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HomeMy WebLinkAbout0056 COTTONWOOD LANE - Health ol 56 Cottonwood Lane, Centerville A = 252 167 i 'i i p 14 �l/ll �QBCYCIEp�o 2J �y l/ll UPC 12534 No.2�153LOR Pos!•CONS° N4ITINOi,MN I Commonwealth of Massachusetts HI f W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C �A ^M 56 Cottonwood Lane Property Address Dean Stanley • Owner Owner's Name information is required for Centerville MA 02632 10/16%:17 every page. City/Town State Zip Code Date df Inspection c,ut Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information C When filling out J c�� forms on the computer,use 1. Inspector: only the tab key to move your Ronald Burlingame cursor-do not Name of Inspector use the return key. Company Name VSLA 58 Oak Street Company Address West Barnstable MA 02668 n City/Town State Zip Code 508-776-8544 S 14124 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3:,4 L��'�. 10/17/17 In ector's Signature Date The system inspector sha 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 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. t5 ns.doc rev.6l16 Title 5 Official Ins econ Form:Subsurface Sewage Disposal System•Page 1 of 17 bu/y, Vn�"' Y • T • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6/16 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 �M 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every 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 1h day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. Cityrrown 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 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 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. Cityrrown , State Zip Code Date of Inspection D. System Information Description: 1000 gallon septic tank 1983 D-Box 2006 3 Infiltrators w/stone 2006 Number of current residents: N/A Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2015 40,000 gallon 2016 21,000 gallon Sump pump? ❑ Yes ® No Last date of occupancy: Nov 2016 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Nov 2016 Date Other(describe below): 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): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank 1983 D-Box- Leaching 2006 B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 18" deep 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: Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments n 56 Cottonwood L M ae Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. City/Town 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 3 $ Scum thickness 3 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 14" How were dimensions determined? Tape measure/plastic tube 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 should have a maintenance pump, no records of pumping. Tees in good shape, inlet plastic, outlet cement. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M 56 Cottonwo od Lane a e Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Working levee Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box very clean &at working level at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: 15ins.doc•rev.6/16 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 ^M 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 Cultex: 27x12x2 w/stone ❑ 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.): 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.doc-rev.6/16 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 56 Cottonwood Lane Property Address Dean t nl Sa e Y Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 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 °M 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. Cityfrown 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 Rear 4 koUse ^ O s 0 A • �.J a b ° a d 0 t? a 0 A" I 21 c� " U a - I 2 Lo Ulf 0 0 ® d Z p 13 - 3'7 t5ins.doc•rev.6/16 Tide 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 Voluntary Assessments ;M 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12+feet 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: B.O.H 2O06 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Cottonwood Lane Property Address Dean Stanley Owner Owner's Name information is required for Centerville MA 02632 10/16/17 every page. City/Town 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'f 56 Cottonwood Lane, Centerville M-252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive,Westford MA 01886 March 27, 2013 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information c (OPY on the computer, use only the tab 1. Inspector: (((��� I key to move your 4 ] D cursor-do not Troy Williams ' use the return Name of Inspector key. 40-1-1 Troy Williams Septic Inspections my Company Name 19 Hummel Drive Company Address South Dennis MA 02660 City/Town State Zip Code (508)385- 1300 S1682 Telephone Number License Number B. Certification ` ' CI)certify thpt I have personally inspected the sewage disposal system at this address and that the (;.informatiT reported below is true, accurate and complete as of the time of the inspection. The inspection c :.was perf I med based on my training and experience in the proper function and maintenance of on site G. sewage tsposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of CC) ,,,Title 5( 0 CMR 15.000).The system: LA- r ax C) ® asses ❑ Conditionally Passes ❑ Fails r' ❑ beds Further Evaluation by the Local Approving Authority March 27, 2013 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 officiaVlnmbn onn:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Cottonwood Lane, Centerville M-252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive,Westford MA 01886 March 27, 2013 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. 