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HomeMy WebLinkAbout0101 COTTONWOOD LANE - Health 101 Cottonwood Ln. (Centerville) A= No.42101/3 ORA Ps 601, F0 Q N GK 1o0ro 5 �: © 0 p fl No.�,L 0 '"1 �k t Fee Q U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEI MASSACHUSETTS Yes Rlpfitation for Nsposal 6pBtCltt ConstCUttion Verlttit Application for a Permit to Construct( ) Repair(/) Upgrade( ) Abandon( ) ❑Complete System Andividual.Components Location Address or Lot No. 101 COI- MW OOD 1/�� Owner's Name,Address,an 1 el.No. tab C.e., eve W111rGrn a rW00D LQ.r� Assessor's Map/Parcel /�/� 25Z I?Gl1- (5 4 y e e Installer's ame,Address,and Tel.No. Designer's Name,Address,and Tel.No. _B�13 tX0vafton 6o9,417�o66,3 `JownCt�$es �(oZ� 5 d�.. rt Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building j'L(AtA(_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures A Design Flow(min.re tired) gpd Design flow provided I gpd Plan Date I I 1�Ct1 Number of sheets Revision Date Title T1 fle. Size of Septic Tank J00 0 Type of S.A.S. ' A , Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by 14 j2 Date /2 a VT 1 - 1 Application Disapproved by Date for the following reasons Permit No. a a)'- 13 Date Issued 1 7 / No. 6 h... (I�� R Fee THE COMMONWEALTH OF MASSACHUSETTS, Entered in computer: =PUBLIC HEATH DIVISION - TOWN OF BARNSTABLE IVIk ACHUSETTS Yes application for Misposar 6pstem Construttionf 3permit «N, Application for a Permit to Construct( ) Repair(') Upgrade( ) Abandon( ) El Complete System Individual Components Location Address or Lot No. 101 GD ffonwDOD D Owner's Name,Address,and Tel.No. f'�@n�EJ� ! E' wl � (1(.,till�)CI IU1 (6Hbg1uUof7 Assessor's Map/Parcel 'AA 25 Z ►?el re e 15 1 n P r,,i 2. Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Bib xL4VC(tlon 5b�`�l7 U(05 -b n(04)k,�tt-R 36,2-- 464► 7 C� nl nS.I \ -ij *i,ne ^6r , Type of Building: Dwelling No.of Bedrooms Is Lot Size sq.ft. Garbage Grinder( ) Other Type of Building :RP EI Cl No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re uiredd) 3 gpd Design flow provided 3 Y� gpd Plan u Date I �q`t I ( Number of sheets Revision Date Title 11 f l P 5 i c—I'l Q n Size of Septic Tank 1 000 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed _Al WM Date I Z 1 T 1 t 1 Application Approved by Date 12 7 Application Disapproved by v Vr Date for the following reasons Permit No. D v 11- y3 b Date Issued 1 .7 a 7 ji THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS QUrtificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(v/) Upgraded( ) Abandoned( )by `t �� � at 101 (.r o W-)n t j),00 (7 g has been constructed in accordance I with the provisions of Title 5 and the for Disposal System Construction Permit No.�Q II V?h dated 1�12 7 // Installer �rZ�C +�-{ 1( t U �� Designer CAM r vr6aQ �n n I (1 PP I( 1 #bedrooms _ Approved de •g flow J gpd The issuance of this ermit shall not be construed as a guarantee that the system will func iol asyd-esign Date 13 J�— Inspector (� '�1�• I No. I' Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construction Permit Permission is hereby granted to Construct( ) Repair(�/) Upgrade( ) Abandon( ) System located at t Co f l,o w ol-)n L! 1(1 f C-Q 1 1'r \h lie and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with i T. Title 5 and the following local provisions or special conditions. .J Provided:Constructi n must Ye completed within three years of the date of this permit Date I /i Approved by G1 f FROM :down cape engineering inc FAX NO. :15083629880 Jan. 04 2012 09:46AM PI T-hufsk c", 200 hWn"'),trect,IITP.TDM"� Wf"', Office: 508-802.464,1 Fax: 509-190-6104 Tnstaucir,*Y)esigPeh(- Dntp: / YIL2— SkIvage 1pmd" 7 na L A, Addrms. 114. ou �--Xf n MJ(O�Kmq IsS LICCI ,i permi L to iast.,,fl I a sc-Ptic system.91: V)Wod La.14. I-wcd On a(Itsi Pi dr-swu by cLattd I Lhat.the mpLIL', sYS-ff'.M Vefffrf,-IlGed iIbOVC WU iTIS'DII'd 3,1111,StUntiallY zCUOYCEILC, to WIdO MLLY minor app-rovod cbatages s(loh ;,q laterui rol-ocation of tQie distnbutioa box am-yor sertic tLUA-. 1 cev.fly that the "L"-Ptic systein Tdowe,11Cnd '-fllove was LAstallud with. Ill.ajur ('11tageF; (J-.r". W.- c.cItel- LjjjjtL 1(.)' lateml rodocah'.011 Of d1c, SAS ox U)Y verdiCal relocatiurl of any compoo.eul of the sep tic system) b-cit is accmdmuv, with StRU, (It Local Remllu6uu�. plus.-Cavislcm or certiiicd as-built by desi�rncr to f0dow. AtA 01.4fjs. DANIELA, OJALA CIVILrl, Ce'T"s, I No 46502 0 FF'/ST 101Y L IE C'.- ur.t:,) l'ITBLIC H EA n v "ftE W.9j, N0T ith TSISTU-L4,D, 1:1f4'rjL jm)`.V3-T. TMS FUNM AND A,L..fW Yj CARD A, KLr(,'F,jVED fff THI�IiAT4NSTAU-Q' LICUEAf,'.UTT)TVTIIIIUI%i. -4t4Ith/6rpiiu/Desi9Drr(leitificztign.17oim 3.26 Ott dni-, �- '� /2 ;� � r R�� �� Q W � b �� � � � --� � N _� � � � � � � �z a _ �� �� � �� � � � � � � � _o � -� G � � �. � C a = � �� � � �. - O (� `__ '� � � � �� � � TRA04S. NO.: CITY/TOWN: 'T��U�LC arc APPLICANT:: 1AJ to DESIGN FLOW: Jo 5pd REVIEWED BY: DATE: N/A OK NO d f�JkS' fiii- � � �,i•du .-.a:r+ ..�. ...L� .1'� '.t, A -��sZ�F3YFN1. L� MK.�f`�1.. Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 CNM 15.220(4)(u)] Locus Provided [310 CNM 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for components) [310 CMR 15.220(4)] v Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways, parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] = Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)(f)] daily flow septic tank capacity(required and provided) soil absorption system(required and provided) whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CAM 15.220(4)(h) and (i)] Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)(j)] Observed and Adjusted groundwater (method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(11)] t Address Sheet 1 of 7 Location of every water supply, public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. f beyond setbacks listed in 310 CMR 15.211 and any catch basins ✓ located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located[310 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[11) Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(o)] Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor (required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to cozlfi��n adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not> 36" deep (unless Local Upgrade Approval or LUA requested) [310 CMR 15.405(1(b)] Address Sheet 2 of 7 NIA OK NO Size OK? [310 CMR 15.223(1)] Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" 1 