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HomeMy WebLinkAbout0022 EBEN SMITH ROAD - Health 22 EBEN SMITH RD. CENTERVILLE A =' 01­ 160 1 _ Owford, NO. 152 1/3 ORA Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - ; M 22 Eben Smith Rd. Property Address Margery Flinchbaugh ' Owner Owner's Name information is required for every Centerville Ma. 02632 May 24, 2017 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information Q#- on the computer, use only the tab 1. Inspector: key to move your cursor-do not Thomas ROUX use the return Name of Inspector key. —�I Company Name 89 Mayflower Lane Company Address East Wareham Ma. 02538 City/Town State Zip Code 774-678-9066 S14531 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was.performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority uy�r�—� xo-,� M6,1 Inspector's Signature Date The system inspector shall submit a copy of this inspection report t the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is required for every Centerville Ma. 02632 May 24, 2017 page. Citylrown 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 in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 22 Eben Smith Rd. I Property Address Margery Flinchbaugh Owner Owner's Name information is Y Centerville Ma. 02632 May 24 required for every , 2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is required for every Centerville Ma. 02632 May 24, 2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow Lt5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is Centerville Ma. 02632 May 24 2017 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy,is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is Centerville Ma. 02632 May 24 2017 required for every Y , 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, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms.(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 336 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is Centerville Ma. 02632 May 24, 2017 required for every Y page. CityrFown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: April 2017Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is Centerville Ma. 02632 May 24, 2017 required for every y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.). Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: no information Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is Centerville Ma. 02632 May 24 2017 required for every y 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: Septic tank is 37 years old. D-Box and SAS are 16 years old. From the design plan on file. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 81 x 52W x 5.3'H Sludge depth: 1" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is Centerville Ma. 02632 May 24 2017 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" <1„ Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank does not need to be pumped out at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Eben Smith Rd. Property Address Margery Flinchbaugh. Owner Owner's Name information is Centerville Ma. 02632 May 24, 2017 required for every Y page. Cityfrown 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.): Tight or Holding Tank tank must be pumped at time of inspection) locate on site plan): 9 9 ( P P P ) ( P ) Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is Centerville Ma. 02632 May 24 2017 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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 is clean and free of solids. D-Box is in very good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,explain why: The septic tank and D-Box are functioning correctly. Therefore, the SAS is draining properly. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is required for every Centerville Ma. 02632 May 24, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is required for every Centerville Ma. 02632 May 24, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, . etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's-Name information is Centerville Ma. 02632 May 24 2017 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately A A eu t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 ITOWNOF BARNSTABLE v LOCATION .J� R) SEWAGE # VILLAGE L1.4 �.�o';�l ASSESSOR'S MAP& LOT /7/-/(0 INSTALLER'S NAME&PHONE NO. � v/cf><,` SEPTIC TANK CAPACITY leleg+ C, t LEACHING FACILITY: (type) Id1el G-L Cl rk f (size) NO.OF BEDROOMS, BUILDER O OWNED FCin Bch 6r4.