HomeMy WebLinkAbout0019 CONANT LANE - Health 19 Conant Lane, Centerville
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No.24530 '4tsrcc,
HASTINON-MN
KO. d D ® 'V_G✓ .' Fee (Ob.
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THE COMMONWEALTH OF ACHUSETTS Entered in computer: V
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
RpIttatton for Mt!5 A *pgtem conotructtou Vermtt
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address 9 CO Owner's Name,Address,and Tel.Nor um
Assessor's Map/Parcel
. p
Installer's me,Address,and Tel.No f ` e is N Address-and Tel.N
Type of Building:
Dwelling No.of Bedrooms '� Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ' ® gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
�0�� � �f Size of Septic Tank Type of S.A.S.y �.
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 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 Pealth.
Signed Date o c15
Application Approved by L. Date (�
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
Fee (06,
computer:
comp d i Entered THE COMMONWEALTH OF MASSACHUSETTS, `" ,
. PUBLIC HEALTH-DIVISION - TOWN OF BARNSTABLE MASSACHUSETTS Yes
� : 1
ZIppYtcation for Mtgpogfal *potent Congtruction Permit
Application for a Permit to Construct O Repair(Xupgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. CaJ[� /V/ Owner's Name,Address,and Tel.No�,& 6W11&
Assessor's Map/Parcel
-
Installer's Name,Address,and Tel.No. ���f..+�� ,� Designer's Name,Address and Tel.No
Type of Buildings
t L /
Dwelling /No.of Bedrooms L Lot Size y sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required)�y� gpd Design flow provided y �, Z gpd
Plan Date Number of sheets Revi nost Date
Title
Size of Septic Tank j/J�Q Type of S.A.S. �� n
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 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
�jBoard of Health. -
Signed _/ Date
Application Approved by 4/ Date
Application Disapproved by: Date
for the following reasons
Permit No. n Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewa a Disposal-System Constructed ( ) Repaired Upgraded ( )
Abandoned( )by i 7
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal,SSystem Construction Permit No. /(} —� I S dated
Installer Designer
#bedrooms N - Approved Be�st n flo: ) gpd
The issuance of this �ermit shall not be construed as a guarantee that the system h� l fu cYion as d igned.((.
Date '7io Inspector � tAI 1�r
---------------.---•—.------ v .
No. Fee .—�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi!6 pogal *pwm Construction Permit
Permission is hereby gran to Construct ( ) Repair ( Li) Upgrade ( ) Abandon ( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided:
Construction must be completed within three years of the date of this permit. /n
Date U.' ! ' Approved by C
I f ,
APPLICANT: —
of-fp--K Mekle/-
ADDRESS:
DESIGN FLOW: gpd
REVIEWED BV: DATE:
N/A OK NO
Le al 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)] X
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)] X
System located totally on lot served [310 CMR 15.405(1)(a) for
.upgrades]- i not, a variance is required [310 CMR 15.412(4)] X
Location of impervious surfaces (driveways,parking areas etc.)
[310 CMR I5.220(4)(d)] X
Location all buildings existing and proposed 310 CMR
15.220(4)(c)] x
Location and dimensions of system components and reserve areas
[310 CMR 15.220(4)(e)] k
RExisting
ulations [310 CMR 15.220(4)(f)]
ow
tank ca aci re wired and provided) X
absorption system (required and provided)
r s stem designed for arba e grinder
[310 CMR 15.220(4)( )]
ro osed contours [310 CMR 15.220(4)( )]
ocaonan log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)] k
Names of soil evaluator and BOH representative [310 CMR
15.220(4)(h) and (i)] X
Location and date of percolation tests (performed at proper
elevation?) [310 CMR 15.220(4)(i)]
erco a ion test results matc loading rate?-[310 CMR 15.242] k
Certification statement b Soil Evaluator[310 CMR 15.220(4)0)]
bserved and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4)(n)] �(
Location of every water supply,public and private, [310 CMR
15.220(4)(k)] X.
Address Corm T W C?wkr1/1 Sheet I of 7
f
f
within 400 feet of the proposed system location in the case
of surface water supplies and gra.yel packed public water supply X
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)] X
Water lines-and dthe'fAibsutface utilities located [310 CMR
15.220(4)(m) if water line cross see 310 CMR 15.211(1)[1]) X
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 of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)] x
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)] X
Test hole adequate to demonstrate four feet of suitable material?
310 CMR 15.103(4)] X
Test Holes adequate to cogfu-m adequate groundwater separation?
