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0007 CYRUS DRIVE - Health
7 Cyrus D-live Centerville " A= 172-150 S M E A D No.53LOR UPC 12543 smead.aom • Made in USA r AM). No. / U Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS aiplitation for Bisposal*pstrm Coneftuttion 3pPrmit , Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. `7 C\1Z(JS DWUG O ner's Name,A dress and Tel.No. e.V1 �+4� * Laa 1W€dL(*E7- Assessor's Map/Parcel `7� 50 C V( Installer's Name,Address,and Tel No. 50S_q77-857 7 Designer's Name,Address,and Tel.No. .5®g-ot73-0j77 (5-3 cj wat S A4 AS60+eg- Ss ckAm Type of Building: 6%j av j Pev_ ?ITLv V) Dwelling No.of Bedrooms Lot Size ( SJr' 3 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) , P-(0 gpd Design flow provided 34,94 gpd Plan Date tj—x? " o 1(., Number of sheets Revision Date Title r7 0 YR_Q5DIZ , T Size of Septic Tank ,0-00 dCA4-.*iJ Type of S.A.S. La►) 500 EA(A®00 CAAAra36X.s Description of Soil r oor dOA?.S E S&ND 3(�" .SEE nct4m Nature of Repairs or Alterations(Answer when applicable) QUS-TjVC�r 1,®®C) Sir PTIC -POWK -to 1j6l >J✓,%dx Ty (A) 56k> G.*"c OAJ !Y 1=6Ei 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. Sign Date �vZ JG/ Application Approved by Date m 3 / Application Disapproved by Date for the following reasons Permit No. Date Issued o n' No. /M(Q i Fee v , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS r JtJYIcatIDTY for GIs#os`f0& stem Construction 3permit M Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. '7 C\IPU5 W7�v( O kner's Name,Address and Tel.No.GgZCET_ Assessor'sMap/Parcel I /a 15Q -7 d kuS /Z CewTe;WVtLC& Installer's Name,Address,and Tel No. SOS- 7T -&$-17 Designer's Name,Address,and Tel.No. $p$-a73-03-17 CA�Ew n� � �Q ism c.c.L *SG (53 S7- M A514 Pc35- SS q- CRkNgOF W V F off AM Type of Building: !W nv 3 PL-P- 'rr'rLs V) / t Dwelling No.of Bedrooms Lot Size (pi S 53 sq.ft. Garbage Grinder( ) i Other Type of Building RC--S!p IS�J7'!it<v No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided .3 T 9, 4 gpd Plan Date 5 o�-� oZ014i Number of sheets Revision Date ,�- Title YRZU5 jag , Cf &-r,)Z"1S7P1 1 /(X-67 i Size of Septic Tank 1,000 Cx-44A-ONJ Type of S.A.S. (7-) Soo C-ALLOY J <,OAOt SEX;_. .--- it Description of Soil ([J C�O.4�S6 5&WD �3D 11 25EX- P4 4JV Nature of Repairs or Alterations(Answer when applicable) U.56 GXJ5-T11VCT I(OOU C:;rK .ON SEF'TIG Ti$J�JK' 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. Sign d Date // "J .A Application Approved by, Date (� 3 Application Disapproved by Date for the following reasons r' Permit No. DzA !'d Date Issued (o A f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO C RTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�) Upgraded( ) Abandoned( )by QAFEWCt-LC EkJ�kc Sef LLr, at 7 (2Y k V S dJ D,l(,16 JTE�(,X/(,( 050 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Nor-�'GJ�o 'J�S 7ated Installer '�' pEwIDE G�r7i3@04LTf!S L- -C Designer :::I(, GJ(Sgt J&L-21mG -"-IVC: #bedrooms Approved design flow p�vZy gpd The issuance of this permit shall not be construed as a guarantee that the system will fu t on dfe�igned. Q Date en�� �%(O Inspector (/ !e - C .. ----------------------- ----- -- - - /� - -------- No. . �ll Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS r Misposal *pstem Construction permit Permission is hereby granted to onstruct( ) ^ Repair(k Upgrade( ) Abandon( ) System located at , UVAus IJ Dj U C 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 co /ple/ted within three years of the date of this pe it. Date r 3 / (O Approved by 0/LG/e-V Ill I 1 .Lv .ivuc I vvuv. � t Town of'Barnstable oat Regulatory Services Thomas F. Geiler,Director MRNSTABL6. Public Health Division KASS. �AT6p A Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: �p`Za"1 Sewage Permit#saa 1 1 i 9l Assessor's Map/Parcel ��Z 1 56 Installer&Desi ner Certification Form Designer: SC E03(neeccn!� , s'nc. Installer: CCtpeu k 10� rPf�SeS Address: 28.5N CcaOnecry Address: l53 Co,AMe.rcia� FAsA 4J0reh4Jr1 Ho 0,25S9. . �°�4►�ee, k A On 6-3 `" Dl Caed4de. 1�44aeCtSeS was issued a permit to install a ('date) (installer) septic system at 7 cycus 'Dc tue— based on a design drawn by .(address) �TC 904 l n eeg znl , T-n 6, dated M a;z7, ?4k (0 (designer) Zcertify 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 boa and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. 1 certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State,.& Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required) was inspected and the soils were found satisfactory. Cv� c4 C>T URcMI�L ; (Installer's Signature) ,L 418 7 • c esigner's ignature (A tt1fip Here) PLEASE RETURN TO BARNSTABLE PUBLIC ALTH DIVISION, CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UN D BOTH THIS FORM AND,AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAullicc formAdesignmertification rorm.doc TOWN OF BARNSTABLE LOCATION 0�qR d-4� .O ktVE: SEWAGE# 016 1W7 VILLAGE 0Ci,-TC-Puy i"�45 ASSESSOR'S MAP&PARCEL I q A 15o INSTALLER'S NAME&PHONE NO.CAV6W%V �.i�!Tc-PFk-c5'aLLc SEPTIC TANK CAPACITY t'o o® C UZ l I` LEACHING FACILITY.(type)W So©C-4L (size) NO.OF BEDROOMS OWNER RICE-hRa 45C Mc--I C-T PERMIT DATE: '(c'3 �� COMPLIANCE DATE: —;?-®I(e Separation Distance Between the:Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N A Feet Private Water Supply Well and Leaching Facility(If any wells exist on siie or within 200 feet of leaching facility) A Feet Edge of Wetland and.Leaching Facility(If any wetlands exist within A 300 feet of leaching facility) � A Feet FURNISHED BY CAPE WM(5 "J?RJ6e& ( `_C� -07 A-5 LI.o 6 _.. AEck B-1 LA5 ` LA 9-3 �4` 3 Town.of stable r� of Barn �y0 r � ' Department of Regulatory Services a&msr Bm : Public Health Division Date b _ u Aga 3 �� 200 Main Street,Hyannis MA 02601 .0 m Date Scheduled Time Fee Pd._ UV V v y Soil Suitability Assessment for Sew e Disposal Performed By: �• V 6. l LJ Witnessed By: V� ri( � L'OCATION&.GENERAL INFORMATION Location Address Owner's Name E .13yA + D_104 Aitp l4eV_%c� '7 (2YRvs i.A&jE <�rcEVzvrLLi Address-1 G°YQU S 'D2 c-4 (V p4L t r?a 5Q C04PC—kJ10C CSn a=IAj6�1, )&--tN Assessor's Map/Parcel: Engineer's Name J C&XX_--1Aje-EP4 =Vt NEW CONSTRUCTIONt REPAIR Telephone# S08 —4-7i -8,g 7-7. _-,08-273-o.3 Land Use._ RQStCJIQ� CAI Slopes(96) d Surface Stones A Distances from: Open Water Body >60 ft Possible Wet Area 1' 0 ft Drinking Water Well I rft Drainage Way_J_ft Property Line »0 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands 3n proximity to holes) 1bn i Parent material(geologic) rl uywc k �r G.n Depth to Bedrock Depth to Groundwater. Standing Water in Hole:. � 'L . l7J Weeping 11'om Pit Face � Estimated Seasonal High Groundwater N VI, DETERARNATION FOR SEASONAL HIGH WATER TABLE Method Used: LXre(f ObSermfio f (, r� Depth Observed standing in obs.hole: } 7 In. Depth to soil mottles:7 I 7 In. Depth to weeping from side of obs.hole: 71_ _ , _In, Groundwater Adjustment ft. Index Well-#r Reading Date: Index Well level� Adj,ttletor e. � AcU.Groundwater.Level _ _ PERCOLATION TEST butpWJ C Thne 101 Observation Hole# ft Time at 9" _ Depth of Pere Time at 6" Start Pre-soak Time @ Time(9"-6 End Pre-soakLo Rate Min./Inch < a '• ' Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:1SEPfICVERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole#J k 2 Depth from Soil Horizon Soil Texture Sdil Color Soil• Other Surface(in.) (USDA) (Munseil) Mottling (Structure,Stones,,Boulders. onsistency.%'oravel) A Laam 10 Ylr 3/ 3a 1�4,i C 'Ro-000'ap sej M.Y. G/. °le drove .s 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 Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munseil) Mottling (Stricture,Stones,Boulders. Consistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, Flood Insurance Rate Map: Above 500 year flood boundary No Yes . ___ Within 500 year boundary No 7, Yes, Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? V6 If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of En onmental Protection and that the above analysis was performed by me consistent with . the required trai g,exper' d e ' n des ribed in 10 CMR 15.017. Signature Date .5-26'/(0 Q-.WEPTICWERCFORM.DOC i TOWN OF BARNSTABLE LOCATION C IRVS .Dk(VE SEWAGE# 19'7 VILLAGE C60TEP_V i,c.,45' ASSESSOR'S MrrAP&PARCEL I'1 ak 50 INSTALLER'S NAME&PHONE NO.C-A C--UJ1Dc, INiC'ft k&F( Q'L �c F SEPTIC TANK CAPACITY LEACHING FACILITY:(type)U;L 500 C-4L C.tOA JD056(size) 1'al ,St X �� NO.OF BEDROOMS OWNER_ RicNARa Gg_%*4 PERMIT DATE: COMPLIANCE DATE: �' - ��(�► Separation Distance Between the:Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N A Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �J A Feet FURNISHED BY 0-AMwjtoE Li[l✓`1E2:172i _LLO AP2aa�� pctK z 3 . g'•y r yy � ~ Town of Barnstable ,KAS& ,�� Regulatory Services Department fD 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. 5/11/16 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, <12"below inlet (per Town Code 360-9.1) ❑`Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) c a� • OTHER Repair deadline: Q:\SEPTIC\DEADLfNES TO REPAIR FAILED SYSTEMS.doc May, 03120`16 21:13 Jim The Inspector Man 5085349919 page 18 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments1>C tV 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owner's Name information is co required for every Centerville✓ MA 02632 5-2-16 a. page_ CitylTown 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, / ��HIOF 144 Vi/, use only the tab 1. Inspector: � �''' • �'% key.to move your . ? • y cursor.do not James D.Sears 1 �: •JAMES •`:m= e the return Name of Inspector n�; SEARS � key. Capewide Enterprises, LLC Company Name �'. l' RRTIE O : 153 Commercial Street '��,;�S i N SFli—�``��` Company Address Mashpee MA 02649 City/Town State Zip Code • 508-477-8877 $1623 Telephone Number License Number . Certification. 