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. 0 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): N/A 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 56 Cottonwood Lane, Centerville M -252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive,Westford MA 01886 March 27, 2013 page. CityrFown 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): N/A ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): N/A 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 Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 56 Cottonwood Lane, Centerville M -252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive, Westford MA 01886 March 27, 2013 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: N/A 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•11110 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 sY 56 Cottonwood Lane, Centerville M -252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive,Westford MA 01886 March 27 2013 page. Cityrrown 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E.the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 56 Cottonwood Lane, Centerville M-252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive, Westford MA 01886 March 27, 2013 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Cottonwood Lane, Centerville M-252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive,Westford MA 01886 March 27, 2013 page. Citylrown State Zip Code Date of Inspection D. System Information Description: 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 ears usage d 12=15,000 gals. g ( y g (gP ))' 11=18,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occasional use Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A t5ins-11/10 F Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 c. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 56 Cottonwood Lane, Centerville M -252 P- 161 Property Address Christopher Bums Owner Owner's Name information is required for every 7 Rome Drive Westford MA 01886 March 27, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): General Information Pumping Records: Source of information: Last pumped on 12/12/06 per info from BOH. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Cottonwood Lane, Centerville M -252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive Westford MA 01886 March 27, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: D-box and leaching were installed to existing tank from 7/24/84 on 12/12/06 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"+feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): 1' Depth below grade: 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: 5'X9'X6' 1000 gallon Sludge depth: 4" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Cottonwood Lane Centerville M-252 P- 161 Property Address P Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive,Westford MA 01886 March 27, 2013 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 2' 8" Scum thickness none 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 14" How were dimensions determined? probe/measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet&concrete outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A P P g Date t5ins•11/10 Title 5 Official Inspection forth:Subsurface Sewage Disposal System-Page 10 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 56 Cottonwood Lane, Centerville M-252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive,Westford MA 01886 March 27, 2013 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.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: N/A p ry' gallons Design Flow: N/A 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.): N/A "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 o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Cottonwood Lane, Centerville M -252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive, Westford MA 01886 March 27, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order. No evidence of solid carry-over or backup in the past were found at the time of inspection. 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.): N/A 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Cottonwood Lane, Centerville M -252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive,Westford MA 01886 March 27, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 cultec 3050's with stone ❑ leaching galleries number: 27'X12'X 2' ❑ 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.): Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 56 Cottonwood Lane, Centerville M -252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive, Westford MA 01886 March 27, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 IL Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form- Not for Voluntary Assessments 56 Cottonwood Lane, Centerville M-252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive, Westford MA 01886 March 27, 2013 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Cottonwood Lane, Centerville M-252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive, Westford MA 01886 March 27, 2013 page. Cityrrown - 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: 15.0' 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. 