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HomeMy WebLinkAbout0086 COTTONWOOD LANE - Health r 86 Cottonwood Lane . Centerville A= 252.- 151 J SMEAD No. H163OR UPC 10259 smead.com • Made in USA "�f No. /J Fee /60,00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes RppULation for Mispo8al 6pstem COiistCULtion 3permit Application for a Permit to Construct( ) Repair(V� Upgrade Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. X6 CD++Ovh w0 LA wner's Name,Address,and Tel.No.,'O -7 7 v- 9D3 -}- Assessor's Map/Parcel `Z3 Z I�'/ ew+Je__i5ttoc i-Ariney Cix G+t jn jfj`�rQ Aia Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.'of 301- 9p Y8 Rolwarr S,vvc lo,-'nC• Boos 91 Vef F J 2N ti" r` Rd. kanAkek. Ata. Type of Building: Dwelling No.of Bedrooms -3 Lot Sized sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33o gpd Design flow provided 313 gpd Plan Date 4-2 - 1-6- Number of sheets Revision Date Title ft C©•nv.4 Lived LA. L Size of Septic Tank jGXj. i h4 J,0V0 Type of S.A.S.3-S00 J4,C/"Jets Z SYr��0^sc� Description of Soil = 7y Le s�a j8= 17" 1�,o�c.M-y SAJO C - �'Kg W4,,, 5" Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Ziro ental C 'e and not to place the system in operation until a Certificate of Compliance has been issued by this Board of e th gne Date Application Approved by Date Application Disapprove Date for the following reasons Permit No. ? `5-— Date Issued - I—. Fee No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: df Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Mi8TJosal 6pstem'Construrtion 3permit Application for a Permit to Construct( ) Repair(k4 Upgrade Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. X 4 (0 ffo-Awa �jQ/��; k�te ner's Name,Address,and Tel.No.,'p?-776-�,7o,3 i Assessor's Map/Parcel Z Z r `. ve f i-e—z1Cac x,*nAeye o If ie, Installer's Name,Address,and Tel.No.S'o - 09_t1,05j5 Designer's Name,Address,and Tel.No.3"pg 90 y!g Co,Zn4- Bex_z P i uer F'I Type of Building: 1 1� Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) {$ Other Fixtures �n gpd Design flow provided ,313 gpd Design Flow(min.required) ? Plan Date Number of sheets Revision Date Title ( n 9OZVA ► r-`) _ t Size of Septic Tank goo Description of Soil A z -e Lodt,w+-.r 5�, R /��ti a-M!11 .'SG C Ckw.., �A nj Nature of Repairs or Alterations(Answer when applicable) i 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 E ironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of eaIth. gne Date Application Approved by Date Application Disapprove Date i 1 for the following reasons 'I Permit No. Date Issued /n 6 17oi 5 ---------------------------.------------------------------------------------------------------------------------------- ---------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded(t✓J Abandoned( )by 'T igar 69 :r4 c , at F T" P /J aar ,p, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.; /4_, dated Designer Installer 0ye (' 4 —e - a' '1� a,.e s� #bedrooms 3 Approved design flow 33(J gpd The issuance of this permit shall not/be coo strue as a guarantee that the system ill fun ',n as�lesig ed. Date , /�J� Inspector --------------------------------------------------------------------------------------------------------------------------------------- No.20 1 — 2 Fee w THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS 30isposal 6pstem Construction 3permit f Permission is hereby granted to Construct( ) Repair( tlOr Upgrade(y,10') Abandon( ) 'a System located at 9 61 n� w/ 1�€ara 1 , r Tf'/�✓lL�i� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date //n 1�?4/� Approved by '` Town Of Barnstable Regulatory Services Richard V. Scali,Interims Director 9� 1639. .��W Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,lA'IA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Forma Date: 6 2Z Sewage Permit# Zo ,5- 178 Assessor's 1VIap\Parcel Z Z P ) et, a Designer: N0/r]AS�' � �L�.Q1J ,, P�• Installer: �fi3�2T g- DER �• 1/i1L Address: Jj Q/X 110 Address: BOX 1,531 On L� B 00QL CO was issued a permit to install a (date) (installer) septic system at 06D ( GENf= based on a design drawn by (address) C t E L -A^J P F. dated (designer) 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfacto Zrtify that t stern referenced above was constructed in compliance with the terms e TEA a letters(if applicable) Iler's gnature) �i3��r a T�y (Designer' ignature) (Affix mp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF CON PLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q%SepticWesigner Certification Form Rev 8-14-13.doc d.ltte Town of Barnstable P it. �D � Department of Regulatory Services M Public health Division Date �J sB7Y 200 Main Street,Hyannis MA 02601 ' lE1J N1A'I a Date Scheduled / c Time 1 v _ Fee Pd. Soil Suitability Assessment for Sewage Disposal taws Performed•By:,H (M S C/u(A \, l /f Witnessed By: �/ .�✓��/ � � ( �(" Location Address LOCATION& GENERAL INFpR unoN C gL co-r-rmiWcoyj -/V, � 1 owner's Name 5TFV'F JANNFiI G�ky j Ep /i wE t/ Address 66 c T TvfJ(,VCe)fJ Ii/,j Assessor's Map/Parcel: Engineer's Name �,��t)4o( m c, EuA(�j NEW CONSTRUCTION / REPAIR V. Sig, 3� 1! �-g Telephono It Q Land Use _ �G slopes(96) /� A I Surface stones Distances ltom: Open Water Body P ft possible Wet-Area_(r/a n Drinking Water Well Dralhe.go Way �A_}t property Line _ft Other ft uIMCTCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands 1n proximity to holes) Parent material(geologic) 0 VT U)45 H �� Depth to Bedronl( Depth to Groundwater. Standing Water in Hole: Weeping fi•omPltPnoe �/a �_l" � . Estimated Seasonal High Groundwater N -�T DETERMINATION FOR SEASONAL-HI Method Used: GH WATER TABLE Depth Observed standing In obs.hole: De{lth to weeping from side of obs.hole: Ib. Depth to Boll mottles: Itt. Index Well 0 Reading Date: Index Well level_ ,_� Groundwater Adjustmont t AdJ•factor„ pdj,Cmundwatetlevel,, _ Observation PERCOLATION TEST bate Thud Hole 1P Time at 9" Depth of Pere Time at 6" Start Pro-soak Time @ Time(9,141 End Pro-soak Rate Mih-fluch , Al. O m llu 5 5 �e,( Sltc Sultability Assessment: Site Passed 3itp Failed: Additional Testing Needed(Y/N) Original: Public Health Division Obser'I lon Hole Data To Be Completed on Back-- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Consefvation Division at least one(1) week prior to beginning, (/ Q:15EPT1 APERCFORM.DOC DEEP•OBSERVATION HOLE LOG Hole Depth from Solt Horizon Soil Texture Sdil Color Solt• Other Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stoneg;Boulders. r sit etency.