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-2-16 y spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. . ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 TRIG 5 ommal Inspection Form:Subsurface Sewage Disposal Syslem-Page 1 of 17 �o Vs r .-May, 03, 2016 21:14 Jim The Inspector Man 5085349919 page 19 v . Commonwealth of Massachusetts iTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 7 Cyrus Drive Property Address Rich &Ellie Merget Owner Owner's Name information is required for every Centerville MA 02632 5-2-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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: Failed system- leaching. The system is a 1000 Gal. Tank and pit. • 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, IN, 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): • 15ins.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r May, 03' 2d16 21:14 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owner's Name information is required for every Centerville MA 02632 5-2-16 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): • ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning In a manner which will protect public health, • safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3f13 - Title 5 Of(elal Inspection Form:subsurface Sewage Disposal System-Page 3 of 17 f May ..03 2016 21:14 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "( 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owners Name i0ormation is required for every Centerville MA 02632 5-2-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet,but 50 feet or more from a private water supply well". Method used to determine distance: • '"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No" to each of the following for all inspections: Yes -No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool • ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 41MEM is less than 6" below invert or available volume is less than '/Z day flow P j T t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 May 0 2016 21:14 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owner's Name information is required for every Centerville MA. 02632 5-2-16 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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 vlell. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private watt.r 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 cerifed laboratory,for fecal coliform bacteria indicates absent and the pretence 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 agalysis 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 servie 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•3/13 Title 5 Official l,ispection Form:Subsurface Sewage Disposal System•Page 5 of 17 May• 03 '209 6 21:15 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owner's Name information is required for every Centerville MA 02632 5-2-16 page. Cityrrown State Zip Code Date of inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following.- Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) • ® ❑ 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: Z. ❑ 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): NA Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 • (Sins•3/13 Title 5 Offldal Inspection Form SubsuAace Sewage Disposal System•Page 6 or 17 May, 03 '2016 21:15 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owner's Name information is required for every Centerville MA 02632 5-2-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank and pit Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No information in this report.) • Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2014-52,000Gais Detail: 2015-49,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy; Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No . Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title S Official Inspection Form'Subsurface Sewage Disposal System•Page 7 of 17 May 0� 2016 21:15 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owner's Name information is required for every Centerville MA 02632 5.2-16 page. City/Town State Zip Code Dgla of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: • Source of information: 2010/ 11 1 13 115. