peltainui lg to all Alternative Chambers and the Special Conditions which reference"bed or field configuration". No credit for sidewall area is allowed ill this colltrguratloll; or b) in accordance with the design specifications of 310 CMR 15.2253 (1) (a)-(c), the Special Conditions which apply to such designs, and the Special Conditions which apply to all Alternative Chambers. 10. Whether installed with or without aggregate, when installed ill a.bed or field collfig-oration, the System may be installed without dishibution piping, but 11111st comply with the following requirements in 310 CMR 15.252: a) the use of leaching beds or fields is restricted to systems with a calculated design flow of less than 5,000 gpd per leaching bed or field(310 CMR 15.2520)); b) the ma--Xhilu n length of chambers in selies shall be 100 feet(310 CMR 15.252(2)(b)); c) Separation distance between adjacent beds/fields shall be tell feet(310 CMR 15.252(2)(f)); d) The effective leaching area shall include only the bottom area,not the sichelt ails (310 CMR 15.252(2)(i)). 11. When approved Alternative Chambers are installed with aggregate ill a.bed or field configuration the effective leaching area required by Title 5 for a conventional system shall apply to the System and shall not be reduced, as provided under the Standard Conditions. The System shall also meet the following requirements: a) the aggregate base under the chambers shall have a mirnimum depth of 6 inches and nlaxiinlun depth of 12 inches, b) the area betiveen chambers shall be filled with aggregate meeting the requirements of310 CMR 15.214 , up to the crown of the chambers with a nlilliinuni of 1 foot of aggregate to the outer edge of the bed; Infiltrator-chamber-Infiltrator hic, Approval for General Use August 22,2013 Page S of 9 c) to prevent the ilntrusion of fines the System shall comply with 310 CMR 15,24%(2); d) the maximuun distance between chambers shall be 4 feet; and e) the horizontal distance fiom a chamber to the outer edge of the bed shall be 4 feet maximum. 12. The System, ahern installedwith aggregate,inlay be installed in accordance with the design specifications of 310 CMR 15.253 (1) (a)-(c) for Pits, Galleries, or Chambers, which state: a) Effective Depth-A maximuun of two feet of sidewall depth below the invert of the inlet of the unit slutll be used when calculating the effective leaching area; b) Surrounding Aggregate -1 foot nnininmnn per side. 4 feet maxilnuu per side; and c) Separation Distance Between Units -two times the effective width or depth, whichever is greater. 13. When illstalled with aggregate and installed in accordance with 310 CMR 15.253(1)(a)-(c),the effective leaching area required by Title 5 for conventional chambers shall apply to approved Alternative Channber Systems and shall iiot be reduced, as provided under the Standard Conditions. The System shall also meet the following requirements: a) The Alternative Chambers must.be installed on an aggregate base of at.least six inches deep. The ma_xirmunn allowed total effective sidewall depth shall be two feet when calculating the effective sidewall leaching area and shall be measured from the invert of the chamber to the bottom elevation of the aggregate; b) The effective width of the Alternative Chamber or Alternative Chambers ill series shall include at least one foot of surrounding aggregate per side,up to 4 feet per side. The effective bottom area.will be increased by two to eight SF:IF with the corresponding addition of one to four feet of aggregate per side; c) The area between adjacent urnits may not be used as reserve