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Home My WebLink About0071 ELLIOTT ROAD - Health F= 248 --14 iott Vfo le 285 S///� / Q,ECYC� /�/i/�f/fKaIN)WNe UPC 12534 No. 2R 9� ,v NAST1Noa.JWH Commonwealth of Massachusetts Title 5 Official Inspection Form OO Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Elliott Road, Centerville M-248 P-285 Property Address 1�9 Sharon Aimico Owner Owner's Name ' information is 71 Elliott Road required for every , Centerville MA 02632 September 17, 2015 page. Cityrrown State Zip Code Date of Inspection M_ Inspection results must be submitted on this form. Inspection forms may not be altered in a* way. Please see completeness checklist at the end of the form. r' Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Troy Williams use the return key. Name of Inspector Troy Williams Septic Inspections ,Q Company Name 19 Hummel Drive Company Address South Dennis MA 02660 Cityrrown State Zip Code (508) 385- 1300 S1682 _ 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 September 17, 2015 _ 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. jIDjeVS t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System• of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owners Name information is 71 Elliott Road Centerville MA 02632 September 17 2015 required for every � , page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y< 71 Elliott Road, Centerville M -248 P-285 Property Address Sharon Aimico Owner Owner's Name information is required for every 71 Elliott Road Centerville MA 02632 September 17, 2015 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•3/13 Title 5 Official Inspection Form:Subsurface Sawage Disposal System•Page 3 of 17 5 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owner's Name information is 71 Elliott Road required for every , Centerville MA 02632 September 17, 2015 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 q nitrogen is equal 9 to or less than 5 ppm, provided that no other failure criteria are triggered. A co of the analysis must 99 PY Y 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 %day flow t5ins•3/13 Title 5 Official Inspection Forth: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 71 Elliott Road, Centerville M -248 P-285 Property Address Sharon Aimico Owner Owner's Name information is required for every 71 Elliott Road, Centerville P MA 02632 September 17, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 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 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owners Name information is required for every 71 Elliott Road Centerville MA 02632 September 17, 2015 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): 3 Number of bedrooms(actual): 1 (deed restricted) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owner's Name information is 71 Elliott Road required for every , Centerville MA 02632 September 17, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 14=38,000 gals. g ( y g (gp )) 13=43,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owner's Name information is required for every 71 Elliott Road, Centervillep MA 02632 September 17, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): NIA General Information Pumping Records: Source of information: Last pumped in 2011 per info from owner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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):h r scribe : t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 2-1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner owner's Name information is required for every 71 Elliott Road, Centervillep Rd, MA 02632 September 17, 2015 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: Tank, d-box and leaching were installed on 1/3/06 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1811+feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ® polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'X10.5'X6' 1500 gallon Sludge depth: 4" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owner's Name information is every 71 Elliott Road required for eve , Centerville MA 02632 September 17, 2015 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 2'8" Scum thickness Thin layer Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/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.): Pvc inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/Afeet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins-3113 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 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owner's Name information is P required for every 71 Elliott Road, Centerville MA 02632 September 17, 2015 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: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Capacity: N/A gallons Design Flow: N/Agallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts msm ar Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owner's Name information is 71 Elliott Road, Centerville MA 02632 September 17 2015 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 level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order with equal distribution to outlet lines. No evidence of solid carry-over or backup in the past was found at the time of inspection. 