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Home My WebLink About0088 ELIJAH CHILDS LANE - Health A=171 - 251 88 Elijah Childs Lane, Centerville I No. 42101/3 ORA ESSELT E 0 0 0 0 "t, Di Commonwealth of Massachusetts �x Title 5 Official Inspection Form In Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 88 Elijah Childs Lane 37 Property Address Carl Valenti Owner Owner's Name T, information is required for every Centerville Ma. 02632 May 1, 2018 1 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 A. General Information �� C filling out forms 12 6 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. r� Company Name 89 Mayflower Lane Company Address ,ate East Wareham Ma. 02538 Cityrrown 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 ��6�- 'M 6, �6 ` Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1, 2018 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 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.doc-rev.6116 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 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1, 2018 page. Cityfrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ` c Commonwealth of Massachusetts p Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �n 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1, 2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. []The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 cam. Commonwealth of Massachusetts Title 5 Official Inspection Form l' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1, 2018 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- 10,000g pd. ❑ ® 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 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1, 2018 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? ® ❑ Wasthe 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 flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 425 gpd t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is Centerville Ma. 02632 May 1, 2018 required for every y page. Cityrrown 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Jan. 2017 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 L c Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1, 2018 page. Cityrrown 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 records 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): Septic tank and single pit. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1, 2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 36 years, design plan dated 11/12/82. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.75'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): Depth below grade: .75 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 5.5'W x 5.8'H Sludge depth: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is Centerville Ma. 02632 May 1 2018 required for every Y page. City(rown 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 24" Scum thickness Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 13 How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, P P 9 liquid levels as related to outlet invert, evidence of leakage, etc.): The outlet concrete baffle is in very good condition. The structural integrity of the septic tank is good. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is Centerville Ma. 02632 May 1 2018 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts �P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is Centerville Ma. 02632 May 1, 2018 required for every 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 N/A 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.): There is no D-Box. 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 pit structure was found and inspected. The pit was dry. The inside walls of the pit were very clean. There was no indication of a hydraulic failure. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ' c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1, 2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit structure was found and inspected. The pit was dry. The inside walls of the pit were very clean. There was no indication of a 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1., 2018 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.): 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.doc•rev.6116 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 �a 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is Centerville Ma. 02632 May 1, 2018 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ��LJ (A '� N 7f 1 Ae- n0JA A io T cu+ 7. Y / 9. 77 O � A �v O o f t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts �n Title 5 Official Inspection Form 1° a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1, 2018 page. Cityrrown 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: below 159" 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: A deep test hole was dug in the vacinity of the pit structure. A soil evaluation was done by a licensed soil evaluator. See attached soil report. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 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 88 Elijah Childs Lane Property Address Carl Valenti Owner Owner's Name information is required for every Centerville Ma. 02632 May 1, 2018 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts City/Town of Centerville y` Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information Carl Valenti Owner Name 88 Elijah Childs Lane Street Address Map/Lot# Centerville Ma. 02632 City State Zip Code B. Site Information 1. (Check one) ❑ New Construction ❑ Upgrade ❑ Repair 2. Soil Survey Available? ® Yes ❑ No If yes: Website 264A Source Soil Map Unit Eastchop loamy fine sand none Soil Name Soil Limitations Loose sandy glaciofluvial deposits Outwash Plains Soil Parent material Landform 3. Surficial Geological Report Available? ❑ Yes® No If yes: - Year Published/Source Map Unit Description of Geologic Map Unit: 4. Flood Rate Insurance Map Within a regulatory floodway? ❑ Yes ® No 5. Within a velocity zone? ❑ Yes ® No 6. Within a Mapped Wetland Area? ❑ Yes ® No If yes, MassGIS Wetland Data Layer: pp Wetland Type 7. Current Water Resource Conditions (USGS): Range: ❑ Above Normal ❑ Normal ❑ Below Normal Month/Day/Year 8. Other references reviewed: t5form11 Valenti•rev. 3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 5 Commonwealth of Massachusetts City/Town of Centerville y` Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed primary and reserve disposal area) Deep Observation Hole Number: DTH-1 May 1, 2018 10:15 A.M. clear Hole# Date Time Weather Latitude Longitude: residential lawn none 0-3% 1. Land Use (e.g.,woodland, agricultural field,vacant lot,etc.) Vegetation Surface Stones(e.g.,cobbles,stones,boulders,etc.) Slope(%) Description of Location: 2. Soil Parent Material: Loose sandy glaciofluvial deposits Outwash Plains Landform Position on Landscape(SU,SH,BS, FS,TS) 3. Distances from: Open Water Body +100' feet Drainage Way +100' feet Wetlands +100' feet Property Line +25' feet Drinking Water Well +100' feet Other feet 4. Unsuitable Materials Present: ❑ Yes ® No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed:❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water in Hole Soil Log Redoximorphic Features Coarse Fragments° Soil Soil Horizon Soil Texture Soil Matrix:Color- /°by Volume Depth(in) Soil Structure Consistence Other /Layer (USDA Moist(Munsell) Depth Color Percent Gravel Cobbles& (Moist) Stones 0-3" O/A Sandy Loam 10YR3/2 3"-15" B Sandy Loam 10YR5/8 15"-68" C1 Med./Fine 2.5Y8/1 Sand 68"A 59" C2 Med./Coarse 2.5Y8/2 Sand Additional Notes: 't5form11 Valenti•rev.3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 5 Commonwealth of Massachusetts City/Town of Centerville y` Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review(minimum of two holes required at every proposed primary and reserve disposal area) Deep Observation Hole Number: Hole# Date Time Weather Latitude Longitude: 1. Land Use: (e.g.,woodland,agricultural field,vacant lot,etc.) Vegetation Surface Stones(e.g.,cobbles,stones,boulders,etc.) Slope(%) Description of Location: 2. Soil Parent Material: Landform Position on Landscape(SU,SH, BS,FS,TS) 3. Distances from: Open Water Body feet Drainage Way feet Wetlands feet Property Line feet Drinking Water Well feet Other feet 4. Unsuitable Materials Present: ❑ Yes ❑ No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed:❑ Yes ❑ No If yes: Depth Weeping from Pit Depth Standing Water in Hole Soil Log Redoximorphic Features °Coarse Fragments Soil Depth(in) Soil Horizon Soil Texture Soil Matrix: /°by Volume Soil Structure Consistence Other /Layer (USDA) Color-Moist Cobbles& (Munsell) Depth Color Percent Gravel Stones (Moist) Additional Notes: t5form11 Valenti•rev.3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 5 Commonwealth of Massachusetts City/Town of Centerville r` Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: Obs. Hole#DTH-1 Obs. Hole# ❑ Depth observed standing water in observation hole inches inches ❑ Depth weeping from side of observation hole inches inches ❑ Depth to soil redoximorphic features (mottles) inches inches ❑ Depth to adjusted seasonal high groundwater(Sh) inches inches (USGS methodology) Index Well Number Reading Date Sh = Sc—[Sr x (OWE—OWmax)/OWrl Obs. HoleMell# S, Sr OW, OWm. OWr Sh 2. Estimated Depth to High Groundwater: below 159" inches E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ® Yes ❑ No b. If yes, at what depth was it observed (exclude A and O Upper boundary: 15" Lower boundary: 159" Horizons)? inches inches c. If no, at what depth was impervious material observed? Upper boundary: Lower boundary: inches inches Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 5 �t5form11 Valenti-rev.3l15/18 Y 9 P 9 Commonwealth of Massachusetts City/Town of Centerville ` Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal F. Certification I,certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. 