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,-- EMM soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 Oflldal Inspection Form:Subsurface Sewage Disposal System•Page a of 17 May 03 '2016 21:15 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owner's Name information is required for every Centerville MA 02632 5-2-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No ` Building Sewer(locate on site plan): Depth below grade: 22"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.): Pipeing house to tank 4" PVC SCH 40 Pipeing tank to pit old orange bur e Septic Tank(locate on.site plan): ' Depth below grade: 1 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene' ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10. Sludge depth: 1„ tsins•3113 Thle 5 Dfrldal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 May- 03 '2016 21:15 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts 9•}Z r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich& Ellie Merget Owner Owner's Name information is required for every Centerville MA 02632 5-2-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cunt.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt-Tape _Sludge Judge 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 at working level, Tank and covers at 1' below grade. Note: Both end inspecton covers. • Center to cover for Inlet old type wall baffle.pumping. yp Outlet Baffle. No sign of leakage Grease Trap (locate on site plan); Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-31'3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 May 03' 2016 21:16 Jim The. Inspector Man 5085349919 page 28 Commonwealth of Massachusetts 9 - Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owners Name information is required for every Centerville MA 02632 5-2-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, x liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or.Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: aMaterial 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•313 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 .May 03 2016 21:16 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts _ Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owner's Name information is required for every Centerville MA 02632 5-2-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No Box Comments (note if box is level and distribution to outlets equal, any evidence'of solids carryover, any evidence of leakage into or out of box, etc.): • Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in 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•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 h May 03 2016 21:16 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich & Ellie Merget Owner information is Owner s Name required for every Centerville MA 02632 5-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: • ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Precast pit. Pit and cover at 27" below grade. Level in pit at 9" below inlet. Need to replace leaching. 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 ,May 03 2016 21:16 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts • a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 7 Cyrus Drive Property Address Rich & Ellie Merget Owner Owners Name information is required for every Centerville MA 02632 5-2-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: . Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins•3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Pape 14 of 17 r May 03 2016 21:16 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich $ Ellie Merget Owner Owners Name requir required is every Centerville re wired for eve MA 02632 5-2-16 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 y i -3 IL / f r i 'S 13-3 - y�'--�, �- .38- 7 b�' EllP 13 / L3 0 1 . 3 o t5ins•MS Title$Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 ii May 03 2016 21:16 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Cyrus Drive Property Address — Rich & Ellie Mer et Owner Owners Name information is Centerville required for every MA 02632 5-2-16 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells o N Estimated depth tc high ground water: 42 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: U.S_G.S. Well-SOW 252 You must describe how you established the high ground water elevation: U.S.G.S. Well SDW 252 at 46' w/4'ADJ = 42. Bottom of pit at 8' below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15Ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•page 16 of 17 r ,Maur 03 �016 21:16 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts a Title 5 