5" per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees (no less than liquid / depth) [310 CMR 15227(2)] �/ Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA [310 CMR 15.405(l)(k)] Minunum cover 9" (Tanks buried more than 9" must have risers / on all openings and on the d-box) [310 CMR 15.2228(l) and 310 J CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<1000gpd, two for systems>1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] -y I��uli� Required when other than single-family dwelling or flow>1000 gpd [310 CMR 15.223(1)(b)] First compartment 200% daily flow; Second compartment 100% daily flow [310 CMR 15.224(2) and (3)] "U" pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address Sheet 3 of 7 i N/A OK NO -1LT 1J.11Llk�'Jl1'VG;�A�S���'� �t�TY7lJL'rll'�_Y��YlYi�'�Ae r�� ,Rv'i�i'�•'&�1U`7" r `.,. . ����.a�4,�tr. ,.1� 4 k.F l Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below water line (when water and J sewer cross, see 310 CMR 15.211(1)[11) Cleanouts required/provided ? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0,02 preferable [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphon problem/ (leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] �serif than 9" [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sump 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] v Capacity(emergency storage above working--design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR. 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, discomiects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating m lead-lag mode. [310 CMR 15.231(6) and(e)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations needed?Provided? [310 CMR 15.221(8)] Address Sheet 4 of 7 N/A 0K NO Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CNM 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] . Inspection parts specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] .......... Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole (if>2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate 1'minimum- 4'maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)] IV Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] 100 feet-maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater (3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10'minimum. [310 CMR 15.252(2)(f)] Bottom area used in calculations only [310 CMR 15.252(2)(i)] Address Sheet 5 of 7 N/A OIL NO Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] If used in gravelless system- make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year (systems<2000 gpd) or quarterly (>2000gpd) good to note on plan [310 CNIR 15.254(2)(d)] Collstruction in fill -Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] a CBr�aa ess er a jWA ��I�T1 Cu­sedwith ck DEP Approval letters for credits and design conditions If pressure dosing do not allow pressure discharge Fto scour soil interface IiBIII�dlZt6F�1 � � � e ers] ... y.. Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance �• Are the variances listed on the plan ? [310 CMR 15.220 (4)(q)] _ RLS Stamp necessary on plan if a component is within ftve feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.4141 Sheet 6 of 7 Address N/A OIL NO Is the system in a Designated Nitrogen Sensitive Area (Zone 11 for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15 216(1)] Pumping to septic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] Address Sheet 7 of 7 Town of B arnstabk • �I RE rbt JDepartmont of Regulatory Services o / Public I[���11>Gl(� I�a������� ]Date BARNBTABLYB . i6Aa& 200 Main Street,Hyanuis MA 02601 9 PIP Pd.#-/0 Date Scheduled_ f / Ttme Soil Szdtability Assessm entfor Se Disposal s S -- PcrPonned By:_ Witnessed By.: ILOCA7['ION' & G EI�TJ,RA L][NT'O][�Im/i ATION locution Address /O / CV ,�a0,01 Lara . Owner's Name Address Assessor's Map/Parcel: - )gQ `� Cngiucer's Name 0 vJ t'` V e NEW CONSTRUCTION RBPAIR Telephone It C� 0� Land Use Slopes CY-) Surface SLunes rN� Distance's from: Open Water Body /. ft Possible WeL.Area ft Drinking Water Well ft Draihage Way _ft Properly l-lne /i/ ft Other ''"^A- ft f .SKETCH., (SLTeet came,dimensions of lot,exact locations of lest Boles&pert tests,locate wetlands'ln pro)inuly to boles) 10 � V � zs��i, T e C 40 Parent material(geologic)_aV-(�/qLS/r Depth to Becb'oclt, / Depth to Groundwater: Standing Water ill Hole: lVe)N�. Wecphig 11'am Pit Roe Estimated Seasonal High Oioundwater DE T ERI INA7C][ON FOR SE AS ONAL HIGH WATER TABLE Method used: Depth Observed standing in obs. hole: In, Depth to sail Izluttlss; Depth to weeping,from side aEobs.hole: _ In, c1ruuarlwuterAdJu811-flent Index Well 0 Rcading Date: Index Well level � _ Ad�I,ftletdr- AliJ,C]Pt?undWutet'l�vul W [Depth bservation ole It ! Time,tit V of Perc Iinp at 6" Start Pre-soak Time @ Timc,(9"4') End Prc-soak. Rate Min./Ineli Sitc Suilabillly Assessment: Site Passed_ Silg--Failed: Additional Testing Needed(Y/1`I) Original: Public Health Division Observation Hole Data To Be Completed on Back---- - ***li percolation test is to be cond acted vviLYliia 1001 of vvei[lend, you must lfil'slt uloffy HIC. Barnstable Conservatloll 1jivlslon at least 011C (1) week prici' to beg0.fl uir..q. Q:\SCPTIC\PLRCF,ORN9.DOC DUCT"?-O.BSRjVAT][®N Depth from ®� �� Soil ----- Soil Horizon �]f + ]L Soil ]Dole # SurL�ce(in.) Texture 'Sdjl color r (USDA). Other .(Munsell) Mottlin g (Structure,Stones'; Boulders. /�� � Con iste c %- ravel -- �5 s DEEP O-R&ER VATIO�d HOLE ]LOG Depth from Soil horizon I-10.1e # (USDA) — Surface(in.) Soil Texture Soil Color Soil (Mimsell) Mottling (StructurOe,Ier Stories, Boulders. U� — 4— . • . L.S Con" err % Gravel D]E-EP ®-d5]ERVA T-10—ITT 11-0—L ]L®� Depth from soil Horizon Surface(jn.j Soil Textur �e Soil Color, # " (USDA) Soil her (Munsell) Mottling (Structure,Stories,Boulders. Consistency gp Onvell --—_. — JU,EEP 02SER V'A.11.11O W Jl.1LO1LlE ' H .. Depth fi-om Soil Horizon � ®� Hole# Surface(in.) Soil Texture Soil Color 5'ofl (USDA) .• (Munsell Other Mottling (Structure,Stones;Boulders, Cans' tenpy r_ ,G pravY Mood Insurance 1( me Ma Above 500 year.food boundary No yes 'Within 500 year boundary No -- Vas.•,_;_„•,_ Within 100year flood boundary No ydg � ](�e>p�l� ut l4TrntwfraJ�y� 000U ring P� ,Vxota,s Material Does at least four feet of naturally occurring pervious matorial exist in all areas observed throughout the area proposed for the soil absorption system' If not, what is the depth of naturally occurring pervious marel'ial� Cu?n:tuf�---ec�fcno� I certify that On (date)I have passed the soil evaluator examination approved by the ]Department of environmental.Protection and that the above analy.