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HomeMy WebLinkAbout0138 ELIJAH CHILDS LANE - Health 138 Elijahs Childs Lane T Centerville P A = 171 246 OP"diefftr 1521/3 OAA 1070 P2 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Elijah Childs Lane Property Address Bank Owned - c/o Lisa Burgess ReMax RE Owner Owner's Name information is Centerville MA 02/18/12 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brian Reyenger use the return Name of Inspector key. Ranger Construction IC-V Company Name r " 46 Crowell Rd. Company Address 3 - I East Falmouth MA 02536 L'`r Cityrrown State Zip Code 508-274-9753 SI 13242 y_ Telephone Number License Number m 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 03/03/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Sftraaf age Dispo21pql • age of 17 • X f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 138 Elijah Childs Lane Property Address Bank Owned- c/o Lisa Burgess ReMax RE Owner Owner's Name information is MA 02/18/12 required for every Centerville 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: System is in good working condition 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•11/10 Title 5 Official Inspection Forth: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 138 Elijah Childs Lane Property Address Bank Owned - c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 138 Elijah Childs Lane Property Address Bank Owned- c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 page. Cityfrown 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 '/a day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments N 138 Elijah Childs Lane Property Address Bank Owned- c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 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. ❑ Z 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M > 138 Elijah Childs Lane Property Address Bank Owned - c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Elijah Childs Lane Property Address Bank Owned - c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Existing 1000 gallon Septic Tank with 1 Tx 48'trench Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Elijah Childs Lane Property Address Bank Owned - c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: NA Date Other(describe below): General Information Pumping Records: Source of information: NA 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Elijah Childs Lane Property Address Bank Owned - c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 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 apprx 30yrs- Leaching installed in 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.0 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments(on condition of joints, venting, evidence of leakage, etc.): Good Condition Septic Tank(locate on site plan): Depth below grade: 1.2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon Sludge depth: 2" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 138 Elijah Childs Lane Property Address Bank Owned - c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 page. City/Town 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 34" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 10" 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.): Tank and T's are in good condition 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 138 Elijah Childs Lane Property Address Bank Owned- c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Elijah Childs Lane Property Address Bank Owned - c/o Lisa Burgess ReMax RE Owner Owner's Name information is Centerville MA 02/18/12 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 •� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Elijah Childs Lane Property Address Bank Owned- c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 11'x 48' ❑ 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.): Good condition- No signs of backup at time of observation 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Elijah Childs Lane Property Address Bank Owned- c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 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.): Good condition - No signs of backup at time of observation 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•11/10 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 138 Elijiah Childs Lane Property Address Bank Owned- c/o Lisa Burgess ReMax RE Owner Owner's Name information is MA 02/18/12 required for every Centerville 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 � 04 3 A p �. 