[310 CMR 15.103(3)] X
Benchmark within 50-75' of system [310 CMR 15.220(4)( )]
Materials specifications noted? [various sections of 310 CMR
15.000]
System components not> 36" deep(unless Local Upgrade X
Approval or LUA.requested)f310 CMR 15.405(1(b)
Address 1 (htj"T ()��e ce-14kewlte Sheet 2 of 7
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 CMR
15.227(6)] X
Outlet tee with gas baffle or approved filter[310 CMR. 15.227(4)]
Note regarding installation on stable compacted base [310 CMR
15.228(1)] X
Separation between inlet and Outlet tees (no less than liquid
depth) 310 CMR 15.227(2) ' - x
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5)) or permitted for
upgrades under LUA [310 CMJZ 15.405(1)(k)] X
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1) and 310
CMR 15.232(3)(0] X
Three access covers (inlet and outlet must be 20" or greater) -
middle access at least 8" (b 7/07) [310 CMR 15.228(2)] X
Access to within 6 "'of grade - one port for systerris<1000gpd,
two fors stems>1000 gpd 310 CMR 15.228(2) X
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)] X
H-20 Where appropriate? [310 CMR 15.226(3)]
Setbacks from resources [310 CMR 15.211 _
Required when other than single-family dwelling or flow>1000
d [310 CMR 15.223(1)(b)] �C
First compartment 200% daily flow; Second compartment 100%
daily flow 310 CMR 15.224(2) and 3)]
"U"pipe through or over baffle, outlet of each compartment with
as baffle or approved filter[310 CMR 15.224(4)]
Address �� lmvT l �G�'I f G�'1/I4 Sheet 3 of 7
Located at leastten feet from any water line? [310 CMR
15.222(2)] X
Disposal piping at least 18"below water line (when water and
sewer cross, see 310,CMR 15.211(1)[1]) X
Cleanouts required/provided ? [310 CMR 15.222(8)] X
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 15.222(6)] x
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) 310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] x
Siphonproblem/ leachfield below pump chamber)
rEndca s or vent manifolds ecified?
e and orientation of discharge holes specified? (not smaller
n 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310R 15.252(2)(h)]
Materials specified (310 CMR 15.251(5) specifies various pipe
types allowed)
7Stable compacted base [310 CMR 15.22](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)] X
Riser if deeper than 9" [310 CMR 15.232(3)( ] X
Inside minimum dimension 12" [310 CMR 15.232(2)(b)]
Minimum.sum 6" [310 CMR15.232(3)(e)]
Watertight cover if<2000gpd); waterproof manhole if>2000gpd
[310 CMR 15.232(3)(d)] x
Capacity(emergency storage above working=design flow)? [310
CMR 231(2)]
Proper setbacks [310 CMR 15.211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20"MUST BE
TO GRADE [310 CMR 15.231(5)]
piping,Service componen;s accessible, (not tee deep,with
disconnects accessible)
Alarm floats - alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-laA—
m ode. [310 CMR 15.231(6) and (8)]
Stable Corn acted Base [310 CMR 15.221(2)]
Buoyancy calculations needed ?Provided? [310 CMR 15.221
Address i s (0 4 ne) (e i/sir wllr Sheet 4 of 7
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(1)
Required separation 4o oundwater? 310 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)] )C
Breakout requirements met?(No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and x
Guidance Document]
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)] �(
Each structure with one inspection manhole (if>2000 gpd must
be to'grade) 310 CMR 15.253(2)]
'Aggregate I'minimum-4'maximum. [310 CMR 15.253(1)(b)]
2'sidewall credit maximum [310 CMR 15.253(1)(a)]
In bed configuration, inlet every 40 s .ft. [310 CMR 15.253(6)]
Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)]
100 feet-maximum length [310 CMR 15.251 1) a
Minimum separation 2x effective depth or width whichever
eater(3x if reserve between trenches) [310 CMR 251 1)(d ]
Situated along contours [310 CMR 15.251(2)]
Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document]'
minimum 2 distribution lines [310 CMR 15.252(2)(a)]
Maximums aration between lines 6' 310 CM R15.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)]
Aggregate depth below discharge pipes 6" minimum, 12"
maximum. [310 CMR 15.252(2)( )]
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
Pressure Dosed System ? Provided pump and piping
calculations as re uired,. 310 CMR 15:220(4)(r)] �(
Pressure dosing required on all systems>2000gpd or alternative
systems unerne+dial approval [310 CMR 15.254(2)and I%A
Remedial Use Approvals]
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
(>2000 dgood to note on plan [310 CMR 15.254(2)(d)]
Construction in fill -Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)?
Im ervious barrier and/or retaining wall ? [Guidance Document] k
IImpervious barrier installation must be supervised by
designer [310 CMR 15.255(2)(b)] k
lRetaining wall must be designed by Registered Professional X
Engineer [310 CMR 15255(2)(a)]
Side slope not exceed 3:1 ? 310 CMR 15255(2)] X
Breakout requirements met? [310 CMR 15.252(2) and
Guidance Document] X
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [3,10 CMR 15.255 (2)(e)]
Check DEP Approval letters for credits and design conditions X
If used with pressure dosing do not allow pressure discharge X
to scour soil interface
Was DEP Approval Letter provided and/or have you a
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for
e etual maintenance ncayreement?
An alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Has ap licant submitted a co y of a maintenance
Are the variances listed on the plan ? [310 CMR 15.220
(4)( )] X
RLS Stamp necessary on plan if a component 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 l vA Sheet 6 of 7
Is the system in a Designated Nitrogen Sensitive Area(Zone I1 for
a public supply well)? [310 CMR 15.214, 310 CMR 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 X
15.216(1)]
Pumping to septic tank? [310 CMR 15.229
Shared System [310 CMR 15.290
Address (a'wf— laile l Gl o Sheet 7 of 7
1 - �l
Town of Barnstable
flpWE Regulatory Services
Thomas F. Geiler, Director
' IARNSfAHLE,
Public Health Division
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: n Sewage Permit# /C Assessor's Map\Parcel 17 0sx
Designer: V V"l ei✓ Installer: 6 rICG Z"i_I eG
Address: Address:
On -,<_s issued a permit to install a
( ate) G / (installer
septic system at 1J CJi,: based on a design drawn by
� �(/� (address)� " ` e►`-rn dated
(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 andj'or septic tank.
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.
~.• ����� OF MAss9
DARWY M
/�k(Installer's Signature) " No: 1140
REGISTE��
SOITA��I'� �( )(to
(Designer's-Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BA STABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
CONIPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU
Q: Health/Septic/Designer Certification Form 3-26-04doc
- TOWN OF BARNSTABLE
LOCATION ®/T/�/(/y`" �SEWAGE#
VILLAGE 41-'l ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.-T1��,�/%�fr_�
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)/ �� ,�i(p/-► (size)
NO.OF BEDROOMS
OWNER - &
PERMIT DATE: ® COMPLIANCE DATE: d
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) or Feet
FURNISHED BY
� �
,.
(�
.�,f
� �� ���
� �� � w � —�
� w��
� � p i �'
� P 9 �
� w � � � � � ����
� � �:� � � � e �.�
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
.Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent %Gravel
D''- a a,� R 3lv �✓
7'=
cd 44d Z• 7/
knd 2.5'Y
DEEP OBSERVATION HOLE LOG Hole# Z
Depth from Soil Horizoh Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling. (Structure,Stones,Boulders.
Consistent %Gravel)
2.5 0
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Cons istencv.%Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consisten ra I
.t
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes _
Within 500 year boundary No—7 Yes e.
Within 100 year flood boundary No ✓ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious aterial exist.in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on ( � / I (date)I have passed the soil evaluator examination approved by the
Department of nviro mental Protection and that the above analysis was performed by me consistent with
the required t7int g , pertise a experience described in 3:10 CMR 15.017.
Signature Date 617
w
Q:X.SEPTICVERCFORM.DOC
T wn of B' -n
Departmentstable. P 4t r
oft
of Regulatory Services
Health Division
Date_
2
Public Her o
�,.,,g�, : �
KAM e$ 200 Main Street,Hyannis MA 02601
rf0 µl'I
b �� Fee Pd.
Date Scheduled I Time
I ,
Soil ,suitability Assess�ner�t for SSgf� isposaI�G(,Y Y t^ /"t tL Witnessed By: .. �. �
Performed By: ;
i i
LOCATION & GENERAL'INFORll�[ATGION 1, Assoc.
Location AddressIq �N>� •T' LE Owner's Name 1 �(AT.
Box Aso 043
Address ktJ M TY 7S 26 -�
�nITE2V l U,G�Innz<1 � _ D
Assessor's Map/Parcel: 173/0� • i Engineer's Name I)A*AtA AA"er K
NEW CONSIRU('1710N REPAIR '` Tel ephone# 5a 3 6 L 29ZZ
Land Use Ic 1 "I ` Slopes'(9o)" C) ( ' Surface Stones e
a
Distances from: Open Water Body y�0 ft Possible Wet Area dU ft. Drinking Water Well ft
i
5 j ()() 0 ft Other ft
Drainage Way ft Property Line
I
SKETCH:(Street name,dimensions'of 104 exact locations of test holes&pert tests,locate wetlands in proximity to holes)
/ I_
W I o 1Q _
ZIf
Q a I \ „ u
ZQ+ \ 1
z z Z� 1
~I J LL7 \ 1 I
wl ~ J wN \ 11
�I V) W O \ \ 1 I
w l 0- II \ 1 I
>I X O� \ \ 1
al i W r w
d
O I o 1 \\ IN
W I � 3NI'1 ?331VM
------------------
I � �
OJ VM3/IJa a3nvd
c.