-iS was performed by me consistent with ilia regidred training, expertise and experience described in �10 CAIR 15.017. Signature-- Dike Q:\S,EPTfC1PERCr0 lZM.DOC I Town of Barnstable bcftBarns d p THE T°�� Av-America City M Regulatory Services Department , i + MRNSTABLE, MASS.1639 Public Health Division �� m plfb MAC h 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.GeilerLeach pit is only3f )undwagter,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 5248 May 4, 2011 Ms Ida Gold 101 Cottonwood Lane Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system at 101 Cottonwood Lane, Centerville,MA was last inspected on 4/21/2011 by Troy Williams a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS • Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action J PER ORDER OF THE B ARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc Postal pCERTIFIED MAILRECEIPT p f1J (Domestic toniy;No Insurance Coverage Provided For delivery information visit our website at www.usps.convo u� - Ln fM . Postage $ M Certified Fee p Return Receipt Fee ` Postm p (Endorsement Required) Herd p ResMcted Delivery Fee_ r=l (Endorsement Required) cc _ . . M Total Postage&Fees CU� ,_..:........_._._ p Sent To Iti Street Apt No.; or PO Box No/p/ L�bMlzo a( !LQ City,State,ZIP+4 e teh✓/LLe. 0i,5T PS Form :0r June 2002tions Certified Mail Providis: �# A mailing receipt ' (as�anay)ZOOZ sun�'OOHE uuad Sd • A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: • Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. to Certified Mail is not available for any class of international mail. to NO INSURANCE COVERAGE IS PROVIDED with. Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To'obtain ReturnReceipt service,please complete and attach a Return Receipt(PS Form 38111 to the article and add applicable postage to cover the fee.Endorse mailpiece Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. • For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery" ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affuc label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery.information;is not available on mail addressed to APOs and Ms. a oft r� Town of Barnstable Barnstable A&Am Y Regulatory Services Department edcaC-I i MRNtiTAQLE, 9 639. `�� Public Health Division �ATEDMA�s 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 1810 0000 3525 5200 April 27, 2011 First Horizon Bank c/o William L. Yan (Buyer) 101 Cottonwood Lane Centerville, MA 01581 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system 101 Cottonwood Lane, Centerville, MA, was last inspected on 4/21/2011, by Troy Williams, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS • Liquid depth in cesspool is less than 6" below invert or available volume is less than ''/z day flow You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOA OF HEALTH rr' o as c ean, R. ., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\I-I SAMPLE 60 Day Deadline.doc ` Commonwealth of Massachusetts _ Z' '�' Title 5- Official Inspection Form -- z5 y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (Buyer) Owner Owner's Name information is 32 Lon Drive, Westboro MA_ 01581 April 21, 2011 required for every g _ _ _ p page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: I ( J O p V key to move your ' (V VVV cursor-do not Troy Williams_ _ use the return key. Name of Inspector Troy Williams Septic Inspections 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 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 Authority71 �•J _A�riil 21, 2011 Inspector's Signature Date E ;, tJ 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 DER 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•09108 Title 5 Official Inspection Form:Subsurface swage Dlspo I Syste Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90- 101 Cottonwood Lane, Centerville Property Address ----� - — First Horizon Bank c/o William L. Yan (Buyer) Owner information is Owner's Name required for every 32 Long-Dfive_Westboro MA 01581 Aril 21, 2011 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): N/A 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (Buyer) Owner Owner's Name -- information is required for ever 32 Long Drive, Westboro MA 01581 y — _ _ April 21, 2011 page. City/Town 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•09108 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 w, 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (BuyerZ _ Owner Owner's Name information is 32 Lon Drive, Westboro MA 01581 Aril 21, 2011 required for every g P page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 1 QQ 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. I ❑ The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria-are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 '/2 day flow t5ins.09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form A -- o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (Buyer) _ Owner Owner's Name information is 32 Lon Drive, Westboro MA 01581 Aril 21, 2011 required for every g p 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: N/A. ❑ ® 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. I ❑ ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts. t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan_(Buyer) _ Owner Owner's Name---------- — — --- --- information is 32 Lon Drive, Westboro MA 01581 April 21, 2011 required for 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 in5peetion? ® ❑ 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 backup? ® ❑ 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•09/08 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 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (Buyer)___ Owner Owner's Name information is 32 Westboro MA 01581 April 21, 2011 required for every on Drive W_ g � _ p page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 i 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 usage last 2 ears d 10=46,000 gals. ( Y 9 (9p )) 09=45,000 gals. Detail: Sump pump? ❑ Yes H No Last date of occupancy: 11/2/10 Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A y, 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (Buyer) Owner Owner's Name information is 32 Lon Drive, Westboro MA 01581 Aril 21, 2011 required for every g _ _� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): N/A t General Information Pumping Records: Source of information: No pumping_info available. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 0 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan Bu er Owner Owner's Name — — information is required for every 32 Long Drive, Westboro MA 01581 April 21, 2011 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, d-box& leach pit were installed on 2/27/84 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"+ I feet Material of construction: ❑ cast iron ® 40 PVC sch20 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.): Flushed lines and found clear at the-time-of inspection. Septic Tank (locate on site plan): Depth below grade: 6" feet Material of construction.- concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5' X 9'X 6' 1000 allon Sludge depth: 41' t5ins•09108 � Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i`; Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments uM 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (Buyer) Owner Owner's Name information is 32 Lon Drive, Westboro MA 01581 Aril 21 2011 required for every g � 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 2 8 Scum thickness 1 I Distance from top of scum to top of outlet tee or baffle 6-1 f Distance from bottom of scum to bottom of outlet tee or baffle 13" — 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 and concrete outlet tees were present. No evidence of leakage or damage was found at the time of inspection. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 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 Date t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments <�M 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c%o William L. Yan Bu er Owner Owner's Name information is 32 Lon Drive, Westboro _MA 01581 Aril 21, 2011 required for every g P _ 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 - I 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): Dimensions: NIA Capacity: N/A-- — — — --- gallons N/A Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -N/A -- -- Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan Buyer)__ _ Owner Owner's Name information is — Lon Drive, Westboro MA 01581 Aril 21, 2011 required for every 9 _ p 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 level with 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. t 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: N/A t5ins•06/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 101 Cottonwood Lane, Centerville Property Address First Horizon_Bank c/o William L. Yan (Buyer) _ Owner Owner's Name information is n 32 Long Drive Westboro MA 01581 April 21 2011 required for every _�_ p page. CitylTown State Zip Code Date of Inspection D. System Information (cons.) Type: ® leaching pits number: 1 -4'X6'with 3' of stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: I ❑ 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.)-. Soil was sandy. Leach pit was found 1' of water due to vacancy with walls found stained above inlet line and up risers. This is evidence of leaching being full and in hydraulic failure when home was occupied. System does not have a minimum 1/2 day flow available. 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 NA 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (Buyer) Owner Owner's Name information is 32 Lon Drive, Westboro MA 01581 April 21, 2011 required for every _ page. Cityl 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 1 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w.M 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (Buyer) Owner Owner's Name information is 9 v 32 Lon Drive,Westboro MA 01581 Aril 21 2011 required for every _ _ _ ___ , 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 I O 3 0 2-. = 3 5 ` q_ 2r r 3 3 L 3 ' 3 -? Y t5ins.09/011 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (Buyer) _ Owner Owner's Name information is 32 Lon Drive, Westboro MA 01581 Aril 21, 2011 required for every g p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam.- Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 + 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: Date 4 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 22.6' 2.6' adjustment _ You must describe how you established the high ground water elevation.- Test hole recorded on plan showed no water found at a depth of 12.0'. Hand augered to groundwater and found at 10.0'. Groundwater adjustment was 2.6' at the time of inspection. Bottom of leaching at 7.6'was found not to be located in the high groundwater level at the time of inspection. USGS maps put groundwater at approx.19.7'_. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 101 Cottonwood Lane, Centerville Property Address First Horizon Bank c/o William L. Yan (Buyer) Owner Owner's Name information is g v 32 Lon Drive, Westboro MA 01581 Aril 21 2011 required for every _ _ _ April , 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17. I 1 TOWN OF BARNSTABLE LOCATION 101 Ooffon j joo d LnJ SEWAGE# 0101/ • y,7G 1 f V LLAGE (2 enat r✓;I I c- ASSESSOR'S MAP&PARCEL �Se7 • /SS/ INSTALLER'S NAME&PHONE NO. IS i R excc,,za_4;an N7 7. ae 53 SEPTIC TANK CAPACITY 1000 qa,/ LEACHING FACILITY: (type) Zt-;')4ra4ors (size) NO.OF BEDROOMS 3 OWNER GJ;) I,'at" Lvarx PERMIT DATE: !2-'�7. / 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 L Al - 31 ' '61 - /s' y AZ•3�'!Z .Bz- zo ' A3" 36 ,fie ) P i ` MAP LOT I54 PAH .` C( tMMI Nwl,;nl,'rf I OF I',NVIRONMI-;NTAi. AI FAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 7 SsJ TITLE S OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM PART A CERTIFICATION Property Address: J01 0- Otj WIX)b W, _0. TE12�t RECEIVED Owner's Name: �fn'?N 60C.KLe-IZ Owner's Address: S14ME Date of Inspection: Ol AUG 2 7 2001 TOWN OF BARNSTABLE Name of Inspector: Dion C. Dugan HEALTH DEPT. Company Name: 1543 Main St. Mailing Address: Brewster, MA 02631 Telephone Number: (508)896-9390 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 fiuiction and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant t Section-15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ,�— � Date: "Elie system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DE:P)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. Notes and Comments k Recommend: Maintenance pumping every 3 - 5 yrs. ****This report only describes conditions al the time of inspection and under file conditions of use nt (hill lime.. This inspection does not address how the system will perform in the fulw-c under file same or different conditions of use. I illy Ins1u�:Iiun Norm 6/1 ti/_1000 page I I'at,c � ul I I 0FFICIA1, 1NSPF, '" ION FOR0�1 -- NO T FOR VOLUNTARV ASSE SMLN'I'S SUBSURFAC ', Si?WA(:14, UISI'(.)SAi, SVS'1'h;M INSPF,('YMN FORM PART A CERTIFICATION (corninttc(l) Properly Address: j Owner: (may ('a,JC�.I.