8 Ag _ '40. p r _ 23.o - Z7.5 ® A 3. r C� D. Of &A 13 t5ins•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Dim system•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 138 Elijiah Childs Lane Property Address Bank Owned - c/o Lisa Burgess ReMax RE Owner Owners Name information is required for every Centerville MA 02/18/12 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: 10+ 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: 2001 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: Design plans on file showing no ground water @ 10+ below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 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 138 Elijiah Childs Lane Property Address Bank Owned- c/o Lisa Burgess ReMax RE Owner Owner's Name information is required for every Centerville MA 02/18/12 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 L1L)1VMU1VVVLA1:1t1 Ur 1V1AbbAt;nUz1)rj110 ExECUTIVE OFFICE of ENVIR oNMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION VLLD APR 1 2005. TITLE 5 TOWN of BARNSTABLE HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A A,(~r CERTIFICATION � b,b r Property Address: 138 Elijah Childs Lane Centerville 1�1� Owner's Name: Don Morin 1 Owner's Address: Date of Inspection: ? c, u Name of inspector:(please print) Wi 1 1 i am E_ •Robi nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, MA Telephone Number: (5081 775-8776. CERTIFICATION STATEMENT i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Sec ion 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 3 -� The system inspector shalt submit a copy of this inspection report to the Approving Authority(Board of Heanh-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 appro.ting authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/152000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 138 Elijah Childs Lane Centerville Owner. Don Morin Date of inspection; Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.,System Passes: !.� I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Syste Conditionally Passes: One r more system components as described in the"Conditional Pass"section need to be replaced or repaired.Th�system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,r o or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. ; The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank H 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 thad the tank is less than 20 years old is available. i s ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or _ obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of oard of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expla TI a system required pumping more than 4 times a year due to broken or obstructed pgre(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND expo air: vJ,, � V. Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 138 Elijah Childs ,`L'ane` Centerville Owner: Don Morin Date of Inspection: — 6 C. Further Evaluation is Required by the Board of Health: nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing protect public health,safety or the environment. 1. Sys hem 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 andahe environment: — Cesspool or privy is within 50 feet of a surface water _ Oesspool or privy is within 50 feet of a bordering vegetated.wetland or,a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ Tile 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. e system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. he 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 frond a pr' ate water supply well" Method used to determine distance 'This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform cteria and volatile organic compounds indicates that the well is Gee from pollution from that facility and - th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fai a criteria are triggered.A copy of the analysis must be attached to this form. 3. Oth r: 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 138 Elijah Childs Lane Centerville Owner: Don Morin Date of Inspection: D. S tem Failure Criteria applicable to all systems: You m t indicate"yes",or"no"to each of the following for all inspections: Yes N 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 day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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 