1 further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.107. 4z�_ zo� May 11 2018 Signature of Soil Evaluator Date Thomas Roux/SE2703 June 30, 2019 - Typed or Printed Name of Soil Evaluator/License# Expiration Date of License Name of Approving Authority Witness Approving Authority Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to the designer and the property owner with Percolation Test Form 12. Field Diagrams: Use this area for field diagrams: • 't5form11 Valenti•rev.3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 5 v Aro 'Ite- a PI Z4 .S -tuJ-ur*e_ • N • NO G No. e Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for )w6pont 6potem Construction Permit Application is hereby made for a Permit to Construct( )or Repair(V/)an On-site Sewage Disposal System at: Location Address or Lot No. / Owner's Narqe,Add r�„s�an d Tel No. Assessor's Map/Parcel -- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. T 7/_573 Type of Building: 2 Dwelling No.of Bedrooms V Garbage Grinder(,,to Other Type of Building �F4 9 1,& No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //P7 gallons per day. Calculated daily flow 25 3e2 gallons. Plan Date %/—/Z ` � Number of sheets ! Revision Date Title Description of Soil ,i e P 4%r/1 1 Nature of Re airs ppr Alterat*ons nswe�when pplicable) Z_ � r1 ®® Ill`10 Date last inspected: Agreement: The undersigned agrees to ensure the construction 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 B and eal Signed Date Application Approved by DateN4 I h to Application Disapproved for the following reasons Permit No. ��l9 `7 � Date Issued 2 No. _ / r E ^4 r ' Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Oig;pool *p5tem-Con.5truction Permit Application is hereby made for a Permit to Construct( )or Repair( volan On-site Sewage Disposal System at: sa Location Address or Lot No. er's Name,Addre s and Tel.No. Assessor's Map/Parcel � � .v/' � �• ,L �� g Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder(-ViO Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow IIN gallons per day. Calculated daily flow gallons. Plan Date //-/2 — Z Number of sheets / Revision Date Title i Description of Soil .S e 2 ,lq'rl Nature of Repairs or Alterations riswer�when applicable) 9' 40 D/7 Date last`inspected: ' Agreement: The undersigned agrees to ensure the construction atitReiof 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- t Al . Cate of Compliance has been issued by s Board of Heal Signed Date��,=; 1 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued a o --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of QCompfiance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(/on by 4 Installer �4/?YTl Go y`/eY �D/957`✓lei®�9 at TA 27-7` C i� Q l has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construc ' Permit No. - dated -+ Date�!/'S . � �'" Inspectors -' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE 761AT THE SYS- TEM WILL FUNCTION SATISFACTORY. k' l .No. 3-------------------- 7/ � �� Fee THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION =BARNSTABLES.MASSACHUSETTS ;i!5pogar *pztem (tonotruction Permit Permission is hereby granted to to construct( )repair(✓**)an On-site Sewage System located at No.# �{� / o✓ C'' / G , All drr V Sweet and as described in the above Application for Disposal System Construction Permit. qr:j y No. Date F The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. Date: I!z-�f i'C Approved by "`✓(r �-f 'Ok- Board of Health CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL NVORKS CONSTRUCTION I'EitNil'l' (1V1'1'110U'I' DESIGNED PLANS) hereby certify that the application for disposal works _ construction permit signed by me dated ��Z��b , concerning the property located at gT �� /� G�i��ra• G,�� Ile meets all of the following criteria: �✓ i�cre ire no «•rods,vilhin _ono tc^_! of'he nronosed septic system here ire no riyite wcils lvithin i 0 iec'. -i the proposed septic system � �'c ooscr�cd ercnndwnter tnbie a !A r= -r ;-eater beio«the iaottom of the !eachin¢ ridlity /ic-er is no incrcise in `low ,ind/rr_?lunge i 7se proposed ,,cre are no vnriinc^s rconested or ie^ded. SIGNED : DATE. LICLNSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF 13ARNSTABLE NUMBER Wlich a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan. this plan should be submiticdl. a� OWL ^ 33ox15D% =A95P.G. o. � 100o GAL. , ► OSAL PIT USE t o oo GAL. oe�% ► s •;1StD4WALL AVL-A = I5�06.F i5f x z•5 i o7SF.Po FoOlJDATIoI� BOTTOM AREA � 4 j O S.r► X 1. O st 5•p G.P O_ . . i I -TorrA t.. t��516N * 42-5 G.P t� � -TOTAL. DA1L%( FLOW = 3306?0 PE2GOLATIoN P-AT>r�''IN 2MlN o�L65S I�— — -FOR - 0 Per p,aea\ O t - of 1 EGT -1 LL RICHARO yGN�1r �aor ALAN A ^� , I Gal• , �� W. 1 6-a50MIS'A-r - BAXTER H 1 "+E S 1��►ST��,�OQ' 4h0 SU10 I CMG•to to, T65T P SS F�'SS To P F*40- 54. ELI 5.