%'Grayell 7 O .A lou DEEP OBSERVATION HOLE LOG Hole# 2— Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency. A �S toga 3 t, a- Z— C (YI DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soli Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stories;Boulders. n t ' Flood Insurance Rate Map: Above 500 year Mood boundary No— Yes Within 500 year boundary No Yes ' Within 1.00 year flood boundary No., Yes Depth of It Occurrint:Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed thrpughout the area proposed for the soil absorption system? -- If not,what is the depth of haturally occurring pervious matartall Certiflention I certify that on [r q (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by ma consistent with . the required tral ing,expertise qy jxperience described in 110 CNM 15.017. Signature Date QAS.l3- ICWERCPORM.DOC I fr lr—,-t Town of Barnstable `4garnstable Regulatory Services Department M�AmfftaC"j IARNSPAete ' 9� "�: � Public Health Division �f0 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7014 1200 0001 0358 3322 5/14/2015 Steven Janney 86 Cottonwood Lane Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 86 Cottonwood, Centerville,MA was last inspected on • March 4, 2009,by Michael DiBuono, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification.. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH s-Mc ean, R.S., CHO Agent of the Board of Health i Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\86 Cottonwood Ln cent May 2015.doc C Town of Barnstable + BARN9TABLL + ,�� Regulatory. Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/28/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE 1 YEAR DEADLINE CRITERIA Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet-of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <1.2" below pit (per Town Code §360-9.1) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of MassachusettsLLv� r W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cottonwood Lane iG^M Property Address Steven Janneya Owner Owner's Name 4 information is t,�y required for every Centerville MA 02601 4/28/15 x. page. Gity/Town State Zip Code , Date of Inspection J1 Inspection results must be submitted on this form. Inspection forms may not be altered in any C_n way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms Q on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain rea Company Name 8 Johns path Company Address S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 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 al Approving Authority _ 4/28/15 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. c 4� t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is Centerville MA 02601 4/28/15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in hydraulic failure. System contains 1000 gal tank, dbox wich is rotted and decayed, and a 1000 gal leach pit. Effluent level in leach pit is up to cover. Invert pipe to leach pit is under water. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusptts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if 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): f ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville . MA 02601 4/28/15 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 ❑ 2 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 1/2 day flow t5ins•3/13 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 M 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is Centerville MA 02601 4/28/15, required for every page. City/Town 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. l 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 r ❑ ❑ 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•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cottonwood Lane_ Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: System is in hydraulic failure. System contains 1000 gal tank, dbox wich is rotted and decayed, and a 1000 gal leach pit. Effluent level in leach pit is up to cover. Invert pipe to leach pit is under water. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ®' No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears'usa e d 167.6 gpd 9 ( Y 9 (gpd)): Detail: 2013: 58,000 gal - 2014: 64,000 gal Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/lndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13- - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Bortolotti Construction (5/13/11) Was system pumped as part of the inspection? ® 'Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site glass on truck Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 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: 35 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 28 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.): System is vented throught the roof. Septic Tank (locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon Sludge depth: 3" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 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 24" Scum thickness 3„ Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was pumped at time of inspection. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: — Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title '5 Official Inspection Form co Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cottonwood Lane Property Address Steven Janney Owner . Owner's Name information is required for every Centerville MA 02601 4/28/15 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was pumped at time of inspection. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy,attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert above normal 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.): Distribution Box shows signs of carry over and decay. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes. ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 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.): No efluent above ground level Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 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 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 page. Cityfrown 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.): No efluent above ground level 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•3113 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 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 £'� � .: E �� ,,r E3 ..r.« .,^-,"y y,_„: •"�'=?" ,v� 'fn �i3' t 3 <mu !'^"� �!E 's`. ^.�,.' ,�; ..0 .. r. � f, yr.��'��',bl' � �•yti�.,.r'1 �a,� Sri}fY t�£I' :i!� v �o� ��,E�¢5's� 3rt���'f'f s� 'y��'' rs�fi � ` E "':':'U��:i '�" 1 � Y°/ 9' - 3 ss i3 f' Ei 3 � 34 � 3 i _5 `;•� t 3 r E ii .:4, �, f f;;%'•� 3•- r x � l P..,� € d•',£a r 3 y �>�� +;':' yn y s�',� ��� �h� �,��`;'33 RN',k' iy.,:: �� ��,, .';�lE. 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EI,y, � e ;�R £ ' fir{ �•_. � f � } �xy Y F `,pp�' ,G}� X § E i ;. y �..IJ }' �.E? •EE�. c�' ` GE� ,3 i u'�;/... r €>SF5 '' fy f i ��� :..E i i f€•' �E`E•` £� � �l:EE E i4 i i ,� � � ,��%:— E:i� !tE.` i F» E v5 a'�3�h� 3r u.�l�':��3>idi�y .;'i'i'��€' s ea �'`'£'I.E!r..'£�f;,,R�Si ��i`E !£. �i�E i�� 3• Es,, '.�.s � �Ej ZE�€,.k.4 Y•�y � �t£� ,� � � £ .A I � 1E EE,� Es.E! Pr... 3'3' va, 4 S,`,3,� .tE C �SS� !R yL�3Y'• 54 ,.E�� s�, '�A9'rE'f i 3. n ..�� tE.�f tt •.Es*E:':.*•,a�.... # 3:��: E�,�q.i� s•S' 3'C1'El:`it`�.5. ... f�:�';v3,uu+, E r Elf, lid ,! �!E ii., v. t"�S};�l,i}}'�},�EE S:'i' � j� ((?� iE,:-- �€�€Ul E3'3 yL' k�',i�3• € r'�P E�1s�E���� �E ����nqq, j�,�� ,q�7 !'. 3 1i '{(EE iE.-. � n3'3.i ,J�� o i �i3$� '3'�: ...q���.x " k•t�.. ! . ^ i ., E £ rVE;riIEl�i 333i ���3 !U[�E'E E E�pP ihE' i �3 K! •�� €.�3�..'� ��..,..���R nP(;,igry i. 3 0 �� c }� � z.. !`� � .• '�� � 'ul�i�, MITI ��y � �i��' �s- 'a 3s33�i R'i �- � a��It""''�i ��#N 3 !31! E k \,• t k4Y � 3 va.�N.. E k,� � ,•� �. ��F33'�E .E,�\4�"F�k ii€�`s ���i,`a<la o::•.... �5. � �'% £,-"��` £ Y„E 5�, 3. ai°f ij - u..,,'i�',' 3 3£E 3��3�"`..��'}i�L lli ��.a� - \� ..•l rr;� 4E� '�,�:. ! � �! x ..., 3 a EaE! � ELd-, f� v � � •e,� \ a•.. �+'i�," .a,� i."f "'�,�'. �.!, -�a, �� i\ �,.• ,(R�� ear, �iuL, .zv},; i.. � .3,.` € p m: 2 Commonwealth of Massachusetts W Title 5 Official Inspection -Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells , Estimated depth to high ground water: 35+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database -explain: usgs map shows nearest lake approximately 35ft below property You must describe how you established the high groundwater elevation: Groundwater will detirmined at time of engineering of new system. System is in hydraulic failure. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form _ e Subsurface Sewage Disposal System Form ,- Not for Voluntary Assessments 86 Cottonwood Lane Property Address Steven Janney Owner Owner's Name information is required for every Centerville MA 02601 4/28/15 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I TOWN OF BARNSTABLE LOCATION 86 COTTVAJ Wood LN , SEWAGE# 2a i5 " 17 6? "VILLAGE C&, 4 e_ry;a e_ ASSESSOR'S MAP&PARCEL , 2" / 5 i INSTALLER'S NAME&PHONE NO. Rpbef T,$,eyC 6 .1»C. 3V 8-93Z e)53o SEPTIC TANK CAPACITY 1,00064 10n o LEACHING FACILITY:(type) 3--6®0 J?q�-HgA Charm.hec5 (size) 91 r X33.3'9 2 NO.OF BEDROOMS _J OWNER PERMIT DATE: (p-JQ - 2 p J S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Al Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) „/f,A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) pp Al JA Feet FURNISHED BY /3Ct� .5M1 lk 1`D �t? ►�.8tN CDo =/tC. `l 2 0 3-3=S'!,3' 9-6 `7!. � �r©n COM-NM0-NT T T OF�L �S =� �EAu; a� /ELT E•�--,,.� �C�IL� i i� EkECUTIVE OFFICE OF E\A-TRO-`^,1E\ _ DEPARTMENT OF ENVIRON`1E'N T_AT, PRO TE C Z- /65 TITLE 5 OFFICIAL INSPECTION FORINI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE`K-kGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: � 1 0�7 G✓p O� N e,17 ✓vi' Cr/dl 6 Owner's Name: ✓ O�i ner's Address: $ v h wo Ge�, e✓vi' Oa r ?-2, F� Date of Inspection: �y�p / Name of Inspector lease print) � " 2~17"/ � Company Name: lam/ — L G if Mailina Address: Pa ,6p]C /d k-G C H Telephone\umber: —p:? CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the below-is rrue, accurate and complete as of the time of the inspection.The inspection,-vas b a zzv r-aininQ and experience in the proper,function and maintenance of on site sewage disposa sysze--s 1 I am a DAP �; approved system inspector pursuant to Section 15.340 of Title 5(310 C1IR 15.000). i `7 CD Conditional:y Passes a CD s 3 Needs Further Evaluation by the Local_�nnroz i� 03 Fails Inspector's Signature: Date: cn rn The system inspector shall submi a copy of this inspector report to the An r P P I p o r__�ufno--, r'oa_a e-J.z=:h t: DEP)within 30 days of completing this inspection.If the system is a shared system or has a deli^'e : gpd or greater, then and the system owner shall submit the report to the a iron-ate regi:� al o= DEP. The original should be sent to the system owner and copies sent to the a-11horitV. -- Notes �e C Gci G'�S e d" A-_ and eV47Jv6cis `'This report only describes conditions at the time of inspection and under the conditions of use at t at time.This inspection does not address how the system will perform in the future under The same or dliferent conditions of use. Title 5 Inspection.Form 611512000 pa?1 1 Page 2of11 OFFICIAL INSPECTION FORM—-NOT FOR VOLU-TARYASSESS',IEtiTS SUBSURFACE SEWAGE DISPOSAL SYSTEM I\SPECTION FORM PART A CERTIFICATIO'!