area when the System is installed ill accordance with 310 CMR 15.253 (1) (a)-(c); arid d) Adj acelnt units (Alterative Chambers with surrounding aggregate), separated by undisturbed soils of less than two times the effective width, shall be considered a multiple bed configuration and shall not be entitled sidewall area 'when calculating the effective leacling area. r Infiltrator-chamber-Infiltrator Inc. Approv.il for General Use August 22,2013 Page 9 of 14. For Systems collstntcted ill fill and irlstalled without aggregate, the System -hall be installed as specified lr1 310 CMR 15.255. Constrllctiorl lll Fill, except.the miillimun 15 foot horizontal separation distance to be provided between the soil absorption area and t11e adj acent side slope shall be measured horizontally frond the top of the chamber. (( TOWN OF BARNSTABLE (�~ LOCATION SEWAGE#ao/j VILLAGE n��d, � �v=�-ASSESSOR'S MAP & LOT rO4 INSTALLER'S NAME&PHONE NO.a 305 Coo Qo7 SEPTIC TANK CAPACITY L-1 7o c) Cr r�, L Rox LEACHING FACILITY: (type) 10 /4` C4 1-'/.1y (size) 6-?X �K,�Ci i � NO. OF BEDROOMS BUILDER OR OWNER I PERMITDATE: ,-? I AS COMPLIANCE DATE: S�J7 / Jr 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 /� of site or within 200 feet of leaching facility) / t/A -Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching faci 'ty.) - �f"1 -�, ,. '^t,Feet "'. Furnishet by . Y 1� 14 �� L G`T'.3 TOWN OF BARNSTABLE Y� LOCATION 57^ SEWAGE # VILLAGE c � ASSESSOR'S MAP & LOT y9 D®y INSTALLER'S NAME & PHONE NO. A- CF;NCO 775= — SEPTIC TANK CAPACITY C Pa o L LEACHING FACILITY:(type) ' ` (size) NO. OF BEDROOMS A. PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r .j O � f __r O R' 3S" �� -o • pl Town ® ' � Barnstable P tk Department of Regtdatory Services a awwerAern : Public Health Division Date MASS. s6jg ,m� 200 Main Street,Hyannis MA 0260'1 ' 44 Date Scheduled.. . AVUmt Fee"Prl. Soil Suitability A.s,sessment for Sew D s os a a Performed By: Witnessed By: LJOCATION &G,NERAL MORMATION. Location Address Owner's Name S tH t Address L4&- �1c Assessors Map/Parcel- Engineer's Name NEW CONSTRUCTION REPAIR _ Telephone# 30 . Land Use Slopes Surface Stones V Distances from; Open Water Body ' ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SIM TCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands{n proximity to holes) �a - m Parent material ay"wAt5 H ,,:... p ...,. (geologic). `Denllt`tq Bedrock'' Depth to Groundwater. Standing Water in Hole: Weeping f-om Pit File. Estimated Seasonal High Groundwater DEA TE,fl MINATION FOR SEASO.T°IAL HIIOII WA7.'ERTABLE. Method Used: A_70;•. G Depth Observed standing in obs.hole: - In, Depth to soli mottles: In. Depth to weeping from side of obs.hole: In. Groundwater Adjustirment____r-- lr. Index Well# . Rcading Date: Index Well lWvel ___. Adj.facto'_Aid.Oroundwuter Level e PEI RCOLATION TEST lUate Y �x►Ine Observation / Hole# finte at rl" Depth of Pere �o Time at 6" Start Pre-soak Time @ jo Time(9"-6' End Pre-soak Rate Min.finch �Z Site Suitability Assessment: ;,Site Passed V' Site Palled: Additional Testing;Needed.(YM)' Original: Public Heald,Division Observation Hole Data To Be Completed Doti Back---------- **4`Af percolation test is to be conducted within 100' of wetland,you most first notify the. Barnstable.Conservation Division at least one,(1) week prior to beginning. Q:\,,sErrIC\PLItCFORM.DOC DEEP OBSERVATION HOLE LOG .dale# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. • onsistency �Oravell L. S DEEP OBSERVATION HOLE, LOG Hole it 2- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders. onsisten % ravel Zell 15 _ LS - i DEEP OBSERVATIO N MOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in_) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Can i to cy.95 t3ravcll DEEP OBSERVATION HOLE LOG Hole# Depth from. Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, a e Flood Insurancebate 1VIap: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within•100 year flood boundary No Yes' Dentli 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? i If not,what is the depth of naturally occurring pervious material`? Certiriication I certify that un 411th (date)I have passed the soil evaluator examination approved by the Department of Environnicntal Protection and that the above analysis was performed by me consistent with . die required train' p clise and experience described in�10 CIvM 15.017. Signature Date Q:\Sj1_PT10PF_RCFORM.DOC CERTIFICATE OF ANALYSIS Page: 1 x, Barnstable County Health Laboratory \9SRCE3u Report Prepared For: Report,Dated: 9/1'1/2008 Craig Crocker C-O-MM Water Department Order No.: G0849129 P O Box 369 Osterville, MA 02655 Laboratory ID#: 0849129-01 Description: Water-Drinking Water � Sample#: 48 H Sampling Location 4"8 Child.St..Centervi11e,111A— Collected: 9/3/2008 Collected by: Cary Oakley House Received: 9/3/2008 Routine-TC i ITEM RESULT UNITS RL MCL Method# Tested i Nitrate as Nitrogen 2,5 mil 0.10 10 EPA 300.0 9/3/2008 Copper ND mg/L 0.10 1.3 SM 3111E 9/10/2008 i I Iron: ND -T A O.10 0.3 Sivl 311IB 9/i0/2008 Sodium 30 mg/L 1.0 20 SM 311113 9/10/2008 I Conductance 400 umohs/cm 2.0 EPA 120.1 4/3/2008 � pH 7.3 pH-units 0. SM 4500-H-13 9/3/2008 Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician. r:ate e Co CJ 1 M W ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 i CERTIFICATE OF ANALYSIS Page: 2 A i� YI Barnstable County Health Laboratory Report Prepared For: Report Dated: 9/11/2008 Craig Crocker C-O-MM Water Department Order No.: G0849129 P0 Box 369 Osterville, MA 02655 i Laboratory ID#: 0849129-02 Description: Water-Drinking Water Sample#: 48 Al Sampling Location 48 Child St.Centerville,MA Collected: 913/2008 Collected by: Gary Oakley Main Received: 9/3/2008 Routine-TC ITEM RESULT UNITS RL MCL Method# + Tested Nitrate as Nitrogen 2.5 mg/L 0.10 10 EPA 300.0 9/3/2008 j Copper ND mg/L 0.10 1.3 SM 311113 9/10/2008 iron ND mg/L 0.10 0.3 SM 311113 9/10/2008 i Sodium 32 mg/L 1.0 20 SM 311113 9/10/2008 Conductance 400 umohs/cm 2.0 EPA 120.1 9/3/2008 I pH 7.5 pH-units 0 SM 4500-H-B 9/3/2008 Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult aphysi5jVn. Approved By: _ (L irector) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level - Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 e: , Page:CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Dated: 7/21/2005 Report Prepared For: Order No.: G053.1.706 Lawrence Smith 48 Childs Street Centerville, MA 02632 Laboratory•ID#: 0531706-01 Description: water-Unflushed Drinking Water Sample#: 31706-01 Samplinl-Location: `4R-Childs$t.Centerville,MA Collected: 7/19/2005 Collected hy: LAM Fridge water Received: 7/19/2005 Test Parameters ITEM RESULT UNITS RL MCL Method# Tested LAB: Mewls Copper 0.32 mg/L 0.1 1.3 SM 311113 7/19/2005 EPA 524.2 - Volatile Organics by GCMts ITEM RESULT UNITS R.L MCL Method# Tested:': LA13 GUMS r �l;l l,2 Tetrlchloloethmle 4-BRL u�/L 0.5 EPA 524.2 719./2005 i 1 h l l-Ti`r'cliloi oethane B17 RL ugL. 0.5 200 EPA 5z4.2 7/1,9/?qos ~ CD ugL -r .tacloroethane BRL �1/2005� 1,1,2 Ti iclhlol oetliane BRL ug/L 0'.5 5.0 EPA 524.2 7C i?/200�' 1 •.1=Dichloroethane BRL ug/L 0.sEPA > sz4.z vl 9/zoos 1,1.