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HomeMy WebLinkAbout0060 DUNCAN LANE - Health 60 Duncan Lane Centerville S MEAD® Uft 1= smaad wm • dads 1n USA rAl 'fir v , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal iSystem Form - Not for Voluntary Assessments 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is required for every Centerville MA 02632 11/3/14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 1 on the computer,use only the tab 1. Inspector: O key to move your cursor-do not James Ford ` ' G, Y use the return j Name of Inspector keY °gran Company Name I ,I P.O. Box 49 Company Address Osterville MA 02655 City/Town i State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The`system: I ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furth r valuation by the Local Approving Authority 11/14/14 Inspe is Signature Date The tem 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 corid'itions of use. t5ins-3/13 Title 5 Official Inspection or .Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is required for every Centerville MA 02632 11/3/14 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or i<n.310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. .i . Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal arid'over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial`infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): i' t5ins•3/13 I; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i� t Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments �i °M 60 Duncan Lane Property Address y! ' Donna Fenner Owner Owner's Name information is required for every Centerville i' MA 02632 11/3/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.),* ❑ Pump Chamber pumps/a@arms 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): i ❑ broken pipe(s), re replaced ❑ Y ❑ N ❑ ND (Explain below): t . ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ 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);ate replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is rp`noved ❑ Y ❑ N ❑ ND (Explain below): i, C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which'�equire 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 u'nl'ess 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: Fi4 ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official' 1Lnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is required for every Centerville MA 02632 11/3/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.Y 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. I� ❑ 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 wator 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Staticaiquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 ? Commonwealth of Mas.sacq, husetts Title 5 OfficialInspection Form Subsurface Sewage Disposal'System Form - Not for Voluntary.Assessments 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name I information is g; required for every Centerville MA 02632 11/3/14 page. City/Town "t State Zip Code Date of Inspection B. Certification (cont.);' Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a?'private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,00gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria Oxist 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. ii 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 tl` ❑ ❑ 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 ! i If you have answered "yes"Jo' 6ny question in Section E the system is considered a significant threat, or answered "yes" in Section 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. E; l5ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Officials lInsp ection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is required for every Centerville MA 02632 11/3/14 page. CitylTownt 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 la'r:ge 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 alI'system components, excluding the SAS, located on site? ® ❑ Were tle'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 siA 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 approxi'rrmation of distance is unacceptable) [310 CMR 15.302(5)] t : D. System Informatioh Residential Flow Conditions ' 2 Number of bedrooms desi -n 3 Number of bedrooms (actual). DESIGN flow based on 3101'�CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 j t5ins 3/13 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ? r_ C r Commonwealth of Massachusetts Title 5 Official, ,Inspection Form Subsurface Sewage Disposal tSystem Form- Not for Voluntary Assessments 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is i required for every Centerville MA 02632 11/3/14 page. City/Town State Zip Code Date of Inspection D. System Information,. Description: t 0 Number of current residents: it Does residence have a garbage grinder? ❑ Yes ® No ii Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected?1 ❑ Yes ® No Seasonal use? t ❑ Yes ® No Water meter readings, if av fflable (last 2 years usage (gpd)): Detail unavailable ; 4' Sump pump? ❑ Yes ® No i Last date of occupancy: 11 ' unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 31&CMR 15.203): Gallons per day(gpd) t Basis of design flow(seatsipersons/scl.ft., etc.): i Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No t Water meter readings, if available: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Officiat Inspection Form Subsurface Sewage Disposai'$ystem Form -Not for Voluntary Assessments wM 60 Duncan Lane i Property Address Donna Fenner Owner Owner's Name informati for every on is required Centerville MA 02632 11/3/14 page. City/Town State Zip Code Date of Inspection D. System Informatian°(cont.) Last date of occupancy/use:, Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part:of the inspection? ❑ Yes ® No k If yes, volume pumped: I gallons How was quantity pumped determined? l Reason for pumping: Type of System: ' ® Septic tank, distribution box, soil absorption system i� ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ InnovativelAlternative 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): f