(:-E�— Date of Inspection: _ $_I I to 1 01 Inspection Summary: Check A,B,C,D or F.,/ALWAYS complete all of Section D A. stem Passes: I have not found wiy information which indicates that any of the failure criteria described in 310 CMR 1.5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System Conditionally Passes: e or more system components as described in the"Conditional Pass"section need to be replaced or repaired. Th stem, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not de lined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and o 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying se 'c tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is s aurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is ava ble. ND explain: Observation of sewage backup or break out or high static wale vel in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. em will pass inspection if(with approval of Board of Health): i broken pipe(s) are replaced I obstruction is removed distribution box is leveled or replaced ND explain: — The system reyui,ccl pumping more than 4 times it year due to broken or ohslructcd pipe(s). I•hc sys',tbq will pass inspection if(wilh approval of the Board of I lealth): �, broken pipc(s) are replaced obstruction is removed ND explain: i of I I OFFICIAL INSPF,CI'ION FORM - NOT FOR VOLUNTARY ASSE.SSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PA RT A CERTIFICATION (continued) Property Address: QL 1=-0-1 � �, �1�_ Owner: Datc of Inspection: a I to 11 t G. Further Evaluation is Required by the Board of Health: _ Conditions exist which require tiu7her evaluation by the Board of 1-lealth in order to determine if the system is failing protect public health, safety or the environment. 1. System ill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is t functioning in a manner which will protect public health,safety and the environment: Cesspool o rivy is within 50 feet of a surface water — Cesspool or p ' is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board o ealth(and Public Water Supplier,if any)determines that the system is functioning in a manner that pr ects the public health,safety and environment: _ The system has a septic tank and soil ab tion system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface wa supply. The system has a septic tank and SAS and the SA is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is ' in 50 feet of a private water supply well. _ "fhe system has a septic tank and SAS and the SAS is less th 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 certifi laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from po tion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 p , provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I'ug,r I ul I I OFFICIAL INSPF:('"HON FORM -- NOT FOR VO)1,11N"1•ARY ASSESSMENTS SUBSURFACF. SEWAGE DISPOSAL SYS"1'EM INSFIF('"HO)N FORM PART A C•ERTIFICA'HO)N (continued) Property Address: ] �O1_QTpUNIACM UJ. Owner: 6rry--i (3�LKt�IZ Date of Inspection: 81tte lam_ D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 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. 1 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• 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) N/A _ the system is within 400 feet ofa surface drinking.watcr supply N/A __ the system is within 200 Feel of a tributary to a surdhce chinking water supply, N/A lie syslcnr is located in a nitrogen seisilivc area (In(crini Wellhead Prulecliun Arca IWPA)urn mappcd Zone II of;r public water supply well It you have answered "yes" to ;illy (lucstiull in Section 1: the syslcnr is considered a significant lhre;il, of answcrcd ..yrs„ in Scclirnr 1)above the large sy,;lcni has Ihilcd. Hlc owner or uperalor of any large systellr conrsidewd a r;iy..nilic;ml lhrcn( uncdet Section 1{nr f,iilvd under Section 1) shall upg,rndc Ill; systclll nr acundancr wish 310('MR I 'i, i0.1. I he syslcllr owner should cnntnel the appropriate rrginnal nl lice of Ilic I)ep;rr(nicnl 11;1re 5 01 I I OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACh; SEWAGE DISPOSAL SYSTEM INSI'1 CTION FORM PA RT I CHECKLIST Property Address: _AJOL-W__TIV n1Q(b.Ljlj• _Q;aYLyt l_1_,E_ —. Owner: CiRRl-A GULL Op Date of Inspection: Check if the following have been done. You must indicate"):s"or"no"as to each of the following: Y 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 e 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: Ye no Existing information. For example, a plan at the Board of Health. _ Determined in the field (if any of-tic failure criteria related to Part C is at issue approximation of distance is unacceptable) )310 CMR 15.302(3)(b)) s ...... , 11,Ige h of I I OFFICIAL INSPECTION FORM -- NOT hOM VOLUNTARY ASSESSMVN'I'S SUBSURFACE SEWACE DISPOSAL SYS'1'1?M INSPEC T10N DORM PA R'I' C SYS'I'l?M INFOMMA'HON Property Address: C J�— O w n e r: Date of Inspection: _ Ohu I Ql FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -3__ Numbc.-of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x N of bedrooms): _3,3D Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no):NQ Water meter readings, if available(last 2 years usage(gpd)): 1999 70,000 gals. 2000 �75,000 gals. Sump pump(yes or no): MO Last date of occupancy: cyRR�U� COMMERCIAL/INDUSTRIAL Type of establishment: �/,4 Design flow(based on 310 CMR 15.20 gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): _ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:��_ N�e� Was system pumped as part of the inspection(yes or no If yes, volume pumped: 1000 gallons-- )-low was quantify pumped determined?AV—&i�' Reason for pumping: M'41A1 f'qNLq AjC'G_; 'IYVE OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool --Privy IVO 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 (Io be obtained from system owner) Tight lank Attach a copy of the I)1:I' approval (hher(describe): Approximate age of all contpon:nts, dale insiallc l (il known) an u d sorce of infuII un: Were scw;igc odors dciccic�l when arriving, Al the sit(' (v� s err uo): No f I'ap,c / of I I OFFICIAL INS1 