-Dichloroethene BRL ug/L 0.5 7.0 EPA 524.2 7/19/2005 1;1-Dichloropropene BRL ug/L 0.5 EPA 524.2 7/19/2005 1,2,3-Trichlorobenzene BRL ug/L 0.5 EPA 524.2 7/19/2005 1,2,3-Trichloropropane BRL ug/L 0.5 EPA 524.2 7/19/2005 1,2,4-Trichlorobenzene BRL ug/I-. 0.5 70 EPA 524.2 7/19/2005 1,2,4-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 7/19/2005 i 1.;2=Dibromo-3-chloropropan BRL ug/L 0.5 EPA 524.2 7/19/2005 1,2-Dibromoethane (EDB) BRL ug/L 0.5 EPA 524.2 7/19/2005 1,2-Dichlorobenzene BRL ug/L o.s 600 EPA 524.2 7/19/2005 1.,2='victiloraetli�ne'' BRL Ug/1; 0.5 5.0 EPA 524.2 7/19/2005. Dichdtiropl i;pane J BRL ug/L' o's EPA 524.2 7419/20.05, 1-3,5 Ttrrrietliyihenzerie I3:RL �:' 0a IPA 524.2 W.1 9/20a^s.. 1.;3=Dicfiloi-olien"zene BRL' U a`s EPA 524.2 7/19/2005 RL. = Reporting Liinit MCL=Maximum Contami;iant Level Supel•ior Court house; PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 ,�%i mar . .. ;.:>:;:;. Page: 2 '`'` �yp CERTIFICATE OF ANALYSIS » :11 Barnstable County Health Laboratory Report Dated: 7/21/2005 Report Prepared For: Order No.: G0531706 Lawrence Smith 48 Childs Street Centerville, MA 02632 1,3-Dichloropropane BRL ug/L 0.5 EPA 524.2 7/19/2005 1.,4-Dichlorobenzene BRL lig/L, 0.5 5.0 EPA 524.2 7/19/2005 2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 7/19/2005 2-Chlorotoluene BRL ug/L 0.5 EPA 524.2 7/19/2005 4-Chlorotoluene BRL Ug/L 0.5 EPA 524.2 7/19/2005 Benzene BRL ug/L 0.5 5.0 EPA 524.2 7/19/2005 Bromobenzene BRL ug/1. 0.5 EPA 524.2 7/19/2005 Bromochloromethane BRL ug/L 0.5 EPA 524.2 7/19/2005 Bromodichloromethane BRL Ug/L 0.5 EPA 524.2 7/19/2005 Bromoform BRL Ug/L 0.5 EPA 524.2 7/19/2005 Bromomethane BRL ug/L 0.5 EPA 524.2 7/19/2005 Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 7/19/2005 Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 7/19/2005 Chloroethane BRL ug/L 0.5 EPA 524.2 7/19/2005 Chloroform 0.55 ug/L 0.5 EPA 524.2 7/19/2005 Chloromethane BRL ug/L 0.5 EPA 524.2 7/19/2005 cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 524.2 7/19/2005 cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 7/19/2005 Dibromochloromethane BRL ug/L 0.5 EPA 524.2 7/19/2005 Dibromomethane BRL ug/L 0.5 EPA 524.2 7/19/2005 Dichlorodifluoromethane BRL Ug/L, 0.5 EPA 524.2 7/19/2005 Ethylbenzene BRL UP/L. 0.5 700 EPA 524.2 7/19/2005 Hexachlorobutadiene BRL ug/L 0.5 EPA 524.2 7/19/2005 I lsopropylbenzene BRL ug/L 0.5 EPA 524.2 7/19/2005 1 Methyl-tert-butyl ether BRL Ug/L 0.5 EPA 524.2 7/19/2005 Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 7,119/2005 n-Buty!benzene BRL ug/L 0.5 EPA 524.2 7/19/2005 1 n-Propylbenzene BRL ug/L 0.5 EPA 524.2 7/19/2005 Naphthalene BRL ug/L 0.5 EPA 524.2 7/i9/2005 RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSISPage: 3 '1 Barnstable County Health. Laboratory Report Dated: 7/21/2005 Report Prepared For: Order No.: G0531706. Lawrence Smith 48 Childs Street Centerville, MA 02632 p-lsopropyltoluene BRL ng/L 0.5 E13A524.2 7/19/2005 sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 7/19/2005 Styrene BRL ug/L, 0.5 too E13A524.2 7/19/2005 tent-Butylbenzene BRL Ug/L 0.5 EPA 524.2 7/19/2005 Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 7/19/2005 Toluene BRL, ug/L 0.5 1000 EPA 524.2 7/19/2005 Total xylenes BRL u /L 0.5 10000 EPA 524.2 7/19/2005 trans-1,2-Dichloroethene BRL ug/L 0.5 100 EPA 524.2 7/19/2005 trans-1,3-Dichloropropene BRL ng/L 0.5 EPA 524.2 7/19/2005 Trichloroethene BRL ug/L 0.5 5.0 EPA 524.2 7/19/2005 Trichlorofluoromethane BRL ug/L 0.5 EPA 524.2 7/19/2005 Vinyl chloride BRL ug/L 0.5 2.0 EPA 524.2 7/19/2005 Water sample meets the recommended limits for drinking water of all the above tested parameters. RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 