4/26/06, 8/7/83 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: AIW 247 Zone C 23.6' 3.9'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plans showed no water found at 14.0' & 12.0'. Hand augered 5' below bottom of leaching with no water found at a depth of 10.0'. Groundwater adjustment at the time of inspection was 3.9'. Bottom of leaching at 5.0'was found not to be located in the high groundwater elevation at the time of inspection. 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 • • Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Cottonwood Lane, Centerville M-252 P- 161 Property Address Christopher Burns Owner Owner's Name information is required for every 7 Rome Drive Westford MA 01886 March 27, 2013 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 f AsBuilt Page 1 of 2 TOWN OF BARNSTABLE LOCATION Z (P �O K/Al _ SEWAGE# VILLAGE; C'�rvT, ASSESSO 'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY e 7" LEACHING FACILITY:(type) _�'0 (size) 7 I��y NO..OF BEDROOMS ' OWNER 1� PERMIT DATE: 7 4d COMPLIANCE DATE: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 j 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 -i FURNISHED BY l I are T ~� D�6a� 63 . j http://issgl2/intranet/propdata/prebuilt.aspx?mappar=252167&seq=1 10/11/2017 I ✓�� l0 51� �!) No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplicotiou for � gpogal *pgtem Cougtruction Permit Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) ❑ Complete System dividual Components Location Address or Lot No. ✓ & ef07_/Z) �&�-0 Owner's Name,Address,and Tel.No. G�Ksr't✓v►�-e J Assessor's Map/Parcel Installer's Na e,Address,and Tel.No. Designer's Name,Address and Tel.No. d1^e �o. �i<cs�7 � 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) _ �j�l gpd Design flow provided 3 (Q(7 gpd Plan Date Pear QU(O Number of sheets Revision Date Title ` Size of Septic Tank 'E2-1 S`r Type of S.A.S. : 3050 Description of Soil (_p 01'hs-f v Nature of Repairs or Alterations(Answer when applicable) 0 ep ,nl vx�S 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 Environ tal Code and not to place the system in operation until a Certificate of Compliance has been issued b s-B�ard'of'i�e gned Date `� Application Approved Date �7 Application Disapproved by: Date for the following reasons Permit No. Date Issued 7 N1. �p 51� mac. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 'Rpplication for Migponl &-epztem Co.n5truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade' Abandon( ) 0 Complete System J�gLwdividual Components Location Address or Lot No. r Q �'077Q�� Owner's Name,-Address,and Tel.No. G�ivT<✓v��-e / J Assessor's Map/Parcel1� C-.O/ z�sG�is b Installer's N e,Address,and Tel.No. Designe/r's'Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) i Other;Fixtures Design Flow(min,required) 3 gpd Design flow provided 3 N 3. gpd Plan Date Y k, '---Z6Db Number of sheets Revision Date Title 77-C0%IAO Size of Septic Tank ?+S't \(SUV G`a- . Type of S.A.S. :30 SCE C c- O-' C Description of Soil L_D 0 r I Nature of Repairs or Alterations(Answer when applicable) i ��ov, 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 Envntal Code and to place the system in operation until a Certificate of Compliance has been issued b_y t}ais-Bvar"d of H`ea�t4 a igned Dante �" 0(0 Application Approved by Date 7 Application Disapproved by: Date for the following reasons - s Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS - (Certificate of Compliance THIS IS TO ERTIFY;- at(the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded Abandoned( )by /7 at 5-6 66-7eAl VaZ)o Lew << �Tr has been constructed in accordance / with the provisions Title 5,and�t-he for Disposal System Construction Permit No. o" 5 j dated Installer �provisions d�—A- Designer'i-r-T #bedrooms 3 Approved design flow 33 0 gpd The issuance of this permit shall not be construed as a guarantee that the system will-furiction as-designed. Date �~ J - 1�v Inspector ———=———————————————=———--——— No. 5 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Migonl *pgtem CZon.5truction Permit Permission is hereby granted to Construct ( ) Repair ( ) 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•. ConstructionJ-m-u7st e completed within three years of the dat of this pe�rrnrt. Date r/�/ / � Approved4b_y_ Town of Barnstable .°Ft"E' .� Regulatory Services Thomas F. Geiler,Director • sexxsr,►atE. • AMA Public Health Division '°'En►��► Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-79.0-6304 Installer& Designer Certification Form Date: \ a, cm Designer: Shay Environmental Services, Inc. Installer: e Address: P.O..Box 627 Address: East Falmouth, MA 02536 On al Q p(o was issued a permit to install a ( ate) C (installer) septic system at J Mn s , CQ based on a design drawn by (address) Shay Environmental Services, Inc. dated (designer) /_\1L\_ 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. ,. 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. \�k OF M,41.7S-9 CARMEco N (Ins er's Si o E' SHAY No. 1181 � a F01STS SANI 0 esigner's Signature) (Affix Des p Here) 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:Health/Septic/Designer Certification Form Sep - 20- 01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 S25roi : .XOTICE: This Form Is To Be Used For the Repair Of Failed -Septic Systems Only. PERCOL,aTION TEST AND SOIL EVALUATION EXEMPTION FORM 1 WrQ.