---- QO 1 I .w
-----
If
i I I
--------
I t PO
N O r r r r 6
F N � y r
m
Parent material(geologic) CJ t�'JS� I Depth to Bedrock .•--r---
Water in Hole•
I Weeping from Pit Pace A
Depth to Cnoundwaker. Standing W ' I
Estimated Seasonali1iigh Groundwater Q j
D TERIVIINATION FOR SEASONAL HIGH WATER TABLE
Method Used: i ! in. Depth to Sall mottles: in,
Depth Cjbserved standing in obs.hole: arountiwnter Adjustment
Depth toiweeping from side of obs.hole: -77�� A_ .ACtOr,,,,._.,-� Adj.OroundwaterLeVel,.,,e
Index Well# Reading Date: index Well level - di
I
PERCOLATION TEST D$tp.��.-a Time--.
Observation Time at 9"
Hole#
Time at G" ....-•-----
Depth of Pere -�J
l { Of& Time(9"-6") ---
Start Pre-soak Time.C@ -
End Pre-soak
v ZM- I
Rate MinJinch
Additional Testing Needed(YIN)
Site Suitability Assessment: Site Passed_—
Site Failed:
Original:,Public i e�lth Division
Observation Hole Data To Be Completed on Back
>' 'thin 1 00' of wetland,you must first notify the
*x�x� n test is to be conducted within
ercola lb
If p ti . , , beginning.
Barnstable Conservation Division at least one (1) week prior to
i
o�t►�T�
Town of Barnstable Barnstable
ti
Regulatory Services Department
BA ANYCABLE, '
�\ A i639. Public Health Division
�0 z
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 70081830000205009434 +
5/7/2010
Today Real Estate
c/o David Holt
1533 Falmouth Road
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 19 Conant Lane, Centerville MA was last inspected on
May 3, 2010, 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.
• Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS.
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 HE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
o1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
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.
A. General Information f� l
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation the Local Approving Authority
5-3-10
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.
t5insp official document•03/08 Title 5 Official inspection Form:Subsurface Sewage Disposal stem-P'e 1lof P 9 P Y 9
l
I I A
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 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.
Answer yes, no or not determined (Y, N, ND)in the ❑ 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.
ND Explain:
❑ 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
❑ obstruction is removed
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont_):
❑ distribution box is leveled or replaced
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
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
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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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
❑ ® 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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
I '
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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-
10,006gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either`yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of'a surface drinking water supply
❑ , ❑ . the,system is within 200 feet of a tributary,to a surface drinking water supply
Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection
El
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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
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 CM 15.302(5)]
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
i
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'M ( 19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440
Number of current residents: 0
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? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 2-10
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203):
Gallons per day(gpd)
1
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:
Last date of occupancy/use: Date
Other(describe):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1978
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade:
24"
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: 18"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 0
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 16"
How were dimensions determined? Tape
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�^M 19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
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.):
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
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):
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
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.
Pump Chamber(locate on site plan):
I
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit has clear signs of hydrolic failure with stain lines above inlet invert.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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 official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
✓ ' � � ^ jar'
( V J
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 15
l
i
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 19 Conant Ln
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 5-3-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Town maps shows groundwater at 20'.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
<.; TOWN OF BARNNSTABLE
(LOCATION
/ "R r► L SEWAGE# --
VII:I,AGE �p GlJ l I ASSESSOR'S MAP&LOT
INSTAL i-ER'S NAME&PHONE NO.
SEPTIC TANK-CAPACFTY
n E��
LEACHING-FACII.ITY:( ) I� � — s (size)
NO.OF'BEDROOMS r
I
BUILDER OR OWNER
i
PERMITDATE: -COMPLIANCE DATF-
b
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom'of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching fhcility) t Feet
Edge of Wetland and Leaching Facility(If any eilands exist
within 300 feet leaching.facility) t� //' �®jL Feet
Furnished by a--rg
1
COMMONWEALTH OF MASSACHUSETTS -to 11 /
7 EXECUTI.VE OFFICE OF ENVIRONMENTAL AF. S e `i
DEPARTMENT OF ENVIRONMENTAL PR CTloO�
o
ONE WINTER STREET, BOSTON, MA 02108 617-292-55 �V
ra OF 8 1997
Lr C070=
DY
WiLL1AM F.WELD � Secretary
ARGEO PAUL CELLUCCI S VDAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
r� / CERTIFICATION {�
Property Address: _1 ,Z ohC�A_ LC-V l? CQA' �`�, t(Z Address of Owner: �,G��ie C�� aaxv—y��Ca S'-
Date of Inspection: I(D — I— 17 (If different)
Name of Inspector: b c �o r S
1 am a DEP approvA system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: k-C -
Mailing Address: O 13ax & Ro 1+�u�.lvi,4•�S
Telephone Number: �� Q (7� �`/
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:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Wiz- y ' Date:
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] S71YSTPASSES:
ave 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.