(condr_ued) Property Address: Co#O L✓p0d G- oii n&- Owner: �®-pier Date of Inspection: Inspection Summary: Check A.B.C.D or E i ALWAYS complete all of Section D A System asses: LI have not found any information which indicates that anv of the failure cute=a described =;0 CNER 15.303 or in 3 10 CNIR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: BSys ern Conditionally Passes: Sys or more system components as described in the"Conditional Pass"section Need tob e renlaC.-d or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health. w ill-p_ss. Answer ves, no or not determined(Y,V\7D)in the for the following statements. If"-not deterrnin,- "-pleas: explain. The septic-tank is metal and over 20 years old, er.the septic tank(-whether metal or not) s ucrara i 1. unsound. exhibits substantial infiltration or exfltration or tank failure is im-rrunent. System ?-ass _i _ ec-o~_ 1-h, existing tank is replaced with a complying septic tank as approved by the Board of Healtr. *A metal septic tank will pass inspection if it is structurally sound.not leaking and if a Certif_cate of Co-pliace indicating that the tank is less than 20 years old is available. NM explain: Observation of sewage backup or break out or high static water level in the disc^motion box`uet0 bZpti'n obstructed pipe(s) or due to a broker, settled or uneven distribution box. System will pass ns e c r ~f approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced `,�D ex "ain: The system required pumping more than 4 times a year due to broken or obsy actec pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: T;rlo C Page 3 of i i OFFICIAL INSPECTION FORM- NOT FOR VOLL�-`.�R` ASSESS: IEN TS SUBSURFACE SEWAGE DISPOSAL SYSTEl2 INSPECTION FOR-V PART A CERTIFICATION(continued. Property-Address: a (O Co 0 tj/o0 -.q 4 Owner: /0-0 $✓ Date of Inspection: // Q C.//Further Evaluation is Required by the Board of Health: /// Conditions exist which require further evaluation by the Board of Health in orde_ o dete- ne if he s s-e-M is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CIR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: i Cesspool or privy is v,-.thin 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated tyetland or a salt mash 2. System will fail unless the Board of Health(and Public Water Supplier,if and-) determines that the system is functioning in a manner that protects the public health.safety and en-Vzronment: _ The system has a septic tank and soil absorption system(SAS) and the SAS is 100 fee-of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is a Zone 1 of a public water s-nil_:. The system has a septic tank and SAS and the SAS is v dthin 50 feet of a rrivate�-N-aTer _ The system has a septic tank and SAS and the SAS is less than 100-Peet but 0 feet or rne-e `om a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP cerdi red laborater,-, for col:far bacteria and volatile organic compounds indicates that the well is free from polluio n Tvm-,hat facile and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than pr--m prc•- de th at r o o er failure criteria are triceered.A copy of the analysis must be attached to this 3. Other: Tirlo Tnc.cnt:nn L <;t /tnnn Page 4 of 11 OFFICIAL, I'_VSPECTION FOR-M—NOT FOR VOLIIN'TARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTTON FORM PART A, CERTIFICATION(conti�,red) Property address: // e✓� ✓l// /��} l7ot 6,3aZ Owner: k9l 0/0,P Date of Inspection: D. System Failure Criteria applicable to.all systems: Youmust indicate"yes" or"no"to each of the fohow na for all inspections: Yes No of sewage into facili,y or system component due to overloaded or clogged S__S or :e:.poo: Discharge or pondina of effluent to the surface of the around or surface�z aters due to an oval-c_ e c- /C4692ed SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clo?ge or esspool '� Lieuid depth in cesspool is less than 6"belo�� invert /tt or available volume is less t an =-= c too-. Lequired pumping more than 4 times in the last year NOT due to�cloQ^ed or obsT=,—d Lipe(s;!. Nu—lb . of times pumped _ te�rryy Portion of-he SAS,cesspool or pnvy is below high ground water elev°ation. vAny portion of cesspool_or privy is within 100 feet of a surface water suppl`-or`-bu-a-.°to a ,u-=ac., ater supply. y portion of a cesspool or privy is:�ithffi a Zone 1 of a public we'_'_. portion of a cesspool or privy is-%Zthin 50 feet of a private water sup-v w-e? portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a n :ate .-ater supply well with no acceptable water quality analysis. [This system passes if the well -,s-ater 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,prodded that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Ab (Yes/-No) The system fails:1 have determined that one or more of the above failure CT a exist as described in 310 C°viR 15.303..therefore the system fails.The system owner should contact dhe Beam e 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• You must indicate either"yes"or"no"to each of the foliowina: (The following criteria apply to large systems in addition to the criteria above; ye no e system is within 400 feet of a surface drin1king water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitise area(Interim Wellhead Pro,ec on A-e= — Zone II of a public water supply well if you have answered"yes"to any question in Section E the system is considered a sii ca yes"in Section D above the large system has failed.The owner or operator of.a—m,larr_e s 7.-sdem o~;_cere significant threat under Section E or failed under Section D shall ua�- adee mir ay"orc 15.3 04. The system owner should contact the appropriate reQicnal office or the'Dcpa V rrre . Tir1r� tnc-crt�nn 4--- K!l C/7nnn n Il Page ; of 11 OFFICIAL INSPECTION FORM-NOT FOR V"OLL-,'-N,TA-?�Y ASSESSAIEN T S SUBSURFACE SE`KAGE DISPOSAL. SYSTFtt I\SPECTIO\ FORM P-RT s CHECKLIST Property-Address: �f (_ ovi t,✓bu C✓ e�vim. Owner: / ` 0 �✓ S Date of Inspection: / { Check if the following have been done.You must indicate"yes"or"no"as to each of the Yes \o Pumping information was provided by the owner;occupant, or Board of Healy. ', Were any of the system components pumped out in the previous two«eeL Has the system received normal floats in the pre«ous two meek period? Have large volumes of water been introduced to the system recently or as part of is insoec=cn? ✓ 1,%v ere as built plans of the system obtained and examined?