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HomeMy WebLinkAbout0022 DOLAR DAVIS ROAD - Health 22 Dolar Davis Road Centerville P fA = 171 204 No. 42101/3 URA 10°I o o I1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29, 2007 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 �Y When filling out forms the o�1 i computer, r,use 1. Inspector: �" � _�o only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name mn 43 Triangle Circle 0-0 Company Address Sandwich MA 02563 7B0"" City/Town State Zip Code 508 364-0894 Pending 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.rTI;le 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 Sectiori 15.340Yof Title 5 (310 CMR 15.000). The system: q w. ® Passes ❑ Conditionally Passes ❑ Fails ra y ❑ Needs Further Evaluation by the Local Approving Authority June 29, 2007 rn Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2881.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is Centerville MA 02632 June 29, 2007 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2881.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Dolar Davis Road M Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29.2007 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. t5-2881.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29, 2007 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 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-2881.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29, 2007 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. t5-2881.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29, 2007 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? SAS also inspected ® ❑ 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)] t5-2881.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n1a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 189 gpd Sump pump? ❑ Yes ® No Last date of occupancy: 2 weeks agoDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe): t5-2881.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 22+years. Certificate of compliance issued 4/12/65(Board of Health permit#85-170). Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2881.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2feet 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.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): Depth below grade: 1.5feet 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: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? As built card t5-2881.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29, 2007 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.): Pumping not requires at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene. ❑ other(explain): t5-2881.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is Centerville MA 02632 June 29, 2007 required for 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 At outlet inven` 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 appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2881.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is Centerville MA 02632 June 29, 2007 required for 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 ❑ 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the leaching pit. t5-2881.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29, 2007 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.): t5-2881.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. LEACH O PIT 4 A SEPTIC TANK I OF 0 2 30 D-BOX EXISTING B DWELLING LOCATIONS # 22 A B 1 17 ft 7.5 ft 2 21.5 ft 3 ft 3 29 ft 8 ft Z 4 29 ft 17.5 ft J ix W H G 3I DOLAR DAVIS ROAD NOT TO SCALE t5-2881.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 22 Dolar Davis Road Property Address Robert& Cathy Sawyer Owner Owner's Name information is required for Centerville MA 02632 June 29 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.)Y ( Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 20+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. t5-2881.