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HomeMy WebLinkAbout0137 CHILDS STREET - Health 137 Childs Street, Centerville A = 229-113 _. i No. 42101/3 ORA ESSELTE 10% o O 0 0 Commonwealth of Massachusetts ,Ip Title 5 Official Inspection Form ,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rn 137 Childs St Property Address Leon Michelove Owner Owner's Name two. information is 00 required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information Sl#- /3361 Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2.. ❑ Conditionally Passes 3.. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9-12-18 In or'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 has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,w Title 5 official Inspection Form Subsurface sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1; 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2)' System Conditionally Passes: ❑ One or more system components,as described.in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 3 ❑ 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 El ❑ 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 El ❑ ND (Explain below): ❑ obstruction is removed ❑Y El ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 l sue` Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l_ :,> 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. I . ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems:. i You must indicate "Yes"o`r"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 s Commonwealth of Massachusetts ;w Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ' ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 , Commonwealth of Massachusetts Title 5 Official Inspection .Form � wa ;i b i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs.T.. St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 'Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A), ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 I Commonwealth of Massachusetts r� Title 5 Official Inspection Form � ., �i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: I Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No i, Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 9-2018 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w. ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner-----pumped 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ,wt Title 5 Official Inspection Form YC'l Subsurface Sewage Disposal System form Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2011 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 46"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts y Title 5 Official Inspection Form wa ,�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 40"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" . How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Ell 3� Title 5 Official Inspection Form i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _J 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping.recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form ! i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�r.•T„, 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official . Inspection Form ! I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address - Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. ' 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 16 ARC 36's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form + ,JF-I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ` 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach field in good working order and holding 2" of water with no sign of back-up into d-box. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form dal; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately • i J1. Po L000 jowl t 3 ,9 3 " r ' RWRiiY! M FFY��•�. V��iiY��sAIA lAllllb RiR- --_ t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts , Title 5 Official Inspection Form ��I' + 4P i�-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 124 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts o �-r Title 5 Official Inspection Form ICI Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Childs St Property Address Leon Michelove Owner Owner's Name information is required for every Centerville MA 02632 9-12-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 No. d�/ Fee Q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTA93LE, MASSACHUSETTS - ftplitation for Disposal 6pstem Construttiun Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components Location Address or Lot No./3'1 Chi! 5 6 7- Owner's Name,Address,and Tel.No. f S o t vc.