uatcr supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the presence of ammonia P Y nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (YesfNo)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. L rge Systems:To be onsidered a large system the system must serve a faci!ity with a design now of 10,000 gpd to 15,000 gpd• You m t indicate either"yes"or"no"to each of the following: (The fol owing criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you ha re answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in ection D above the large system has faulcd.The uAmcr or operator of arty large system considered a significa t threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304, he system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST Property Address: 1 38. Eli ' ah Childs Lane Centerville Owner: Don Morin Date of Inspection:_-5 -3o 6$ 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 T. t/ 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: Yes .no n✓ 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(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 138 Elijah Childs Lane_ Centerville Owner: Don Morin --- Date of Inspection: 3 "3 e) tq FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): f-:�'8. Number of current residents: Does residence have a garbage der(yes or no); Is laundry on a separate sewage system(yes or no):,f�o [if yes separate inspection required] Laundry system inspected(yes or no):,L0 Seasonal use:(yes or no): ti 0 Water meter readings,if available(last 2 years usage(gpd)):, 2004 - 98, 0 0 0 Sump pump(yes or no):.Ld 2003 - 86, 000 Last date of occupancy: '3 3,o-63 S- COMMERCIA USTRIAL Type of estab11i ent. Design flow(b ed on 310 CMR 15.203): gpd Basis of des i i flow(seatslpersons/sgft,etc.): Grease trap resent(yes or no): Industrial aste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water m ter readings,if available: Last dat of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: i Was system pumped as part of the inspection(yes or no):— If yes,volume pumped:_gallons--How'was quantity pumped determined? Reason for pumping: TYeeptlilc SYSTEM tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):.& Zj 6 l'agc 7 of I I OFFICIAL INSPECTION FOI01-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:138 Elijah Childs Lane Centerville Owner:_ Don Morin Dole of Inspecllon: � �3a_a BUILDING SE ER(locate on site plan) Dcpth below adc: Materials o construction:—cast iron _40 PVC_odicr(explain): Distance ont private water supply well or suction line: Comme s(on condition of juints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade:_ I Material of construction: . oncrcte " metal fiberglass=pol)•ethylene _orlrcr(explain) —' If tank is metal list age:_ Is age confirnned•by a Certificate of Compliance(),es or no):—(attach a copy of certificate) Dimensions._ (, a' G Sludge depth: I ' Distance horn top of sludge to bunonn of outlet Ice or baffle: Z scum thickness: 1r2 „ Distance front sop of scunl to top of outlet Ice or bafllc: - 1 Distance from bottom of scum to bottom of outlet nee or ba(lle: I low were dimensions dctcnnincd; C) t'�L� �;�e &, C Z�a2 S Comments(on pumping recommendations,inlet and outlet tee"or baflle condition,structwal integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): h GREASE TRAP: (locate on site plan) — Dcpth below grade: Material of eonstru lion:____concrete metal fiberglass 1rol)-c0lylene—other (explain): — — Dimensions: Scum thickness: Distance Gorn i p of scum to top of outlet tee or baffle: Distance Gorn ottonl of scum to bottom of outlet ice or battle: Date of last p roping: Conunenls n pumping recontntendalions, utlel and outlet ice or baffle conditiu:t,structural integrity,liquid levels as related t outlet invert,evidence of leakage,etc.): 7 'age g of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIIIATION(continued) ?rope rty Add ress: 138 Elijah Childs Lane en ervi e Owner: Don Morin Date or Inspection: TICIIT or IIOLDIN TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grad . Material of cons Ilion:_concrete_metal_fiberglass__polyethylene other(explairt): Dinunsions. Capacit}': allons Dcsign Flo . gallons/day Alarm pre nt(yes or no): Alarm Iev I: Alarm in working order(ycs or no):— Date of I st pumping: Conune s(condition of alarm and float switches,etc.): D1STIUBUTION BOX:ZCf resent must be