h;C"HON FORM - NOT FOR VOLUN NARY ASSESSMEN'1'S SUBSURFA(T' SEWAC E DISPOSAL SYSTEM INSPE("FION FORM PART C SYSTEM INFORMATION (continual) Property Address: Owner: G( � Datc of Inspection: _SjjtO U l BUILDING SEWER (locate oil site plan) rr Depth below grade: Materials of construction: _cast iron t/40 PVC__other(explain): _ Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): �i o•Ads 01 ilk T%C a 7- . !ZA6 N f 4,04�4 T1'i o ofF� Nn- -S46 4 S O d c SEPTIC TANK: (locate on site plan) Depth below grade: W It Material of construction: concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: D Sludge depth: " Distance from top of sludge to bottom of outlet tee or baffle: 2 5/ 1 Scum thickness:_( 19 tt Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: G`r How were dimensions determined: by tape and rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): TAAfk WX 5 PQ^AEtl C-LdEdA/ A 4 RESvLT 0 r TIZI s JA)5,Q�d/ * Recommend: Maintenance pumping every 3 - 5 yrs. GREASE TRAP: (locate on site plan) Depth below grade: Material of constnuction: _—concrete--metal__fiberglass_polyethylene_____other (explain)-------- ---- ---- --------- Dimensions: _ Scum thickness:- ---- ----------- Distance from top of'scum to lop of outlet tee or baffle: Distance from holtonl of'scunl to botlom of outlet tee or haftle - - Date of last pumping: -- --_-_.._..--- Commcnts (on pumping reconlnlendaIioils, inlet and oullel tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, ci(:.): I'atr,c � of I I OFFICIAI, INSPECTION FORM -- NOT F(.)R VOLUNTARY ASSESSMENTS SI113S11R1�AC'I? SIsWA(:F, DISPOSAL, SYS'11?M INSI IJ-PION FORM PART C SYSTEM INFORMATION (r.onlinucd) Property Address: �91 C.UTT0�1�baD L.tJ Owner: Gf}Q,y (J�yLaCI�ET� Date of Inspection: Slit, Inl TIG11T or 11OLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) A Depth below grade: Material of constniction: concrete metal fiberglass___polyethylene__other(explain): 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: (if present must be opened)(locate on site plan) It Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) /r Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump,chamber,condition of pumps and appurtenances,etc.): ti I'aµ')of I OFFICIAL INSPECTION FORM _ NOT FOR V0L,UN'1'ARY ASSESSMEMYS SUBSURFACE SEWAGE DISPOSAL SYS'I'EM INSPECTION FORM PA R'1' C SYSTEM INFORMATION (continue(l) Properly Address: _LQ—[(p--jMNv�ne)V tiv. CeVQrT t-4-t? Owner: 6rl'Qy IRLL(.IC- �� Date of Inspection: 4l I(o CO I SOIL A13SO1111TION SYSTEM (SAS): _/(locate on site plan, excavation not required) I l'SAS not located explain why: Ty leaching pits,number:_&,AJC �x y ` /J�-r liV/3 ` or s-i6i(lK 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.): P, i FGolm W / bF L/ Q c ti i41 IT:., ', AI A CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to irdet invert: _- Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): " Recommend: Maintenance pumping every 3 - 5 yrs. PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: _ ------ I Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of'vegetahon, etc.): 11;1K..c 10 ul' I I i i OI 1 ICIAI, INSPECTION C 1 lON FORM - NOT FOR OR VOLUNTARY ASSESSMENTS SUBSURFACE, SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 101 ('(7TnNWQCk-- 1J`l. C't=N' �2�J, tr Owner: (bU-r-k--YL Date of Inspection: -4L(al0 L- SKE'rcti 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. I A = 37 D y 3G'G „ its NbusF �IVI v� V a �0 Pagc I I ur I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE? SI?WA(:1? 1)ISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continue(i) Properly Address: jO�MtN\A-* , Owner: _-dit:V { P L t Date of Inspection: —a.lt OI SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water W feet Plea a indicate(check)all methods used to determine the high ground water elevation: Obtained from system designplans on record-If checked date of design plan reviewed: 2 2 F41- P gn 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 round y ater elevation: Tip s ' - - Z y I No....................... L� FEs..... d.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH cw Applirttttun for Disposal Workri Tunitrttrttun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _=o±...AS4.....�•-•-••• .n...QQQ__d.---....C)....--•--• C .. c v i .�.--........M�_... ........ Location-Address or Lot No. + ..... iLl _. _ �_ 1�1t �Z__..�..4�:..... .V.:1.1 ................. Owner Add e; ss .......... C ...0si..........C-z cP. ..... _... ...�.. 1- A�fit: .E . .......................................... Installer Address VU Type of Building Size Lot_Qj.Ck4 .......Sq. feet Dwelling—No. of Bedrooms_. .r e -......................Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building ._ .._..... No. of persons.M ear.._.... Showers (2) — Cafeteria fixtures .............................:.............. -----------------------------------------••••••-- w Design Flow........55............................gallons per person per day. Total daily flow........3 3>0...._..... ..........gallons. WSeptic Tank—Liquid capacitylQa�..gallons Length_$'' "_ Width�_`-Q... Diameter................ Depth 5'.-FS'............... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.__.._........._....sq. ft. > __._. ............ Diameter.....KX.._..... Depth below inlet....�........... Total leachina area..Seepage Pit No._ .....sq. ft. Z Other Distribution box (YQ Dosing tank� (b.32) '" Percolation Test Results Performed by.. ..k.$................................. Date._T/Z-7_ /J 5.3.............. aTest Pit No. 1.45,. ._......minutes per inch Depth of Test Pit....U........... Depth to ground water. N qm ............ C% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... --••••• ------•••--•-•-•-•--••-- Description of Soil•...4 .2 ........ !�+'fl.t....1©...SJ t 2 z M e d t V w` S PA n�...._� ..._... -------------------------------------------------------------------......................... w UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------•••••••••-----•••••••••-••••-•-...........••••••••••••••••-•-••--••..............••••--•--•---••••--•-•-•---••--•••-•--•••••••-•--•-••-•-•-•.......•••••••••-•••••.......--••--••••. Agreement: I ie undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with t pr visions of TITILj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in per io 1 e sate of Compliance has been issued by the board of health. igne ._..- •--•---.. �...-•--•-••--••......••-••••........•. .. ... .......... Api a 'on Approved By_.. ...