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 TOWN OFppBARNSTABLE Lod'. YON�22- Wit' SEWAGE # ti ILLAG,E Cewfet V I f l e ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY (000 21I LEACHING FACILITY: (type) R i (size) NO,OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: 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 ECO -Jech CLtsSoectI(> LEACH O PIT O A SEPTIC TANK I.o 0 2 30 D-BOX EXISTING B DWELLING LOCATIONS # 22 A B 1 17 ft 7.5 ft 2 21.5 ft 3 ft 3 29 ft 8 ft w 4 29 ft 17.5 ft Z J K W r 3 DOLAR DAVIS ROAD NOT TO SCALE RECE ED ECOJECH 1 NOV 12003 Environmental www.eco-tech.us TOWN 01= BitiragSTABLE HEALTH DEPT. THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A `� e CERTIFICATION l Property Address: 22 Dolar Davis Road MAP L-.T Centerville PARCEL Owner's Name: Christopher&Susan Congalton Owner's Address: 1500 North Lake Shore Drive LOT Chicago,IL 60610 Date of Inspection: November 7,2003 Name of Inspector: (Please Print) David D. Coughanowr,R.S. Company Name: Eco-Tech Environmental Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: (508)364-0894 CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature 4 9�)- Date: �Jd v (©I 2Od 3 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 NOTES AND COMMENTS Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****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. Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 22 Dolar Davis Road Centerville Owner: Christopher&Susan Congalton Date of Inspection: November 7, 2003 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B] System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no,or not determined(Y,N,or ND). in the_for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not),is structurally unsound,exhibits substantial infiltration or exfiltration, or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced. ND explain The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain 2 Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 22 Dolar Davis Road Centerville Owner: Christopher&Susan Con alton Date of Inspection: November 7, 2003 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 and 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. 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 by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3)OTHER 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 22 Dolar Davis Road Centerville Owner: Christopher& Susan Congalton Date of Inspection: November 7,2003 D) System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed by 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) No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore,the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 22 Dolar Davis Road Centerville Owner: Christopher&Susan Congalton Date of Inspection: November 7,2003 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? N Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? including Y _ Were all system components,exeludin the SAS located on site? Y _ Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y _ Existing information.For example,Plan at the Board of Health. Y _ Determined in the field(if any of the failure criteria related to part C is at issue,approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 22 Dolar Davis Road Centerville Owner: Christopher&Susan Congalton Date of Inspection: November 7,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): n/a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan available at Health Dept. Number of current residents 0 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required) Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings,if available(last two year's usage(gpd): 108 gpd Sump Pump(yes or no): no Last date of occupancy: September,2003 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sgft/etc.): Grease trap present: (yes or no) Industrial waste holding tank present: (yes or no): 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: System not pumped in recent past(Owner's agent) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: X Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) Innovative/Alternate technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe) APPROXIlVIATE AGE of all components,date installed(if known)and source of information: Age: 18+years Certificate of Compliance issued 4/12/85(BOH permit#85-170) Were sewage odors detected when arriving at the site: (yes or no) no 6 Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Dolar Davis Road Centerville Owner: Christopher&Susan Congalton Date of Inspection: November 7, 2003 BUILDING SEWER_(Locate on site plan) Depth below grade: 2 ft Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting,evidence of leakage, etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling__ SEPTIC TANK:Yes (locate on site plan) Depth below grade: 24 inches Material of construction: X concrete_metal_fiberglass_polyethylene other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 5 in Distance from top of sludge to bottom of outlet tee or baffle: 29 in Scum thickness: 