�►� hereby certify that the engineered pi an signed by me u�;ec 0 2-4— Wo concerning the property located at � ' . � " ' C :�sa\,Rmeets all of the • This failed system is connecred to a residential dwelling only. There are no .oruner.ia! or business uses associated with the dwelling: r� c::: The soil is ciass;f ed as.CLASS I and the percolation rate is less than or equal to 7t:nut:s per inch. The applicant may use historical data to conclude this fad: or ma� � c. :or,duct Pre!trr.tcar, tests at the site without a health agent present Gi There :s no increase to flow and/or change in use proposed ' <� = co • (here are no vanances requested or needed• cc o • The bottom of the proposed leaching facility will not be located less than fourteen ;l;j fee: aoove the maximum adjusted groundwater table elevation fAdiust the ;rnundwater table using the Fnmptor method when applicablc l Please complete the following: D( Ground+ Surface. Elevation !using GIS information! 61 t,.w' ci�.�C�3f:on :d;us(ment for nigh G.W. 2 = 32,o ; J 7T-TRFt(t,F BETWEEN and B A, C 5SQatA--, D ATE asec ,,,;ran the above irformacion, a reoair permit will be issued for �edrnorns T2,�imum. No additional bedrooms are authorized to t`te future without engineered =system plans. _ --- — i TOWN OF BBA/RNSTABLE OCATION U�i� t�JOD.I/ SEWAGE# (� � VILLAGE �' dy7-� ASSESSO 'S MAP&PARCEL 9�-50) -/(- 177 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY I 07T e-K Y LEACHING FACILITY:(type) �a ����•� (size) NO.OF BEDROOMS OWNER �- PERMIT DATE: COMPLIANCE DATE: , Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY a 6-3 �f o/eT- Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form ` Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the f computer,use 56 Cottonwood Lane- Centerville S 7 (� only the tab key Property Address to move your Anthony and Wendy Colesano cursor-do not use the return Owner's Name key. 56 Cottonwood Lane Owner's Address Centerville MA '02632 City/Town State Zip Code " July 13, 2005 , Date of Inspection: Date c7d cam- `- T 2. Inspector: a , efl i David D. Coughanowr, R.S. Name of Inspector = : r, Eco-Tech Environmental Company Name N) r- 43 Triangle Circle rn Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority PS July 13, 2005 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. t5-2115.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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: t5-2115.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ 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 t5-2115.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG M Subsurface Sewage Disposal System Form A. Certification (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t5-2115.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection 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 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® 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 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No ® ❑ 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. t5-2115.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5of16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form A. Certification (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2115.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'G1+ B. Checklist 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection 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, including the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] t5-2115.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection 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 gpd Number of current residents: 3 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 ears usage d 262 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2115.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 21+ years. Certificate of Compliance issued 7/24/84 (Board of Health permit#84-296) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2115.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): Depth below grade: 1 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 ❑ Yes ❑ No certificate) Dimensions: 8.5 ft x 5 ft x 5 ft (1000 gallon) Sludge depth: Not determined Distance from top of sludge to bottom of outlet tee or baffle Not determined Scum thickness Not determined Distance from top of scum to top of outlet tee or baffle Not determined Distance from bottom of scum to bottom of outlet tee or baffle Not determined How were dimensions determined? Permit application t5-2115.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Cottonwood Lane Property Address Centerville Ma 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection 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 should be pumped dry at time of system repair and examined for structural integrity and water tightness. A new PVC tee with a gas baffle should be installed 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): t5-2115.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection 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.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Not determined Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box was not opened because conclusive evidence of system failure was observed at leaching pit. A new D-box should be installed at time of repair Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2115.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection 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 ❑ 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.): An observation hole was dug into the leaching pit stone. The soils became progressively more saturated with increasing depth. Effluent was observed in the peastone layer indicating that pit has reached the limit of its leaching capacity. t5-2115.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of 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 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.): t5-2115.