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.): N/A * 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: t5ins-3113 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 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owner's Name information isequired or every 71 Elliott Road, Centerville MA 02632 September 17, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2-27'X 4'X 2' ❑ 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.): Soil was sandy. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owner's Name information is required for every 71 Elliott Road, Centerville MA 02632 September 17, 2015 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.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .y 71 Elliott Road, Centerville M -248 P-285 Property Address Sharon Aimico Owner Owner's Name information is required for every 71 Elliott Road, Centerville MA 02632 September 17, 2015 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 [ 7 , tiz 2� .s yz � t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Elliott Road, Centerville M-248 P-285 Property Address Sharon Aimico Owner Owner's Name information is 71 Elliott Road Centerville MA 02632 September 17 2015 required for every � , 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: 12.0+ 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: 9/10/04 Date Observed site (abutting hole within 150 feet of SAS ® ( 9 ) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: MIW 29 Zone C 9.1' 4.5'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 12.0'. Hand augered 5' below bottom of leaching with no water found at a depth of 10.5'. Groundwater adjustment at the time of inspection was 4.5'. Bottom of leaching at 5.5'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Elliott Road, Centerville M -248 P-285 Property Address Sharon Aimico Owner Owner's Name information is 71 Elliott Road, Centerville MA 02632 September 17, 2015 required for every P page. Cityffown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 V4(V tf4V [0 VJ.VJ rtSt, - +d It V we `- Town of Barnstable Regulatory Services Thomas F.Geiler,Director f sAMVrAB Public Health Division + +" Thomas MdCemt,Director 200 Main Street,Hyannis,Ntk 02601 Office: 508-862.4644 Fax: 508-790-6304 Installer&Designer Certification Form ]Date: 1/03/06 J �- Designer: _Shays Environmental Services,Inc_ Installer. Robert Se acetic Services_ Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street. MA 02536 Yarmouth,Its On 9/04/0 _,_Robert Septic Service was issued a permit to install a (date) (installer) septic system at 71 Elliot Road, Centerville,MA based can a design drama by (address) Shay Environmental Services.Inc. dated_March 10,2005, (designer) XX I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank- I certify that the septic system referenced above was 'installed with major changes (i_e. greater than 10' lateral relocation of the SAS or any vertical relocation.of any component of the septic system)but in accordance with State& Local Regulations. Plait revision or certified as-built by designer to follow. CAIRM.t'd taller' ignature) E. ` NOl 11u1 ' t (!Designer's Signature) V (Af Desi`. -drnp Here) PLEASE RETURN TO BA.RNSTABLIE;r PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION, THANK YOU. Q:Hcat1h/ScpticlDcsigncr Certification Form No. � T— "" r S Fee THE COMMONWEALTH OF MASSACHUSETTS ' Entemd in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for �Diopooar bpotem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. G/D%/ ?D&N%EpZ✓If-I- Owner's Name, Name,Address and Tel.No. � Assessor's Map/ParcelW r L c ° 0 a� ,,� � . Mey s ass Installer's Name,Address,and Tel. o. Designer's Name,Address and Tel.No. Roaer -/7 (I' vS ;'r/rt c pt art at s ( FSkQ vcf » CCo 3on aa 7en& fit � m 5'0� s'y� -d7� Ce Type of Building: Dwelling No.of Bedrooms Lot Size/30� �sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures / C Design Flow! Jgallons per day. Calculated daily flow c gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil � �•e_ r��.�. Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of t Env' ental Code and not to place the system in operation until a Certifi- cate of Compliance has Health. Signe Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued —————————-————————————————————————————— ...+.-...: �..:.: .,,_ .. - 9� ? i 4 .,r ^-:r:Ka.-Y .L.nJ�r„(1,,,,.;.r9?.,,.s.a„ :'^ti. -..._. ..