r'�l�e: a CERTIFICATE OF ANALYSIS fir• �••. >;� Barnstable County Health. Laboratory roc a �'; Report Dated: 7/21/2005 Report Prepared For: Order No.: G0531706 Lawrence Smith 48 C.MIds Street Centenlille, MA 02632 Laboratory ID#: 0531706-02 Description: Water-Unllushed Drinking N3'ater Sample 4: 31706-02 Sampling Location: 48 Childs St..Centerville,MA Collected: 7/18/2005 Collected by: LAM Ice Received: 7/18/2005 Test Palm 2eters ITEM RESULT UNITS RL 'mcL Method# Tested LAB: Met(ds Copper 0.37 mI/L 0.1 1.3 SM 3111B 7/19/2005 Water sample meets the recommended limits for drinking water of all the above tested parameters. / Approved By: ` ✓_!/ (L irector) 74C RL = Repoiiuig Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page: 1 CERTIFICATE OF ANALYSIS ` Barnstable County Health Laboratory Report Dated: 9/19/2005 Rellort Prepared For: Order No.: G0532871 Lawrence Smith 48 Childs Street Centerville, MA 02632 Laboratory 1D#: 0532871-01 Description: Refridgerator Water-Drnildng Water Sample#: 32871 Sampling Location: 48 Childs Street Centerville,MA Collected: 8/30/2005 Collected by: S.Rask Received: 8/30/2005 Test Parameters i ITEM RESULT UNITS RL MCL Method# Tested LAB: IC Lab Fluoride BRL mg/L 0.5 4.0 EPA300.0 8/30/2005 Nitrate as Nitrogen 1.9 mg/L 0.10 10 EPA300.0 8/30/2005 LAB: Metals Iron BRL mg/L 0.10 SM 311113 8/30/2005 Sodium 31 mg/L 1.0 20 SM3111B 8/30/2005 LAB: Physical Chemistry Conductance 330 umohs/cm 1.0 EPA 120.1 8/30/2005 pH 7.4 pH-units 0 EPA 150.1 8/30/2005 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a physician. Approved By: ( Director) - F F RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Health Complaints 03-Aug-05 Time: 9:25:00 AM Date: 8/1/2005 Complaint Number: 18308 Referred To: DAVID STANTON Taken By: SHARON CROCKER Complaint Type: GENERAL Article X Detail: INJURIES Business Name: Number: 48 Stree . CHILDS ST Vill e: CENTERVILLE Assessors Map_Parcel: Complaint Description: HE HAD A BAD ACCIDENT AND WOULD LIKE HEALTH DEPT TO GET INVOLVED AND DOCUMENT OR NOTIFY PUBLIC. HE HAS A REFRIG. WHICH IS APPROX.8 YEARS OLD. SIDE BY SIDE WITH WATER AND ICE DISPENSERS ON OUTSIDE. JULY 14 HE TOOK A GLASS AND FILLED WITH WATER AND IMMEDIATELY FELL DOWN. IT TURNED OUT TO BE AN ACID PRODUCT WHICH GOT INTO THE WATER (POSSIBLY FROM FEON) BURNT MOUTH, THROAT,I NTESTI NES- EXTENSIVE INJURIES. CAN'T SMELL OR TASTE SINCE JULY 14. Actions Taken/Results: DS WENT TO SAID LOCATION AND SPOKE WITH THE BARNSTABLE COUNTY DEPT. OF HEALTH AND ENVIRONMENT TOOK A WATER SAMPLE FROM SAID LOCATION. THE WATER SAMPLE CAME BACK FINE. THE DOCTORS THINK IT IS AN ACID BURN; HOWEVER, THEY DID NOT TAKE ANY SAMPLES OR DO ANY TESTS FOR WENT TO THE ER 1 Health Complaints 03-Aug-05 WHEN THIS HAPPENED. HE ALSO HAD FOAMING AT HIS TEETH. HE SAID ON A SCALE OF 1-10 AT THE ER, IT WAS A 10. HE CANNOT SEAL HIS LIP TO A GLASS ANYMORE. DS RECOMMENDS HE CHECK BACK WITH THE DOCTORS, AS WE DON'T CONDUCT ANY TESTS, ALL WE CAN DO IS GET A WATER SAMPLE, WHICH HAS ALREADY BEEN DONE BY THE COUNTY. DS THINKS THIS IS PROBABLY NOT FROM THE FREON, BECAUSE THE FRIDGE WOULD MOST LIKELY NO LONGER HOLD A COLD TEMPERATURE IF THE FREON WAS LEAKING OUT. Investigation Date: 8/3/2005 Investigation Time: 11:00:00 AM 2 Honk I Map I Toolbox 1 Hclp ilk �cE UI fi �� a r.