(revised 04/25/97) Page I of 10
DEP on the World Wide Web: http:Nwww.magnet.state.ma.us/dep
Z�'j Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 cl Cov'ca� "e cze'�cQ
Owner: (iGA-Va_ 1c Lk S-4
Date of Inspection: i o —2L-`j-
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 levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
Cl 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 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 I 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 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: N ck Lo-h\o- c� ex4
Owner:
Date of Inspection: t a -Z Z_l-7
D) SYSTEM FAILS:
You m t indicate ei;r,er "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 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 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 1/2 day flow.
V Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
/ Number of times pumped _.
V Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
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.
El 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:
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 a 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �C� `''h`Ah� �—a.v%Q
Owner: CcLfz c_.oa ink `Criss-�
Date of Inspection: (d—
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 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.
V _ As built plans have been obtained and examined. Note if they are not available with N/A.
v _ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
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)]
it
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: q C h CLhf LcA,z� �-
Owner: C.O-Vq Cad
Date of Inspection: ►o -Z2. 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow:11140 g.p.d./bedroorn for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):
Laundry connected to syste (yes or no):14
Seasonal use (yes or no): 5 2-- &z3-b 9b 3� sa�� 77
Water meter readings, if a fable (last two (2) year usage (gpd): '
Sump Pump(yes or no):
Last date of occupancy: pi
COMMERCIAUI N DUSTRIAL:
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:ha
nformationIA,/l
�'i
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: stallons
Reason for pumping:
TYPE O� STEM
_�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)
I/A Technology etc. Copy of up to date contract?
Other n
APPROXIMATE AGE of all components, date installed (if known) and source of information: ���f5 '*/
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: L—
Owner: C,a Tq-C-O&
Date of Inspection: (o
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: -14 st 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:
(locate on site plan)
tt
Depth below grader
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: ' f
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_ p
Distance from top of scum to top of outlet tee or baffle:_ 4�Ir
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 invest, structural
integrity, evidence of leakage, etc.) '— eT V te ena-
G)IA-1A
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 inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(reviasd 04/2S/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: I S CuhcLy^+ "9-)C--�k qd p'—
Owner: Cwe� C:vdr. �`C�IS�t
Date of Inspection: (v — Z_Z-c�7
TIGHT OR HOLDING TANK: Clank 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: gallons
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:V
(locate on site plan)
Depth of liquid level above outlet invert: i� `''
Comments:
(note if level and distribution is equal, 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.)
(rsvisad 04/25/97) Pago 7 of 10
i
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property dress: z C;L'-� 4:��
Owner: a-k"— C: QiC`,t k<
Date of Inspection: to
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:,
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
tr �► < <�w��� ti��
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
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.)
PRIVY:I )
(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)
Property Address: C1 Co la a,h-- Unot �--
Owner: C - Z C-0& 16 Q.nk'i-"NvUk -,C
Date of Inspection: Lo - Z'2_ -7
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 �h
O
(revised 04/25/97) Page 9 of 10
L �.
l;0 CATION k SEWAGE PERMIT NO.
4571— , 1�
36- 01
IILAGE to
v i
INSTA LLER'S NAME & ADDRESS j
"xf-yiia H/cic Y
7L Ct, ,K/ri�e� 1 .4-*..ti/_
BUILDER OR OWNER
su rFoi-/c /IE�Ft7-r
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 79
r-
�, ,,
1
c
�� '�
I�
1 � � � � '
A
.7� L.�...... Fxs.....a 5
No........... ...
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF ,,HEALTH n �4
_.."W.tl......................OF....�'.!�bP. '?A&41----------------------........----------......... 31//►�'
Apptira#ion for Dhgpoii al Vorkti Tonvarnrtinn Vamit
Application is hereby made for a Permit to Construct r ) or Repair ( ) an Individual Sewage Disposal
System at:
....�Q?�.. � ..oll..9.tJf......................................................... - c._------ �4.-.� .........................................
Location,• Location-.Address �_ or Lot No.
...................... �7v l°� !�.................................•--•---- .... �4°!°.4.t'........../ i9 S 1f7... �..L�S
• Owner Address
....................... --------------------------- ....
nstaller Address
Q Type of Building Size Lot.Ar4.0aQ........Sq. feet
Dwelling—No. of Bedrooms_'!haP........................Expansion Attic ( ) Garbage Grinder OVO)
I OOQ............. No. of ersons.??4E -__--_-- Showers �) — Cafeteria
p,,, Other—Type of Building p ( ( )
Q' Other fixtures ----------------------------
W Design Flow...M ...........s s ..............gallons per person per day. Total daily flow....................;.3..Q..........gallons.
WSeptic Tank—Liquid capacity44W..gallons Length................ Width-------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.........._.........sq. ft.
Seepage Pit No-----------------_- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (✓) Dosing tank ( )
Percolation Test Results Performed by....................................................... ... Date........................................