Official Inspection. Form kf a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Cyrus Drive Property Address Rich & Ellie Mer et Owner Owners Name information is required for every Centerville MA 02632 5-2-16 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file • t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ( 7 Cyrus Drive '�I ` Property Address t Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name tab P.O.Box 763 Company Address Centerville Ma. - 02632 1 rerwn City/Town State Zip Code l (508)428-4028 S14454 ® 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 PrIJ was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/20/2008 0 Le n 9$pector's ignatur Date C— N e system inspector shall submit a copy of this inspection report to the Approving Authority(Board s olealth or DEP)within 30 days of completing this inspection. If the system is a shared system or j has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the f report to the appropriate regional office of the DEP. The original should be sent to the system owner �..; y {x� ar)d copies sent to the buyer, if applicable, and the approving authority. **t*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. 7 Cyrus Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . M 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 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: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: of sewage backup or break out or high static water level in the distribution box due ❑ Observationg p g to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 7 Cyrus Drive-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes_(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh = 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 7 Cyrus Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 ❑ ® 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. 7 Cyrus Drive•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ❑ ® 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. 7 Cyrus Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,cwM °v 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site.inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes,uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 7 Cyrus Drive-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 i Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2006:30,000 g ( y g (gpd)): 2007:26,000 Sump pump? ❑ Yes ® No ' Last date of occupancy: 5/20/2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 7 Cyrus Drive-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a.copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 7 Cyrus Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 6 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.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 14"feet Material.of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gallon 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 7 Cyrus Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 7 Cyrus Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 7 Cyrus Drive Property Address Simon Yampolski- Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons . Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 not present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 7 Cyrus Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000gallon ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Leaching Pit was dry at time of inspection.Stain line is 22" below invert. 7 Cyrus Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 7 Cyrus Drive•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 'Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size 2 ] Zoom Out J,J;J fl.J J J J LJ In +k. Ar R.A 71 R, 1C''y r y} i 4 I 0 20 Feet --�s Set Scale 1" = 20 I Aerial Photos r`nn,,rinhf 9Mr-,?n A Tn.e.n of Pnrncfnhln KAA All rinhfe rac—, http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=172150&map... 5/28/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Cyrus Drive Property Address Simon Yampolski Owner Owner's Name information is required for Centerville Ma. 02632 5/20/2008 every 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: Bottom of LP 40' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 Plate#2 annual ranges of groundwater elevations. 7 Cyrus Drive-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 r Town of Barnstable �Of YHE Tp� o Regulatory Services 1ARNSTABLE, : Thomas F. Geiler, Director Y� ib& �0� plFo �A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction.Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIC\Disclaimer Private Septic Inspections.DOC Y ASSESSORS MAP P.ARcIEL quo S'r No.. , -. C� 0 Fms.... ................. THE COMMONWEALTH OF MASSACHUSETTS F BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiou for Bispwial Vorkg Tnnitrurtiun t Application is hereby made for a Permit to. Construct ( ) or Repair j><) an Individual Sewage Disposal System at: .. ^ L cation-Address or Lot.No. No. ....................._.----------. ...---------------•--•-•----•--....._.. � J/. 'C/?2 5 ............0 T .......------•-----------. Owner Address Installer Address U Type of Building Size Lot.. -.Sq. feet �. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .__..---.... No. of persons............................ Showers a YP g -------------•-• P ( ) — Cafeteria ( ) Otherfixtures -------------------------------------------------------•-••----------------•-----------------------------.....---...---------•-....------...--------- WDesign 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--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......... ----•-----------------•-•-----------•-------------------•••---- 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........................ .......................................................... ............. ------------------------------ --- ------------- ----------------------------------------- O Description of Soil..............................................................................................................-......................................................... x w x ---•------------------------••-•---------••-----------------------. --••-•--•--------•-----•-----••-----•----------------------------•. . -------- ------ U Nature of Repairs or Alterations—Answer when applicable............ s f�f�:- .......-----.�a ......... l 2 -----,.._ . -------- ' l ---------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of ComplianWI--enen su b e b d f health. Signed ..... ----- - --- - ---- ........... ...... .... ate ApplicationApproved By ...................................._--------------......... -------_--_-....................... te Application Disapproved for the following reasons: ....................................................................................................................................... ................. ....... ................ ............. ... ................................. .................... ............................ ............................................ ............................. Dare PermitIVo. ..----- /... .-.. v�O I.................. Issued ....------------------------------------------...-- Dace ,r f �c.J o �/ t7 � � ,l f•�(�a THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH * TOWN OF BARNSTABLE Appliration for Di"ass 1 Works C9nn3unrtiun err it Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: .............. v/� d7.�S........��...................... Location-Address ,� �or Lot No. ( - .. Owner Address ,-� � Installer Address ___: Type of Building ..S Size Lot__ S..��-t..Sq. feet I-, Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building a g ---•------------------•-•--- No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow........................._573 ......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............:........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__...................... a ----------••-••••--•--•--•----•--------------••••----------•••-•-----•....------.._.......--•-----•-......................................................... 0 Description of Soil........................................................................................................................................................................ x U ._..--•••••-•-••---•-•----------•--•-•----------•-------------•--•_._...•----------•------------•--•---••----•------•--•-•--•-----------••--•-•--•••---------••-•--•-••••------------••-----..._._..-•-- w 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliancelh'- een i su by t e bo d f health. ee Signed ..----i: _1Y.....i Application Approved By _--------------- � V __ e ................................................. Date Application Disapproved for the following reasons- ----------------- ------------------------ --------- ------ ----------------................................------------------- ------ -- ----------------------------------- ------------- - ------------------------- ---- ----------- ----------------------------- ------------------------------------................. --------------- Date Permit No. .-........✓�J' -------------------- - a-------- --------------------- Issued c D ...-.-.... ..--------------------- ---- ------------ ..-..--.. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLEL Certificate of Torapliaxnce THIS IS TO CERTIFY, That theAndividual Sewage Disposal System constructed ( ) or Repaired O by----------------------------------------------------------------------- 'Ole/ 0T� C C I.Soler at ----------------------- ---------------------------------------- ................... C' )T ------------------------------------------ has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..... .-... .C2.,1.........- dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY! DATE..............................................................................................J,� I,'�_ C/ .•-....--.. Inspector ....................---- .......................- =..................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.. .. .: .C�,l.. FEE..�d_..._••--.. Ropastt1 Workv Towartution ramit Permission is hereby granted...................... _! J�-� 6 OA-4 ----•--------------------------------------------------•.-----------••----............._------ to Construct ( ) or Repair (X) an Individual Sewage Dial System at No. - Street as shown on the application for Disposal Works Construction Permit No,__ _:A...Q./.._ Dated.......................................... •------•--------------------•----- _ ................................................... DATE DATE---------------= . Board of Health FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS T.O.F. EL.= 65.7'± FINISH GRADE OVER D-BOX= 63.3'± FINISH GRADE OVER CHAMBERS= 62.9' - 63.3' 3/4"TO 1-112" DOUBLE WASHED PROVIDE EXTENSION RISER REMOVABLE WATER-TIGHT COVER OVER SLOPE @ 2% MIN. OVER SYSTEM STONE TO CROWN OF PIPE 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION WITH COVER OVER INLET& RISER TO WITHIN 6"OF FINISHED GRADE 4" SCHEDULE 40 PVC INSPECTION PORT WITH ACCESS METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL FINISH GRADE OUTLET TO WITHIN 6"OF F.G. MIN SLOPE 1% BOX TO F.G. (SEE NOTE 21) 2" OF 1/8" TO 1/2"DOUBLE WASHED CODE AND ANY APPLICABLE LOCAL RULES. @ FND. EL.= 64.3'± F.G. OVER TANK EL. = 63.5�± 5"DIA. OUTLET(S) STONE OR GEOTEXTILE FILTER FABRIC 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE PLACE RISERS ON ALL DESIGN ENGINEER. TOP OF SAS= 60.33' CHAMBERS WITH PROPOSED 4 9„ MIN. 9"MIN. „ 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL SCH. 40 PVC 36"MAX. 59.50' 36"MAX. OT EL= 60.00� INLET PIPES TO 6 OF SYSTEM UNLESS OTHERWISE NOTED. BREAKOUT SEWER PIPE i FINISHED GRADE ���. 3" DROP MAX _ � �.I 4. TO PREVENT BREAKOUT. THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN 6' 3 " L 27± 2"DROP MIN 3 9" MIN.SLOPE @ 1% PROVIDE WATERTIGHT ELEVATION -60.00' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A 13" 4"PVC IN FROM -JOINTS (TYP.) p ��� 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF 14" SEPTIC TANK (D) 4"PVC OUT TO C� � 0 O � 0 0 � � � o o 0 � � o p THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. CONTRACTOR TO PROVIDE LEACHING FACILITY oa o 0 oQ o � � � � � � � � � � � � � r---I � c� 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. TSPECIFIED DROP BETWEEN o L___! 12" 6" _ o� 00 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. INLET AND OUTLET CONTRACTOR CONTRACTOR SHALL , rr--�� SHALL VERIFY SIZE 48" VERIFY CONDITION OF OUTLET TEE 59.87 MIN. 59.70 2� 0 f__1 C� 0 0 °° � 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK AND CONDITION OF j EXISTING TEES �` GAS BAFFLE 6" CRUSHED STONE (�� °° o o �� FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS EXISTING SEPTIC AND REPLACE AS OVER MECHANICALLY cpc 00 NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH TANK NECESSARY COMPACTED BASE 4 0, 4 0, f ! AND DESIGN ENGINEER. 5 - 8.5 (TYP) 4•0' 4.83' -- 4.0' 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF 65.00' OUTLET DISTRIBUTION BOX TO BE INSTALLED ON A LEVEL STABLE - 25.0' (�'P') ESTABLISHED ON THE CORNER OF BULKHEAD AS SHOWN ON PLAN. BASE. FIRST TWO FEET OF OUTLET 57.50, GROUND WATER ELEV= < 51 .10' PIPES TO BE LAID LEVEL. 12.83` 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK 5' MIN. ;1-,�li/ftiEiK tIVU v itVV THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT CROSS SECTION VIEW 2 - 500 GALLON CHAMBERS 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES TYPICAL CHAMBER PROFILE TO THE DESIGN ENGINEER. NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. Tl=(ZT 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM PERC NO. 15047 APPROPRIATE AUTHORITY. INSPECTOR: _.David W. Stanton, R.S. _ 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED EVALUATOR:John L. Churchill Jr., PE, PLS UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT, DRIVES, OR -� TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING. C.S.E. APPROVAL DATE: Nov. 