�jr' i� b 'i ,a MM �jl��G';5brak8f85'R.,iu`3fi,_i3�" Name:LAWRENCE W. SMITH CENTERVILLE, MA License Number:807 Status:Suspended Licensing Board:Sanitarians License Type:Sanitarian Issue Date: Expiration Date:12/31/2001 School: Exam Date: This web site displays disciplinary actions dating back to 1993. This license has had disciplinary actions taken during this time. Click here to view this information. l Division of Professional Licensure 239 Causeway Street Boston,Massachusetts 02114 Phone: (617)727-3074 Please send your technical questions or comments about this web site to REG.WebMaster@State.rna.us Disclaimer Privacy Enforcement Process Glossary -\ COM. NiONWEALTH OF MASS-'1CfiUSF I-I S Isis EXFCL`TFVE OFFICE OF ENVIRONMFNTAI., AFFAIRS I) PARTMENT OF ENVIRONMENTAL PIZOTECTION (��F t11�TFR SFR1"r1. BOSTON. NIA 02109 61 '-9]-5WO 1 W11.I104F k%Fl D �wa4 TRa Y O\F_ C;ncrnc,r 350 MAIN STREET 'I�' '1CN/ ` uar: WEST YARMOUTH,MA n^^ ��v1Fi F�t'� t iFi� nRGrc)r.nln.cl.l.tttcu 508-775-2800 /p 7 (�nrnrn nncr l.t Gn�crnr'rOF .,�0" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO � :� PART A A i CERTIFICATION Y . , MAP 249 PAR 009 -Y� PROPERTY ADDRESS: 48 CHILDS STREET,CENTERVILLE ADDRESS OF OWNE DATE OF INSPECTION: NOVEMBER 16, 1998 BILL SMITH NAME OF INSPECTOR: JAMES D.SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth, MA 02673 TELEPHONE NUMBER: (508)775-2800 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: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: DATE: NOVEMBER 16, 1998 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: SITE OVER ALL PASSES, INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. ANY CHANGE IN THE USE OR FLOW MAY OVERLOAD THE SYSTEM. B SYSTEM CONDITIONALLY PASSES: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved b the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or NO). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) Years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (Revised 04/25/97) Page 1 of 10 DEP on the World Wide Web:http://www.magnet.state.ma.un/d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 48 CHILDS STREET,CENTERVILLE Owner: SMITH,BILL Date of Inspection: NOVEMBER 16, 1998 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). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled 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: N/A 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (Revi sed 04 25 97 Page 2 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 CHILDS STREET,CENTERVILLE Owner: SMITH, BILL Date of Inspection: NOVEMBER 16,1998 D]SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: N/A 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (Revised 04/25/97) Page 3 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 48 CHILDS STREET,CENTERVILLE Owner: SMITH,BILL Date of Inspection: NOVEMBER 16,1998 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. N/A As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The manholes were uncovered,opened,and the interior was inspected for condition of 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: X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. N/A Existing information. Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)] � I (Revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 48 CHILDS STREET,CENTERVILLE Owner: SMITH,BILL Date of Inspection: NOVEMBER 16,1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 g.p.d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 2 Garbage grinder(yes or no): YES Laundry connected to system(yes or no): YES Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year usage(gpd): 1998 16,000/1997 27,000 Sump Pump(yes or no): NO COMMERCIAL/INDUSTRIAL: 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 date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: N/A System pumped as part of inspection:(yes or no) If yes, volume pumped: Gallons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system X Cesspool X Overflow cesspool Privy Shared system(yes or no)(if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components,date installed(if known)and source of information: UNKNOWN Sewage odors detected when arriving at the site: 9 g (yes or no) NO (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 48 CHILDS STREET,CENTERVILLE Owner: SMITH,BILL Date of Inspection: NOVEMBER 16,1998 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: N/A (Locate on site plan) Depth below grade: Material of construction concrete metal Fiberglass Polyethylene other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How dimensions were determined 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: N/A (locate on site plan) Depth below grade: Material of construction concrete metal Fiberglass Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 5 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 04/25/97) Page 6 of 10 ' SUBSURFAC E SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 48 CHILDS STREET,CENTERVILLE Owner: SMITH,BILL Date of Inspection: NOVEMBER 16, 1998 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Capacity: Design flow: gallons/day Alarm level: Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: N/A (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) PUMP CHAMBER: N/A (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 04/25/97) Page 7 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 CHILDS STREET,CENTERVILLE Owner: SMITH,BILL Date of Inspection: NOVEMBER 16, 1998 SOIL ABSORPTION SYSTEM(SAS):X (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, 1 alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) ONE OVERFLOW POOL T DEEP,COVER 26"BELOW GRADE,NO INLET TEE POOL DRY,HIGH WATER MARK Z UP WALLS,NO SIGN OF WATER LEVEL BEING HIGHER. CESSPOOLS:X (locate on site plan) Number and configuration: 1 Depth-top of liquid to inlet invert: 4" Depth of solids layer: 6" Depth of scum layer: 2" Dimensions of cesspool: 6" Materials of construction: BLOCK Indication of groundwater: NO inflow(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.) MAIN POOL AT WORKING LEVEL,COVER Z BELOW GRADE,NO IN OR OUTLET TEES.TEES SHOULD BE INSTALLED. PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 CHILDS STREET,CENTERVILLE Owner: SMITH,BILL Date of Inspection: NOVEMBER 16, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100(locate where public water supply comes into house) O F, ,l 1 1 5° /4 r" (revised 04/25/97) Page 9 of 10 liIN F `:1' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 CHILDS STREET,CENTERVILLE Owner: SMITH,BILL Date of Inspection: NOVEMBER 16, 1998 Depth to no groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record X Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE:TEST HOLE 12'BELOW GRADE, NO GROUND WATER.TEST HOLE IS T BELOW BOTTOM OV OVERFLOW POOL.TEST HOLE NOTED ON PAGE 9. (revised 04/25/97) Page 10 of 10 ACCESS COVERS MUST BE WITHIN INSPECTION 9" MINIMUM. INVERT ELEVATIONS : DESIGN CR I TER I A : GENERAL NO TES : 6- OF F/N/SH GRADE PORT 3' MAXIMUM COVER l0/.3 FIRST 2' TO INVERT AT BUILDING: 98.0 DESIGN FLOW: BE LEVEL INVERT IN SEPTIC TANK: 97.25 2 BEDROOMS AT 1 /0 G.P.D. PER I. THIS PLAN 1S FOR THE DESIGN AND CONSTRUCTION 98.4 INVERT OUT SEPTIC TANK: 97.0 BEDROOM EOUALS 220 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4- DIAN PIPE 96• 1 CLEAN SAND BACKF l L L INVERT IN DI ST. BOX: 96.67 III TICAL ATUM IS 98.0 �� 97.0 // - AROUND AND 2" OVER CHAMBERS INVERT OUT DIST. BOX: 96.5 NO GARBAGE GRINDER 2 SET. SEE SITE PLAN.ASSUMED. FOR