Test Pit No. 1.......A...minutes per inch Depth of Test Pit... Depth to ground waterAV_ll.4.18
Test Pit No. 2................minutes per inch Depth of Test Pit__-_____--_-_____-_ Depth to ground water........................
.............................................i....---......................................................................................................
O Description of Soil...Q2 ' _ 4e t/. ---------SU •SQ--------------
----------------------------
y���` �yy" /1?E=_o ut-----�/,Ve `50!= � -- - ---- ........... ... . . .
U Nature of Repairs or Alterations—Answer when applicable._----------------------------------------------------------------------------------------------
-----------------------------------••---.....---...------------._....------....-----•-•--...-•----••----......------------------------------------------. ..............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i Ili LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operatiori•until a Certificate of Compliance has been issued by the board of health._
Signed` ......._ � ......�----------------- 1..� _....
/� iC���'$Y ����r Date
Application Approved BY C� to
Date
Application Disapproved for the following reasons:.............................................---------------------------------------------------------.........
........-------------------••----•-•-------------------------------------•------............--------------••----•-•---•----•----•-•------------------•---•--••--------•----•--••---------•-------------
Date
Permit No............................................... 20-7k-
...------. Issued_.-•----•-�----- -------------------------•--------
L -1 -
Date
1
I a.
No....... ......a's...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Jr�.4/......................OF....alC ,�'?�th ..!..........,....... ---------••-...........................
,Apure#ion for UWpviia1 orki Tonitrnrtion rrutit
Application is hereby made for a Permit to Construct ( ``!) or Repair ( ) an Individual Sewage Disposal
System at:
11p� ... .........( ...rt� J ....h.fr...... ...'�•f//
Location Address or Lot No. a'•Id 09
e _
.....------•--•--•..............••-•-•----•-----------------------_-•-_•-•_••••......•• ..............................................................••••••.........•__•--
Owner �; Address
,� f /�1,t F,�( �'' . .J Ile 4... 7t.�..ACC?
—= .......... .................... ......_...•..........._ ....
l_....
r S feet .
Installer r Address
d Type of Building Size Lot../—4.r�� q
Dwelling—No. of Bedrooms_...' ' ...............................Expansion Attic ( ) Garbage Grinder ( 0)
Other—Type of Building ' /t:': ............. No, of persons.?!`f t':,`.......... Showers (..2) — Cafeteria ( )
a Other fixtures ----------------------------------•-... .
Design Flow... g P P P Y Y
W ...._.:_.�_________________gallons per person per day. Total daily flow................. ....___......gallons.
WSeptic Tank—Liquid capacity::r?Z�..gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (--I Dosing tank ( ) 11
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I.......2!�----minutes per inch Depth of Test Pit... Depth to ground water. '_!' !t(j°':.,0—,
(s� Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------------------------------•------------------------------...._..........----••-----•.....--------•--...............................................
Description of Soil ✓,.1.. .rrf'.w-.'------ -------- -- ------- ----
�... ..✓.c/.... - ..•.. t .�'` �'
W ------------------------------------------------•--------------------------------------------------------------------------------•----------...........................................................
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
---------------------------••--•-•---•-•--....--------•-----------...---•----------.........---•------------------------••-----------------•--•-----••-••------------------•--------------------.------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systemlin accordance with
the provisions of TITLE: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health. f
Signed':- .. �........-�,. � •--- - _ .................
�
-7 Date
Application Approved B W_ 4,14t. � 1:._ �!'l______
Date
Application Disapproved for the following reasons: -----------------------------•-----------------•---•--••---------•--••--•-_---.
.....................•-----....--•-•--------•-------------------••---------------•---........---------....-----------------•. ---------- --•-----•------•----------••--•--••••----•-----------••..-••--
Date
Permit No......................................................... Issued_.......................................................
i
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9..F HEALTH-1
�.
Trriifiratr of Tomplianrr
THIS I TO CE �IFY:,(°That the Individual Sewage Disposal System constructed (�or Repaired ( )
by.. ._. -
._ .... ------------
/ j
at..f.?,z i✓11:�i„ i 1 b1 t%xai� a d✓a �
has been installed"in accordance with the provisions of T T*' 5 of The State Sanitary Code as,described in the
application for�Diisposal Works Construction Permit N _Z _.f� . ............. dated_ -.� _ :.._.._.____...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE 'CONSTRUED AS A GUARANTEE THAT THE
SYSTEM &LL. UNCTI N SATISFACTORY.
DATE. ....".`.1��� P 46 Inspector.. -`= ........ ...'.`........
;. THE COMMONWEALTH OP'MASSACHUSETTS
BOARD O,� HEAL
T J
,1 J yam.
No......................... FEE..... . ...........