t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I r I. Commonwealth of Massachusetts Title 5 Officials, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 60 Duncan Lane Property Address Donna Fenner j Owner Owner's Name information is MA 02632 11/3/14 required for every Centerville . page. City/Town ! State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, datelinstalled (if known)and source of information: I installed on 8/3/09-per as- guilt j I Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): " I Depth below grade: feet Material of construction: w ❑ cast iron ® 40 PVC 1 ❑ other(explain): Distance from private water'supply well or suction line: feet Comments (on condition of.joints, ventin evidence of leakage, etc.): I I Septic Tank (locate on site:;plan): I'', 30" Depth below grade: feet i Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) I ; I 'c ,i If tank is metal, list age: s years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal. 2 Sludge depth: ' t5ins-3113 i' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i. l_ a. Commonwealth of Massachusetts Title 5 Officiarl :lnspection Form Subsurface Sewage Disposal,,System Form -Not for Voluntary Assessments 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is required for every Centerville MA 02632 11/3/14 page. City/Town State Zip Code Date of Inspection D. System Information,(cont.) Septic Tank (cont.) V.. Distance from top of sludge,to bottom of outlet tee or baffle 30 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees were present. There were no sign of leakage. The covers were 4" below Grease Trap (locate on site',plan): Depth below grade: feet r . Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum f top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle C Date of last pumping: Date - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of MassO'chusetts Title 5 Official, Inspection Form Subsurface Sewage DisposaFSystem Form - Not for Voluntary Assessments ;M 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is required for every Centerville MA 02632 11/3/14 page. Cityfrown State Zip Code Date of Inspection D. System Informatioh'�(cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tar;k must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ me'fa[. ❑fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Capacity: gallons Design Flow: k. gallons per day Alarm present: !' ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes El No Date of last pumping: k f Date i; Comments (condition of alarm and float switches, etc.): e o. i "Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No t f i, S l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 l; c. Commonwealth of Massachusetts Title 5 .0fficial Inspection Form Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is (; required for every Centerville MA 02632 11/3/14 page. City/Town State Zip Code Date of Inspection D. System Information�(cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even 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.): The D- Box was normal i. Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/a * If pumps or alarms are not,in working order, system is a conditional pass. i Soil Absorption System (SAS) (locate on site plan, excavation not required): i ; i If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is required for every Centerville MA 02632 11/3/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits! a number: ® leaching chambers number: 10 -ARC 36 HCper as-built ❑ leaching galleries number: i ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name gf technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no sign of failure.A�camera was used for the inspection. J 'i r Cesspools (cesspool must;be pumped as part of inspection) (locate on site plan): Number and configuration „ . Depth—top of liquid to inlet'%hvert Depth of solids layer !i Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 t Commonwealth of Massachusetts Title 5 Official: Inspection Form _ Subsurface Sewage Disposal;System Form -Not for Voluntary Assessments 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is MA 02632 11/3/14 Centerville required for every �''� page. City/Town State Zip Code Date of Inspection D. System Information'(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 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.): N/a t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 1 Commonwealth of Massachusetts W Title 5 Officia Inspection Form Subsurface Sewage Disposal'System Form - Not for Voluntary Assessments 60 Duncan Lane Property Address Donna Fe nner Owner Owner's Name information is required for every Centerville MA 02632 11/3/14 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 a iters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately j , d i 3 � a�` as 3 39 ay .If y � L k I' 7 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 - s Commonwealth of Mass4chusetts Title 5 Official Inspection Form Subsurface Sewage Disposal'!System Form - Not for Voluntary Assessments g , 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information,is required for every Centerville MA. 02632 11/3/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Y., Site Exam: ❑ Check Slope ® Surface water j, ❑ Check cellarI,. i I ❑ Shallow wells Estimated depth to high ground water: 22 +/- 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(ebutting property/observation hole within 150 feet of SAS) ® Checked with local.Board of Health-explain: Topo and water contours map ❑ Checked with Ideal excavators, installers -(attach documentation) i El Accessed USGS database -explain: i 1 ` c ' You must describe how you.established the high ground water elevation: see above s; I i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I ; e�• Commonwealth of Massa6husetts W Title 5 Official .Inspection Form Subsurface Sewage Disposal.'System Form - Not for Voluntary Assessments I 60 Duncan Lane Property Address Donna Fenner Owner Owner's Name information is required for every Centerville MA 02632 11/3/14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i' is `� f i i f, i .i l I i0 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. 