(If they were not available note a;\:_-'0 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? V17— _ Were the septic tank manholes uncovered.opened,and the interior of the tank i snected for-.he :,ord=o^ of the bafflesor tees, material of construction.dimensions,depth of liquid,depth of sludge and de h-of scum Was the facility ovmer and occupants if different from owner ro,.ided�; th s_f^=ri �_ .-^�._-( F )p �� c-ont_ maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been deten--`r`.ed`as or: 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 a.i=st e =—,� , is unacceptable) [310 CMR 15.302(3)(b)] 4/1:!7 Page 6 of I l OFFICIA-L INSPECTION FOR-X1--NOT FOR VOLUNTARY ASSESS-ATENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTE NI INFORIIIATION Property Address: L✓OLV C �Owner o el e Date of Inspection: // 0 FLOW O\DITIO\S , ztESIDE\TIAL -�� — G.2 41 Number of bedrooms(design): 3 -Number of bedrooms(actual): 3 DrSIG flow based on 10 C�IR 5.20 (for example: i l0 gpd x_ofbedrooms_ : \umber of current residents: Does residence have a garbage grinder(yes or no): ef Is laundry on a separate selvage system(yes or no):/ ;if yes separate inspectirn recu-red: L aundry system inspected(yes or no): Seasonal use: (yes or no):;" Water meter readings; if available(last 2 years usage(gpd)): Sump pump (yes or no): AV Last date of occupancy: yi//t✓t CO'.-NI IERCIAL/T\DUSTRIAL Type of establishment: Design flow(based on=10 C_ R. 15.203): gpd Basis of design flow (seats/persons.%sgft,etc.): _ Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): \on-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings. if available: Last date of occupancy/use: OTHER(describe): GENERAL ENTORMATIOZ Pumping Records Source of information: If—4-V'to V-V as system pumped as part of the inspe on(yes or no): /l/u If yes;volume pumped: gallons--How-was quantity pumped determined? Reason for pumping: y T�T SYSTENT _Septic tank, distribution box, soil absorption system _Single cesspool _Overflow-cesspool Pri-vv _shared system(yes or no) (if yes; attach previous inspection reco:cLs,if an,) Innovative;'Alternative technology. Attach a copy-of the current operation and:nain:ena__e obtained from system owner) Tight tank Attach a co-ov of the DEP approval Other(describe): Approximate age of all components. date installed(if known)and rce of info m. oL: (V eb Were sewage odors detected when arriving at the site(yes or no)? (V T'ir?o C �nrnort;n., L,.v.„ <Ji ci�nnr. � Page 7 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLL-.-.- -NRI ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM FART C ,Q/ SYSTEMINFORMATION(contmued) Property Address: 0 (a T7pt� 6c/0(9 C� /—C- N� // Zf Dot 6 �� Owner: /IZO K Bate of Inspection: / 6 BUILDING SEWER(locate on site plan) Depth below grade: pZ 6 Materials of construction: L,-6ast iron other(explain,: Distance from private water supply well or suction 1ine: Comments (on condition of joints.venting, evidence of Ieakage,etc.): f SEPTIC TANK:_(locate on site plan) Depth below grade: � Material of construction: -concrete_meta'__fberglass_polveth}-lene —other(explain) if tank is metal list age: _ Is age confirmed by a Cerrncate of Co reliance(yes or no _,,anach ace^ o certificate) p Dimensions: b Sludge depth: Distance from ton of s1_udge to bottom of outlet tee or baffle: Scum thickness:L-Q Sf /,/ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottoy�of outlet tee gr baffle: How,vere dimensions determined: e a i e Comments.(on pumpingu et recoLntnendations,inlet and o tee or baffle condition. s-micrUral,mieg,7- , 11cuid I as .ed to outlet invert. evide e of leakage.�pc.): /'!� wt �n ✓I o� f�2G c'e� G'7� �-Gl�f �i✓LI ��// �G vt G✓t ��1 ON GREASE TRAP: (locate on site plan) Depth below grade: MateIlai of cousSlctlorl:_concrete—metal_fiberglass polvetn-"iene 0.Th-2 (e xplaln): — 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 purnping: Comments (on pumping recommendations. inlet and outlet tee or baffle condition. as related to outlet invert; evidence of leakage, etc.): I , ,aQe8of11 OFFICIAL INSPECTION FOPUNI-NOT FOR VOLU'\TARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTETNI INSPECTION FOR-NJ .Q SYSTEM INFORIOIATION(continued) Property Address: v O N 64/00d L-a .0mmer: Date of Inspection: // z l/ fa TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(iocate or. site pia~ Denn below trade: Material of construction: concrete metal_fiberglass rolve hylene o ner e�^lam Dimensions: Capacity: gallons Design Flow: gallons./day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches,etc.): DISTRIBUTION BOX: `� (it present must be opered)(locate on site plan) Depth of liquid lex-el above outlet invert: Comments (note if box is level and distribution.to outlets equal.any e-6dence of solids.cz_1,-over. leakage intojrpout f box, etc.):nee A /� �0 PUMP CHANIBER: /V (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber.condition_of pumps and appurtenann, etc.,: Thin � Tn rnartinn h'nrir (mil�[--;nnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM—'SOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEIII\SPECTION FORM PART C SYSTEM IOFORNIATIO' (continued) Property address: _C?I/ pv/ Gt/00a/ �Q _ Owner• 0 � Date of Inspection: /( SOIL ABSORPTION SY STEINI(SAS): (locate on site plan, excavation not required) If SAS not located explain.why: Type <eacl �g pits, number:� (� ,Fj ��� C�S 7`/ leaching chambers, number: r �� leaching galleries,number: leaching trenches.number. length: leaching fields; number, dimensions: overflow cesspool; number: innovative'altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level ofponding,damp soil. condition of, e�e-aro etc. : CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan_) \umber and configuration: Dept-.