-•--- .•--••-•• ------•--------------------------------------•-•-••-••-•-•....•••... ... ............ j Date A ; ieation Disapprove or a following reasons:.......................................................................................................... ••..........................•----•----------•------•--------•--------------••---•---•-----•--.............----................---•-----------------------------------------------------------------...--- Date PermitNo.......................................................... Issued-.................................. Date No......(.....f/....... •. Fxs...... ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q45.�1............ .....OF............. ...--------...........---..... Appliratiun for Disposal Works Tonstrurtion Vrrmit Application is hereby made for a Permit to Construct (}.) or Repair ( ) an Individual Sewage Disposal System at: � ...�!On., �....... ........... = ' .... ........... f1: ....----•................................ Location-Address or Lt No "n ° = i t--- N � ......................: !*� Owner Ad l d ess 3 � V.��,w �� ..... _ -- .......................................... Installer Address UType of`Building Size Lot..1.Q,t� 0,14. ...._..Sq. feet Dwelling—No. of Bedrooms._ (" . ......................Expansion Attic ( ) ` Garbage Grinder ( ) Other—Type of Building., _ No. of ersons.:l—"_��;;__--___ Showers a g, •-- :-=-r• '-�••------ P . ._._._�.........---------------•--••(.�.> — Cafeteria ( ) Otherfixtures ...............................................----•-•----•-••..... W Design Flow......._.3 ............................gallons per person per day. Total daily flow........ .......................gallons. WSeptic Tank—Liquid capacity.a.�p.Q._gallons Lengths'_.(ma's_ Width.i4`-.�Q_" Diameter................ Depth_`-_ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area......_.............sq. ft. Seepage Pit No........t............ Diameter.._.. F....... Depth below inlet.....49........... Total leaching area... 0,g:.....sq. ft. Z Other Distribution box O Dosing tank ( ) Percolation Test Results Performed by... r,�. _ ;._; ._1 J.a. ................................ Date...m ?7./a .............. 1 Test Pit No. 1_ ........minutes per inch Depth of Test Pit.....}. .......... Depth to ground water...t�.u_c,_�...... r14 Test Pit No. 2................minutes per inch Depth of Test Pit...._............... Depth to ground water........................ 1x ------•--••---------------••-•-- ---••-••--•-•-------• ••--••------....-•-------•-•-•----...._......•--•--......•....--•-----.....-•---------•-••--....•. O Description of SoilSoil £s•� '1 z $4 r 1'� + ..._..?. `i ' tit Uf--A-*04------.:2L.,.`s 2u �--•• ` 'v t*t t :F =p� • �- --•. . ..... ....... .......... � UW ------------------------------------------•----...------•---------..._..-•-.......-----•---•-----••----•--•-••--------------.......................................................................... Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------•-----.........-•-------------------.......-----------•--.---------------...------ ..................................... ............................ Agreement: he undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with t p visions of TITL L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in pe io,' _ I,a e ' Cate of Compliance has been issued by the board of health. ....k1c D to Appl. on Approved BY ... ---------------------•---•------•-----•--------------.......... 'i ----------- EY �` /.tl A ication Disapproved f t following reasons:-------•---------------•------------•-----------------••------•-----------------....---•-----••-•-•----------. ....................................... •--------•------•---------•-•----------•--•---•---------------•.......--•--------•--••---------••-----•------•-----•------------•----•--------.....•--......... Date PermitNo......................................................... Issued-....................................................... Date n^t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF............ ............................. (9rdif iratr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ,y) or Repaired ( ) by ' 4 f.,)6,-J-�==-------------------------------- ............................................................................................................. f Installer at------- - •---•--•------------ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code s cribed in the application for Disposal Works Construction Permit No-----q.5 ._._I f................ dated_./.. .............. LL NOT THE ISSUANCE OF THIS CERTIFICATE SHA BE CONSTRUED AS A AIrI E THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................•---.....---..........•--....---•-.----- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF.HEALTH 1n. .....................OF.......... 1C..C^y .. Y;31�.. No... ..yjt_f��...S. FEE...J,l-� ............ Disposal Works Tons#rurtion Oprrmit Permission is hereby granted..... a c_r ~......ao;(............... . ... to Construct or Repair ( ) an Individual Sewage Disposal System at No..... _...j. ..._. t- � -c ......fin C .: �- Street as shown on the application for Disposal Works Construction P�rmit No__ _____ __________ Dated.......................................... ------------ '-- ---- -------------------------------------- ------------ -------- DATE.---•---------/------------------------------•---......------------------...----- oard of Health FORM 1255 A. M. SULKIN, INC., BOSTON .r �.. „ *'fie J S 1.•, -; i r x,t. ._4 - s `l i:,+ 1 s;.r 'e v � `01 e S Q/ 1« a tip- I�t't h 1 Yry ,J IJ , :' !) �.!" A S 4r k �'¢`^4 ��1 // ��++ yy��i 11 j /+. 4l C.Y � J•.lp S 1 Ir. y�.` S ' _• �Vf � !`V ��rT(r. II.:*�./ 1 �Z P� St..t � IV]" ��'� NIA ������?fy�.� ���r`n ;.t � •� ! +�tfi l a ' zs3 4 P� 'fSs• ALJO ORSE In t: No.10951 Q FFssIONAL�a�\ LEGEND EXISTING'' SPOT ELEVATION '-Ox0 " ;.u,. �E.RTIFIED PLOW PLAN EXISTING CONTOUR -- — IV Z- 7 FINISHED SPOT EL.EVATI.ON . 'ROBE ;k .FINISHED CONTOUR O � � ��:EWU¢c APPROVED + BOARD :x t�LpR �a I N HEAILTH P -O '`� `'' , OATS AGENT 'SCALEI / ' ta' DATE 1-2 IJ ""3 I CER1"I1 FY "THA1` THE PR®PiNI<Ea'. I�GISTERE REOISTEI lO ,"F JfDfl.PIG. ' � �� '' SUILIDING.. SHOWN ON THIS PLAN .' CIVIL- V LAND �, ': � �, CONFORMS TO THE ZONING LAWS. ENO:IN'EER L!R' E rk Df�.SY��° � Y }� OF b SNSTABLE, MAS 712 MAIN STREET CH.' n HYXNN' 'I S, VASS. =' 1 $H ' "T ''�F",3.,�""_... ATE Rr,(3, I. r'tiPD `,alJRi/ YOF 4r w . E/T NOTE /I` NEK T. f1ESEPYIC ?'AN.