0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: vayes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migonl �§p.5tem Cow6trUCtion permit Application for a Permit to Construct( ) Repair( ) Upgrade *Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1V4A11P/ /�/9 fie- el Installer's Name,Address,and Tel.No.� e�/G 7�� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size25e f�d sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required)— gpd Design flow provided — gpd Plan Date Number of sheets l Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil �� ►.,.. Nature of Repairs or Alterations(Answer when applicable) ^�J,> ZYY9 JZ i J 0�� 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 T^5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by t o d of e t Sign ,, Date 10,17114 Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Mff2y Date Issued r Fee THE COMMONWEALTH OF MASSACHUSETTS "Entered in 4�� PUBLIC HEALTH DIVISION - TOWN'OF BARNSTABLE, MASSACHUSETTS Yes f ZIppgication for �Bi5p` o5al 1&p!5tem Cougtruction Permit Application for a Permit to Construct( ) Repair( ) Upgrade , Abandon( ) ❑ Complete"System ❑Individual Components f Location Address or Lot No � //,}r J Owner's Name,Address,and Tel.No. Assessor's Map/Parcel // / j R ,,q L e) �d Installer's Name,Address,and Tel.No.7;7/4­—,/�4r J J yl/ Designer's Name,Address and Tel.No. Type of Building: p i Dwelling . No.of Bedrooms J Lot Siza!',/ � sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required)- gpd Design flow provided 3 2-- gpd Plan Date ?. Z — Number of sheets / Revision Date Title / Size of Septic Tank �(�GY �,t'� IH�Type of S.A.S./0 �QDS /4YL�3hJ !��►d'��'i Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of T'q 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by t s •o d of e t Sign /?�-�_ Date 0 > !,l n Ii Application Approved by , 7A__.- ® .0 1 _ Date Application Disapproved by: / Date for the following reasons i Permit No. /, � Date Issued THE COMMONWEALTH OF MASSACHUSETTS I BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) i Abandoned( )by at has e co strutted in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. / dated Installer Designer #bedrooms Approved design flow gpd The issuance of this' er >it shall not be construed as a guarantee that the system ill fu ti n as design d. Q C Date � O� Inspector � Vb✓- No. ✓70�� Fee THE COMMONWEAL,TH._OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Zi,5po!6oY *pfstem Cou5truction Permit Permission is hereby granted to Q D t/ruct ( �epa r ) U gr/a'd�ebancon ( ) System located at I CiV y , and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction us be completed within three years of the date of this p i . Date / r�"/ Approved by _ i TOWN OF BARNSTABLE LOCATION QU1 CCel t4l, SEWAGE# O q--Z 3 L) VILLAGE U.- �� ASSESSOR'S MAP&PAR_CEL 7 26)' INSTALLERS NAME&PHONE NO. _C I�rug- 4-14t.,rc 412a SEPTIC TANK CAPACITY ODO , 1 LEACHING FACILITY:(type) < 36 Y-C (size) b = NO.OF BEDROOMS 3 OWNER 1*,-Al _Ja.fb S PERMIT DATE: 7—Z g-Q 9 COMPLIANCE DATE: & ",5 -®9 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 f 1 S V Ov - Z Z Town of Barnstable Regulatory Services Sl, Thomas F. Geiler,Director NAM Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: 8 0 Sewage Permit# Assessor's Map/Parcel l 7 ZD Installer&Designer Certification Form Designer: BA5 S RIVE-- CN�s1N£C(L!N(, Installer: 0Jd.4zg g= C=���- Address: P. 0, 136X 3 Address: rQ 46 0.)( S-"' OfNNI S Mfg o20 On C .mom ,was issued a permit to install a (date) (installer) septic system at 60 E7 N 66 N) WO CEM1ENI LLf based on a design drawn by (address) q� �A tZJ VS h. NL�1J '(U N6 dated 01 / (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required)was inspected and the soils were found satisfactory. �jk%OF4M,? z� KOMASJ.�` ytJ McLELLAN (Installer's Si re) CIVIL v 36471 a °' (Designer's a re) (Affix e' n -� p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTH. BOTH THIS FORM AND AS- BUILT CARD ARE RECENED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:loffice formsWesignercertification form.doc Town of Barnstable P 4 1 yo Department of Health,Safety,and Environmental Services �PV Public Health Division Date 6 c� 367 Main Street,Hyannis MA 02601 '�Ec►�Ft¢iR+��� Date Scheduled.a a F Tune /O Fee Pd. i t tF r'; Soil Suitability Assesisment for Sewage Disposal t Performed By: TT1Dt r l S M0—U-E UAN,��� Witnessed By: In / LOCATION & GENERAL INFORMATION Location Address �� OWCAN 1 l'ANS Owner's Name ,I�11`I XF JAMR,s CC—N-p tv I u 1 Address 5A �6 Assessor's Map/Parcel: '177/.W Engineer's Name 100MAS Mt�G- �-i� 'N NEW CONSTRUCTION REPAIR V/ Telephone N 508' 3()5' Land Use Slopes(%) 15010 Surface Stones N� Distances from: Open Water Body ft Possible Wet Area NA ft Drinking Water Well ft 1 Drainage Way /eft Property Line > �� ft Other ft SKETCH: (Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) �o D ro WA)6AN 0 LANb 0 q39 5EE p�N Fes. Ul i Parent material(geologic)���L�.11(_ Oln Depth to Bedrock NJA Depth to Groundwater: Standing Water in Hole: I Weeping from Pit Face / /A ► Estimated Seasonal High Groundwater ID DETERMINATION FOR SEASONAL HIGH WATERTABLE Method Used: * FRIMp ► Depth Observed standing inobs.hole: in. Depth to soil mottles: ld in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment It Index Well#,fQJreading Date:JHQ4 Index Well level •Z Adj.factorJL5L Adj.Groundwater Level ► D PERCOLATION TEST - Datz7T'in�e ( :�d Observation l Hole M Time at 9" ► ., . Depth of Perc _ Time at 6" Start Pre-soak Time Q Time(9"-6") ,,{{ End Pre-soak LE5Y TtIpN 9 h /7 r �M I^J Rate Min./Inch 3v �� Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---j Copy: Applicant �,r DEEP OBSERVATION HOLE LOG Hole # Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. 0Gravel I " o A LS 164Q, 313 ivA �b4n <* &A O ollCI ftq SPA 2•5 ,6 or J ",;,DEEP`OBSERVATION HOLE LOG ,Hole #" . Depth from' ` Soil'Horiion I Soil Texture Soil Color Soil t• { Other Surface(in'.) 