—top of liquid to inlet invert: Depth of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: _ indication of groundwater inflow(yes or no): Comments(note condition_of soil; signs of hydraulic failure,level ofponding, cmdii on cf vegeta-en. PRIG-'Y: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil. signs of hydraulic failure, level of pondin_.coneitio~C.-I" 1��? \ 1»:lP!`}lull -/�rri� �i.•(�:nnnn Q Pa Lye, 10 of 11 OFFICIAL INS PE CTIO\ FORM—\OT FOR VOLLITA-RY ASSESSMENTS SUBSURFACE SELVAGE DISPOSAL SYSTEM I\SPECTION FORM P AsRT C SYSTEM ENTORidLATIOii' (continued` Property-Address: Cl �� OH (�✓Ot�G� !�A�� Owner: P 0lo e Date of Inspection: SKETCH OF SELVAGE DISPOSAL SYSTEM Provide a sketch of the seNvaae disposal system includuia ties to at least two permanent-ef rence land narks cr benchmarks. Locate all wells within 100 feet. Locate«here public water supply enters tie buy'din_. f1 " 35 ' 03 - 3S ' Page 11 of!1 OFFICIAL INSPECTION FORiI—NOT FOR VOLUNT--kRY ASSESSMENTS SUBSURFACE SE_%37AGE DISPOS_AIL SYSTEM INSPECTION FOR-AT PART C / SYSTEM INFORMATION(continued) Property Address: Ll p ri(,"-pad 4ea ki-y- _ Owner: � o �✓ S' Date of Inspection: l� Q SITE EXA_,N'I Slope Surface eater Check cellar i S`ralloxt-wells Estimated depth to ground water��feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-1f checked,date of design plan reviewed: Ob d site (abutting property/observation hole�7t ''n1 0 feet of SAS) Necked with local Board of Health-explain: Checked local excavators, installers-(attach documentation) Accessed USGS database-explain: You must des 'be how you established the high around ivate elevation: T;..io � Tn rnari;nn �nrm (.+1{!�nnn 1' �\Vla L_`: t-•rJv\tt.�� � � �t�7tZL�o�K •� up C>Aff�.AC� �-RI d.JO�.SZ, �L;;[.t L� t~=L.aw L t�v •c 3 , 33r7 G.Pt� r�Q-t-Ic Tit-!LC = 3�0� t�,o °/o • �}r 6.P.v USE- IoOGl 'GAL. i SPOSA.t_ PtT - USG (o��o �n.t_• dui - /C�, �� -` - • ICU Sr✓• ,, � '2.S + 3 7S G.P.D. �vv1° v + > ►„u � ����i.�'�'c�•t 4tT � BrriTO.K A2EA= Cjd SF. ry JG IP _ . t oc�o G f+L- � Sri'. >< t •c� = K.�O �.'RD. � of�w. S�="F'•-Th*�� TOTAL "L7E.S{6I.i = 425 G.P.D. N 430 'f'oTA L_ tUAt L-f FLvw = 330 6,.F D• ao I GDt�TIOt.I CZ15TE : 1"tra 'Z.�4tt W•00 LEAS. Gvt �. FvutaD Am At- VJ. N Y ;Vr �, _ s : 1 . � � J f No. 19334 y i Y+ !�G T`jTtJ/l Litt C'n r-- ram. .,,. ... .,.,.n ----. •, to .�G3.0 d vE loon +tFCl. •a `Box Sep--iC w4 0" GAL. ett e(7,3 N PIT p Wira,•t a`c WAS► ED A v . i t=tZ`t-tl✓tF C7 FLbT L Pro>=-t LE' Lac-AT;0t-4 c r-Wr I —4 T�4 A,r Pt A t`t jZ L T'a Zia u cam: t 1r.1�t_z�rJ Gc 1PL�(S W VTC A T{-t�: 5{DE.Lt►-�� L✓OT CG?JI�ZEM&),4T DF THE; �ti-rc 1p 123 g A X"Tr Q- < TL-415 Pf_A" i S WOT ZASG0 Vi,4 Ae•1 tt�l,rl:llrtt,t.i� �,c�c_slt��' T{ttw UFt=SF�i 5t1aJLr> AFL"st_tEAt-.i'T" U-,Lo res ;z u 1,t3tt.� �!� ► ► c Jlze Ot.__.�___T _�_'..==-_�q. teet -- Dwelling—No. of Bedrooms• __._rlC-5�____________________Expansion Attic ( ) Garbage Grinder ( ) Pa, Other—Type of Building ____________________________ No. of persons•_-___.-____-_______--____-- Showers { ) — Cafeteria ( ) Other fixtures --------- ------------_--- -------- Design Flow_________________________�g. _._gallons per person per day. Total dais flow___....__________. _ Y -------------gallons. Septic Tank—Liquid'capacity."y° _gallons Length---------------- Width---------------- Diameter---------------- Depth-___-_._____---- x Disposal Trench—No-..-:--------- ------- Width-------------------- Total Length_------------------ Total leaching area--------------------sq. ft. 3 Seepage Pit NO.___ -____ Diameter.................... Depth below inlet-------------------- Total leaching area..................sq. it. z Other Distribution box (k� Dosing tank ( ) Percolation Test Results Performed by---- 1;' --•--ll((_Y �---------------------- Date______g- Test Pit No. 2_____________•-_minutes per inch Depth of Test Pit-__•__-•_--___-___-- Depth to ground water------------------------ --------------------------O Description of Soil___G _ ____-_ - U -- x ---------------------------------•------------------------•----------------------••----------------------•---------------•-------------------------------------------------•--------------------- 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 TITIE 5 of the State Sanitary Code—The-undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed--- -----�'t =.... `I s_�.. ------------- �.�­ -= Dat Application Approved By___... .._�__. - R Date l '� _ -3�-B,J---------- Date Application Disapproved for the following reasons:-------•-------------------------------•-------•----- ------•-----------------------•--•---------------•--•------------------------------------------------------------------------------------------------------------------------ -------- Date PermitNo..................................---------------— - 'Issued------ •---- •------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD �OF HEALTH ........ .........--.......OF..........f3..+! .f litS "�?4./ .- ............... Trr ifirate of fin mpliFan.rle THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�) or Repaired ( } Fnstaller at------- ' c ►?". s _ i#e+t? !--------- �-----j-----ld AF.; ' el? t -••....................._----••- has been installed in accordance with the provisions of TIT LE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------.3_ w_ _' --------- dated_-..-__--_._ THE ISSUANCE OF THIS CERTIFICATE:'SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. - DATE--- Inpetor.- i" C/---------- --- -----------------•--------- = - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF No. .z FEE--- - `" -• 431ap asnl Marko Tnnstrwinn runfit Permission is-jaereby granted---------� t --------------- ----------------------------•---------------- ---------- to Construct ( or Repair ( ) an Individual Sewage Disposal System at No.