U�
Bioposal fWorks Tomitk Uan anti
Permission is hereby granted•.'` tea 2�'_ ..i`7 j�'' ._, ,... .__... .._ r ....__.
to Constr�f t (5or R ' ' (-�an Individ wa j D p�ystem iy�
at No. ' ,' G, .. "
Street - •_ F
Dated_._I) �l _....._.as shown on the application for Disposal Works Construction Per `No...... ........ . __.____.. .......
f �.. - ....-----•.........
Board of Health
DATE.---- �1 �J g
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS a
t
CON E�LEGEND
N AK �R
0
—� SS PROPOSED CONTOUR
L\1 / EDGE_ OF Pq 1 ® PROPOSED SPOT GRADE•
' _'r _ _ — ___ I _`V EMEN 7' i —— g�j —— EXISTING CONTOUR
s2
�� _� —` 72,3 + 96.52 EXISTING SPOT GRADE SITE
•� — ' — — _ _ _ _ ` W— EXISTING WATER SERVICE
co
TEST PIT
1 I w I Lo 8 2-
80 << 1 LOT 36 Q
I
'j Q I! AREA = 14988 sf �i' LOCUS MAP N.T.S.
GENERAL NOTES:
ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
\� BOARD OF HEALTH AND THE DESIGN ENGINEER.
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
78( T�n 'n _ _/,` OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
3 \ D �� V LOCAL RULES AND REGULATIONS.
L Nn 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
v / TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
—— __ i 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
76 \�� 7-Op OF FN pN l78 ENGINEER NE ROBEFORE WCONSTR CONSTRUCTION CONTINUESHALL BE S.
TO THE DESIGN
1l _ 82. 76 / 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
/C THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
i M HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
741/ /' 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
_° _ TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
I11 EX15T, 1 ,000G 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
\ 76 THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
SEPTIC TANK CONSTRUCTION.
10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND REMOVED PER TITLE V.
72,E N / FILL WITH CLEAN MEDIUM SAND.
\ ^ e �\ / n 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION
e X%St. Leach Pit 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY
(Note 1• AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY
74 13. NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED LEACHING
J 32 00. _--- /' 14. ALL PIPING TO BE 4" SCH 40 0 1/8"/FT (UNLESS SPEC. .OTHERWISE)
msp. po 1 _ ___ j BENCH MARK 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW
1 FOR THE USE OF A GARBAGE GRINDER
70�� a� ff --TH-2 \�.72 � PAINT SPOT ON /o� 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING
\� 7 C O N C PATIO C OR ft S ELEVATION 7 4 17. PROPERTY IS IN ZONE OF CONTRIBUTION TO SALTWATER ESTUARIES.
BARNSTABLE GIS DATUM 18. INSTALLER TO FIELD VERIFY H2O CERTIFICATION PRIOR TO INSTALLATION.
70 OF
No. 1140 "' PROPOSED SEPTIC SYSTEM UPGRADE PLAN
19 CONANT LANE, CENTERVILLE, MA
' NITA�\p� MAP:173 Prepared for: Mike Dedecko
LOT.• 056 Engineering by: Surveying by: SCALE DRAWN
SURVEY REFERENCE: 'U-w` LCPW..'183114 DARRENM.MEYER,R.S. Roo—Tech Environmental
1 =20' DMM
PLAN OF LAND BY BAXTER & NYE, INC.. PO BOX981 (508) 364-0894
EAST SANDWICH,MA 02537 DATE: CHECKED SHEET NO.
DATED: DECEMBER 16, 1976 508se2-2922 06/28/10 DMM 1 Of 2
Rev: 06/30/10 - revised tank inlet elevation.
,
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:69.94
FOR A DISTANCE OF 15' AROUND THE
PERIMETER OF THE S.A.S.
,SEPTIC TANK PROPOSED D-BOx PROPOSED S.A.S.
T.O.F. EL.=82.16 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER �t`� OF '�gss9
OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.),AND SET TO 3" OF F.G.