BENCH MARKS IIIGAS r95.5 INVERT IN LEACH CHAMBER: 96.42 97.25 v BAFFL f 96.67 1X 6. SEP T l C TANK REOU 1 RED: 3 OUTLET l0 HIGH CAPACITY INFILTRATOR BOTTOM OF LEACH CHAMBER: 95.5 220 G.P.D. X 200% - 440 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND Mum CHAMBERS I N TRENCH FORMATION ADJUSTED GROUND WATER: N/A D-BOX SEPTIC TANK PROVIDED: 1500 GAL. MIN. MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1500 GAL OBSERVED GROUND WATER: N/A CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6- CRUSHED STONE OR BOTTOM OF TEST HOLE *! : 88.9 SOIL ABSORPTION SYSTEM REOU/RED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DES!GN PERC RATE l 5 M!N/INCH PROFILE : NOT TO SCALE SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 220 GPD / 0. 74 GPD/SF - 298 S.F. REOUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED: l0 HIGH CAPACITY INFILTRATOR CHAMBERS. 62.5'x 7.79 SF/FT - 487 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 487 S.F. x 0. 74 - 360 GPD APPROVED EQUAL. PER TRANS NO. X228042 DATED 612212013 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED PRECAST CONCRETE OR APPROVED POLYETHYLENE. BOTH SHALL BE WATERTIGHT, D-BOX SHALL BE WATER 129-92' N 85e ' "E SOIL TES T P I T DA TA s TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE INDICATES 1_ INDICATES OUTLET. PERCOLATION = OBSERVED TEST GROUNDWATER 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE". s-8 r RCH 1-888-D l G-SAFE AND THE LOCAL WATER DEP T. TP #! P+14132 TP +2 FOR LOCATION OF UNDERGROUND UTILITIES. '00- � HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR L 0 T 3 I BM. BRB/FND 99.4 0" 99.4 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE EL-99.93 LOAMY I O YR LOAMY I 0 YR �� '4 SAND 2/2 Q SAND 2/2 DES/GN ENGINEER TWO DAYS PR l OR TO CONSTRUCTION 20. 006-+ S.F. OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE 9" - - - - - - - - - - - - - - - - - - - - 98. 7 8' - - - - - - - - - - - - - - - - - - - - 98. 7 / CONSTRUCTION INSPECTIONS. /00.3 / O p L OAMY I O YR L7 n LOAMY I O YR l +99 7 SAND 4/6 SAND 4/6 ! TPRI y 9. EXISTING CESSPOOL TO BE PUMPED DRY AND / 0 30" - - - - - - - - - - - - - - - - - - - - 96.9 28 - - - - - - - - - - - - - - - - - 97. 1 / � � g C / MED-COARSE IOYR C J MED-COARSE IOYR BACKFILLED. CATCH BASIN // / + 99 'f m SAND AND 5/8 SAND AND 5/8 / TP-2 m / GRAVEL GRAVEL l 0. 1 NVER T AT THE DWELLING TO BE RELOCATED TO THE CESSPOOL A; m j LOCATION AND ELEVATION SHOWN. w / o EXISTING DECK 1 -NOL L Y 8`140L L Y / DWELLING D eox 99 4 // NO WATER NO WATER cD I - 20'OAK 126- 88.9 120" 89.4 N -W W 1500 GJLLON r ` SEPTIC \TANK ' ` DATE: SEPTEMBER 4. 2013 _T TEST BY: STEPHEN HAAS WITNESSED BY: DONNA MIORANDI j / w GARAGE PERC RATE: C 2 M/N/l NCH ��4f H ,1"+99.8 I 10 HIGHICAPACITY 2O_MAPLE I NF I L TRA,TOR CHAMBERS I N 99 6 7c V r 18-OAK 4�I /00 I / CB/OH FAO UP/2 J) - SEPTIC S `y' S T E M DES / G N i 5 D_KADE-FENCE - - -- - - -- - - ss 85'42 17 W COID14FND 48 CH l LDS S TREET MAP 249 PARCEL 009 / CB/DH FND BA f? N S TA B L E ( C E N T E R V l L L E ) MA R°UTEZ PREPARED FOR LEGEND �F ■ CB CONCRETE BOUND B E A T R I C E_ S M I T H r LONG POND = yq�N -W WATER L I NE O HYDRANT SCALE l 20 ' SEPTEMBER 1 2 . 20 / 3 y US -G GAS L!NE P I n S BEET OHW- OVER HEAD WIRES STEPHEN A . H A A S -0 LIGHT POST -E- UNDERGROUND ELECTRIC LINE E N G I N E E R I N G , INC -T- UNDERGROUND TELEPHONE L 1 NE / \' �� 9 2 3 FR o u t e 6 A -CTV- UNDERGROUND CABLEVISION LINE / �jj I �I�� Ya rmo u t h p o r t , MA . 02675 40.4 SPOT ELEVATION �� '�� \\ ( 508 ) 362-8 1 32 __ -- 40------- EXISTING CONTOUR MOM0 /0 20 40 40 _ PROPOSED CONTOUR LOCUS MAP JOB NO: 13-086