opcncd)(localc on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of - leakage into or out of box,etc.): - O PUMP CHAMBER: locate on site plan) Pumps in working ord (yes or no): _ Alarms in working o cr(ycs or no):_ Conunen►s(note a dition of pump chamber,condition of pumps and appurtenances,etc.): I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Elijah Childs Lane Centerville Owner: Don Morin Date of Inspection: . . SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required) If SAS not located explain why: Type 1 /ch g pits,number: �eaing chambers,number:--z 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.): c /6 6 LY CESSPOOLS: (cesspool mus a pumped as part of inspect ion)(locate on site plan) Number and configuration: Depth—top of liquid to inlet in rt: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwat inflow(yes or no): ' Comments(note condit on of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on to plan) Materials of construc 'on: Dimensions: Depth of solids: Comments(not condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 14 Page 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:138 Elijah Childs Lane Centerville Owner: Don Morin Date of Inspection: 3 CT— O,,$�- SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. dG�- 0 t G L`b t g 10 4 Page 1 I of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Elijah Childs Lane Centerville Owner. Don Morin Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground waterer feet Please indicate(check)all methods used to determine the high ground water elevation: , Obtained from system design plans on record-If checked,date of design plan reviewed: =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 hpw yo established the high ground water elevation: er 5 f'G i 11 No. 1 �P 6� Fee s`'' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[pphratfon for Diopozal *pftem Conztruttion Permit Application for a Permit to Construct( . )Repair( )Upgrade(�)Abandon( ) IJ Complete System ❑Individual Components Location Address or Lot No. 13 ���,1v Gh)/ . 1� Owner's Name,A�dldress and e1.N i�Y�� . Assessor's Map/Parcel v/ �� eC® Ge �/iJ/� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 49®/'A10llIZI C®1151111" 7 .3 Type of Building: Dwelling No.of Bedrooms Lot Size J q.ft. Garbage Grinder(�L� Other Type of Building &1h&4 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3, gallons. Plan Date Number of sheets Revis on Date Title t0lodAs 6�eo/-lam � �l^51aw � 1jP_C� Size of Septic Tank is-v� Type of S.A.S. 4� e /�`l CO,O Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees 4o 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 thi oar of alt Signed Date Application Approved by AL Date Application Disapproved for the following reasons Permit No. ICY"� — to# Date Issued 9 C� _ low + t Fee THE COMMONWEALTH OF MASSACHUSETTS �} ' ntered in coputer: Yest/✓ PUBLIb HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ; rication for-3ig�pogar *pztem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade(�)Abandon( ) V Complete System ❑Individual Components Location Address or Lot No. ,3$ �� a/C Owner'spName,Address and Tel.N Assessor's Ma /Parcel t Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. eel Type of Building: Dwelling No.of Bedrooms y Lot Size / 5sq.ft. Garbage Grinder(- D Other Type of Building of of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow W3, 516 gallons. Plan Date Number of sheets Revision Date Title _ 101"195e SF'1611-ie A&514W Iat Size of Septic Tank /S"�� Type of S.A.S. 66 - 1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 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, oar4 of Health- Signed y/Z /�Y/ G�-G Date Date Application Approved by _� _ t Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ` Certificate of Compliance THIS.IS TO CERTIFY, that the,On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(t/) Abandoned( )by s D/lJ /f at 13 l/Lai C has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. f dated T r 1 e /(-)1 Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date l I �N I Inspector. iv-dei'��j _ = `--'4,.;,` ` (,�:``I� ------------------- / 6 — No. Fee THE COMMONWEALTH OF MASSACHUSETTS CFI PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Diopoal *pgtem Construction permit Permission is hereby granted to Construct(/ )Re air , )Upgrade(�Abandon( ) System located at l3 S1/ 4/7 C'� l/I , Ryls�q Cea.s�lyi'l/e 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. n / ~ Approved by Date: i M­ R.0 low V%- gggh Ut�h; Si IV. m a R.