+�' DLidfl y23 d/NG PIT APE MORE TH4N Oa"dEt/ . s,MAParj A "0plA/l J. 7*Z& CONC'ef c®t�e�'R /O Lr9 ICI S�,l.�LL B� ®IP�3L/6/�1T TO GRAD. ''lN , -'kA 4wPYC' P/PE JyerAVY CA 57 .5*'A .AA L l3E USED MIN. P/TCM ® a COVERS /F/N �FC'/✓EK/A Y � 141m. CONGR�TE # A, • G o3• CO YEllw C4—CAM .SAN O I -Aft i— &ACsAeF/LL - U94I10 LEVEL 2�LAYER I�tON hIPE. 1 0.0 a C7AL. • d s s • s • •r r p m4c r, MIN.P/TCN' DIET. • • • • • s r r e • yyAS/dFD S70- ®O1r v sa � ° • • otr . • c ° °+ fP t r a 3`4 AtPlr ! ; s s o r o • • • ••• ♦ @ • • I S / o !/3 +- s s • • • o s r p D PREcAs r,$zAr,94GE { a;?. �'« t13` K � 4?�:�a�� r o. '• <:"s • r . �, • • e r es °_o Pl7 dR E�1//t/ 4ff4RVA7/,PY-1 4T AM14 �INCY �.� ( (SSE 7 [!�lL.aT)O/v; ®/.4A�t.,, . IC ��'s Rf»y� /`�€:i L/� �C.��f;" a t y..,+c 4) *" -Y�•/{��•'c ,.§ nz<" •�y�®VN� i�Y'e JrE� TA�E .- �Ni '; it/✓1f7/�!/6/®iY .46MP� �'7 �._ ,.•. $, .'a, ..ri �.,:./T/® V�,` rry r. _ 5 ,007Z �' YJJ Fri��if Y-,lo� � .t'- !-!: �+ /IING '/�/T .:,�;: J=T-r ♦ei ffEwa„tr.f 87-46§ti I B _f .EAC .tA7 1y - - "w �` r� ,� !/1/f�►',1, a., J�i1►sExsl off` p $CALE /• a/Jy�/V.�l�N — —�r. ell �r. S®/L 7.*ES 1�I 3 3 v Gfa4L. OAy SO L..TEST #/ T.�2 QTiAL EJTINOA7«`E®. LO _ r NUMBER o� 44-ACNIN6 Pin /, FCEY« Et �9. �Y. DATE OF SOJL TEST /�3 « SIDE A—ZACH Alb PER P!Z SQL PT. _ RESULTS IgIJTNE33EB dY J T' J Gci3 r ®OTTOM LICK/NG PER P/T Jl�` S4• FT L.i3�+r'� REI�CQLAT/ON Jta$YBs5 'f Tv PENCOLATJON RATE fk2 Z-44"l-rJMIN. INCH s TOTAL LEACH//YCr A�@E.4 2�� sq. FT.. ,` F sc3/L Z-" — , � RES�'�t�'E GEACHJN6 AREA�SI?. FT. . i �- b ,a �✓� . Sd OFrL( �i_.f : �G,7 1 S1. . 4_V7',/.,J!1) 'ass ALBERT C1'/7� V.i E RO-at�T ' 4.4, A-� S 0/ 1 BR UCE t, C3 R N ELDR v� U No.10951 O 4 3.6?Iq€�6E�IN�IJ`/ R/ t�,0111G. a 9Q�FG/ST.EP����`' L_JC"L. u 7.� 7.f2 MAIN ST.- HYANNI9 MAC 5-5_ . .. tcas. D FSSIONAt �� ts1� �JiICOUNTL�RE63 CA/.AN T: Mc�C J Al �dTE= I Z.. t 4 3 � ND GROUNf>.YYAT O SUS G1' GRD tlNl� Lt/.ATEiP,AT ELEp/... JOB )VIO;, 3 2� 7_ $Na:ET :.r• � ova I- io ` LOCATION SEWAGE PERMIT NO. VILLAGE �b/U I N S T A ER'S NAME i ADDRESS OoL d UILDE R OR OWNER DATE PERMIT ISSUED , DATE COMPLIANCE ISSUED �, �... . ��< �.� a 31 7 37. y ,� �. ALL SHALL TE SYSTEM PROFILE MARK Ds WITHC MAGNETIC TTAPE OR BE NOTES PROVIDE WATERTIGHT MIN. 20" DIAM. (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS APPROX. NGVD ACCESS COVERS TO WITHIN 6" OF FIN. GRADE PROVIDE INSPECTION PORTS TO 2. MUNICIPAL WATER IS EXISTING \ TOP FOUND. EL. 75.6' WITHIN 3" OF FINISH GRADE �s 2% SLOPE REQUIRED OVER SYSTEM 73 5' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. w MINIMUM .75' OF COVER OVER PRECAST /vim 4. DESIGN LOADING FOR ALL PROPOSED PRECAST Loc s UNITS TO BE AASHO H-j_Q 73.3' ADD TEE 4"0SCH40 PVC XZ *: PIPES LEVEL 1ST 2' 5. PIPE JOINTS TO BE MADE WATERTIGHT. o a 70.5' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE T10-EE EXISTINGSEPTIC TANK** TEEWITH 310 CMR 15.000 (TITLE 5.) o \71�.9 ** "` 70,1' 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND 000000OOOOOO GAS BAFFLE °�'0 °00 O 92' NOT OTHEROPURPOSE.E USED FOR LOT LINE STAKING OR ANY Wequaquet o 70.317' 70.20' s9.2' Lake ...i.. 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. 6" MIN. SUMP 16 H-20 HIGH CAPACITY UNITS 12" MIN. INT. DIM. 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT INSPECTION BY BOARD OF (NO STONE PROPOSE) 6" CRUSHED STONE OR MECHANICAL HEALTH AND. PERMISSION OBTAINED FROM BOARD COMPACTION. (15.221 [2]) (EACH UNIT: 34 x 75 x 16) 6 7� OF HEALTH. Route 00 % SLOPE) ( 1 % SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP FOUNDATION EXIST. SEPTIC TANK 15' D' BOX 12' LEACHING VERIFYING THE LOCATION OF ALL UNDERGROUND & FACILITY OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NOT TO SCALE WORK. *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL BOTTOM TH 1 EL. 62.5' UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 11. ANY UNSUITABLE MATERIAL ENCOUNTERED PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM SHALL BE REMOVED 5' BENEATH AND AROUND THE ASSESSORS MAP 252 PARCEL 154 PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT AND REMOVED. 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE CONDITIONS IF NOT SUITABLE SYSTEM DESIGN: SAS DETAIL 1" = 20' GARBAGE DISPOSER IS NOT ALLOWED 72.97 .5, x 74.92 DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD x 75.30 U x 73. F\ \ USE A 330 GPD DESIGN FLOW � \ 'i x 74.64 \ \ SEPTIC TANK: 330 GPD (2) = 660 N BENCH MARK - CORNER OF x 74.62 's s \ �Z RE-USE EXISTING SEPTIC TANK** � M CONC. BULKHEAD EL = 74.6 �\2.49 O LEACHING: x 74.81 \ ' x 74.22 10nO 6� -',\ (� 4.73 SF/LF x 6.25' LENGTH = 29.56 SF PER '� ■ 4 S _ / `t 72.32 T�i i. r-At>C_�Y IPJFII 5.T \ BL. CHER 2" MAPLE �° \ TRATOR UNIT LOGS '� (SAVE) M� . 4 2�{sAVE) � \ � 330� GPD/0.74 GPD/SF = 445.9 SF LEACHING REQ D TEST HOLEx 73.09 74.33 ' 8 74 29 \\ ARNE H. OJALA PE, SE , TH 1 eMac 4.61 T' OR . RY �2.17 445.9 SF/29.56 SF/UNIT = 15.1 UNITS ENGINEER: o TH 2 PAnO 4.47 3. 2 \\ THEREFORE, USE GRAVELLESS SYSTEM OF (16) WITNESS: DON DESMARAIS, RS 73 1 . 0 4.34 74.43 74.14 \72.04 H-20 HIGH CAPACITY UNITS' IN FIELD DATE: NOVEMBER 22, 2011 HED q 3 0 \ CONFIGURATION SHOWN 3. 7 � 4.0 � 4 PERC. RATE _ < 2 MIN/INCH s 1 4' 5.64 74.77 74.45 74.23 \\ 16 UNITS x 29.5 SF = 472 SF > 445.9 SF CLASS I SOILS P# 13471 BL CHERRY 4.01 EXISTING \ 472 SF (0.74) = 349 GPD (OK) (SAVE) DWELL' a 71.64 i x 73. DECK 74.00LOT 154 _ I TOP FNDN. 1 ELEV. 2 ELEV. ' I �, .8 3 75.6 75.02 74.41 a� � 0„ 73.5 0„ 74.2 �, 20, 11,424f S.F. N OO 171.42 A A .�0 3. � � LS L$ 2. 3' I 4.79 73.91 73.52 /ct 71.19 APPROVED DATE BOARD OF HEALTH MA 12„ 12 10YR 2/1 „ �� 7 .59 10YR 2/1 I 73.18 °s I 4� w � B B °�, ,3 73.30 ' TITLE 5 SITE PLAN !c 72.98 )(71.08 LS LS Ftic� .41 , OF „ 10YR 5/6 10YR 5/6 72.27 I= �13 037t 04 101 COTTONWOOD LANE 34 70.6 34 71.3 0 I 89 CENTERVILLE PERc C C I x~io.73 0 ��1',6 p r�qs ss PREPARED FOR - S DAIS ELA WILLIAM YAN _ \ o OJALA MCS MCS I 00 i OJw� ill"kn CIVIL Vol i 0 \ �No.4098U ��� ��,� ^No�� � o `� c NOVEMBER 29, 2011 2.5YR 5/6 2.5YR 5/8 169.7 G� �.l s s j�� FN� x'9.78 /'LoLf,,1 ,.,; off 508-362-4541 � _ st �syss y��,Q` gssyc , I fax 508-362-9880 DANIELA. ti� downcape.com D.4;VIEL �� � m . "+ OJLA c U c1V A, �` down cape engineering, MC. ` 4 132" 62.5 120" ` 64.2' No.a0980 5 2 civil engineers Scale: 1"= 20' ; ��� of suRV � G� land surveyors NO GROUNDWATER ENCOUNTERED I ° E�°�'- y �'S�°NAt ��' 939 Main Street Rte 6A -2 6 ry 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675