7 (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. o DEEP OBSERVATION HOLE LOG Hole # Depth from Soil Horizon Soil Texture Soil Color Soil 'Other Surface(in.) (USDA) (Munsell] Mottling (Structure,Stones,Boulderes. "stencv.° Gravel) r A • V ` DEEP OBSERVATION HOLE LOG Hole # Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) ' Mottling (Structure,Stones,Boulderes. ! Consistency.o Flood Insurance Rate Map: x Above 500'ryear flood boundary No_ Yes Within 500 year boundary No— 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? 4 `I\, If not, what is the depth of naturally occurring pervious material? Certification, NOvr ' 9Q I certify that on (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required traini g, expertise and e perience described in 310 CMR 1.5.017. Signature_ Date 7' (,p• or Commonwealth of Massachusetts A, 7, ®� Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 60 Duncan.Lane, Centerville, MA 02632 - Property Address Michael D. and Lorraine W.James Owner Owner's Name information is required for Centerville MA 02632 06/08/2009 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.Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the �� computer,use 1. Inspector only the tab key to move your Reid C. Ellis cursor-do not Name of Inspector use the return key. Ellis Brothers Const. Company Name qQ 23 Enterprise Road, P.O.Box 59 Company Address Yarmouth Port, MA 02675 City/rown State Zip Code 508-362-6237 S121891 Telephone Number License Number r 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 in'"po pl spection.The in was performed based on my training and experience in the proper function and T.aintenaneq of oR slte sewage disposal systems. I am a DEP approved system inspector pursuant>�Section 15.340°of Title 5(310 CMR 15.000).The system: ` t? k ❑ Passes conditionally Passes ❑ Fai a] r ❑ Needs Further Evaluation by the Local Approving Authority Inspedo�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. (04 t5ins•09108 rme 5 Otficid system.Page I or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D.and Lorraine W.James Owner Owner's Name information is Centerville MA 02632 06/08/2009 required for every page. City/rown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary:Check A,B,C,D or E/ ys complete all of Section D A) System Passes: ❑ I have not found any information w iich indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "non or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or extrration 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 VND(Explain below): i t5ins,09108 Title 5 Mimi tnspec6m Form:SOmelaoe Sewage Dmposal System•Page 2 or 17 Commonwealth of Massachusetts .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D. and Lorraine W. James Owner Owner's Name information is required for Centerville MA 02632 06/08/2009 every page. C mown State Zip Code Date of Inspection B.-Certification (cunt.) B) System Conditionally Passes(cunt): ❑ 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 e0lard of Health: ❑ Conditions exist which require furthei evaluation by the Board of Health in order to determine if the system is failing to protect public ieafth, safety or the environment. 1. System will pass unless Board f 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 R:feet of a surface water ❑ Cesspool or privy is within 54 feet of a bordering vegetated wetland or a salt marsh t5ins•0901 Me 5 OWXW hVqcgon Form Sfsiafaoe Sewage(:i4osal system'Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Duncan Lane,Centerville, MA 02632 Property Address Michael D. and Lorraine W.James Owner Owner's Name information is required for Centerville MA 02632 06/08/2009 every page. Cityrrown State Zip Code Date of Inspection __-B..Certificatiop (cunt.) _(eftith 2. System will fail unless the Board of (and Public Water Supplier,if any) determines that the system is function» a manner that protects the public health, safety and environment: ❑ The system has a septic tank and it absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tribut iry to a surface water supply. ❑ The system has a septic tank and 3AS and the SAS is within a Zone 1 of a public water supply. . ❑ The system has a septic tank and AS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS anc 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 analysi performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of mmonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure riteria 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 �Q rt9 a-, Alif"44t� lk6� �Qv lovf� ❑ 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'/Z day flow t5ins,pgrog Title 5 omcial Uupection Fwm:SW=fffaw Sewage Disposal System•Pap 4 of 17 Commonwealf of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..' 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D.and Lorraine W.James Owner Owner's Flame information is required for Centerville MA 02632 06/08/2009 every page. cityrrown State Zip Code Date of Inspection B.Certification (cunt.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ? AnX portion of the SAS,cesspool or privy is below high ground water elevation. ❑ U/ • CIO Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privyis within 50 feet of a private water supply well. P PP Y ❑ 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.] ❑ co/ 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 failu i E) Large Systems: To be considered a large dystdin 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" r"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 fee of a surface drinking water supply ❑ ❑ the system is within 200 fee of a tributary to a surface drinking water supply ❑ ❑ the system is located in a n'rogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Kone II of a public water supply well If you have answered"yes"to any question in So bion E the system is considered a significant threat, or answered"yes"in Section D above the large s stem 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.09108 Tdis 5 Ofidal trmpection Fomc Subsasface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D. and