� 0, ,r ot 5. p LE a TOWN OF AWTAB LOCATION Z-Z Y'v 4v SEWAGE #-,9" 07, VILLAGEL4 'S A— :ASSESSOR MAP & LOT 'PHONE No LER'S NAME& INSTAL, SEPTIC -TANK CAPACITY LEACHING FACUjry: (type) elf" (size) ://�6% N0.:OF BEDROOMS, B UIL 0 PERMIT DATE —DA COMPLIANCE DATE,. p: ; t': Separtatio nDistaficc:1166veen the.,:'* MaximumF 4. i, justed"Grou'n''Wat&fTdbi6ibih6B Quoin of1exhi6g�Fqcili eet- -Wa6 Private Supply Well-and:!,.each! Fatiljty. �J..If-an 7 wells y ..q, on.sue.or:within:�O.O.feet f o -leaching faciLty . Fe et Edge ofWetland and Lek. hAng FaciLty(If MY"wetlands east W1 P 300;feet;of 16k ltrg faciLty o, Feet Futushedby �_- � ;7 p-W­ S % o" ear TW; 1" 4t, to T .tt vo F. F., TOWN OF BARNSTABLE E C LOCATION ��� /L�L�rd/r� �tiC� L-/ SEWAGE # �/" ��7 VILLAGE fell I , ASSESSOR'S MAP & LOT/7/-,941Z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 7,fG LEACHING FACILITY: (type)17yeZ .4,%j �� (size) NO.OF BEDROOMS BUILDER O OWNER AL. PERMIT DATE: �`d' �/ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private-Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by L1,9 s4t__A../waro9 /$ Rear �dt r w 33 G vo' 5g� J n.{q _ a Fa - rti,ry - YCt AA �1. -- � x mk But ;r jr IN x'` M _ - ' r (' 2 lit F n� � Fin$...36................. THE COMMONWEALTH.OF MASSACHUSETTS BOA R® !-I EA T ��.................OF....... .�........_........ Appliration for Disposal Works TonTotratrtion Vrrutit Application is hereby made for as Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at: M - ' - ------•-_... --•-••--• �.-- _ _ - � - ------ --------- za......MX6 Location- ... --•------------------------•--------. ..........--...... ........................... ' V�. ... - w Address -t -............................... ..................•- ------. - - .... Installer Address �-� Type of Building Size Lot/_��___9r?!`___)_Sq. feet �., Dwelling—No. of Bedrooms.......... ...........................Expansion Attic (' ) Garbage Grinder Other—T e of Building No. of persons................ __ Showers — a YP g --------------------•------- P •--------- ( ) Cafeteria ( . Other fixtures --------------- .......--------------••--.•----•-----••--••-..... W Design Flow... .. __..____ __._.._:gallons per person per day. Total daily flow..............................................................gallons. WSeptic Tank—Liquid capacit __ ._. allons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No............. ..... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No-.--- iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-- --------------------------------•----------------__----------------- Date Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2..............,minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •------------•-----------•----••••••................................•--......._•----....----------•-......................................................... 0 Description 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 TITL!Z- 5 of the State Sanitary Code—_The undersigned fur er agrees not to place the system in operation until a Certificate of Compliance has been iss e board th. Sined :.. =------------ .................... •-----••--••---••----•••_-•-•- ... -- ate df Application Approved By N� ....C . --------------- Date Application Disapproved for the following reasons__________________________________________________ ••--•---••-•............................ ---....._..... ..............................................----------•-------•........................................----------------------------------------------------------------•-----•----------•-••-----_._.. Date PermitNo......................................................... Issued....................................................... Date �� 36/ 36 NO.- -.......... ' i Fizz....... .................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H EA .......................................OF....... ..• 'd.i. `_t ''• °..... _.,:.................. Appliration for Btspoii al Works Tongtrnrtion jinmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syste.�.. . ... ............ .... . .- �-- .-. �. f .... ... f j Location-Addre or.#Lot C.if gyk. Er. yf No, Owner c .,' Address ........................................ Installer Address C U Type of Building Size Lot°' _... C1_Sq. feet Dwelling—No. of Bedrooms___....... ............................