1997 _ `sS'7o DATE: May 12, 2016 _ 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. , 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE 9 �s' TEST PIT#: 1 Benchmark SOS., ��� ' MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. Corner of Bulkhead " ELEV TOP= 63.10' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, Elev. = 65.00' LOCUS ELEV WATER= < 51.10' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). { Approx. M.S.L. APPROX. WATERLII� C 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN + PERC RATE LOCATIONW ,'����� ,u �,: � - SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. DEPTH OF PERC _ 16. PROPOSED PROJECT IS LOCATED WITHIN: n 11" SPRUCE ASSESSORS MAP 172 LOT 150 ►� "Sly /� ; , TEXTURAL CLASS: _ 1 m OG� • y OWNER OF RECORD: RICHARD T. & ELBA I. MERGET a 61) a UB 0" 63.10' ADDRESS: 7 CYRUS DRIVE •C, Loamy Sand A 10Yr 3/2 CENTERVILLE, MA 02632 4" 62.77' rrt, FEMA FLOOD ZONE X �� 13"OAK `. Loamy Sand �' lOYr 5/6 COMMUNITY PANEL# 25001C0561J o � 17. DEED REFERENCE: DEED BOOK 23279, PAGE 159 a , 30" 60.60' 18. PLAN REFERENCE: PLAN BOOK 257, PAGE 94 TWIN 10"OAKS BH - ZONE 2 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. TWIN 8"OAKS 20, PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY PROPOSED INSPECTION PORTS TWIN 5" OAKS MAP 172 Fine-Coarse Sand FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY #7 LOT 150 / C 2°.5Y 6/4 FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. 5"PINE 16,553t S.F. 25/° Gravel SITION TO A EXISTING 21 DEPTH OFOTHETBOTTOM OF THE SAS AND HIN 3"OF FINISH ED SCH. 40 PVC PIPE LEXTEND TO WIL BE PLACED ITA VERTICAL OH GRADE. A �� ,-- 2-BEDROOM REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS. DWELLING LOCUS PLAN TOF=65.Tt DC-1 SCALE: 1" = 1000' 144" 51.10' MAP 172 t LOT 149 �S , (1) \ No Mottling, Standing or Weeping Observed (2) 1 " : . - TP 1 PERC NO.11 Pi 15047 _ EXISTING SPOT GRADE 13" PINE `-{._, '3i1' NUMBER OF BEDROOMS (DESIGN) 3 (MIN. PER TITLE 5) INSPECTOR: David W. Stanton, R.S. EXISTING CONTOUR TP EVALUATOR: John L. Churchill Jr., PE, PLS TWiI•, .'� PIN. % . / DESIGN FLOW 110 GAUDAY/BEDROOM 63x1' � TOTAL DESIGN FLOW 330 GAUDAY C.S.E. APPROVAL DATE: Nov. 1997 r PROPOSED CONTOUR `. . DATE: May 12, 2016 50 PROPOSED SPOT GRADE ' DESIGN FLOW x 200 % _ 660 GAUDAY TEST PIT#: 2 EXISTING GAS LINE 13" PINS DC-2 S'FF O�, USE EXISTING 1,000 GALLON SEPTIC TANK ELEV TOP _ EXISTING UNDERGROUND UTILITIES V f CHIC b�' ELEV WATER= < 51.10' i PROPOSED / CO� .. ' DISTRIBUTION BOX EXISTING OVERHEAD WIRES 4 �~ ( � INSTALL 2 - 500 GALLON CHAMBERS PERC RATE _ <2 min./inch 1. DEPTH = ` 6" PINE 12.8 W/ AGGREGATE EXISTING WATER UN OF PERC 36"- 54„ BRICK"-,., SIDEWALL CAPACITY TEXTURAL CLASS: 1 TEST PIT LOCATION 13" PINt (3) PATIO (LENGTH + WIDTH) (2 SIDES) (2' HIGH) (0.74 GPDfS.F.) = GAUDAY EXISTING 1,000 GALLON SEPTIC TANK (25.0' + 12.83') (2 ) ( 2' ) ( 0.74 GPD/ S.F.) = 112.0 GAUDAY 0„ � 63.10' -:7 `L� Y Loamy Sand PROPOSED 4" SOLID SCHEDULE 40 PVC PIPE FIRE BOTTOM CAPACITY A 10Yr 3/2 PROPOSED 2-500 GALLON (LENGTH x WIDTH) (0.74 GPD/S.F.) = GAUDAY 4 62' PIT77 ❑ PROPOSED DISTRIBUTION BOX LEACHING CHAMBERS w/ (25.0' x 12.83') (0.74 GPD/S.F.) = 237.4 GAUDAY AGGREGATE GARAGE B Loamy Sand (-�� PROPOSED 500 GALLON LEACHING CHAMBER TOTALS: 2 30" 60.60' �� SHED �3 TOTAL NUMBER OF CHAMBERS REV. DATE BY APP'D. DESCRIPTION �'J�1 TOTAL LEACHING AREA 472.2 SQ.FT. ��� PROPOSED SEPTIC SYSTEM UPGRADE Perc 2 A, TOTAL LEACHING CAPACITY 349.4 GAL./DAY 54" . " PREPARED FOR: 0 CAPEWIDE ENTERPRISES Fine-Coarse Sand MAP 149 �9`�sQ�., �o,` /Q� J� � C 2.5Y 614 LOT 89 `�� JALbl� /p� 25% Gravel LOCATED AT 7 CYRUS DRIVE NOTES: � ��' CENTERVILLE, MA 02632 EDGE OF �� / SWING-TIES SCALE: 1 INCH = 10 FT. DATE: MAY 27, 2016 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP E / T 144" 51.10' k>EVL/ 0 5 10 20 40 FEET EACH SEPTIC SYSTEM COMPONENT. 0 DESCRIPTION DC-1 DC-2 No Mottling, Standing or Weeping Observed Als, r''''-' 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF �` CORNER �0' PREPARED BY: NE(OF STO1) 23.9' 36.2' JOHtV �-. THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST ` / RESERVED FOR BOARD OF HEALTH USE CHURC JR. JC ENGINEERING, INC. PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL ` CORNER OF STONE(2) 36.6' 45.6' `` 2854 CRANBERRY HIGHWAY ., BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. / \ EAST WAREHAM MA 02538 3.) ENTIRE PROPERTY IS LOCATED WITHIN A DEP APPROVED ZONE 2,THE CORNER OF STONE(3) 46.8' 36.3' ���.' ,- �- ' SITE PLAN �� _ � 508.273.0377 GROUNDWATER PROTECTION OVERLAY DISTRICT AND THE ESTUARINE CORNER OF STONE (4) 37.8' 23.5' "- Drawn By: SJ! Designed By:MCP Checked By: JLC JOB No. 3496 WATERSHEDS. SCALE: 1 10'