3 in Distance from top of scum to top of outlet tee or baffle: 9 in Distance from bottom of scum to bottom of outlet tee or baffle: 12 in How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Pumping recommended within 1 year and maintenance pumping is recommended every 2 years Liquid level at outlet invert.Tank and tees appear structurally sound and functioning as intended.No evidence of leakage in or out GREASE TRAP: none (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Dolar Davis Road Centerville Owner: Christopher&Susan Congalton Date of Inspection: November 7, 2003 TIGHT OR HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal _fiberglass_polyethylene_other(explain) Dimensions: Capacity: gallons Design flow:_gallons/day Alarm present(yes or no):_ Alarm level: _ Alarm in working order(yes or no):_ Date of last pumping: Comments:(condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: at outlet invert Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.) D-box appears structurally sound with no evidence of leakage in or out Few solids in tank PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 e l Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Dolar Davis Road Centerville Owner: Christopher&Susan Congalton Date of Inspection: November 7, 2003 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located,explain why: Type: X leaching pits,number 1 _leaching chambers,number _leaching galleries,number _leaching trenches,number,length _leaching fields,number,dimensions _overflow cesspool,number —innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) Soils above leaching pit appeared unsaturated.No evidence of surface ponding,breakout, lush vegetation or other evidence of hydraulic failure was observed. Leach pit was dry and cover showed no effluent contact staining. CESSPOOLS: none (cesspool must be pumped at time 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 or no): Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: none (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Dolar Davis Road Centerville Owner: Christopher&Susan Congalton Date of Inspection: November 7,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100'(Locate where public water supply enters the building) LOCATIONS A B 1 17 ft 30 ft 2 29.5 ft 38 ft 3 29 ft 49 ft A LEACH 30 PIT EXISTING DWELLING SEPTIC TANK 2 I o 7. ❑ D-BOX # 22 B T z J K W H DOLAR DAVIS ROAD NOT TO SCALE 10 r Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Dolar Davis Road Centerville Owner: Christopher&Susan Congalton Date of Inspection: November 7,2003 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 15+ feet Please indicate(check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed X Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: Checked local excavators,installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Town of Barnstable GIS Department records indicate that groundwater in over 15 feet below the surface An observation hole was to a depth of 4.5 feet below bottom of leach pit Applying a groundwater adjustment of 4.0 feet(Index well SDW-252 Zone D,October reading=47.5)demonstrates that the SAS is above adjusted high groundwater. 11 No.... 5..L. Fps....✓� ............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® Off" HEALTH w�. .. ............OF........ -�. `..: .G.. -.....Ar J 1-.......•..------------ Appliration for UWposal nrkii Tnnitrnrtinn ami# Application is hereby made for a Permit to Construct ( -or Repair ( ) an Individual Sewage Disposal System at: .... -.�.z _---:D�t�A�� D��.----------� ----- ..�: ....!......,.....-------M... S........................... Location-Address or Lot o. I L Owner ` Address ....... ..... .......... Installer Address Type of Building Size Lot.. f51-e').6.S:'_..Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) �.... Other, tures ...............•••--•.........-- W Design Flow.......fir ..........................gallons per person per day. Total daily flow........ .__gallons. Septic Tank—Liquid capacity. ©&!gallons Length................ Width---------------- Diameter---------------- Depth................ W Disposal Trench—No........:............ Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No.___..�______________ Diameter.....��'._...... Depth below inlet.._..(!...._... Total leaching area Z.d ._.._..sq. ft. Z Other Distribution box ( ►/) Dosing tank ( ) Percolation Test Results Performed by w��(.ei1�.___.. �`.z ..L t.JQ..._.__._. Date.... .....�L .C._�_.��-._... aTest Pit No. 1_... .minutes per inch Depth of est Pit''...11.