-3 Assessor's Map/Parcel '2'2C( 2) 13 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. JlcS A Tr 5-09 - lt0"-7/S L �v��nrP P✓�:1� fhJc7 �G5 C 'y��71�5�� Type of Building: Dwelling No.of Bedrooms Lot Size ;?0,1 M sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons 2, Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 30 gpd Design flow provided 3YY, gpd Plan Date 6 7lil Number of sheets Z Revision Date Title Size of Septic Tank 4 X I y t;,V< Type of S.A.S.— 4&. H L. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -NS kC Jj A1e',u) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig Jj Date 7 X Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Oa. 1 —�°�� Date Issued7zl J rk Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTA$LErMASSACHUSETTS Yes ftpYication for Misposal *pstem Construction 3permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.1-3 5 S T Owner's Name,Address,and Tel.No. f st,tt�vcN.J Assessor's Map/Parcel 9 2 C( - Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. J�.xal�s A 113(vw-) Tyr 5-04b"400-7/5 IF/,51Nrr✓/n15 Wv>kS S -�/77-5313 r Type of Building: Dwelling No.of Bedrooms Lot Size 20,1 C0 sq.ft. Garbage Grinder( ) Other Type of Building hws o No.of Persons 21 Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Design flow provided 3`/Y,If gpd Plan Date GL�t 7//1 Number of sheets 2- Revision Date Title -' Size of Septic Tank X/g f//V C, Type of S.A.S. AtC 3 G C _ J Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: . Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal6tem in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si Date 711 Z /' Application Approved by Date 71 W f Application Disapproved by Date for the following reasons i Permit No. --�EJ f, e1-�` Date Issued I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the ✓On-site Sewage Disposal system Constructed( ) Repaired( � Upgraded( ) Abandoned( )by m _S A, Z(aw"i T NC v at (' ] �(�S �j�' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No110/1_101a- dated -7 h L I Installer o A bt wo Tw Designer EN fi)N'C Ir V5 #bedrooms Approved design flow C1 gpd The issuance of this permit shfah not o strued as a guarantee that the system wil 'on d s gned. Date �/ /C� Ins- ---------------- ---------------------------------------------------------------- No. 9/) — ::�"a,-4 Fee /4(� r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS 30isposal 6pstem onstruction permit Permission is hereby granted to Construct( ) Repair(I/) Upgrade( ) Abandon( ) System located at- l 1 7 ( D s 51- t/10ty ✓!!� 1/,0 N kk and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with I, Title 5 and the following local provisions or special conditions. Provided:Construction just be +ciompleted within three years of the date of thi ermit. Date 1 Approve i Town of Barnstable Regulatory Services St, Thomas F. Geiler,Director MRNftAMZ. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: -71 M I i Sewage Permit# go i l ..may Assessor's Map/Parcel Installer&Designer Certification Form Designer: i✓.,�; n¢ra,r.�,� War l"s, Inc . Installer: Address: 1z W. Crb s S e ICA iz-f• Address: C-e1�i—e CV , ,-e MA u ' �Z(� - On t.. /` p -G3_2 ��\ WL was issued a permit to install a (d te) (installer) r septic system at + 132 CVi``Ot_. S r. C ti'f= based on a design drawn by (address) dated (designer) I I I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required) was ' cted and the soils were found satisfactory. HOF4f PETER T. u McENTEE nstal er's Signature) CIVIL ,o No.35109 s (Designer's Signature) (Affix Design re) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:\office forms\desipercertification form.doc Town of Barnstable P# Department of Regulatory Services Public Health.Division Date Z 200 Main Street,Hyannis MA 02601 M!a r Date Scheduled Time Fee Pd. O Soil Suitability Assessment for Sewage Disposal . 1—e-C Performed B C- FK Y' Witnessed By: LOCATION& GENERAL INFORMATION Location Address / 3-7 C'h '1 0 3 _ .-- Owner's Name C�vt ✓Y I L( Address Assessor's Ma el 3 P : Engineer's Name )9ek,/mc-F-4e-t_e E NEW CONSTRUCTION REPAIR x Telephone# . e 3-'73�7-4�7�S' � Land Use '4244,osC�+a� l Slopes(%j = Surface Stones Distances from: Open Water Body ::�?2_a D ft Possible Wet Area."71 ft Drinking Water Well Drainage Way ft Property Line I Z+� ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands?n proximity to holes) _4 I - � 9' i . Viz - - s ecL t -�-k r„r-e—w4­1 Parent material(geologic) VJ�� Depth to Bedrock Depth to Groundwater. Standing Water in Hole: G y !� Weeping from Pit Face Estimated Seasonal High Groundwater 2✓ DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: - __ in, Depth to soil mottles: In, Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well.# Reading Date:__-_____- Index Well level � Adj,factor,,,,,ga,..a_ Adj-.Groundwater level PERCOLATION TEST Ditto Tlme.