�IZ�z4�E° ��t Sam INv. S3 LOAM 4 ptST. INV. s,►1S4w1. BoK SCPTIG , 2, (000 INS! �L TANK LEACH SptJ�� PIT INv. INV. I / WIT14 522 YL� t7R �/ I'/3�q•I WAS"r.D 6TOmrw F1sdL Mb� C6P-TIFICsC pLoT PL-A-W Spate. (I . PROFILE 1.oc4zloN (' E•IJT�2�/11.�3 I Wo SCP.I-E SCA a I VATS II -17.•v2 IIJATER- p L_p.t l REF 62EN GE CERTIFY -THAT THE �:,auorzwrlco ;SNoVYN N6.R6o1.1 COMPLYS yJITM THE S I o�L%W Grll I Auk S6'T5AGK R.SpQu%TLICMEN•f> TOWN of SMZA,�rA•ESLZ� ANv ►S PL T34 54S peo �a. L.OGp.TED WITNIu N GLooD P}�AIN DA'T E Il"I?'$Z' (.� SAIATra m a NAYS We.C. REG I S'Z-��6V'tAN o S u ftV�s�(oZ-5 Tull PL&IQ 1`2 WorT B�AE o F SD a AN os'rG¢.viLlFr • MASS. I i /A. -I r �l"I' e.t l V V l---Y e_ -r V45 1=F SE"T5 'Sllout,'p ray TOWtj OF B STABLE g � 1 17'�/LOCATION C �/� SEWAGE # I� VILLAGE 6e,17 /!/�/��P /� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. vr Zfll/ SEPTIC TANK CAPACITY /,OOd 64 LEACHING FACILITY: (type) �/� 6/ (size) NO.OF BEDROOMS 3 p� BUILDER O R O/a /,0//- PERMITDATE: Z COMPLIANCE DATE: Z Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le ching facility /!�__/ Feet Furnished by o �" t R Pa- .2y t 33 lie �J. qq ;4y No. ........1..7..E F�$..A ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD )OF HE H ............OF...... . .--. .. ................................... Appliratiun for Disposal Worko Tonstrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at � ocation-Addr ss or t o. ` OwCSIL. ......... ......... .. ................ er . . Address______________••-•---•--•-••--•-----------• f� Installer Address �.. QType of Building Size Lot_____��yr ..........Sq. feet U Dwelling—No. of Bedrooms.___._.._..................................Expansion Attic ( Garbage Grinder (o6<j Other—T e of Building No. of persons____________________________ Showers — Cafeteria Q' Other tures W Design Flow...............____Z:'_�_________.gallons per person per day. Total daily flow__._.___..__.____�_j,o.____.__._.._.gallons. WSeptic Tank—Liquid capacity fd4�. allons Length................ Width................ Diameter................ Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...... Diameter____________________ Depth below inlet.................... Total leaching area_________...__.___sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... aTest Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ L Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R.' ................................... --... -................... •------------------------------------ •... ....... •------------------------ •------------------ •-••-- ODescription of Soil......................................................................................----------------•---------•-----------------•----------•••••-•---........._...-•- 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'T':Lip 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been issued by the and of health. gne . ----••--•.........................•--------•--------------•......_....._.__.....-- -••- ••••• ........-.... ApplicationApproved By....... -------•----- -----------------------------•----------------••---•...------•-•----•-• .... . ----- Date Application Disapproved f t following reasons---------------••----•------------••----•----------------------------------------•-----••--••------•-•.........-- Date PermitNo--------------------------------------------------------- Issued....................................................... Date .� A No..��... .0 FHB... ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................".................O F...................---....---.........---------------------...........................•--- Appliration for Biapnia1 Works Tnnitrurtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................__................................. •- •---------•---------•---••--------- --....------•-•--.....---•._.........•--•----•.....................•--••-••-•--••--............... Location-Address or Lot No. ......................__--...................................................................... ..........•-...................................................................................... Owner Address W Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures -.-.--.-•......................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. f4 Septic Tank—Liquid capacity............gallons Length................ Width_.............. Diameter-------.