�1, PERMPTDATE: COMPLIANCE DATE: jo19i Io I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �t 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 27 � � S A �}` t Ln u R �,s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is Centerville Ma. 02632 May 24, 2017 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20'+/- 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: 8/26/01 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: From the design plan on file. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 22 Eben Smith Rd. Property Address Margery Flinchbaugh Owner Owner's Name information is required for every Centerville Ma. 02632 May 24, 2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 22 Eben Smith RD— Centerville Main Floor Deck Kitchen Dining Room Bathroom Master ?J1 Bath y� f Master Bedroom ` I closet Garage Pantry Stairs to9asemerrt Living Room Closet Bedroom Family Room Bedroom Porch / it Basement C. BulkheadJ��� . G Laundry Closet Theater Room 67 Stairs Closet Open Area 5 y Lmechanical Office 0 oil tank Fee ) / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l/ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS es 01ppfication for Mtgoml *proem Construction Vermtt Application for a Permit to Construct R 'r —` pp ( ) epat ( )Upgrade( )Abandon( ) O Complete System I�ndtvtdual Components Location Address or Lot No. 7,z ,!5, eM 51x/ W, Owner's Name, ,AAjddress and Tel No Assessor's Map/Parcel �� l/le- '`a "' ; 7) W �/ Installer's Name,Ad ress,and Tel.No. Designer's Name,Address and Tel.No. 7 '71 Type of Building:Dwelling No.of Bedrooms of Size ` /5_ sq. ft. Garbage Grinder(/o Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow a gallons per day. Calculated daily flow a gallons. Plan Date ® Number o sheets Revis' n Dat Title Gj' Z Size of Septic Tank a F,rie . Type of S.A.S. irk S Xas X I Description of Soil Nature of Repairs or Alterations(Answer when applicable) �J'lr 7�p Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t ' Bo d He h. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ^.:y�.7` "`s:s I 3,....XTs�'.r�,aj• stt;a^-u -+ .r "�i ��- '� ,) n i - fia a - ti n ^•.. i < �tt �a wf3 OF BARNSTABI E _ SEWAGE # ' LOCATION �,� r/S-r.� `�irl: , ... • /"ci?�. . AS�ESSOR'S MAP & LOT/'>1-/[cr INSTALLER'S N.AME.&PHONE NO. ` iv�of><io:✓S �cr'><�J S/.?.S-3`,?C SEPC TANK:CAP ACITY,. ovt G, LEACHING FACILI I'1' .(type) Sa" r C -&I; -5 6J size 1. . . ( > . NO.OF.BED'ROOMS ) - BUILDER {O:WNE 6Cln><chz up�i f ' PERMITDATE ��'G'r COMPLIANCE DATE o h 0- Separation Distance Between the '`Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet r ... piri Water Supply Well and Leaching Facility (I-any wells exist on.site or wttfitn.200 feet.of leaching facility) �� •- -Feet Edge of Wedand-and Leachnng;Facility,(If any wetlands exist within.3ZS0 feet of leaching facility) Feet I� Furnished by4. ti ' -- — — - — I� I , b , � fr c d 1 t 1 � �1 tL V No. f�`^" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:f V i !/ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01pprication for Mi,5pont 6p5tem Construction Permit Application for a Permit to Construct( )Repair/Upgrade( )Abandon( ) ❑Complete System [?` ividual Components Location Address or Lot No. 2 Z r Ae4 Owner's Name,Address and Tel No L� Assessor's Map/Parcel CeqIvel-v/Jle Installer's Name,Ad ress,and Tel.No. Designer's?Name,Address and Tel.No. - �Z 7 7�~939% �6z - yr. Type of Building:Dwelling No.of Bedrooms 3 j CILot Size 1.:i 215_ sq.ft. Garbage Grinder('60 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow a gallons per day. Calculated daily flow �3 0 gallons. Plan Date Z 1 �� Numbe�©r o sheets Revisw Date 4 Title �� �t° J S� r00w Size of Septic Tank �oDD9q' �iY�3�`: Type of S.A.S. Description of Soil C2� '�. C�_Cl 11� �s L-IN 1 !�4 0\.k Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is Boar 6. Health. Signed Date f/81_z9/ Application Approved byW� rt �� 'E7�° Date Application Disapproved for the following reasons Permit No.W,04'/'6 ACOZ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance � THIS IS TO CERTIFY, that t.e O -site Sewage Disposal System Constructed( )Repaired (�Upgraded( ' ) Abandoned( )byFlo li'�l✓� ' at Z Z 114_2 ?Xl has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit A rO.4" dated� Installer Designer The issuance of this permit hall not be construed as a guarantee that the system�will function as designed. Date ( Cl �c, Inspector ""�sL L C ��L � ----f-------------- — / — ————— /� ---. _..._ . No. � i�'m" i 6 �l/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migponl 6p.5tem�)U ongtruction Permit Permission is herebyranted to Construct Repair trade Abandong ( ) P ( g ( ) ( ) / System located at Z d�1 ��/�` Y4 �'c�J7�-cP✓l/i�/CJ 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 must be completed within three years of the date of this,,permit. Date: g;;A X7, Approved b f. 