Lorraine W.James Owner Owner's Name information is required for Centerville MA 02632 06/08/2009 every 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 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,a eluding 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 sae and location of the Soil Absorption System(SAS)on the site has / been determined based on: _L�/ ❑ 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•09/08 Title 5 Official n Form.Subsurface D' em•P 6 of 17 Mspae6o Sewage Disposal Syst age Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D.and Lorraine W.James Owner Owner's Name information is required for Centerville MA 02632 06/08/2009 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes VNo Laundry system inspected? ❑ Yes CJ No Seasonal use? e 4 ❑ Yes 2 No Water meter readings, if available(last 2 years usage(gpd)): Detail: C7�ZOV-7 cg e - 7 Sump pump? ❑ Yes n3eNo Last date of occupancy: 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•09108 Tits 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'r 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D. and Lorraine W.James Owner Owner's Name information is required for Centerville MA 02632 06/08/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) !f/ezl- Sao c C> f Last date of occupancy/use: - Date Other(describe below): General Information Pumping Records: 09 G/1✓� 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 stem: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach-a copy of the DEP approval. ❑ Other(describe): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D. and Lorraine W. James Owner Owner's Name information is Centerville MA 02632 06/08/2009 required for every 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: Were sewage odors detected when arriving at the site? ❑ Yes 0/"No Building Sewer(locate on site plan): 13 I Depth below grade: feet Material of constructiV40 El cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): 92,ti /Al Tom- c: �`�' �- '1/0 40 Septic Tank(locate on site plan): Depth below grade: " � -3 7ieal of construction: ncrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: (/ years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No � Dimensions: Sludge depth: t5ins•09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D. and Lorraine W.James Owner Owner's Name information is Centerville MA 02632 06/08/2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 22 4 Distance from top of sludge to bottom of outlet tee or baffle J� v Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 t or baffle Distance from bottom of scum to bottom ol outlet tee or baffle Date of last pumping: Date Title 5 MOW Inspection Form:subsurface Sewage Disposal system•Page 10 of 17 t5ins•09/08 Commonwealth of Massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.' 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D. and Lorraine W. James Owner Owner's Name information is Centerville MA 02632 06/08/2009 required for state Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pu a at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and floats vitches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 l5ins-09108 Commonwealth of Massacnuserm Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D. and Lorraine W. James Owner Owner's Name information is Centerville MA 02632 06/08/2009 required for State Zip Code Date of Inspection every page. Citylrown D. System Information (cunt.) g- 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, ndition of pumps and appurtenances, etc.): Soil Absorption System(SAS) locate on site plan, excavation not required): If SAS not located, explain why: 1 4 �f//x ��c� -� ate,/ 6 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 12 of 17 t5ins-QW08 uommonweaim or massacnusWus Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D. and Lorraine W. James Owner Owner's Name information is required for Centerville MA 02632 06/08/2009 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: ❑ 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.): � (cesspool Cesspools must be pumped as of fispection)(locate on site plan): P 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 at 17 t5ins•0908 Commonwealth of massacnuse« Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D. and Lorraine W. James Owner Owner's Flame information is Centerville MA 02632 06/08/2009 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at leasl two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate 7whey public water supply enters the building.Cheek on of \i boxes belo : hand-sketch in the area below `` \ ❑ drawing attached separately tv. e 9 � dd 6 3 w f/ Title 5 Official inspection Farm:Subsurface Sewage Disposal System-Page 15 of 17 t5ins•0901 Commonwealth of Massachusetts IN Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J�< 60 Duncan Lane, Centerville, MA 02632 Property Address Michael D.and Lorraine W. James Owner Owner's Name information is Centerville MA 02632 06/08/2009 required for State Zip Code Date of Inspection every page- Cityrrown D. System Information (cont.) Site Exam: ❑ Check Slope � • O� ❑ Surface water `,;rg `SI�y►� ❑ Check cellar � 'Of ❑ Shallow wells yiJ�l Estimated depth to high ground water. 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: 36 /V 6Y ✓ �rV V Before filing this Inspection Report,please see Report Completeness Checklist on next page. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 t5ins•09108 A• Commonwealth of Massacnusens Title 5 Official Inspection Form iSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Duncan Lane,Centerville, MA 02632 Property Address Michael D.and Lorraine W.James Owner Owners Name information is Centerville MA 02632 06/08/2009 required for CitylTown State Zip Code Date of Inspection every page. E. R ort Completeness Checklist 7nspection Summary: A, B, C, D, or E checked 'nspection Summary D(System Failure Criteria Applicable to All Systems)completed ystem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 t5ins•0908 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTE ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 =N? RECV EO WILLIAM F. WELD MAY 19n � Governor r� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC ON FOi DPBARMfD B. �RUHS ARGEO PAUL CELLUCCI Lt. Governor PART A i HEALTH DEPT. Co loner ��, O CERTIFICATION \ Property Address: 60 Duncan Lane, Centerville, MA Address of Owner: � 8 Date of Inspection: April 9, 1998 (If different) Name of Inspector: _Gordon E. Burrpus I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name:- Gordon E. Bumpus Mailing Address: 215 Osterville West Barnstable Road, Osterville, MA 02655 Telephone Number: (508) 428-5640 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: April 17, 1998 The System Inspector shal submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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 Hof Health, will pass. .Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web hitp.mvww.magnet.state ma.us/dep Printed on Recycled Paper C • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:?4i `160 Duncan1Lane, Centerville, MA Owner: Bob Marks 1 Date of Inspection:' *fil'9, 1998 BJ SYSTEM 3CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WELL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 4 2) SYSTEM WELL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS\THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 I } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 60 Duncan Lane, Centerville, MA Owner: Bob Marks Date of Inspection: April 9, 1998 D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined 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 ® Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. ® _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ® _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. ® _ 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. ® _ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® _ Any portion of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes` No 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 60 Duncan Lane, Centerville, MA Owner: Bob Marks Date of Inspection: April 9, 1998 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant, and Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ The system does not receive non-sanitary or industrial waste flow. ✓ The site was inspected for signs of breakout. ✓ All system components, excluding the Soil Absorption System, have been located on the site. ✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. ✓ _ Existing information. Ex. Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)]. (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 60 Duncan Lane, Centerville, MA Owner: Bob Ma& Date of Inspection: 1pril 9, 1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 2 Garbage grinder (yes or no): No Laundry connected to system (yes or no): Yes Seasonal use (yes or no): No Water meter readings, if available (last two (2) year usage (gpd):' 1996 - 80.000 gals. and 1997- 84,000 gals. Sump Pump (yes or no): No Last date of occupancy: Presently ocgVied COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped in 1995 -per owner. System pumped as part of inspection (yes or no): No If yes, volume pumped: gallons 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) I/A Technology etc. Copy of up to date contract? Other 1000 gal. septic tank- 1000 gal. leach pit l6'X 6') with stone. APPROXIMATE AGE of all components, date installed (if known) and source of information: Jan. 31177-per Town Hall. Sewage odors detected when arriving at the site (yes or no): No (revised 04/25/97) Page 5 of 10 t: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 60 Duncan Lane, Centerville, MA Owner: Bob Marks Date of Inspection: .Vril 9, 1998 BUILDING SEWER: None (Locate on site plan) Depth below grade: Material of construction: cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: Yes (locate on site plan) Depth below grade: 28" Material of construction: ✓ concrete _metal _Fiberglass Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance —(Yes/No) Dimensions: 1000 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 0" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 0" Distance from bottom of scum to bottom of outlet tee or baffle: 0" How dimensions were determined: Measuring stick Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) The septic tank was in very good condition. The baffles were clean and there were no solids or scum in the tank. There were no signs If hydraulic hilure or solids carryover. 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 60 Duncan Lane, Centerville, MA Owner: Bob Marla Date of Inspection: 4pril 9, 1998 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or 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 level: Alarm in working order_Yes; _No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: None (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 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.) (revised 04/25/97) Page 7 of 10 r� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) c Property Address: 60 Duncan Lane, Centerville, MA Owner: Bob Marks Date of Inspection: 4pril 9, 1998 SOIL ABSORPTION SYSTEM (SAS): Yes (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: I - 6'X 6' with stone leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) There wrre no signs g[ hvdraulicfiilure The leach pit was 4'under the drive The bottom¢ thepit to grade was 11 ket The adjusted high groundwater was 12.2ket which equals a 1.9foot separation. CESSPOOLS: None (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: Mne (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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION (continued) Property Address: 60 Duncan Lane, Centerville, MA Owner: Bob Marla Date of Inspection: April 9, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks. Locate all wells within 100' (Locate where public water supply comes into house). � 60 a� 1 • r ` �x6P jow4. �. �0 ro G.6 ,N --I. • (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 60 Duncan Lane, Centerville, MA Owner: Bob Marks Date of Inspection: April 9, 1998 Depth