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria (/1,) Other,fixture -----•------------------------------------------------.----•--•-•---•--••--•-•------•--------•--... - - W Design Flow.....- ....,�:.:. .......... ......... allons per person per day. Total daily flow..:.........................................gallons. WSeptic Tank—Liquid capacit/��allons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No .... ............. Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No.. __.. ._ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P.' •---•---•----------------------------------------------•-------....------•-•--•--------•---.._......-••••-•---.............................................. 0 Description of Soil....................................................................................................................................................................... x V W -----------------------------------------------------------------------------------------------------------------------------------------------------------------•-------•-------------..._......----- 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 TITI, . 5 of the State Sanitary Code— hendersigned furter agrees not to place the system in operation until a Certificate of Compliance has been iss deb the board ''l e'aith. Application Approved BY .............. / � ........................... ............ Date Application Disapproved for the following reasons------------------•------------------------------------••------•-------------------------•---•-•--....------..-- ..............................................----------•-....----------....------------....--------•--------------•--.....----•-----•------------------•-•----------................................. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF% _DEALT 1 n f ..........................................OF..................................................................................... Twrrtifirttte of Tontplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ii uer at -------------------------------•--------••-------......•-•-•-•-•--•-•-----•---------........:.---------......----•----••-•--- has been.installed in accordance with the provisions of T�T) 5 2 State Sanitary Code as described in the application for Disposal Works Construction Permit No.__ .....:...... .......... dated_.._____.___.___....______.___._._..._.__..._. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................................•-----....Flzv 0........ Inspector---•--. THE COMMONWEALTH ��,��O--F��MASSACHUSETTS . BOARD 0 EAL�� ..•mow. �..�.-H.�,„,�� '�� p '� .....................................OF..................................................................................... l� No......................... FEE........................ 11iopos al-Vorko Twonoirur#ion unfit Permissizoisaherebygranted -- :.... ::�-------------------------------------------------------•--------....------...........-•---........... to Construc .or Re air ( an Individual ew,3g@ D* pos I System atNo............... - -- ....- r- �:�f ---- ----�---......a...�-----------------•----------•-----••-•-•-----..... ' Street as shown on the application for Disposal Works Construction Permit No..................... Datgd..... ----------------------- Boa o Health DATE----------- ................................... t i FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS S>k L-1r L6 vr&nn l L_.4 .4 3 3t�Z0oAA � i UO G,arca�G.E L-aRll..tDtclL �{ radl '( FLow = IIC> x 3 t 33U G•P•t7. ' C,�PTIc- -i"n�1tC = �SSov lS0 % • 4.;1 6.Fv. s ? USA- IOOo 6/S.L. m /D lD CS��•-ice � �, / 14 Ic>p SFE. It 2.S + 3'7S G.P.D. SO s FV. C� ? �ovND• 12.t Tcrr'AL. vE.SI6Q c 425 -r0TA t_ •Z>4t L-( Fr .ow + r N I 330 mow. � � •;'� � cy Gt✓!1G�LpTIOtJ QQTE : 1"10 2.m1u•de L". I r.+�k �'�� ID �___ PLoP n sm e ALA fag Al T W. TI .,•�t1 Ala.?,Uk�'tj � �1 ;��I•�10 Q .Ri;� \' ( \�' ,�� ��fC.a y� g�: _°�c• SronAL E�� Me.'T 0 �' ��+ Sg Tor P.40 . i,1•.. l jcx. -- 12� 8v .. 7!J .ii n �, t►.1y.� 5�0,� AM + d ,"— l o0o S�izfal.. 4'Ppb Dtir. IW GAL. 5S•8 2' "box SC.(, Se nc INV. t o } 4 L Io0o SS..© :'• G¢A✓E�. GAL. LAN P , A WiT lAiwI��Z \14A D ; ' AEI tcD lb[ATio" E4dj 12 No Sca.t..a= �a�1�1;C IL QviA.T IJ o WATT r GGtz-rtF-.{ TI-(AT T"G_ Foo�-DAT►OW -5tAaJJQ PLA1.1 jZt= E�1G� 4 UZ L=b14 CC 4APLYS W I TI A TNT e>i v r.l.t WF_ ; Utr:Editcf•1FS OF TNT `o ' 64 atiJt� ScTt�ncK S'c4 , I -Tovi L i ot`= "�pR�.