'I LE No.4F2 0°%21 '01 AI� 10:32 1 D:BORTOLOTT i CONSTRUCT i OhJ FAQ;:508, 42S 9'K)9 PAGE 1 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM [ •�fie; • ��"A-�. , hereby certify that the engineered plan signed by me dated 8 ' ( , concerning the property located at meets all of the following criteria: a This failed systern is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed i There are no variances requested or needed. + The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted gi-oundwat.er table elevation. /Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation (using GIS infortnution) B) G.W.Elevation 3-S + adjustment for high G.W. 33 J a _ �• DIFFERENCE BETVJEEIN A and 13 ° SIGItihD . DATE: EJ f NOTICE Bt;>ed upon the above information, a repair permit will he issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered :,e tic system plans. y;health Folder:parcoxmp TOWN OF BARNSTABLE j LOCATION �d'Z �i is SVi- �i /i 1j SEWAGE # VILLAGE ASSESSOR'S MAP & LOT_17/-/her INSTALLER'S NAME&PHONE NO. ` s i�v/ofi�� 0:✓5�� ��I �/ -3,�� SEPTIC TANK CAPACITY /am <" LEACHING FACILITY:,(type) 3`00 C, (size)NO.OF BEDROOMS _J BUILDER O OWNED FCrn�cgfxgUy�j c, I PERMITDATE: / '/G1-0 COMPLIANCE DATE: J0)910 I 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 �,rz Cur �'+��� :+ a , i d �,'� ti S�� .. � � d �!� ��� ,_ �z r. r LOlcATION L-- CSEWAGE PERMIT NO. VILLAGE.. I N S T A LLER'S NAME i ADDRESS U I L 0 E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 1�,� � 3' 2 �y No... 2.7.I 9 FEs...3 ............. THE COMMONWEALTH OF MASSACHUSETTS BO .ARD F' !-IEA TH -Tiv .-......OF..... :. ...... ..................... ApplirFation for Dispnoal Works Tonstrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S�7 a� ..._. cat-•-:•Address 6�;� ®,�, •• �� t.No. .... — •: (!l�[ ------------------•--------.............------- Ow e ^ Address a ------. •. ..... .. ........ •. ................. ...........� °--- °{................................._...-----------......... Installer Address Type of Building Size ----Sq. feet U Dwelling—No. of Bedrooms..............................................� Expansion Attic ( ) Garbage Grinder ( )U 4 Other—Type T e of Building ...... No. of ersons............................ Showers C4 yP g ---------------------- P ( ) — Cafeteria ( ) Pa Othgr fixturees. --------•--------------------------•-------------- .... w Design Flow....... .................gallons per person per day. Total daily flow.........3-:�-e-----_------------.-gallons. WSeptic Tank—Liquid*capacity�,l� allons Length................ Width................ Diameter.--..--......... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.../47 0.... Diameter..49............ Depth below inlet.....��............. Total leaching area..2-..O.;2.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..... .a. ................................_......_.. Date... ................. a Test Pit No. 1................minutes per inch Depth of Test Pit---1-.h........_. Depth to ground water.e-pe...a........... G74 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --•------•••-----•-------•---•.....................................•.........---•---•••••----.-----••--•._.....:...:...:_......-----........_...--•-•-•-•-- O Description of Soil----------- '.3' 9�.�.........._ .= " ----50 .,k.../-P.../V x c, 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 ITIL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' s ed by the boaM of health. Signed ........... (J � /g Date Application Approved By...... /_. ... .P10........ Date Application Disapproved for the following reasons:-----•---------•----•------••-------•-------•-----------------•-------. ..-----•------------------•---•-------•. ...............................•--------..........---------------•--•----•------...._...----------------------------------•------•-•------••-------------------------•-•----••------•-••-•-•------------ T Date PermitNo.......................................................