to Groundwater: 12.9 feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record ✓ Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers ✓ Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Lust be completed) Hand augered to groundwater at 13.5,ket. Attusted to high groundwater using Cape Cod Commission Technical Bulletin .. and USGS maps. (revised 04/25/97) Page 10 of 10 M Permit Number: Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: 60 Duncan Lane , Centerville , MA Lot No. Owner: Bob Marks Address: 60 Duncan i.ane , Centerville . MA Contractor: Gordon E . Bumpus Address: 215 Osterville W , Barnstable Ed . Notes: Ostervi.11e , MA STEP 1 Measure depth to water table to nearest 1/10 ft. .............................................................................. .Date _4/9 /9 8 13 . s month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... I W 2 9 © Water-level range zone B STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... 4 /9 8 6 . 3 month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment • 6 .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ............................................................................................................. 2 9 No......................... FE$. �/.................. THE COMMONWEALTH OF MASSACHUSETTS r BOARD 1-HEALTH a� ........OF..... ....... ./-e_ .........................-................------. Appliratiun -fur Uioputittl WOrkli 0=34rurtiun Prrniit Application is hereby made for a Permit to Construct ( ) or Repair } an Ind'v' al Sewage Disposal System at: L r u 3 �a ,� .. ---------- ----- Location-Add r s / or Lot No. Ow�fr Address •-----•------ ---- Installer Address d Typeg Size Lot . ..g. !._.Sq. feet U Dwellling n No. of Bedrooms-_.--. .._............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building 7.-'!!t_0V0.& jE.. No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------ W Design Flow...........��......................gallons per person per day. Total daily flow................OY—a.0............gallons. WSeptic Tank-Liquid capacity-60-p__gallons Length................ Width............---- Diameter----............ Depth.-..----_.----- x Disposal Trench—'No..................... Width............ ___. Total Length.................... Total leaching area.------.__--_-_---sq. ft. Seepage Pit No........I....'... Diameter__,00.O...S�epth below inlet.................... Total leachiit area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) 4 /®� aPercolation Test Results Performed by.......................................................................... Date--------------------------------------- a Test Pit No. 1................minutes per inch Depth of 'Pest Pit..------------------ Depth to ground water..-.-.--.-.---._---.---- fz Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth p to gr ound water________________________ G ,_-.,-•-------_- - ------•-----------1°----------I----•- •--- -r A-------' ------- Desc iption of Soil- �=� ' --•-- �------.. ® 4� .�? �-... ._... W ✓i c,�� = ll ••v '---•--•--....-----•------------•---------•-----------------•-------------------•----••-•------- .......................... 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 Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. I 'fined... - - --....-�---./. --- --•---•-----•--...__ /�/./!�J_!__./� , Date Application Approved By.. ; /-d - S` Application Disapproved for the f ollowing reasons:.............. .. __....____.__................_._..............................Date.............. -------------------------------------•-•-.---------------------------................................................................................................................................... Date Permit No.---..C, � = Issued...................... -------------•---•......-•---•--- �• Date ,i 4 - No.. FEa. .......�...v... r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' -------OF_... ...'-....x� Appliration -for Bi_gpwial Works C omitrurtion Vrrnlit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: / (C , Location-Address t or Lot No. Sou-T �.. !�._� r......--./._.. C•--•-•...E7/ G Owner Address a T�f/fv 1/? f� c �/ n S Installer Address Q Type of Building Size Lot!�Z...�_..�� ---Sq. feet U Dwelling-No. of Bedrooms..----.;.................................Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building _____--------- No. of persons............................ Showers ( ) Cafeteria ( ) al Other fixtures __--.__--_----___________________ W Design Flow_._..._..._.��____________________gallons per person per day. Total daily flow..............__.:_ io �1__..........gallons. WSeptic Tunk d Liquid capacity .--_ gallons Length................ Width................ Diameter................ Depth---------------- x Disposal Trench—No-____________________ Width-------------------- Total Length----------_........_ Total leaching area--------------------sq. ft. Seepage Pit No......../_______-- Diameter______________1---- -Depth below inlet.................... Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) f aPercolation Test Results Performed by------------_----- -----------------------------•----------------------- Date----------•---------•---.---------- ,� Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water..-.-_-..--_-----.--. -. ;1-4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....-.-..--.__.---_..__. -•-------------•--------------------------------------•--------------------------•-----------••------•---.................------••-•-•--•-- O Description of Soil.... '_._:_' �r� e- -----=------- ----------------------------------•--------------------- ------'------------------------------------ ---.._..---- V y ------------------`------:---=---=•----------------------- 11 V 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ig - - t Date A lication Approved B ' - • �__'___'?...f--_-.-7/ PP PP y----------; �_...... Date Application Disapproved for the following reasons:................................................................................................................ ------------------•---•-......