-----_._ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..-.--------.--_.... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 04 Percolation Test Results Performed by.......................................................................... Date........................................ 0-1 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.---..--...........----. f� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ pa --------------------------------------------- •------------------------------- -....... -... ... -.............. •-----•------------•-•----------------- -••---- 0 Description of Soil........................................................................................................---------------------•--------------------------._.............. x W ----------------------------------------------------------------------------------•-••---••-----------------•------------------------------------------------•-----•-----------•-------•--•--••.-•-•-- VNature 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 TILT LEE E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been issued by the board of health. ge --••---••---•------•------------------•--•--•---.............-•--••---............__ .... .. �..._ Application Approved By------•-----`...a' --•--------------•-•------•---------•---•--•---------•--•---•------•-• -'�` - •------ --- ---- ------------ Date Application Disapproved f t-Ff following reasons----------------------------•-----------------------•-------•------•-•-•---------•---------•-------------------•- ..--•---•..............•--•-••--•••-•------------------------•-•---•-------------•----._........-••-•••......---------•...-••---•----•--------•------•--•-----•-•-----------------... ---•-••-•-••-- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................................................... Trr#ifiratr of Tautplianrr TH�S IS TO CERTIFY, That the Individual Sewage Disposal System constructed r Repaired g P �' (� ( ) b -••••-•..............•••••••--=••---•--•----•._...._........---•••.............••.................•. y ° nstaller at .., ' ------------ has been installed in ac prid ce with the provisions of T Tl j` of The State Sanitary Code s de ribed in the application for Dispo orks Construction Permit No 31!'../ I.............. dated--.. -.- —76!',,,'j.__----..-------. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W14 FUNCTION SATISFACTORY. ....................................................... Inspector- = ................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Nol................... FEE.."u.............. i V k nr� trnrtion rrntit Permission is ereby granted....::_. :........... .... to Constru or W JI� vidua a sal System . F �� atNo. ................... �� Street /n---.-Ze;_ as shown on the application for Di Po Works Construction Permit No.....................D t ,J V................. ............................................... --- --------------------•-•---......_............... I. rd Health DATE......... . ---...---••--•...............••----•--•--•------•- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS SI►.l�Gt.L FAMILY - 3 BEOIZOOM CgiLDs `. IL � IJO GA¢gAGE 6GUMOSM I DAILS( Fi-OW : 110A 3 = 7530(;.Pc , SEPTIG TAkiK a3o)cl'5o>% :A95G.P..o �, 5552 ^ da 4S 115E loon GAL. I �S �D15POSAL P1T _VSE 1000 GAL. 150 5.F X 2•S a 3'l�! G.Pq - �� lit i �cv�IDl�'['Io1� ; /5f BOTTOM UREA= So 5.F x 1. 0 1. 0 o _ o -TOTA 1.. p>c516N s ,g:25 G.P 600 ( 7 Of, • '�$ -foTAL DA 1 LY FLow! = 330 G.Po — ra+lv_ I T•1•Ik f PE2coLATION PATEE;r'IN 2MIN oP Lr=:$5, i 1 1 0 PIT Arts a I D q I FIICHARD �\ ALAN A. a1 w. tom} BAXTER ytR' 1 "+ES �A No.2'0 .�jl°:Mk�l�'T — I. 4& 15 i i�u -4 `1 STFa�o4 .� I �y I 4"o sua� TEST (?SS TOP F140= 54, 14OLE 12 t 5 ' LOANt loot/ IW. 4 DIST. GAS.. t SohSvI�. Box INJ. 56PTIC. Z, 1000 Ili. �1LL TANK GAL. 52 LSAGu PIT INV. INY. WITW 51.2 CA,a. RAJ I'/3�g•IIL IWAsuco 6TaN6 Elsd.li 9' 1c wr I P I G O PLOT P L A W SAN,. PROFILE �IohJ i� 42 12' No. SCALE 5C-ALE o WATER— p>..p.1•.1 REF 62EN GE 1 CERTIFY THAT ?NE �butJbATIoIJ SNOkYN -. E{ER6iOtJ GOMPl.YS 1nlITN'CH6 SID�LiNELOOT AW o S E6T eAC-Y, 26Q R.EMEN'f� q F 'f 1.1E S9 TOWN or: $AIZM,,TASLP, AND IS PL. T31C. 3� LOCATED -WITNIN N•6 GLOoo P 4114E3a- D/►T BAxT6cZe tJYE INC. ` $LEG 19"C_V_E+'D LAUD S u M.Y PYol1'S TN13 PL&KI 115 P1orT grsl-v ca AN vs-rEiZVILLFr • MA~�i5• IN,5TR•VMEN'- SV2vG--Y �'TNE 0r-r5E'T'S Suoul,�• ' 1.-Il_1V"_�'. APPLIGA► -r ' A r A,I. G, Z IAA , i III/- ! . . LOCATION SEWAGE PERMIT NO. _ Lot Elija_Childs Rd. 83-178 VILLAGE .. Centerville I N S T A LLER'S NAME i ADDRESS Robert B. Our Co Inc Great Western Rd. No. Harwich. , Maes. 02645 BUILDER OR OWNER Alan Small DATE PERMIT ISSUED 5/16/83 DATE CO-IMPLIANCE ISSUED 17 2 r � _ _ � . �, 2�'� .�'' o 3s � � a,�' �o' �b {ti