��T 93L.� i k�ili H I N L A t•�'' � . �" uti-rr. " 0STE CZV%L.L TI-{15 FLAW IS WOT 2>ASC� U�-1 pal IWS�C:JMC;tJ 1�tJi:vcY TiAC: SI-IGWta AP Lt cA."-r a.t��r �.c ufi�cr> ru t� reLtictN�t: LO-V LIWa, LO C T 10'4 C E w A G E PERMIT NO. VILLAGE INSTALL R'S NAME & ADDRESS BUILDER OR OWNER DATE PERMIT ISSUEDh/� DATE COMPLIANCE ISSUED �� vZ� d 3 � K(9 777- -W- `77�=777`�M, T77711rll!"�r�rY 7. 7,77,, w. 'j BMHMAM TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLAR SOIL TEST, 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE DATE OF SOIL TEST &a.a, 0,_Z9_Qj___ 100.00 10 FT. MINIMUM ELEV. CLEAN SAND SOIL TEST DONE BY (ASSUMED) CONCRETE WITNESSED BY --- COVERS LOAM AND SEED 4" SCHEDULE 40 PVC PIPE OBSERVATI.ON HOLE i MIN. PITCH 1/8- PER FT. PERCOLATION RATE. MINJINCH -AT INCHES, 2" LAYER OF TO 1/2- DEPTH HORIZ TEXTURE COLOR MOTT. OTHER LEGEND: WASHED STONE 6" MAX.- 98.30 MAX. VENT 3.00 4" CAST IRON PIPE 96.05 MIN. NOT REQUI�E� D EXISTING SPOT ELEVATION 00,0 .0-8 A LOAMY SAND ' 10YR4/2 NO , ROOTS OR EQUAL) MINIMUM EXISTING CONTOUR ----00---- PITCH 1/4- PER FT. I-x 1 CU. FT. �F FINAL SPOT ELEVATION B-34 8 LOAMY SAND 10YR6/8 -ROOTS FINAL CONTOUR --t-209-f CONCRETE SOIL TEST LOCATION ANCHOR 34-120 Cl LOAMY 2-5Y6/4 COBBLES FLOW LINE 95.30 UTILITY POLE _0_ REPLUMB PIPING MEDIUM SAND 10" '--ELEV. 97.00 TOWN WATER —W - -TMIN. 1/10 IF NECESSARY) CATCH BASIN 4 9197 GAS LINE G �4 g liols 0 ELEV. ELEV. 96.45 -I LEVEL 6. 5,27 6" ro SUMP C 0 ELEV. 0'--_ ADD GA ELEV. 9 ELEV. 95-10 CLEAN OUT Q FLE BAF CESSPOOL C.P. 0 DISTRIBUTION ELEV. LIQUID OU TLET 8 HIGH CAPACITY INFILTRATORS WITH QEPTH TE E 77 BOX -94.8Q:j STONE IN AN (TO BE PLACED ON FIRM BASE) 4 FEET 14 INCHES- TO BE WATER TESTED 6*17 11' X 48' X 10* TRENCH FORMATION 5 FEET 19 INCHES IF MORE THAN ONE OUTLET 6 FEET 24 INCHES 1500 GALLON 7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE) WELL N/A NO WATER ENCOUNTERED AT 120 - ELEV.' SOIL ABSORP110M 8 FEET 341NCHES SEPTIC TANK ZONE 3/4- TO 1 1/2- CLEAN INDEX DOUBLE WASHED STONE SYSTEM (SAS) ADJUST 1 FREE OF FINES & SILT DESIGN CALCULATIONS USGS PROBABLE WATER TABLE ELEV. = NUMBER OF BEDROOMS 4 SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ;ELEV. = GARBAGE DISPOSAL UNIT NOT TO SCALE BOTTOM OF TEST HOLE-ELEV. - TOTAL ESTIMATED FLOW 110 GAL/W/bAY X 4 13R.) --440-`GAL./DAY REQUIRED SEPTIC TANK CAPACITY 'GAL. ACTUAL SIZE OF SEPTIC TANK GAL. SOIL CLASSIFICATION DESIGN PERCOLATION RATE MIN,/IN. EFFLUENT LOADING RATE GAL./DAY/t.F.' LEACHING AREA SO. FT. (11X48)+(59X2X10/12) LEACHING CAPACITY AREA X RATE) AIM G AL./DAY X (126.33 X 0.74 RESERVE LEACHING CAPACITY _416ik GAL: DAY NOTES: 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO -DtiP. TITLE 5 AND THE TOWN OF RULES AND C REGULATIONS FOR THE,-SUBSURFACE DISPOSAL OF SEWAGE. 2, ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6" OF 'FINISHED GRADE. 3. ALL COMPONENTS .OF THE BE,CAPABLE SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS-71-+EY ARE UNDER OR WITHIN. 10 FT. OF DRIVES OR �PARKING AREAS. H-20 LOADING SHALL BE X USED UNDER OR WITHIN 10 FT..OF DRIVES OR. PARKING AREAS. Ix, 4. ANY MASONARY UNITS ,USED TO BRING COVERS TO GRADE SHALL BE MORTARED IN PLACE. , NO DETERMivihTkD-N -HAS ObZEN MADE :AS TO CIOMPO'A!�C;Et V'611­rl APPOCANT IS TO DEEDED OR ZONING REGULATIONS,. wN OBTAIN SUCH DETERMINATION FROM APPIROPRIATEIAUTHORITY� 6. UTILITIES SHOWN..ARE APPROXIMATE ONLY: EXCAVATION CONTRACTOR IS TO CALL "DIG-SAFE r AT,1-888-344-7233 AT'LEAST72 HOURS PRIOR TO COMMENCING WORK ON SITE. X 7. CONTRACTOR IS TO VERIFY GRADES AND.ELEVATIONS' AS WELL AS LOT 67 SITE CONDITIONS PRIOR TO COMMENCING,WORK ON SITE ANY,YARIAMON AREA 15,528 S F IS TO BE.BROUGHT. TO THE `ATTENTION OF THE DESIGN ENGINEER IMMEDIATELY. 8. PARCEL IS IN FLO OD ZONE _S__ 9. LOT IS SHOWN ON -ASSESSORS MAP AS PARCEL 10. EXISTING SEPTIC SYSTEM 'IS TO 113 E PUMPED AND.REMOVED, ow, A DECK T DW 0 � 1500 •GALLON APPROVED: BOARD , F HEALTH SEPTIC TANK r, TE R.H. DA SOIL TE ­AGENT� TEST PROPOSED 'SEPTIC ' DESIGN FOR AND tircl r jCo SHED -7 7 LOC, NQ11 0 WT 64 1 03)on EIJ- JAH CHIMS 1N." '',BARNS.' ' X s NAR JWGfiYZW"G WSW 235, GREAT'WESTERN ROAD 508- 'P.- 0. 'BOX 713 • SOUTH DENNIS,� MASS. 398�73922 02660 , ........... ROUTE 28 Wcusl DATE SCAL-E,,J,, 20 AUQ30' ' 001 REVISED JOB NO. 00 REVISED LOCATION MAP VEET'L C:�S.8\PROJ\5215-00\DWG\5215-�-00.DWG 0 2001:.SWETSER,ENGINEERING if-------