F.G. EL.=76.Of o
• �F.G. EL.=73.50f F.G. EL: 72.90t F.G. EL: 72.90(MAX.) D s
E R -
a. No. 1140 i
L ® 20'"t w 9" MIN COVER/ L o 20' L m 10'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) E0
O Sm1% (MIN.) 36" MAX COVER ® $�196 (MIN.) ® S=1% (MIN.) t
4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC
• X4NITA10 ?�'1
o" le S. 11.3" rROWS
INV.=70.89 4e"LIQUID �INV.=70.64 INVER
t£vEt
GAS BAFFLE PROPOSED INV.=69.65 5 UNITS AT 6.25'/UNIT + 0.75' WEDGE 32'/ROW
D BOX BSORPTION SYSTEM PROFILE
INV.=69.85 �_� INV.=69.55
EXISTING 1.000 GALLON SEPTIC TANK
EXISTING SEW RESTORE VEGETATIVE COVER
ER OUTLET
BACKFILL WITH CLEAN PERC SAND
TO TOP OF CHAMBERS 75„
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING �'•' ':; 1: :.':;.,•+
PIPE INVERTS PRIOR TO CONSTRUCTION
BREAKOUT=TOP ELEV.=69.94 ,: <•
2) D-BOX SHALL BE SET LEVEL AND TRUE TO INV. ELEV.= 69.55
GRADE ON A MECHANICALL COMPACTED SIXMIN IN
INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 68.61 EXISTING SUITABLE
310 CMR 15.221(2) 2.83' MATERIAL
5 MIN. ABOVE BOTTOM OF
3) REPLACE EXISTING 1,000 GALLON SEPTIC T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.83' = 11.32 r+ 76"
TANK WITH 1500 GALLON SEPTIC TANK (8.11' PROVIDED)
IF FAILED, DAMAGED, OR UNDERSIZED. BOTTOM OF TESTHOLE EL.=60.50 _ USE 4 ROWS OF 5-HIGH CAPACITY ADS 16008D PROFILE
4) INSTALL INLET & OUTLET TEES AS REQUIRED - BIODIFFUSER (H20) UNITS-NO STONE W/ CONTOURED WEDGE
SEPTIC SYSTEM PROFILE TYPICAL SECTION
T 16"
N.T.S. NJA 11.2"
)60 A
DESIGN CRITERIA SOIL LOG P#: 1!
NUMBER OF BEDROOMS: 4 BEDROOM EXIST DATE: aJUNE 28, 2010
�-�34"---�
SOIL TEXTURAL CLASS: CLASS I SOIL EVALUATOR: •+DARREN M. MEYER, R.S., CSE. SECTION END CAP
WITNESS: DAVE STANTON, BARNS. BOH
DESIGN PERCOLATION RATE: <2 MIN/IN 16"" HIGH CAPACITY (H-20`f BIODIFFUSER UNIT
Elev. TP- 1 Depth + Elev. TP-2 Depth DAILY FLOW: 440 G.P.D. -�� _�
50
DESIGN FLOW: 440 G.P.D. 72. A 0" 72.55 0"A MODEL 16" HICAP
GARBAGE GRINDER: NO NOT DESIGNED FOR GARBAGE GRINDER LOAMY SAND LOAMY SAND
( ) 1OYR 3/2 10YR 3/2 LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT
PROPOSED SEPTIC TANK: USE EXISTING 1,000 GALLON CAPACITY 71.65 B 7" 71.88 8" EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY
LEACHING AREA REQUIRED: (440) = 594.59 S.F. B LOAMY SAND LOAMY SAND DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
1oYR 5/8 1oYR 5/8 SIDE WALL HEIGHT 11.2
.74 69.58 35" 69.63 35" OVERALL HEIGHT 16
DISTRIBUTION BOX: 5 OUTLETS (MINIMUM) (H20 LOADING) C1 c1 OVERALL WIDTH 34" 4640 TRUEMAN BLVD
PRIMARY S.A.S. MED. SAND MED. SAND 13.6 CIF HILLIARD, OHIO 43026
USE 4 ROWS OF 5 2.5Y 7/3 2.5Y 7/3 CAPACITY- 16" ADS BIODIFFUSER H-20 UNITS-NO STONE mos.,
(101.7 GAL) novaNCEo DRAINAGE SYSTEMS, INC.AND EXTENDED 0,75' Wf CONTOURED WEDGES 65.25 C2 87" 65.22 C2 88"
BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.70 SF/LF OF BIODIFFUSER) FINE SAND FINE SAND PROPOSED SEPTIC SYSTEM SITE PLAN
(BIODIFFUSERS) 20 UNITS x 6.25 LF x 4.70 SF/LF = 587.5 SF 2,5Y 6/6 M
PERC®63.75 2.5Y 6/6
, 19 CONANT LANE CENTERVILLE MA
(CONTOURED WEDGE) 4 ROWS x 0.75' x 4.70 SF/LF = 14.1 SF 60.50 144' 60.55 144' Prepared for: Mike Dedecco
TOTAL AREA = 601.6 SF PERC RATE <2 MIN/IN. ("C" HORIZON) P
DESIGN FLOW PROVIDED: 0.74(601.6 GPD/SF) = 445.18 GPD > 440 GPD req'd NO GROUNDWATER OBSERVED - Engineering by: Surveying by: SCALE DRAWN JOB. No.
DARRENM.MEYER,R.S. Boo-Teob ffnrhvn=eote! NTS D.M.M.
• 1, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 poSOX981 (508) 364-0894
to conduct Ball evaluations and that the above analysis has been performed by me consistent with the DATE CHECKED
requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Evol. Exam in October, 1goo. EASTSANDW/CH,MA02537 SHEET N0.
06-M22922 06/28/10 D.M.M. 2 of 2
Rev: 06/30/10 - revised tank inlet elevation.
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