�........ Depth to ground water...I................ (z, Test Pit No. 2................minutes per inch Depth of Test Pit...... Depth to ground water........................ O Description of Soil lJ ?�' v p,Rx�-l.l'• �Jf;1�3�..iZ p` L- x P t •• . -• I--------------------- c, --------- ------�y--mil--�/�ti3----.....�-----s'�►�-------- --------- --------------- -------------------- W ••-•••-------------- --•-•------•------------------•--•-••-••--•------------------•--•-•••••-•---•••----•------------•-----------•••--••--------•---••--•--••-•-•-•••--•-•--•-•-•............-•----.--•- UNature of Repairs or Alterations—Answer when applicable.____._......................................................................................... --------•-------------------•--------------••-•-•-••••-••-•-•--••-•-•••--••••-•••••--------------••-••••--•---•••-•••••----•••-------•••------••---•••---••-••---••-------••-••••••--•••............-••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT L- 5 of the State Sanitary Code— The un rsigned further agrees not to place the system in oper on until a Certificate of Compliance has b s d bVtheob of health. ------. Signed � \y - / � s Da Application Approved B Date Application Disapproved for theVllowingDreasons:......-•----••--••-•----•••-•-•---••-•--••-•..............................................Da.t............... .................•-••--.............---•----•--------•••........-••-•-•-••----•-------......_..-•----••---•••-•----•--•-•---••-••-•-------••----••----••-••-•---•-•••--••----•-•-•--------••--•--------- Date PermitNo......................................................... Issued....................................................... Date NQ.5V. Fics.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliraafiaan for' DispoliFal IUD 0 Tonarnrtiaan !unfit Application is hereby 'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........... ...............�`�t-t� I> .�1 �i7 G�►.,i'C` off'...... M 5...............•-------------Location-Address or Lot No � -- _ �� C ,o lam_!G� 127r 13_�l . =F_Y n_N►.d �� n 5 S O ner ..-t dre __''d e-................. ....................................................' /if -... Installer Address Q Type of Building Size ...sq. fe Dwelling—No. of Bedrooms...._�................................Expansion Attic ( ) Garbage Grinder ( aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Othe -fixtures ...................................................... W Design Flow..... ...............................gallons per person per day. Total daily flow--------� e..._................_gallons. WSeptic Tank—Liquid capacity nU!�:.gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length..........._........ Total leaching area....................sq. ft. Seepage Pit No.-.-,I--------------- Diameter...J�'.__.___. Depth below inlet.... ............ Total leaching areaZC�.......sq. ft. Z Other Distribution box (✓) Dosing tank ~' Percolation Test Results Performed b?kN__ _._4-:.. .....__.... Date... ...... a. Test Pit No. 1...!:2.'_..minutes per inch Depth of est Pit___-1_2........... Depth to ground water__" "'............... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ........................................ _ Ave=Description of Soil----- I U ---••-•--•••---••------•---•---••---•.......---•-••-••---•-•.....-'!-"L-••L...-....a.....•••••t`.'--.........--s..........--------•---------•-------------------------------------- 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 TITS 5 of the State Sanitary Code—The unrsigned further agrees not to place the system in, operation until a Certificate of Compliance has been s�u�ed by the oadof health. Signed------ .....� err�--� , •- ' ate Application Approved By''...... ..................................... -----------•------'-Date--••-......... Application Disapproved for the ollowing reasons:-••--••...---••-•-•--••-----•--••-•-•----------••---•--•-----•-...•-•-••••••-•------••-----•-••••-•............. ......................................................--•--•-----••....................•-----••....•-•--............-•••-••-•-••--•-•-.•••_.._..•----------------•-•--•------••----••-----............ Date PermitNo......................................................... Issued.....................................:.................. Date THE COMMONWEALTH OF MASSACHUSETTS Y -_ BOARD OF HEALTH OF'y i:-1 ........................... Trrfifiratr of. TompliFanr THIS,IS TO CERTIFY, That the Individual Sewage Disposal System constructed (: ) or Repaired ( ) b P..- t......•.