- Issued......./ ...................... Date t. % No..�a: ►.-. .� " Fxs......:.................. THE COMMONWEALTH OF MASSACHUSETTS ,. BOARD OF HEALTH -F`... r 40....... .....OF.....yl.r-- r rs✓l ----"(/ .... atiou for Dispatial Works Tnnidrn.rtiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_.:.:...---------- ......----- ...._....... ......................... .....-•--••............_...........-•-..... .................................... Location-Address f t Lo No • :.� ..... .._' ` .......................... ..........�r ....... ".... r^ .. . ....••••••-•••••••••......••••...........•••.. �� � �jOwner � � Address a rat, "' . . `-��_... ------...: --------------- _... ... ? ..... Installer Address d Type of Building • Size Lot8l_-_. '-� ....Sq. feet U Dwelling—No. of Bedrooms..... :-------------_----- -._..Expansion Attic' ( ) Garbage Grinder ( ) Other—T e of Buildin No. of persons........................ Showers a YP g --------._..•...__...---•-•- P ---- ( ) — Cafeteria ( ) Otherfixtures .._....-•----------------------------------•---------..----•••-•-------•-------------•-------...........---------------.....•----..._.......---•------ w Design Flow......=. —. ......................gallons per person per day. Total daily flow_--_.....2.�_�.-_.__................gallons. WSeptic Tank—Liquid capacity..Ze�hnffallons Length................ Width................ Diameter................ Depth....._.......... x Disposal Trench—No..................... Width.................... Total Length.................:.. Total leaching area....................sq. ft. +, � Seepage Pit No._�er_�" ------- Diameterl?............ Depth below inlet....0�.............. Total leaching areal.*.P.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed ....................................... Date.. ,, Test Pit No. 1..............>.minutes per inch Depth of Test Pit--- _A.......... Depth to ground water 4............ Lt, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------------------------------•............-•---•------......_..._ .........._.....................----•-•-•.................................................... .. O Description of Soil `� � .. •------- x - U ..............•-•------••-•---•-....-•-•-•--•------...---------•--------••-•--•••-----••--.....----••....------------•-•---------•--•--•----------•--------•••-.....----•-•...-----•..........-••-...... w UNature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------------- ------------------------ •-------------- ---------------------- •-------------------- -------------------------------•-•----------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. r' Signed= .......................................................... ...................:... _ !' Date Application Approved'By...... : 4> !- i. a�' .. _Da -,I IJ_........ Date Application Disapproved for the following reasons:•. =--••--•-------••..........-•--•-••-•-----•-...--•---••--•----••----------•••---------------•••......------- ........----•-•-----------------------------•-----•----...--•----•---•------•---------.......-------•---------------------------•--•------------•---•••--•-----••-•-----•--••••-------•-•-----•--•.-•--- Date PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF......«• rN�r.'.. .. ............................................. (9rdifirair of Tompliatta ii THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) ...--------•............................................. Installer at...............7.,1..7-- -----•----- -------S:�.... `-------- -------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code gs:,•described in the appliccation for Disposal Works Construction Permit No._e l3 t.510................. . dated_............................................. f ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAt THE r ' SYSTEM WILL FUNCTION SATISFACTORY. � DATE..... `- ........................................ Inspector-- ,:. �::.. ... L9 ........................... w THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............O F......., 1..? el y..r............ • �i��r�a�tt1 nrk� �un��r�trtilan rrnti# Permission is hereby granted---.. -•--•-------•----------------•---..----------.--..--...------.-_---------.--•---_---•- to Construct ( or Repair ( ) an In Ividual Sewage Disposal System atNo............4 .......zeg..........i✓z�-.... .. .. ...... ................................................ Street as shown on the application for Disposal Works Constructio it No..................... D✓atede ------------------------- --------------- ------------- - DATh... � Board o th FORM 255 HOBBS & WARREN, INC.. PUBLISHERS 2 '�� ,y �"-�it.Y,.t_E:Y4='Q,MIL� -`3 F`1_DL'�OON� � • . � y �' Iidl t..�� FLa� s 110 � 3 • ��O G•Rt? �t rlc 'T'•�-tK = 330,. (r o % • 4-9r,6.PD. �g2 �Op 72 Q3 USA- t000 6AL. SuGU ,LL AZE L (SD 6-P.V. ! � $e7t'717�t/t SEA a C,p �=• 1 � � sue. ► .o t 5o C�.PD. F1�aP ��_TOTA L �e6l6w = -425 !.•p D• EXP .z ' P�r TOT'4 L. '0.&1 u-( V=LOVI/ = 3W&PD. _ PMC-OLQTIOQ Q'wre l t., w 2.m &J'OQ Is--%. 293 0 �u�JDAno 15 Z'lo Feco., m CD CA 107. G 8� SSA le 04Z> SOT •mp C/ t�5 ..G..-�i / 4 Q a = ILJY 3 LopM d•Roe 1oor� uN 'A 1 5 400PPb DISC iw. tC. -sox 51•(, Sync 3 ►►1vc ( rAW ' 1000 tW: GAL. 51 SAuoy L�gcH .2 : .g f PIT WAt+•1�D � � , pL,b`f' I=>L.4 �.i. r, LdGAT1O El�rEz\/ILL& { t4 ..,o s�a..t_+ � ( " do SATm- �D VATWL pt-AtJ R�� R yGE l cGtZTt(-=,4 TkAT TNt �rov41DAn00 5t• aWQ t�ti::Qt_n1,1 CcaMPt_�l5 W tTN Tta::: SID�.t_iN� � auv ScTt�nuC 1~cQ�t�E�c"TS 0; TM� '(owt.1 or BAJ?aJ TQ C�JT K.vI�-C.� l-iccwAL 01J)j UA`CC 18 P� ✓ U`(C-- 10C. RGGlS M--V.SD LA.WG 5U2vSYaT-'4 `I't-Il5 C�I.A1-1 l'S 1.JoT �ASCD vtl Aw • v>TEevt�t.G � M.�►SS• ANnt...t L�t rl <MALL_- r TOP FNDN. AT EL. 59.0 r SYSTEM PROFILE ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT 70 SCALE) r ACCESS CCvER (WATERTIGHT) TO MINIMUM .7a OF COVER OVER PRECAST WITHIN 6" bF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM — _ 56,0' 2" DOUBLE WASHED PEASTONE EL. 56.5' RUN PIPE LEVEL == FOR FIRST 2` 3' MAX. I \ EXISTING ' . _ 53.4' GALLON SEPTIC 55.1' LOCUS = p� TANK (H- 1U ) GAS 53.(�' E1mmo O E7E] CIC. z BAFFLE �� a 52.6 Ea a ca C1 fo 0 ca E C E] 0EOE CD EIaEDE 6" CRUSHED STONE OR MECHANICAL �$ 2' C) CI Q Ea E� d 0 © C:� � 50,6' COMPACTION, (15.221 [2J) C T E9EN 171 Y DEPTH of Flow = 4 (� `sLopE} 3/4" TO 1 1/2" DOUBLE WASHED STONE TEE SIZES: s INLET DEPTH OUTLET DEPTH 14 LOCATION MAP NTS LEACHING FOUNDATION-- EXIST. ---µ SEPTIC TANK 48' --- D' BOX 16' FACILITY ASSESSORS MAP 171 PARCEL 160 CONTRACTOR TO CONFIRM SUITABLE SOILS IN AREA OF PROPOSED ti ADJUSTED GROUNDWATER EXPECTED AT LEACHING FACILITY AT INVERT ELEVATION DOWN TO 5' BENEATH ELEV. 36.6'f LEACHING FACILITY PRIOR TO INSTALLATION OF ANY PORTION OF SYSTEM. KNOWN SOILS TYPE: CARVER �7 Chain Link Fence S- shed NOTES SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED ) 1 . DATUM IS APPROXIMATED FROM BARNSTABLE GIS E \ DESIGN FLOW: BEDROOMS ( 110 GPD) = 330 Gf'D 2. MUNICIPAL WATER IS EXISTING 330 „ u...,. {�7 I?r clG !; Fe n�nr_ _ _ .__ _. 3. MINIh-UM PIPE PITCH TO BE 1/8 PER FOOT. 16 ap4e �? ,ad J 40 White Pine ___ Utility Cluster _� w _-- O'Cr6wn 5 60 Crown SE -'TIC TANK: 330 GPD ( 2 ) 660 4. DESIGN LOADING FUn' AL_ f'FZECA� Deck 5. PIPE JOINTS TO BE MADE WATERTIGHT. Existing U`;E A 1000^ GALLON SEPTIC TANK (EXIST) c -� S failed leach 6. CONSTRUCTION DETAILS +0 BE IN ACCORDANCE WITH MASS. 4. r" o _ ENVIRONMENTAL TIT I NVIR N N OD L V. ,• �. _` pit Li"ACH ACHING: _ E 0 E L CODE E Q 2(30 + 9.83) 2 (.74) 118 7, TH15 PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND la NOT 'IDES' TO BE USED FOR ANY OTHER PURPOSE. \ 30 x 9.83 (.74) - 218 I \ 10 Oak BOTTOM: 28' Crown 454 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4„ PVC. TOTAL: S.F. 336 GPD 9. COMPONENTS NOT TO BE BACKFIL.LED OR CONCEAL-ED WITHOU USE (2) 500 GAL LEACHING CHAMBERS WITH 4' STONE INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED _ _ _ _ _ _ FROM BOARD OF HEALTH. EXIST. DWELL. Top Existing Septic AT ENDS, 2.5' AT SIDES AND 5' BETWEEN UNITS - 10. PUMP & REMOVE EXISTING FAILED LEACH PIT •, TOP FNDN EL=59.0' Tank EL=56.53 Lot 269 f 15, 215 s. f. ` � LEGEND .,� --_-- TT TL E 5 SITE PLAN PROPOSED SPOT ELEVATION of 22 EBEN SMITH ROAD �10 100x0 EXISTING SPOT ELEVATION IN THE TOWN OF: PROPOSED CONTOUR ( CENTERVILLE ) BARNS I ABLE 100 EXISTING CONTOUR PREPARED FOR: B OR TOLO TTI �0 \ \\` CON STRUCTION/FL.INCHBAUGH i Benchmark: water shut Off 20 40 GO �O \ „� at elevation 57.6' 20 0 <5 _ BOARD OF HEALTH APPROVED DATE MA SCALE: 1" = 20' DATE: AUGUST 26, 2001 off 508-362-4541 fax 508 362-9880 AAA I ���tN 6F Mq�q ��P`tN Of MqJ � ARNE down cape engineering, Inc. �o� ARNE ���G a OJALA H. R a IVIL CIVIL ENGINEERS NOJAt o. 9w9 -tl U. 2 48 c .a LAND SURVEYORS �s ��C T f 61 939 main st. Yarmouth, ma 02675 01 --204ARNE H. OJALA, P.E., P.L.S. _�_DATF