� Observation Hole# Time at 9" 3 zy 5�c ,5 Depth of Pero Tlme at 6" Start Pre-soak Time® Time(9"-611) End Pre-soak Rate MinJlnch Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(Y/N) . Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100.' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTlWERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones;Boulders. Consist v lon`t l� . DEEP OBSERVATION HOLE LOG Hole# Z— Depth from ,., Soil Horizon . - Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,.Boulders. Cons'stency.% s 3 z. E �A, 5ih-j 2,57Y 76 ��—n DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munselq Mottling (Structure,Stones,Boulders. Consistency, Gruel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Col or Soil Other Surface(in.) (USDA) (Mansell) ',Mottling (Structure,`StoneslBoulders. nsi Flood Insurance Rate Ma Above 500 year flood boundary No_ Yes Within 500 year koc:dart' No'z 5h Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at-least four feat of naturally occurring pervl material exist in all areas observed throughout the area proposed for the soil absorption system? r If not,what is the depth of naturally occurring pervious material? Certification I certify that on << < (date)I have passed the soil evaluator examination approved by the tion and that the above analysis was performed by me consistent with Department of Bnvironmental Protec the required training,expertise and experience described in 10 CMR 15.017. Signature `Zl Date g Qi\SEFTIWBRCFORM.DOC w* \4 oFtKEr, Town of Barnstable Barnstable AAmedcaNy Regulatory Services Department • IlARNSTA6LE, 9 MASS. $i63q. Public Health Division �' m Qj �� ArfaM a, 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.GeilerLeach pit is only3f rundwagter,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 5347 June 14, 2011 Mr&Mrs Joseph D. Sullivan 137 Childs Street Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 137 Cbilds Street, Centerville, MA was last inspected on 5/11/2011 by Shawn McElroy a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. • Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow.. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health j, Commonwealth of Massachusetts T ' - F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information_ 1. Inspector: I l� Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this ad6Ekss and tozL the o . information reported below is true, accurate and complete as of the time of the�*ction. i1"ie ins ction was performed based on my training and experience iii the proper-function and .M.,Ointenan(�Ezof o Ite sewage disposal systems. I am a DEP approved system inspector pursuant' o Section 135.34"af Title 5(310 CM 15.000).The system: a ❑ Passes ❑ Conditionally Passes ® Falls N ❑ Needs Further Evaluation by the Local Approving Authority \.n i» c:> 5-15-11 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 D-EP.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. I / V t5ins•11/10 Tttle 5 Official Inspection Form:Subsurface Sewage Disposal Svtern-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the'Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 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 wM 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) 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 El 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•11/10 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 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ . The system has.a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged 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 '/day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion`of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet_of a surface drinking water supply ❑ ❑ V. the system is within 200 feet of a tributary to a surface drinking water supply E] 0 the system is located rn.: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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M y 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? El Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 5-2011 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.): R 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•11/10 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped 3yrs ago 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) (f 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 inspectiony y y p of the I/A system b system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 1972 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36' feet Material of construction: ®cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 30"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age:.: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 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 20" Scum thickness 3" 5., Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of.leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 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 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction:' ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: ' Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy-attached? ❑ Yes ❑ No t5ins•11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in workingorder: Yes No ❑ ❑ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is Centerville MA 02632 5-11-11 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal r ❑ leaching cNarribers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was filled beyond capacity at inspection. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): s 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �C, O C a ay' OP t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Vol u ntary*Assessments ^M 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope r ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Childs St Property Address Joe Sullivan Owner Owner's Name information is required for every Centerville MA 02632 5-11-11 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COM%10\NVEALTH OF IVIASSACHUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENN'IRONMENTAL PR T TION� f OBE WINTER STREET. BOSTON. >•tA O'lUS 61?-_'9.-5 W'ILLIAM F.W'ELD � ll'yo9tisf 199 TRUD CO?T Govemc - T blF ;retar% ARGEO PAUL CELLUCCI 4P '4aTH .STRUHS Lt.Governor SUBSURFACE SEWALE DISPOSAL SYSTEM INSPECTION FORM Z Commissioner PART A +y CERTIFICATION i C \ ����. Address of Owner: Sip ' Property Address: � S S`T� Csta>�`�-v a V►'0- C�dv�.� �• �- Date of Inspection: "(IJIOkckl (If different) Name of Inspector: 1 am a DEP approved system inspector pursuant to tion 15.340 of Title 5 (310 CMR 15.000) Company Name: C, eb�°V I��JCahl 4U�*u Mailing Address: 6 L\ e� Telephone Number: igOb- u=—I CERTIFICATION STATEMEIsT I certify that I have personall\ inspected the sev`age disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspeo,o7.. The inspection was penormed based on my training and experience in the proper function and maintenance of on-site sewage disposa; systems. The system: Passes Conditionally Passes Neeo� Further Evaluation By the Local Approving AuthoriN _ Fa:!s Inspector's Signature:LW Date: \0 The System Inspector shal' 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 o, ha; 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: _ 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: 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, 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 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. (rov:sed 04/25/97) page 1 of 30 DEP on the woad Wooe Wen htta./Awww magnet state.ma.us/oec 0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Q / CERTIFICATION (continued) Property Address: ) G `.�'`'t cis S I ��,� (—Q.�.t�* de Owner. Date of Inspection: ! g It a , 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 pipets).or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the BoardkofiHealth). Describe observations: broken pipe(s) are replaced obstruction is removed f ' distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). -The system will pass inspection if(with approval of the Board of Health): ....... broken pipe(si are replaces obstruction is removed 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 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 prn� is within 50 feet of a surface water Cesspool or pri%, 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 I of a public water supnly 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 is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) ._.OTHER ... . (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) / Property Address: ✓t Owner: C,-- Date of Inspection: D) SYSTEM FAILS: " You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The bans 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 overloaded or clogged SAS or cesspool. . Static Mould level in the distribution boa 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 1/2 day flow. Reauired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe's.;. Number o;times pumped_. Anv portion o'the SoO Absorption System, cesspool or privy is below the high groundwater eievation An,, ponion of a cesspool or privy is within 100 feet of a surface water suppiv or tributary to a surface water supply. Any portion of a cesspoo' or privy is within a Zone I of a public well. Am ponion of a cesspool or prn-v is within 50 feet of a private water supph• well Anv ponion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water suppiv well with no acceptable water qualm anaivsis. 