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection 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. LEACH LOCATIONS O PIT 4 3 ❑ D BOX A B 2 1 27 f t 22 Ft SEPTIC 2 31 f t 27 f t TANK o 3 36 f t 33 f t 4 31 ft 46 ft A 8 EXISTING DWELLING # 56 W Z J C W Q 3 COTTONWOOD LANE NOT TO SCALE t5-2115.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Cottonwood Lane Property Address Centerville MA 02632 City/Town State Zip Code Anthony and Wendy Colesano July 13, 2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 30+ 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: USGS topography maps You must describe how you established the high ground water elevation: USGS topography maps indicate property is over 30 feet above nearby Wequaquet Lake. t5-2115.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 16 - jv COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO 8 PART A CERTIFICATION Q1 Property Address: 56 COTTONWOOD LANE CENTERVILLE LOT 178 Name of Owner JOANNE SWANSON �� e Address of Owner: 26 WILDROSE AV.HOLDEN MA.01620 v ati rme Date of Inspection: 4/19/99 y 'yS� �9`99 Name of Inspector:(Please Print)JOHN GRACI e A-4 I am a DEP approved system inspector pursuant to Section 15,340 of Title 5(310 CMR 15.000) y Company Name: n/a Mailing Address: n/a Telephone Number: n/a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Ev uation By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life, Inspector's Signature: /submit Date:4/20/99 The System Inspector sh a copy of this inspection report to the Approving Authority(Board of Health or DEP)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. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOM MEND PUMPING EVERY TWO YEARS. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 66 COTTONWOOD LANE CENTERVILLE LOT 178 Owner: JOANNE SWANSON Date of Inspection:4119/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection I B. SYSTEM CONDITIONALLY PASSES: nCa 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. n1a 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 complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced Wa 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 56 COTTONWOOD LANE CENTERVILLE LOT 178 Owner: JOANNE SWANSON Date of Inspection:4/19/99 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 AND SAFETY AND THE 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 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 nta_(approximation not valid). 3) OTHER nLa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued)' Property Address: 56 COTTONWOOD LANE CENTERVILLE LOT 178 Owner: JOANNE SWANSON Date of Inspection:4/19/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: 1 have determined that one or more of the following failure conditions exist as described 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 X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 56 COTTONWOOD LANE CENTERVILLE LOT 178 Owner: JOANNE SWANSON Date of Inspection:4/19199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: . Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X 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: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)J X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 66 COTTONWOOD LANE CENTERVILLE LOT 178 Owner: JOANNE SWANSON Date of Inspection:4/19/99 FLOW CONDITIONS RESIDENTIAL' Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):3 Total DESIGN flow: = Number of current residents: 1 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):JLQ Water meter readings,if available(last two year's usage(gpd): nta Sump Pump(yes or no): NO Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nta Design flow: nta gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):_NQ Industrial Waste Holding Tank present:(yes or no): Na Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:Wa Last date of occupancy: Wa OTHER: (Describe) nta Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):M If yes,volume pumped 1000 gallons Reason for pumping: MAINTENANCE TYPE OF SYSTEM X 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.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: Wa APPROXIMATE AGE of all components,date installed(if known)and source of information: 1984 PEMIT#84-296 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 COTTONWOOD LANE CENTERVILLE LOT 178 Owner: JOANNE SWANSON Date of Inspection:4/19/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 1'6„ Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ Wa Dimensions: L 8'6'H 5'7"W 4'10" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 3C Scum thickness: 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: iE How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: n& Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:l7La Distance from bottom of scum to bottom of outlet tee or baffle Wa Date of last pumping: Wa 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.) WA revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1 Property Address: 56 COTTONWOOD LANE CENTERVILLE LOT 178 Owner: JOANNE SWANSON Date of Inspection:4/19/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wit Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: Wa Capacity: nLa gallons Design flow: Wit gallons/day Alarm present: NO Alarm level:jita- Alarm in working order:Yes—No—: NQ Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DID NOT EXPOSE PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of t 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 