•... f! 1 ! TT r e ....... / Installer . f m —has been installed in accordance with the provisions of TI L 5 of The`State S�nitary Lode as�d'es6ribed in the application for Disposal Works Construction Permit No......................................... dated-_............................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM Wl F NC ION SATISFACTORY. DATE....::..... l ..................----------•------------.... Inspector...�.I_lr� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH s No t- . t f Vie- ..... •................................... FE ..-•--. .. 13isposaal Works Taan#rnr#iaan unfit Permission is hereby to onstr4et''( �.or�I epai ( an Individual wage Disposal ystem r le as shown on the application for Disposal Works Construction Permit! Nq; ."!1 P.... D'ated.:: j!.-. ....................... R, Board of Health r DATE------- s _.... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS SITE PLAN SHEET I Of a SCALE: I 'r � 0 A s �ilxy J. 3 r-v Aprrl,A. Lr--AGN la rA \2` O O ® C�vX- i 3-778 D1i1L -51,$ U A� �L.eL- 5 3 5 • rl $ Dl I is � S/C` v r -4ilA �O G' ({O' " � ..r...�wv..w+r..w..•........t....«....... •r WILLIAM M. No. 19771 416 b ap b F I, � REV STEREO LAND SURVEYOR. ZONE �G Gf✓PJt" �/IL1. - 1 P��.��a, PLAN REF. DATE 21 14 BENCH MARK*DATUM �� ",� '� WM. M. WARWICK 8 ASSOC., INC. DOMESTIC WATER SOURCE 10 W80X SO/ - NORTH FAIMOUTN FLOOD ZONE. o - MASS.. OZSS6 - 16/7) 361 -Z6 58 LEACHING 8AS/N SECTION Nor TO SCALE r Shceri 2 -7Z Z ?4"C.I MH COVER EARTH FILL BRICK AND MORTAR COURSES AS REO'D• TO BRING COVER TO GRADE 8,!"LOW INLET P/PF .., . ;: -—'•':1=_y. ?- TO WASHED PEA STONE FREE OF IRONS, # , T : FINES ANO OUST IN PLACE �t . • '' OPENING W/TH 4%g" L ' 4' TO I%p"WASHED CRUSHED STONE FREE OF OUTER 0/AMET£R IRONS, FINES AND OUST /N PLACE AND 1314"INSIDE DIAMETER • I. CONCRETE TO BE 4000 PSI 28 DAYS • 2. REINFORCED WITH •6% . . . 6,".NO. 6 GA. W.W.M. ' 3. 2'AND 4' SECTIONS ARE. AVAILABLE FOR \ , GREATER DEPTH REQUIREMENTS � -�--,2 --� 4. NUMBER OF PITS REQUIRED p � M/N. to NOTE: EXCAVATE TO ELEVATION 3�� OR EFFECTIVE DIAMETER (NOT TO EXCEED. 3 TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL WAMR-AftE LOAM AND: CLAY BENEATH PIT: REPLACE TYPICAL PROF/LE EXCAVATED MATERIAL WITH CLEAN GRAVEL TO' DESIGNED GRADE. /B'STD. LT. WGT. C.I.My COVER 4"C./.P/PE 4'8/T.FIBER P/PE DWELLING FLOW LINE T/GNT✓oINT OUTLET LEVEL /f TO FIRST ✓0/NT 'T ��E£ I4" o o 1 10 of 1 I d T 10 100 1 1 1�•� 1 11000 00 1 1 1 I 7 `STD. PRECAST CO NC. /ST BOX TO BE �'S• v •. � �r o 00 0 0 1 1 1 . '. i2'AL.SEPTIC TAN --- INS I i 1 000 00 0 1 I I ;ALLED ON LEVEL, 1 it 000 00 43 1 1 -�--B .';• gTABL£ BASE 1 11 000 00 1 1 ' i �SEPTI TANK TO BE 1 if 000 00 0 1 i 1 INS T LL D LEVEL, 1 it 100 00 1 1 STABLE BASE. ,111400 100010 0 1 1 I ' ZEACN/NG BA_S/N , 1 1 1 p 0 0 0 0 1 l , BASE TO BE L EV£L 11 0 Q 0 1 1 SOIL AND PERC. DATA PERC. RATE MIN. /IN. TEST PIT NO. f 3778 TEST PIT NO. 2 0- TEST BY 132L14,0- �' D � C'oP./s�E,yoIL WITNESSED. BY: iZoQ 6. Ir-�y-p b' TEST PIT GR. EL._$ LL,ElL-Q Mep. DATE: SAt`J o tt 1 47 t / 9 No 60Zz jP�1at1 - DESIGN DATA GENERAL NOTES BEDROOMS 215 NO'HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL'2"GPD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK I"E" .GAL. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE SIDEWALL AREA?-�GAL./SQ.FT. TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA GAL./SO.FT. SANITARY SEWAGE EFFECTIVE ON JULY 1 , 1977. LEACHING REQUIRED 9 SQ.FT.. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL LEACHING.Alk OF HEALTH. ZQ,FT. AT COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES 1/4" / FT. UNLESS INDICATED OTHERWISE. + sn SEWAGE DISPOSAL SYSTEM o afaRrtW FOR.. LIB tv�L. - S L�,v ka­j w MO ff 3417 : tiC�- (pZQj _bCIL-4?- AVlAv " I7 >P2417 1- I-®A� �7J FSc/ONAL E�G� TLV t LLB T M l�'c • _-....._. SCALE AS INOICATEO DATE Zf 14 f�y WM. M. WARWICK A ASSOC., INC. 8OX 801 NORTH FOOL MOUTH PROFESSIONAL ENGINEER MASS. 02556 - (6171 563 -Z658 L CATION SEWAGE PERMIT NO. VILLAGE INST A LLER'S NAME . na ADDRESS s U I L D E R OR OWNER i DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r ♦� � . �A � ._ ... .�: ,s f i_. � l ^ �1�4 �' s _ _ J� � n _.�--_._ _._.___ ir IN, 8 y_c,_Act . s�;-r5les 4 �� do 0� k ' 1-1-e c�_c_e►�,� - __.___W__________—.._____.�—.__.----_-._�� � tp r _ - 9 y I�x�PT gjEa r,,S kAJ + 1a o4\jb*( qa Mow G«•J-jz, SGw�ea.. Pao pfjsea I AD O r� I I Qo_ _ ► i b i l fj 1 1 I 3 i I � � ( a 1 �U to rp fi C i I G_ 0 'C N o _ 571 S !^ ro C I os,e4 i� 'C �a io I ,Cb r C � I � i 10, I � o C O p � G 1 i i i 1 i