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 appiv to large systems in addition to the criteria above: The vvstem serves a facilm 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 a mapped Zone 11 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 04/25/9.7) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: „�3,2 CL� s >9 Ea! 2 t c�e �i 2 Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each-of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. — None P No n f the system components have been pumped for at least two weeks and the system has been receiving normal Into the system recently or nod. Large volumes of water have not been introduced y flow rates during that pe g as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facilit- or d%%eliing was inspected for signs of sewage back-up. — The system does not receive non-sanitary or industrial waste flow. — The site %%as inspected for signs of breakout. — All system components. excluding the Soil .Absorption System, have been located on the site. u — The septic tank manholes %%ere uncovered, opened. and the interior of the septic tank was inspected for condition of —~t baffles or tees, matenai o; construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil .Absorption Sv-stem on the site has been determined based on: The facd.it,, owne� ;ano occupants. if different from owner) were provided with information on the proper maintenance of Sub-Suriace Disposal System. Existing information. Ea. Plan at B.O.H. — Determined in the field :if am of the failure criteria related to Part C is at issue, approximation of distance is unacceptable (15.3023),b'j l (revioad 04/25/97) Page 4 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.ti1 PART C SYSTEM INFORMATION Propem Address: � �✓�?Z C G�.� r�S 0 " : �' Q,c r,{ Lt Owner: �� Date of Inspection: FLOW CONDITIONS RESIDENTIAL- Design fiow.930 o.d.1bedroom for S..A.S Number of bedrooms. O3 Number o.current residents: O j Garbage g,, der (yes or nw—ND Laundry co—ected to system (yes or no). Ig Seasonal use Ives or no:: , Water meter readings, if available (last two Q1 year usage tgpd): Sump Pump (ves or no):__t_jo Last date of occupant\- - - COMMERCI AUI NDUSTRIAL• Type of establishment. Design fio%% ¢alionslda% Grease trap present. noes or no` Industnal \baste Holding Tani; present. Ives or no_ Npn-sanrtarn waste discnarged to the Tale 5 system ;ves or no_ \later meter readings. if available Las:(late of o tupa^c' OTHER: .Describe Last oate of occuoanc% GENERAL INFORMATION. PUMPING RECORDS and source of information IVC(f(� PI1t;V�A°(� Itj &I► 4a_s r c�;r,,rv,,r n1 � � ,.�D�r��,n� % xhn41rOCr System pumped as part of rnspectiO cues or no:,&JO If ves, volume pumped ¢allons Reason for pumping - TYPE OF SYSTEM K_ Septic tank/dTsrrbtm�Jsoil absorption system Single cesspool Overflow cesspool Pmo). 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: Sewage odors detected when arriving at the site: (yes or no) 1 Q (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION' FORM PART C ' SYSTEM INFORMATION (continued) 2 / Property Address: '- j 7 C X.,i,/s �� t��d.��G-c l At Owner: L= - 5 e�ZF -- Date of Inspection: BUILDING SEWER: (locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction Ire Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: t�jS (locate on site pl n Depth below grade . t 11 Material o' construction: —Xconcrete _meta' _Fiberglass _Polyethylene _other(explain! If tank 15 metal, list age _ Is age confirmed b•. Ce^:ficate of Compliance _(Yes;No Dimensions ill! Ci P9' Sludge depth _ 1i Dtslance from top of sludge to bonom of outlet tee or ba^e Scum thickness: Distance from top of scum to top of outlet tee or ba^a _ Distance from bonorn of scum to boron of outlet tee or bar.e.�0'� How dimensions were determined 1lud. Comments: (recommendation for pumping, condition of tniet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity evidence of leakage. etc.( 9C 1 GREASE TRAP: (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: Comments: (recommendation for pumping, condition of islet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural Integrity, evidence of leakage, etc.; (revised 04/25;9N Page 6 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �..2ot roc� I Q Owner: � _ � 4 ' Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible, excav jon 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,_ -- Alternative system Came of Technologv. Comments: mote condition of soil, signs of hydraulic failure, level of pond mg,condition vegetation, etc.) O N CESSPOOLS: _ (locate on site plan- Number and con•figura:ior, Depth-top of liquid to inlet Inver, Depth of solids laver: Depth of scum layer. Dimensions of cesspool: Materials of construction Indication of groundwater inflow (cesspool must tie pumpeC as par, of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION (continued) Propert% Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: '?ank 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: Capacm gallons Desig,% flov%. galions,da Alarm level Alarm in working order _ Yes: _ No Date of previous pumping Comments: (condition of inlet tee, condition w alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site pian. Depth o! liquid level above outie: ime i Comments: incite if level and distribution is eaua!, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN-FORMATION (continued) Propert% Address: 1 ? � ', s J `Q t c f tic CAd{G1 Q Owner: � Date of Inspectio 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) . z 3 a � L9 (revised 04!25!97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ' Property Address: Owner: Date of tnvpectis Depth to Groundwater� Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting properly, observation hole, basement sump etc.) Determine it from local conditions Chec� with local Board o: healtn Checi FE.MA Maps Check pumping records Check local excavators, installers Use L SCS Data f• Describe in you• own %%orris hog+ \o;; established the High Groundwater Elevation. (Must be completed; -IvP© Of— ¢od"d cc-h-VA-nave 4 R's i lraviaad 04;2515'. Page 10 of 10 TO OF BA RNSTABLE: LOCATIO . 7 C�i S f SEWi�GLF VILLAGE. Ce AUsEsson's MAP&LOT-----,—, INSTAJ,pR;S NAB l*PHONE NO m TANK CAPACITY U: l I ' CM151PA-co l'I"K (type) -bUJLDBR Olt OWNER x PBRR�J'tDATE. E......: _..�. .�. ._._ ,..,....�.: �S�Catia��9e�t�n��$cEv�eeta t3�or �Maxlmum A.clJwstGc(G��auirtlwatei Tahts to�e Entt�rn o�LuaGhln�R�u�l�ty. ...- „,.�.,r }RU �iI' r supply wa told L hing 1?a A .(7f y veils extsi w�t�,n BAR feet oi;laitstau�factitty) ,_.,._„ �ci�t Edge o' 'fN�lgm _und Leacblu�P�c�llty{�uny:wetlnncls exasE wld3la 300 fe -v leda f��uci � t 1. ")A of _ ' , 0 0 L 0 0 o 4� >/2-!q� TOWN OF BARNSTABLE LOCATION 7 CA :IW� S_ SEWAGE # VII:LAGE �`I�ely�r/�� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO- SEPTIC TANK CAPACITY LEACI-UNG FACILITY: (type) 1 4 (size) lam G NO.OF BEDROOMS bUILDFR OR OWNER It 1 PERMITDATE: 'COMPLIANCE DATE. Separation Distance Between tbe: 1 Maximum Adjusted Groundwater Table to the Botiom of Leaching Facility Feet ji Private Water Supply Well and Leaching Facility (if any wells exist on site or within 200 feet of leachink facility) Feet_ Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fa ' 'ty) meet Furnished by( )LuW h = fr•r 5,. ._� get Y ; i \S v D C a g" 6-0- 37 ' TOWN OF BARNSTABLE LOCATION J3 1 c��� sr SEWAGE# '2(`)r 1 —;L VILLAGE r*Nt fit'VJ)V ASSESSOR'S MAP&PARCEL ;Z2tJ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) Atc- 3G t4 C ff';XC7 (size) 60° fleW 4 NO.OF BEDROOMS t `OWNER o PERMIT DATE: 7111,11➢ COMPLIANCE DATE: y Separation Distance Between the: O{ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility C 4c& % Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY d 'T 4 4- 73 �. "RGck '� F t LEGEND EXISTING LEACH PIT IEL.=101.17 ENCHMARK SET N �D x 100.98 EXISTING SPOT GRADE TO BE PUMPED, FILLED WITH SAND & ABANDONED tside Cor./Conc. Ldg. 1 WEST Mg1N -- gg -- EXISTING CONTOUR (Assumed)- :W. N 0.H - OVERHEAD WIRES EXISTING SEPTIC TANK ' S W EXISTING WATER SERVICE (TO REMAIN) sc sc TOP OF TANK, EL.= 98.24t � ' W Pine G EXISTING GAS SERVICE INV.(OUT) = 96.91E S 7g�19 40 ;�o° x 104.18 Locus u�aa a [� TEST PIT 210.00' $ BENCHMARK 102,10 �/ 10tt ion CaMotta G�p�o'o9`Je�S o ( � ��� �? Q 3 W " aid awn i i �� '+f101,86 �• 94.87 LOCUS MAP 02.46 NOT TO SCALE 6 103 100,87 x � C .00 � GENERAL NOTES: i o{ 1\0 102,90 -b' '�� 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL i 101.81 C� �� '`f BOARD OF HEALTH AND THE DESIGN ENGINEER. edge i 103.55 A; / 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 10 .42 OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 010 i \ C LOCAL RULES AND REGULATIONS. PORCH GARAGE 103,1 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 12' i I 102.79 DESIGN ENGINEER. BM • .1 .103.21 103.20 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING L.J [ Q 0.57 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ��i97.1 \\ 100`6..4O EXISTING PAVED ENGINEER BEFORE CONSTRUCTION CONTINUES. �i \ % / HOUSE #137) DRIVEWAY 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. �t I ,�� T.O.F.=103.34E 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 102.20 {�I I N THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF can N 1W)j. I I •` , ��+ 2.42 ___10 2 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.P 0 o Q,:Io1 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 0) :Ni coO / �� 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. :61-4-20 99.60 + 10 6/ �� LAMP / o� 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS r*I :�tlSbIKE ✓- Q AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE TP-1 i 9''7 1 \ i' 101.44 �j , DIRECTED BY THE APPROVING AUTHORITIES. �� \ \ V 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY +I 9V-.96 \� `\ (LOT 62) a� THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING TP-2 :0 \\ APN 229-113 ^� 0� `� CONSTRUCTION. CL LJ \\ X.