COTTONWOOD LANE CENTERVILLE LOT 178 Owner: JOANNE SWANSON Date of Inspection:4/19/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: _nta leaching galleries,number: 13La leaching trenches,number,length: nLa leaching fields,number,dimensions: nta overflow cesspool,number: Wa Alternative system: Wa Name of Technology: jlLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: nta Depth of solids layer: Wa Depth of scum layer. nLa Dimensions of cesspool: nta Materials of construction: nta Indication of groundwater: Wit inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:n& Depth of solids: nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 COTTONWOOD LANE CENTERVILLE LOT 178 Owner: JOANNE SWANSON Date of Inspection:4119/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a r B Dec a AA 55 AO a, A D \1L RA a� � 3C revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 COTTONWOOD LANE CENTERVILLE LOT 178 Owner: JOANNE SWANSON Date of Inspection:4/19/99 NRCS Report name: nLa Soil Type: nLa Typical depth to groundwater: nta USGS Date website visited: nLa Observation Wells checked: N_Q Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL-12+FEET revised 9/2/98 Page 11 of 11 NO... - -8 y—Z=� 6 r Y ." I Fxsf°....................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH It 1 .........................--. ..-------.....OF........--....-----.--................-------............................................ Applira#ion for UispniFal Works Tnntrnrtinn Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 56 Cottonwood bane .Lot ..�.�8...__.... -................-................................................................................ ...-- Location-Address or Lot No. ------J...8S...A.- edalt�t..-Truat........................................ --•---.Cottonwood Za.ne................................................ Owner Address a ......J.saP.1. ennedY....-•---------------------•----•-••--............. .......Centerville---Mass.,L.......................................... Installer Address Q Type of Building _.. ;-<w ---- Size Lot._1-2.4,Q-61..2...Sq. feet Dwelling—No. of Bedrooms........................... ...........-------Expansion Attic ( Y) Garbage Grinder ( N) Other—Type of Buildiii �.Ca ?e= '''No. of persons._Sp_e_c...H.QuaeShowers (2 ) — Cafeteria ( ) a Other fixtures-- ._Bates_-tub..va th...Shoxere.._2...Laus...kitchen.-sink...................... W Design Flow...1.1-O�Be gom..__.____gallons per person per day. Total daily flow.................3..3CL.._.............._gallons. W Septic Tank—Liquid capacity.l OQDgallons Lengd-61 .!!...... Width...a 3/4 Diameter_- 4.t.6.5. Depth..!.'.!!_.. x Disposal Trench—No.....N..._........ Width....N............. Total Length......X........... Total leaching area.......N----------sq. ft. Seepage Pit No..-___--..-___-____ Diameterl_Q!X6...... Depth below inlet..6!............. Total leaching area...5j48.......sq. ft. f' z Other Distribution box (Y ) Dosing tank ( ) Percolation Test Results Performed by.......N.t____...ZQSST M.................................... Date......a/VB.3-----------_--. aTest Pit No. 1-----2........minutes per inch Depth of Test Pit...1.fi$'!...... Depth to ground water----NQne........ (i Test Pit No. 2......2..._..._minutes per inch Depth of Test Pit.._1. ..... Depth to ground water____Ne.on -_--___. -----------------------------------•---------.............................................................................................................. ODescription of Soil........ oarse---Sand---&--.Gravel------------------------------------------------------------------------------------------------------ x W -----•------------•------------•-•-••--•-•---------••--•----------------•••••-----•---•---•-----....-----•--•••------..__....•••----------------------------------------•---•---•-•--••-----------...... UNature 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 iITLi: 5 of the State San,y Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as ee ssuedtby t e b rd of health. Signe ..... ..... ---- ----------•---- - ------ -------------- D eo Application Approved By--•--�= �1��f� ............................................... Date Application Disapproved for the following asons. •-•----•-------------------•---------------•----•••----••-•--•---------------•-------•-•-•--•--•------......_.. ---------------------------•------------......----------------------------•----------------•----------- ------•-•----•----•-------------•-•----•-------------------.....-----------------•------------ Date PermitNo......................................................... Issued-....................................................... Date No.. ...... _ FEA?......................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ------------....OF.....--•---............................ Anpliration for Uiinniia1 Workri Tnntrnrtiun 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......56 Cottonwood Lanz .......Lot # 1.78 ........................................................ Location.Addressotto d Tor Lot No. 1 -•--••-•---- -----------------------------------••-----------•-•----•----------------_........_------ J-&.JRaa _:Ly...= wne Owner Address a :.oae 1 ��r e�z; Centerville Mass. ......... __-_--- Installer Address d Type of Building Size Lot.. 2....061 .2-• Sq. feet U DwellingNo. of Bedrooms............ .............................Ex Expansion Attic Y — p ( ) Garbage Grinder (N) a Other—Type of Building --------- A]0,a....... No. of persons.a73eC_ IOU `?Showers (2 ) — Cafeteria ( ) Other fixture::_'-,2 Bath__tubs wl th__showers l vs__kitchen sink W Design Flow ,..0Z-a'drQQTTI_._____._gallons per person per day. Total daily flow.................33D.................. ons WSeptic Tank—Liquid capacity_1-Q00gallons LengtIS�_ ;'.____._ Width_..8.t_3/4 Diameter.rj-4.-1-65. Depth____ x Disposal Trench—No. ......... Width...X............. Total Length......X........... Total leaching area_._-__Y..........sq. ft. Seepage Pit No-------I----'.._.-_. Diameter.l CL.Y.C.'_-- Depth below inlet..6................ Total leaching area..5..df'a....... ft. Z Other Distribution box:,(Y ) Dosing tank ( ) 4 Percolation Test Results Performed by.-_------ •--_-.....�s��:`.�______________________________________ bate...... .f1163_________.__..... aTest Pit No. 1..... ........minutes per inch Depth of Test Pit... . 8 t1...... Depth to ground water----NPne--------- 44 Test Pit No. 2......2.......minutes per inch Depth of Test Pit---1_� ........ Depth to ground water----N.On..._.--_ . ------------------------------------------------•-------------.....------..._....-----------...._...-----•----------•-----------.........----------•-.-•--•- D Description of Soil........Coarse...Sand & Gravel -------- -------------------- / \ ..•__________________________________________•_____________._._..__.?_......................................_._..............._.......................................................................... 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 TITLE 5 of tlye State Sa ry Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance as ee ssued by t e b rd of health. Signe ------------ � D Application Approved By__..,.,_.. �. , 20n _ �l..._� ..� ........_. Date Application Disapproved for the following • --•---••---•--•------------------------•-•-----••---•--------------•-•---•--•--•--•.......................... --- ------------------•------------......-------••---'•--------.......-----------•-•-------•--•----•......----•-................. --•-....------ Date - Permit No.......................................................- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tn#ifiratr of Tontnfinnrr THISJS TO C RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by --• - -----•---••...................•-•---•-•-------------------••---•---------....•-•----•-.....---------------------••--•-------.......0. Installer has been installed in accordance with the provisions of TITLE 5 of he State Sanitary Code as described in the application for Disposal Works Construction Permit No....9/`A__/�..__................ dated_............................................. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WIL FU�ION SATISFACTORY. DATE ...._•. ..........................................................11 Inspector-. ---•------_--_----••-•-- t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH V �iy L l ................................OF..................................................................................... f. No...... .---•--•••-- FEE........................ Disposal nrk T.nngtrt ion rrnti# Permission is hereby granted............... �•---. � .............................I.................................................... to Construct ( ) orRepair -, an Individual Sewage Disposal System atNo -^ ---------------•-------•--------------------------------------------------- Street as shown o/theap icatio for Disposal Works Construction Permit ated.......................................... .,.�� r Board of Health DATE_ ... --- -------------•----......-•----. FORM 1455 A.•M. SULKIN, INC.,, BOSTON C T10N � S WAGE P R NO. A G Et I N S T A LL &VS NAME i ADDRESS i S UILD'ER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 7 y� cy I 1. . ,. I I -- , _ , -I ­­ � 1.717-1 - 1 1 1 1 1 1 1 1 1 � _W'177,�11.,_4_ 5 �", "' 11 "'.­,": - � ­_ . , - - - - I i , ", , �� , -� " "" i7�­.7-7-, I--�;� "' 1,� -7 - ­ - --,�'- , , ,,-� , , �,� "� 7 ,-,­ I,- ',�-:,,�, 3�. I �I r i, ?",4tii�- '! 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I ­­ ­ - 6 1 1 '.1 r � I . 11-- I �_ , , , ,,,6 , I r � I I I 1 I " � I I � . - I � I i I �, I , I r , I : , I r, I - " I � . . � - I 1, I 11 - � I I - 6 _r 1. 1 ,6, . 1 6 1 , - I I � 61 1 1 - 6 . 16 " I 1 6 1 -, 61 1 � I I I 1, 6 � A - I � . �_, 11 :;r�­ I � I � 16 ­ 1 1 1 - 6 , I SECTION A -A ��►;•���.���,.,ta.� ,���x�� ������, ,:�.,.,, I��,��.�,G PROFILE VIEW OF LEACHING SYSTEM - *NOTE ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C. VENT PIPE O Least 24 inches Odor toll Ta ` {a 10' min. from Schedule 40 PVC w/Charcod Odor Fnter ? y t r f I sY a sh Existing Foundation I house to septic tank �X cover must Not to Scale be b £ 1$ TOP OF FOUNDATION = ELEV. 100.00 (Assumed) Septic tank coven must be wlthk to GRADE w/Steel Cover " + { " within a in. of fintehed 9�e rode=vier Septic Tank- O&W _ trolle over D-eex-9a0U A\ over SAS-MOD ' 3 of 1/8 - 1/2" Washed PesaMne y , ` ti 56 Cotteirewood^Lo DIST BOXta 3/4" to 1 1/8 " llaahed Crushed Stone i �° j� acrft '{' � RUB ,....,•, rya 7Y`F yA-Io; r(3 i �r' s = 0.02 _ 4" PVC (CAPPED) INSPECTION PORT TO BEt '� � �+ 1p 12 EXIST. sa0.D1 a Greater 3. 1Aodemen Cover Top OF S l7ew =9375 y`�"' INSTALLED AND TO BE WITHIN 6" OF GRADE EMT.PME n 1 000 GAL o 50' s= D.o1'per foot a a' �£"r't s , 'r ,f t + ✓' ~. �. r .i FROM EXIST. FOUNDATT[N `6 SEPTIC TANK o j f R. t 4, , /j/ n o.erer rn N 5 +�JS CONCRETE RJLL FOLNDA ---JJ o n H-10 n ,Mi, a, r .. - 2' ;EFFECTIVE DEPTH '..w xj'A' ,; 'µ �., ' •-� t 4 , m m o n o o ,Z " E f f e e "v a vnoon eMis»sae c+w cos r«►atn.a..Ard Di r..o.,' r`,, , SYSTEM PROFILE > ° ed st'one m 4' ,�' 4' GENERAL NOTES Sidewall Not to Scale - c 5 i 12' 1 3 Units @ 7' = 21' = o Effective Vktth ; 1. Contractor is responsible for Digsafe notification, Verification of Utilities 6 In.ot 3/4'-t 1/2' o m , 1' , 1 and protection of all underground utilities and pipes. aampoed stone Qo 5L 5 ct 2. The septic"tank and distribution box shall be set NOTE ALL COMPONENTS MUST HAVE RISERS TO WITHIN B' BELOW GRADE 9 Effective Length level on s of 3/4"-1 1/2" stone. 