------- - '' £ street as shown on the application for Disposal Works Construction Pfmmit No------------_---_ Dated_ DATE----- ` Board of alto FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 16 „ 44 i Window 31"x Y n 22 \� 22 30 U1 26 26 frl rz S Window 31"x 1 16 4 �� ' I-'b} era 1 5 m�; 8;25; 44 EXISTING: BASEMENT LEVEL 16 S`_ 44 vJ TvLc 22 G�lt�cst= 26 i D 1 l I 26 1 16 4 W EXISTING: FIRST FLOOR NOT --o S C.A-L�,:-D CL= CLDSC l� SC= S�P,i2-ci5t fit..-✓L- io02 16 / �r « 44 I / WA�IIIA D2 y/1 indow 31"x]3 d LF3n��r,100nn ` nti 26S�S��.�N C6'd 26 3 2- ri 11 ,151, off, LC 5 I {20o M indow 31"x]3 16 4 I l 44 Gl=-lLrN(� 6tT Of-f-C- -T-V EOOAA PROPOSED: BASEMENT LEVEL (No-r TD IS. { ;,•�,�o �z _, ��sL- �� _ �y '' 16 44 22 26 SAML j 26 SA M t,. Pc 5 �•x(4�-411�(r� 16 4 j 44 PROPOSED: FIRST FLOOR L N OT S c,A LC- Ind= 1JJ Dov D = ]70 0¢— i No...f _�.G�- `/ <e -FEs...l i'................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH AppfirFa#ion for Disposal IV nrk Tonstrnrtiun Trani# P Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: -•.............._--... �/2�i.�t. 11Q�C?��� ,t�. ................ ........... �`�v......l= ../� ... ��t _13` ---•-• 4 Lo ation�s Add re Y—> Lot No. ...................... �.��r... rG..:..a-SC2 L�..�' _........... . �...... ••- � Owner- r Address a ........•----•--...... �iCT�',�t�1 ......................... ........../_ jcxz rac w....,1 11�........................................ Installer Address Type of Building Size Lot____�� 6._ .Sq. feet Dwelling—No. of Bedrooms'r4r_....................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ..__..... W Design Flow.......................... ��......__gallons per person per day. Total daily flow------------------SY-l0.............gallons. 04 W Septic Tank—Liquid capacity_1�_gallons Length................ Width................ Diameter__-............. Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No ipeo __. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (p- Dosing tank ( ) Percolation Test Results Performed by....&—/T .;?d tiu......A(A........................ Date....... ........... aTest Pit No. 1-------A--__minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0-4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --•---•---••-----------•--•••-----••••--•••-•-•-•••---•------•----•--•...........................•--......................................................... O Description of Soil r -1..2.. i x U ---•-•---•------••-:-------••••--•---•---•-•••--••.....••••--•-•---••-•--•--•-•--•-•.............••-•--•-••-•----------•--------•------------•--•-•--. ........................................... 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 iITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been isissued bfy, he board of health. Signed.7_t_S..... : W.jl c�a� '..�. ...... ®-...........1FA. Date Application Approved By.......... �. ..` ----/A:.3/-8 _________. Date Application Disapproved for the following reasons:............................................................................................................. ................•---.........-------------------------------•---------------------------.......-•-------- ------------------ Date Permit No.......................................................... ................. ....... Issued-..... - -" 2 Date ab FE$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............r ApplirFatiun for Disposal Works Tuntrnrtion thrmit Application is hereby made for a Permit to Construct (' ) or Repair ( ) an Individual Sewage Disposal System at: ................_--....... .......................................... ......----•-•--........_..........._..---------------•-------------.:......---=-.:...-•-------- Location-Address — or,Lot No. r Owner c Address •...................•--••------• ------•-----..........._............................__........._ ................................ Installer Address QType of Building ` Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms___-. K-_:.....................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------------------•-----------.........:-----------------•-----------------------------------------------------------..........--•--• r'W Design Flow...............................:..........gallons per person per day. Total daily flow........................ ...._...gallons. WSeptic Tank—Liquid capacity.:...! _gallons Length................ Width................ Diameter--.__-_-_______- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........... z!.__._ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (t.- ) Dosing tank ( ) �-' 9� 2'S-Bt.3 W Percolation Test Results Performed by..__�9'1-�-�I'-'_�''-�'_�'t:.�.....L�.Y4:�______________________ Date.___......_.____......_......____._____. Test Pit No. 1......... .....minutes per inch Depth of Test Pit.................... Depth to ground water......................... f Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------------------------- ----------•- --------------------------------------------------------- - - D Description of Soil...-r'' r - ". --------- �'"•l ,.......�'�'�� V .--------------------------------•-------••-------------------------------------------------------------------------------------------•-...------------...------------....----------------•------------- 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed....... :=f/. i L / ./ --- . Date Application Approved B - ��..<G l - -r ,i'� �orj PP PP Y ---- r Application Disapproved for the following reasons:...........................................................................................Date..-_--_..__N ....................•-•----•-------•-•--•----•---•-----------......-•--•-------------......---------•---------•-----......-------------------•---------•----------------•--------------•-•------------- Date PermitNo......................................................... Issued_..................................................... - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD ;OF HEALTH l..... .bOV .........OF..........!..J.. .IZ:dIL! `L1.