_.........---•_.-•-•---•--------------......•-•----•-----------•----••-•--------•-----•--•••-----_.....--••••---.-•••-•--•----------------------•-.----•-......--------•- Date PermitNo------------------------------------------------ ........ Issued........................................................ Date .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - I w.l.prtifiratr of ITITutpliiattrr THIS ISt �TO CERTIFY, That the •Individual Sewage Disposal System constructed (G)or Repaired ( ) by...._.. ;= 1 ' r Installer at. 't�' = ..: .T /1=-='---•-----`---`------°------ --------'---------- = ' .( l ......�.......,--_-.-.a, �Gf... ------------------------------ has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit ________________ dated...-,✓!1____�__\1__'- ..K_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY DATE..--•••-. C 1 - °r� '�.. � `-----. ..----�-r�x-`---:r"> Inspector---------� �`;•---- -- ........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , No.------ FEE.. r Uinpa6a j irk r tr rti�aat rrmit +/ j _. Permission is hereby granted_. 14lr1�Cf7____ :__.. ..._ t'1 t ,..�- �, is-- -----•--------------•---------•--•-•-----------•------------- to Construct f( or Repair'-() ) an Individual Sewage Disposal Sys em,, - �-•� at No.. `=' '/ !� T '� -- ' ' ! x l-r 1_ �ii >i "'�-� ........' f Street / as shown on the application for Disposal Works Construction Permit No._._-.---------------Dated__���...___-- ................... Board of Health DATE_---_-------------------- -------------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ,T-- �. - } r _ E '9 ` wt caber o*r 40 - 1 tN OF 04, �9� CRAIG y� sapric. .5yjrerAA To is •y> RAYMOND .t7 c SHORT DESfC.'-4 Olt No. 27483� y �'�a L OADfNGr �Fsy/OM Al ENX TOWN wRTE2 .5 uppt -V�LOT . PLAN I F'll C A 1 O No 6;;..gd-22fF' 'Y/LZ,4 Q P-- ' + A1. r:- 1" DATE C ►� [ N C E= o&.,F/,v G .4 0 7— 4/3 A j QOOK 2.5Z I)''0q'q'0 ;7 -�9 .Ci 1- E 1? G /.� 7'?i' Y D A T E t? . 717Y CERTIFY THAT THE BUILDING _ G. LAND BURY o '10a ON THIS PLAN 15 LOCATCD ON ",' MOUND AS SHOWN HERCON AND CONFORM TO THE ������Y� OY — LAWS OF THE TOWN OF JosEPHM. Z"t 6A E - W H C N C O N S T R U C T E D . c MONAHAN,,JR. y q v 13660 ASSOCIATES OC6 : 57CRCD ENGIWEERS Il LANDS SURVEYORS y® scJa��•� 'min ;;APE OFF1CT OUILDING— 1265 ROUTE ZO ,)UTH YARM O UTH.0 MASS. 026G4 Y-..p11fL.WY LOCATION - SEWAGE PERMIT NO. f o 7 VILLAGE c-EA-7' L L !1 1 INSTA LLER'S NAME & ADDRESS (s'1r 7'0,11 11L 0 Azz a Zlt c.. B U I'L D E R OR OWN E.R - /1/0 /� i' G F; ft�,� 5 0 L-TFI ijTA-J DATE PERMIT ISSUED /o 7�. DATE COMPLIANCE ISSUED &A l s J��` ���r(� a N 2� EXISTING CONTOUR:---- SEPTIC SYSTEM DESIGN SEPTIC SYSTEM SECTION 4 PROPOSED CONTOUR:•••-•••••••• 2"PEASTONE o EXISTING SPOT ELEVATION:25.5 FLOW ESTIMATE:'o COVERS WITHIN 6" 3/4"-1 1/2"PROPOSED SPOT ELEVATION: 5©. 3 BEDROOMS AT 110 GAL/DAY= 330 GAL/DAY 102.97 LOCUS TEST HOLE: OF FINISHED GRADE WASHED STONE L TOP OF � �a� UTILITY POLE: -0- ° FOUNDATION ""` ' n- mn, „R INSPECTION PORT ?P SEPTIC TANK:LINE: ^` , . T, ELEV=99.8 HYDRANT: 330 GAL J DAY x 2 DAYS=660 GAL GP OJT 100.3 3 MAX.RETAINING WALL:® USE 1000 GALLON SEPTIC TANK (EXISTING) a ELEV' COVER (EXISTING) � (1'MIN) LEACHING AREA: ° EXISTING 99,61 99.86 1000 GAL ELEV. 99 53 99.36 USE 10 ADS ARC36HC CHAMBERS WITH 1.5'OF STONE SEPTIC TANK ELEV. 98.44 LOCATION MAP ELEV. ELEV. LOT 43 (24,950 SF) AROUND SIDES AND 3'AT ENDS (56'x 6'x 0.9'DEEP) a (6"OF S ONE UNDER) 1.5 3' 1 5 3 ELEV. ASSESSORS MAP: 147 PARCEL:20 56'x 6' -� PLAN BOOK:252, PAGE:32 SIDE AREA: (56'+6')x 2 x 0.9=112 SF (0.74)=83 GAVDAY 99.34 TEE SIZES:(TO BE CONFIRMED) GAS BAFFLE USE 10 ADS ARC36HC CHAMBERS FLOOD ZONE:C BOTTOM AREA: 56'x 6'=336 SF (0.74)=249 GAL/DAY INLET:6"UP,13"DOWN AT OUTLET TEE ELEV. WITH 1.5'OF STONE AROUND SIDES AND Y AT ENDS CAPACITY 332 GAL/DAY OUTLET:6"UP,14"DOWN (56'x 6'x 0.9'DEEP) (H-20) (TO BE VENT 5.44 = Y ADJUSTED GROUND WATER ELEVATIO �-93�.O � N TH-1 103.0 00.E BED BED TEST HOLE LOGS O/AHORIZON ELEV. y0°�D00 ROOM ROOM LOAMY SAND 3p BATH ENGINEER: THOMAS McLELLAN,P.E. 6„ 10YR 3/3 102.5 WITNESS: DAVE STANTON,R.S. B HORIZON 2nd FLOOR DATE: 7-28-09 LOAMY SAND 24„ 10YR 5/8 101.0 PERCOLATION RATE: <2 MIN/IN C HORIZON (P MEDIUM SAND USGS GROUND WATER ADJUSTMENT: 2.5Y 7/6 �' 0. WELL:SDW-253, ZONE:C, ADJUSTMENT:4.5' OBSERVED 0"009 LIVING ADJUSTED GROUND WATER ELEV.=93.0 174" 5 ROOM 180"1 GROUND WATER n93 102 MOTTLING AT ELEVATI N \ I I NOTES: \ 103 A04 _._ - - - I BED \ ` - ROOM KITCHEN 1.VERTICAL DATUM: ASSUMED BATH 2.MUNICAPAL WATER IS AVAILABLE. _ _ -4"PVC PIPE TO BE-USED THROUGHOUT SEPTIC SYSTEM_ O __ 1st FLOOR 3.SCHEDULE 40 _ EXISTING FLOOR PLAN 4.ALL PRECAST UNITS SUBJECT TO TRAFFIC LOADS TO CONFORM WITH AASHTO H-20 SPECIFICATIONS. Vcl 5.PIPE PITCH= 1/8" PER FOOT(UNLESS NOTED OTHERWISE). <.� IA,, 6.FIRST 2'OF PIPE OUT OF D-BOX TO BE SET LEVEL. 9�0 .�\ ON. '� a�n�\ / / \ . 7.THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE USE OF A GARBAGE DISPOSAL. \ 8.ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE STATE OF MASS.ENVIRONMENTAL CODE(TITLE FIVE)AND LOCAL HEALTH REGULATIONS. 9.CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. W ' ��� d pcN�I I D 10.GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED 3'. EX / palie I I `�s �p F G OFp F pWELROOM \ \t/F $ UNG f /� I �? �0, 11.FIELD SURVEY PROVIDED BY TERRY A.WARNER,P.L.S.,HARWICH,MA. top fnd.=102.97 ST \ ;o/�.-� \- - 12.THIS PLAN REQUIRES THE REVIEW AND APPROVAL OF ONE OR MORE TOWN DEPARTMENTS AND om o{Bank / \ i LP.� / l a _ IS SUBJECT TO CHANGE UNTIL SUCH TIME. 8ott %' I \ % / _ '100 13. EXISTING LEACH PIT IS TO BE PUMPED AND REMOVED. ' DECK 97 TH-1 \ . .J _ . ... . . . Stone P -~ / Top pf Bank439-8V I \ f f \ \ /� / / ' ' / / S 83°3S30"W 9g - I / \ SITE PLAN 98 / / -103 ELECTRIC / / - LOCATION: CAPE AND VINEYARD 60 DUNCAN LANE, CENTERVILLE,MA 99 I BENCHMARK AT // O^ / / �0 , I LEFT CORNER / ?i� T{; .>.�5 J tr PREPARED FOR: I I OF WOOD STEP ELEVATION= 102.84 CIVIL MIKE JAMES 100 ` l / DATE:7-28-09 SCALE: V 20' BASS RIVER ENGINEERING � s 9 Day CIO, P.O.BOX 1163, EAST DENNIS,MA 02641 r f THOMAS J. MCL LAN P.E. M9-18 0� 96 508-385-3426