3. Backfill should be clean sand or gravel with no Z 000 6' stones over 3" in size. w Bottom of Test Hole 2 Elev.- 86.00 4. This system is subject to inspection during installation PERCOLATION TEST Groundwater Observed - NONE OBSERVED SOIL ABS❑RPTI❑N SYSTEM (SAS) by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance CULTEC 3050 INFILTRATOR CHAMBER H-20 (OR EQUIVALENT) with Title V of the Massachusetts state code, the approved plan Date of Percolation Test: APRIL 26, 2006 Test Performed By. CARMEN E. SHAY, R.S., C.S.E. NOTE: OVERALL HEIGHT OF INFILTRATOR IS 30" /EFFECTIVE HEIGHT IS 24" and Local Regulations. Results Witnessed By. WAIVER (PER BARNSTABLE BOH) 6. If, during installation the contractor encounters any soil conditions or site conditions that are different EXCAVATOR: Shay Env. Svcs. ALL OUTLET PM FROM THE from those shown on the soil log or in our design Percolation Rate: Less Than 2 MPI ® 60" DISTRIBUTION SET LEVEL �T LEAST BE tr CONCRETE txneEx installation must halt & immediate notification be Test Hole Test Hole "` `' - 2' made to Carmen E. Shay - Environmental Services, Inc. iaroa�co9SCH. 4,0 • " _ No. 1 No. 2 7. No vehicle or heavy machinery shall drive over the ems. I2• iMLEr septic system unless noted as H-20 septic components. DEPTH SOILS ELEV. DEPTH SOILS ELEV. { - , D 9s o0 0 98 : e, 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. .00 sand 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Sandy O Loom 4" - 1 t.�- 10. All solid piping, tees & fittings shall be 4" diameter fO YR 3/2 10 YR 3/2 PLAN SECTION CROSS-SECTION 0"-18' A, 96 0'-tan A, 96 Schedule 40 NSF PVC pipes with water tight joints. 11. Municipal Water is Connected to ALL OF The Residence and Abutting Loamy Loamy Sand 3 HOLE H-10 DISTRIBUTION BOX Properties Within 15o Feet. to YR 5/6 10 YR 5/6 THE PROPERTY LINES ARE APPROXIMATE AND 18'- 60"1 8, 93.00 18"-6o' I Be 93.00 COMPILED FROM THE SURVEY PLAN BY J. FINN & ASSOC.. ENTITLED Med. Mod. CERTIFIED PLOT PLAN OF LOT 167 COTTONWOOD LN, CENT., MA Sand Sand DATED MARCH 10, 1985 2.5 Y 7/4 7-5 Y 7/4 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN G 86.00 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 0-_ t44 Cn as.00 so'- t44 THE SEPTIC SYSTEM INSTALLATION. C O T T O N TWO O D LA NE EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE (40 FOOT RIGHT OF WAY) NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE FROM THE EXISTING LEACH PIT TO BE DISPOSED OF AS PER BOARD OF HEALTH SPECIFICATIONS. ------------------------- ---------------------,-------w. .---------------------------- _ Perc1 j 94 - \t f ' 94 THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY Depth to Perc: 60" to 78" I I \ ��-------9s Perc Rate= 2 MPI ASSESSORS MAP 252, PARCEL 167 Groundwater Not Observed -=---- _ No Observed ESHWT __ ------ �s.00' �,,` `-_�_----�' �, LEGEND ADJUSTED H2O Elev. = None 96 'A LOT #178 ��\ i -98 12,062 Square Feet +/- � `-_i_____�� /� 104X1 DENOTES PROPOSED SPOT GRADE 2-18'IMAM. ACCESS MANFIOLES PROJECT BENCH MARK 9TOP OF FOUNDATION _________ ELEV. = 100.00 (Assumed) ---_-- ------- - X 104.46 TING �- � � w 3 � j' DENOTES EXISTING --,�; :�:--- - 98- m I z w I SPOT GRADE T N. y ~ PROPERTY LINE 0 �'o i PL 1------�I nl INLET l t\ 9r PROPOSED CONTOUR k EXISTING I i -- - ---97 EXISTING CONTOUR THE ACCESS COVERS FOR 1HE SEPTIC TANK, DISTRIBUTION BOX AND LEACHING COMPONE14T �t 3 BEDROOM! is a►•Y SET DEEPER THAN 6 INCHES BELOW FINISHED I I • .. C..»�_ a �._ CO - -- GRADE 51IALL BE RAISED TO MATFNN B' OF FNNSHED GRADE. HOUSE I I DEEP TEST HOLE & STEEL REINFORCED PRECAST CONCRETE �. PLAN VIEW '�A1L ttF-T'lE�BAD OR MUMS �56 I TEST HOLE #2 � PERCOLATION TEST LOCATION 1 ELEV.= 98.00 3-24• REMOVABLE COVERS- TESt HOLE -I ------ _J 6 FOOT STOCKADE FENCE o ELEV.= 98.00 - - •Tfi a � _ 4' ''� '' DEC DECK '` _ z. / j � REV.: 12/4/06 Calculations REV.: 12/6/06 Dave INLET 8'min.0 2'min. Inlet to outlet e. s_• , FJ Uquid lava* OUTLET 23 VetStP LOT P LAN 5! --rO Failed 0 ..:�y p E o 4!-Crd aapth EXIST. Leach Pit r»' ` 1000 al. ;" • t`` ' SHED OF PROPOSED SEPTIC SYSTEM UPGRADE +o g Septic Tank _ PREPARED FOR g�° ~ END-SECTION D-Box ANTHONY 8c WENDY COLESANO CROSS SECTION 1 . , AT TYPICAL 1000 GALLON SEPTIC TANK »s.os' ,' #56 COTTONWOOD DRIVE NOT TO SCALE CENTERVILLE, MA Design CalculationsQo f Number of Bedrooms: 3 Bedroom EXISTING REPARED BY: Garbage Grinder. No ? C�1 R�YI�'N E. ,SH14 Y Leaching Capacity Required: 330 Gal./Day (MIN. PER TITLE V) c� Septic Tank : - 2 x 330 Gal./Day = 660 USE EXIST. 1,000 GAL. Septic Tank. I" f Al U, ENVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch . Bottom Area: 0.74 gal/sq. ft. x 312 sq. ft. = 230.88 gallons 0 20 40 50 A 4 V- P.O. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 152 sq. ft. = 112.48 gallons s 'sTE EAST FALMOUTH, MA 02536 Providin . = 343.36 gallons gNITAR\Q'-. TEL/FAX : 508-539-7966 Use: (3) 3050 H-20 INFILTRATOR CHAMBERS, HAVING A 2' EFFECTIVE DEPTH, SCALE: 1"=20' SCALE: 1"--20' DRAWN BY: CES DATE: APRIL. 26, 2006 (4' W x 7' L) TO BE USED WITH V OF WASHED STONE ON THE SIDES AND 2.5' OF WASHED STONE ON THE ENDS. PROJECT#SD895 FILENAME: SD895PP.DWG SHEET 1 OF 1