• \ ;� /, 1 1. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS �, I I \� 20,100tSF o I \ I 10'0,46 ' IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND �\ �.\ �oApr 0 i REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). �\ ___ o} CB/dh 0aA S 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE 6.30 100,8$ O% �F INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. 100,53 � MAss9 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND "Isle, -� ��F CyG IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. °f- .. .edge of lawn ' ' +'.. . o PETER T. PLAN REVISION - 7/12/1 1 ` 96,74 •`� 56.02 0 McENTEE - 1. CORRECT CREDIT AREA PER LINEAL FOOT FOR Arc36HC. I� \\�� 75.62' \� � � � o CIVIL �' + 94,87 .�� � "_.____ ���,�� No. 351�0 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 6 N 86*43 50 W stdc(rode fence ' °�F EG/STEM 137 CHILDS STREET, CENTERVILLE, MA 99,90 Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO. SULLIVAN, JOSEPH D & RITA M Engineering Works, Inc. 1"=20' P.T.M. 175-11 Private Dri ve wa ! 137 CHILDS STREET 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED y CENTERVILLE, MA 02632 /1 1 P.T.M. 1 SHEET(508) 477-5313 6/27 Of 2 4 1 I NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL.94.3 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D—BOX PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT INSTALL INSPECTION PORT OVER END UNIT PORCH pF T.O.F. OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE EXISTING F.G. EL.=100.6f F.G. EL: 97.3t F.G. EL: 97.3(MAX.) MAINTAIN 2% GRADE (MIN.) OVER S.A.S. i L 2' L = 5'(MAX) <Jp ® S=1% (MIN.) ® S=1% (MIN.) INSPECTION PORT 4"SCH40 PVC 4"SCH40 PVC C? it RI 1o^I ia.. a" 10.75" TO D� EXISTING 48" LIQUID INVERT LEVEL INV.=93.90 GAS�BAFFLE INV.=94.12 PROPOSED INV.=93.95 1 TRENCH W/12 ADS Arc 36HC UNITS ® 5'/UNIT = 60' = 46.2' 60 INV.=96.91 t D—BOX ' P, EXISTING SOIL I P EXISTING SEPTIC TANK NITS MUST BE STAMPED H o20 E, S.A.S.e ESTABLISH VEGETATIVE COVER LAYOUT BACKFILL WITH CLEAN NATIVE OR NOTES: PERC SAND TO TOP of CHAMBERS F2" 15.5' 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE ^' INVERTS, PRIOR TO INSTALLATION. TOP ELEV.--94.33 2) D—BOX SHALL BE SET LEVEL AND TRUE TO INV. ELEV.=93.90 1 12" GRADE ON A MECHANICALLY COMPACTED SIX "' 15.5" INCH CRUSHED STONE BASE AS SPECIFIED IN BOTTOM ELEV.=93.00 6 310 CMR 15.221(2). 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' MIN. ABOVE BOTTOM OF 0 ` 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE T.P. EXCAVATION OR G.W. 3 OUTLETS — H-10 LOADING' 2" AS MANUFACTURED BY TUF—TITE, ZABEL OR EQUAL. EXISTING SUITABLE OX NO G.W., EL=86.0 s MATERIAL D—B B SEPTIC SYSTEM PROFILE ADS Arc 36HC UNITS TO BE INSTALLED IN TRENCH CONFIGURATION WITH NO STONE 63.25" N.T.S. TYPICAL SECTION ts" F . - - - - - - - DESIGN CRITERIA SOIL LOG 34.5" DATE: JUNE 20, 2011 (REF#13,320) NUMBER OF BEDROOMS: 3 BEDROOMS SOIL EVALUATOR: PETER McENTEE PE SOIL TEXTURAL CLASS: CLASS I WITNESS: DONALD DESMARAIS R.S. HEALTH AGENT TOP VIEW DESIGN PERCOLATION RATE: <2 MIN/IN ELEV. TP- 1 DEPTH ELEy. TP-2 DEPTH 60" DAILY FLOW: 330 G.P.D. 97.0 FILL 0 97.0 FILL O END CAP END CAP DESIGN FLOW: 330 G.P.D. 96.0 A 12" 96.0 A 12" FRONT VIEW SIDE VIEW E GARBAGE GRINDER: NO SANDY LOAM SANDY LOAM REAR/TOP CAP TOP VIEW 10YR 4/2 10YR 4/2 95'5 B 18 95'S B 18" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW LEACHING AREA REQUIRED: (330) = 445.9 S.F. TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY 74 SANDY LOAM SANDY LOAM DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. 10YR 5/8 10YR 5/8 4640 TRUEMAN BLVD EXISTING SEPTIC TANK: 1000 GALLON CAPACITY 94.0 36" ;i, 94.2 34° HILLIARD, OHIO 43026 Are 36HC DETAIL PROPOSED D—BOX:: 1 INLET, 3 OUTLETS, H-10 RATED C1 PE ` C1 EMS UNITS MUST BE STAMPED H-20 36'/4/48" ADVANCED DRAINAGE SYSTEMS. INC. SOIL ABSORPTION SYSTEM MED. SAND MED. SAND PROPOSED SEPTIC SYSTEM UPGRADE PLAN 2.5Y 6/4 2.5Y 6/4 USE ADS Arc 36HC UNITS IN STONELESS TRENCH CONFIGURATION 10% GRAVEL 10% GRAVEL 137 CHILDS STREET, CENTERVILLE, MA (GENERAL USE APPROVAL FOR 7.79 SF/LF IN TRENCH CONFIGURATION) Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 12 UNITS = 60.0 FT ` Engineering by: SCALE DRAWN JOB. NO. 86.0 132" i 86.0 132" 60' x 7.79 SF LF = 467.4 SF Engineering Works, Inc. NTS P.T.M. 175-11 / F?ERC RATE <2 MIN/IN. ('C HORIZON) 9 9 12 West Crossfield Road, Forestdale, MA 02644 DATE DESIGN FLOW PROVIDED: 0.74(467.4 S.F.) = 345.9 G.P.D. NO GROUNDWATER ENCOUNTERED (508) 477-5313 6/27/1 1 CHECKED SHEET �.