�,,t'�!t �............................. (Irrtifiratr of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (" ) or Repaired ( ) bY.............A ze AQ)._.........' c. . -----------------•-•-------•-•-•------....---------..................--------------------------•...------..-•-- Installer at.:........... v r------14$...._-...... .........._ .N..---,..... ----------- ----- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....... ......... dated..---------------------- ....................... THE ISSUANCE OF THIS CERTIFICATE"SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 000 z— DATE.. / -•-..�. ...._.. Inspector------------- ------per------ ........................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......�..�.W..�............0 F.........l.�./..'��/1±�.��..,,t:4.t<t�.�..Fry.......................... +v+d FEE... _ Disposal orku %ontrnrtion rrmit Permission is ereby granted ! • e �`aGro -•--------------------------------------••-----•--------.....----...............----- to Construct (tor Repair ( ) an Individual Sewage Disposal System at No.......... _tr 1!' .............. ..............+6A`-............. Street as shown on the application for Disposal Works Construction it No..................... Dated.......................................... r .ir -----•---------••-•----....---. DATE. a � - o................................ r ...... Boad Vfa10t?h -- ---- - FORM 1255 HOBBS & WARREN, INC., PUBLISHERS L 0 CATION%6 SEWAGE PERMIT NO. VILLAGE is I N S T Al ER' NAME i ADDRESS 3 U I L D E R ON OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED /,2 • � �'�._...�-1a _ s A .^ �`'/ t� � ��, }� � � �� �� �� ��, L'&t L14 F L UW s ltV +C ISO G•P•U .•s �tsi�j"t G TAti1 tC 330.. (�i 0 %d • 4-9 155, G, j �CI£-W,4�.1.. Ae.�.A - 15r7 S.F=. i �o�• t I�' �� Q' \ 1��O SF' , �c 'L.S + �'lS G.P.D. �vG° v � �TM��/•l.�►t..►t 4t+' 1 ', to�vt ,new a sr=. p ►, �' t oc>o G AA- SO 6r;: A 1 -C1. 0,�'q,� a TOTAL. '1>1~S16Q = 425 41 { Vm12GDt.p,-Y10Q CZI�TE S � tU ZMi+J,Ott Lf-%. P:;,L)MD +t eo ti 0F ilk' 8'l� dI111JHRia At •� L tVo. 1034 1 NF, j .� Zs,f3a ,-.Y nary =iau.a ��.-. • I/\/�NI'/ %/i'I�'�/T/fig• 4- ' ...,!/ACC .�J%/� -�4 j• 6,r_ �Y q� U ' --Z u65G1L 4 ,0� DtST tw. rNu 'fix 9?�j SEs"�C I to loco `h,U tuv T'aK ' GAL. . LAN 4:: N PIT , Y" G `• WASUED r , STO+.,E g(•D IT— uo -;SC ( bAT�: tJ� U-) C t 1z T 1 P`r T t-(A T T 14 C-_ vG Frx�Np 5►.aO� W Pt A t..1 1Z `cca 1.1 cE t CcaNIPL VG W MA T't-a 51 DE.Q ate V-),23 L mc a. G5•'t'C-.q- /tL-L o _ T1-�IS PI-AW I 4JOT �rCr�� z 1t.t,r`:J�✓lC_tJ; �t�t-�L.t�At�.t T 11 t`+.;r c r-M t N t� LOT ?-t�•��.*� � •AZZZ"1�t.►� � !tau LOCUS N KEY: SEPTIC SYSTEM DESIGN SEPTIC SYSTEM SECTION p EXISTING CONTOUR: ---- O 4PROPOSED CONTOUR: - = p �� 2"PEASTONE OR FILTER FABRIC EXISTING SPOT ELEVATION: 25.5 FLOW ESTIMATE: COVERS WITHIN 6" 3/4"-1 1/2" 0 O O� PROPOSED SPOT ELEVATION: 25.5 104.04 WASHED STONE 0 3 BEDROOMS AT 110 GAL IDAY- 330 GAL/DAY OF FINISHED GRADE Z 2� TEST HOLE: FOUNDATION DATION "` ' INSPECTION PORT � �Q UTILITY POLE: -O- m%�a��������� a\m%�. FENCE LINE: SEPTIC TANK: ELEV.=100.64 n 0 HYDRANT E: 330 GAL/DAY x 2 DAYS= 660 GAL 1/g 3'MAX. '""��` Z ;' CO RETAINING WALL: ® USE 1000 GALLON SEPTIC TANK (EXISTING) 101.04 er ft. COVER \ \ ELEV. a 1/g (V MIN) o 100.28 LEACHING AREA: (EXISTING) er 100.53 ELEV. 100.18 00.01 1 ft. 3-500 GALLON CHAMBERS(8.5'x 4.8'x 2'EFF.DEPTH)WITH ELEV. ELEV. D-BOX ELEV. H 97.81 LOCATION MAP 4' 4 ELEV. LOT 165 (10,362 SF) 2'OF STONE AROUND SIDES AND 4'AT ENDS (8.8'x 33.5'x 2') 1000 GAL (6"STONE UNDER) ASSESSORS MAP:252 PARCEL: 151 SEPT TANK x 3 LAND COURT CASE 20239C SIDE AREA: (8.8'+33.5')x 2 x 2=169 SF (0,74)=125 GAL/DAY IC 3-500 GALLON CHAMBERS WITH TEE SIZES: (TO BE CONFIRMED) 99.81 2'OF STONE AROUND SIDES AND BOTTOM AREA: 8.8'x 33.5'=295 SF (0.74)=218 GAL/DAY INLET:6"UP,13 DOWN OUTLET:6"UP,14"DOWN ELEV. 4'AT ENDS (8.8'x 33.5'x 2'DEEP) CAPACITY=343 GAL/DAY GAS BAFFLE AT OUTLET TEE N TH-1 104.0 TH-2 104.0 TEST HOLE LOGS O/A HORIZON ELEV. O/A HORIZON ELEV. DECK LOAMY SAND LOAMY SAND ENGINEER: THOMAS McLELLAN,P.E. 10YR 4/3 10YR 4/3 7" 103.4 9" 103.2 WITNESS: DAVID STANTON,R.S. B HORIZON B HORIZON BATH DATE: 6-2-15 LOAMY SAND LOAMY SAND KITCHEN BED 24" 10YR 5/8 102.0 30" 10YR 5/8 101.5 BATH ROOM PERCOLATION RATE: <2 MIN/IN C HORIZON C HORIZON BENCHMARK AT MEDIUM SAND MEDIUM SAND ORANGE PAINT MARK 2.5Y 7/4 PERC AT 48" 2.5Y 7/4 ON CONCRETE BRICK ELEVATION=103.58 LIVING GARAGE ROOM BED BED 144" 92.0 144" 92.0 ROOM ROOM NO GROUND WATER ENCOUNTERED 104 \ Shea NOTES: � EXISTING FLOOR PLAN 1.VERTICAL DATUM: ASSUMED 6°'0 2.MUNICAPAL WATER IS AVAILABLE. \A 1� r ji3 \\ ~\ 3.SCHEDULE 40-4"PVC PIPE TO BE USED THROUGHOUT SEPTIC SYSTEM. 4.ALL PRECAST UNITS SUBJECT TO TRAFFIC LOADS TO CONFORM WITH AASHTO H-20 SPECIFICATIONS. )�\ "105 LP � � 5.PIPE PITCH= 1/8" PER FOOT(UNLESS NOTED OTHERWISE). 6.FIRST 2'OF PIPE OUT OF D-BOX TO BE SET LEVEL. 103 G0 \ e\ s 7.THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE USE OF A GARBAGE DISPOSAL. 18"oak 8.ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE STATE OF MASS.ENVIRONMENTAL C E { 102 \o` o= CODE(TITLE FIVE)AND LOCAL HEALTH REGULATIONS. �I \� 9.CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. \ \ 101 QP��J� ��`'O���Goe �r? 10.GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED 31. \ \ 10� 11.FIELD SURVEY PROVIDED BY TERRY A.WARNER,P.L.S.,HARWICH,MA. NZ \ \ '°j 12.THIS PLAN REQUIRES THE REVIEW AND APPROVAL OF ONE OR MORE TOWN DEPARTMENTS AND �� IS SUBJECT TO CHANGE UNTIL SUCH TIME. \ \ o r 104 13.EXISTING LEACH PIT IS TO BE PUMPED AND FILLED WITH SAND OR REMOVED. 14.D-BOX TO BE WATER TESTED TO ENSURE LEVELNESS AND EQUAL FLOW. 99 100 \ \ \ W o 2 \ \ \ \ 103 Q dC0 \\� \\ \ \ // //�• \99 \ \ \ \� Shed / SITE PLAN Q \ \ \ \ LOCATION: \ \ \\ \\ LN. CENTERVILLE MA \\ \\\ \\ \\\ 220 86 COTTONWOOD Q 98 \\ \ \ 55gaµ' PREPARED FOR: STEVE & JESSICA JANNEY \ r \ \\ \ 102 i , SCALE: 1"220' V DATE:6-2-15 \ c , 98 101 \ � . \ \99 100 '` BASS RIVER ENGINEERING THOMAS J. McLJELLAN, P.E. P.O.BOX 1163, EAST DENNIS,MA 02641 508-385-3426 OR 508-364-9048 M15-15