-Y°-.,.i,.�.;•�. _.. b- �r,x -•�.. err '� .ti 4 T No. s Fee 1 EEMU! in computer: ' THE COMMONWEALTH OF MASSACHUSETTS � Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIpphratiou for �Oizpooar 6pftem Cow6tructton permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components a Location Address or;Lot No. J� L C t0%/ L -rtl 4E12✓/1 G L Owner's Na��4ddress and Ted.No. / /� / n �y (� ( C L f—1 6 / , P ( � Assessor's Map/Parcelx a f e «�c///`"` C� Ci�C�ItrlolV/ 5� / Ins.t�1ler's Name,Address,and Tel.No. gsigner's Name, dd s and Te o. /sor2i5 �f'�f yE�TtC 1c ✓ rnNn � ay � rp�.w.w•f �/v/c�PI rf ar►��s� �'31l NO /3olc t,,A7 t '�-ct/.,ra&4_ t�YI OZ�3 S� - CoYB"- 5-3rc) 5og. 5'YY -07� Co Type of Building: 1" Dwelling No.of Bedrooms ' Lot Size��'�� sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date - Title Size'of Septic Tank Type of S.A.S. Description of Soil ✓/ 2f C Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of vironmendal Code and not to place the system in operation until a Certifi- cate of Compliance has-b even issu by t of+ ealth.-,*- Signed Date Application Approved by Date 115 /o Application Disapproved for the following reasons �., Permit No. t Date Issued • THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CE that theOn-site Sewage Disposal System Constructed( Y )Repaired ( )Upgraded( ) Abandoned�j )b at 7 t `,has been constru�te �n�aco(o dance with the provisions of ide 5 d e for Disposal System Construction Permit No.4160 b dated J Installer Designer .�"t The issuance of this permi shall n t be construed as a guarantee that the ystem wil un to as esigned. Date f -�/ � Inspector No. �`'�`JY "�"`/��" ------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLES MASSACHUSETTS &5pogal *p5tem Con5tructton Vermtt Permission is hereby gra e a to Co struct( WRepairQ)Upgrad -a System located at �� 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:Construct n jnjj'st be 9ompleted within three years of the date thislpe, t. 1 Date:_. Approved by TOWN OF BARNSTABLE �� LOCATION 1 b .'"e— SEWAGE # VILLAGE � ✓l1�\ SOR'S MAP & LOT F� XS INSTALLER'S NAME&PHONE NO. _ 1 SEPTIC TANK CAPACITY DO LEACHING FACILITY: (type). t!�v_r1E_%0__ M (siz�h �24 4 f�: � NO.OF BEDROOMS S t�11.5,q W. � I V1J�►esni BUILDER OR OWNER ^vim `�`�S PERMTTDATE: ep I V `T COMPLIANCE DATE: ✓ L _Z Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 `7 y� a� i f�all bit _ Si! iAT V- O IP 30 LOP O P£A1 RAIUAI(s i _ - yy z 4- b � a44a a�yHa a4va . � lr lI � 1, • _;?Nl7 T-r Ook Pi A-n.) 69 C� V n SEP-14-2004 TUE 07:36 AM FAX N0, P. 02 Bse 10026, Pa208g 471855 DEED RESTRICTION WIIEREAS, Marie Etchells of 50 Holly Hill Road, Banistable (Centerville), Barnstable County, Massachusetts 02632, is the owner of the land in Barnstable (C;entervilic), Harnstuble County,Massachusetts,described as follows; Being LOOT 3A as shown on a plan of land eiititled: Plan of band in Unstable (llyannis), Mass. for Barry 0. Petridis, Scale 1" _ 50', June 3, 1982, Baxter & Nye, inc,, ?registered Land Surveyors, Osterville, Mass.", which said plan is duly filed in the Barnstable County Registry of Deeds in Plan Book 365, Page 78, with an address of 71 Elliott Road, Centerville,MA 02632,rand hereinafter referred to as the Property, WHEREAS,the:Towil of Barnstable Board of Health, as Lt pre-condition to the issuauee of a disposal works construction pcifflit for the soil absorptions system.to be constructed at the Property, requires the owner of the Property to restrict the utunber of bedrooms in the house to be con.stroc;ted at the Property, shad to record with the Barnstable County Registry of Deeds a docu,rmont evidencing;such mstriction, NOW THEREFORE, I Mario 13tcheils, agree with the Twmi of 13anistable, Board of Health to restrict the cumber of bedrooms in the house to be constructed at the property to one (1)bcdroorn amid hereby place the following restriction on the Property: 1, The house to be located at 71 Elliott Road, Centerville, Ma.ssachusctts, may have no snore;than one(1)bedroom; and 2. This restriction shall be pe,nnwient, rem with the land, and be binding; upon all successors in title, For title, see deed dated August 22, 1986 recorded in Book 5341,Page 70, EXECUTED AS A SEALED INSTRUMENI'this /9 clay of September,2004, Marie Etchells I IProperty location: 71 Elliott?lead I C:entervillo,MA 02632 { i eta'•-14-?UU4 TUE 07:36 AM FAX NO. P. 03 Bk 3.9026 P9 209 #7185 COMMONWEALTH OF MfASSAC]E USETTS iiarnstable,ss: On tills 134-k'- day of Septernbcr, 2004, before me, the tindersignod notary pttbbe, Pcrsaiially api?caret the said Made Vkhells a each personal ly known to Inc.,or Velch proved,tonic tlr`ou&?h Satisfactory evidence of identilioation,which was o (other) .,... „•..,.,....•.... .............,..,,..... .. ...... to ba the PcrsonW 'WhOse• rm,114 WMI-signed en the preceding or attached d.Qp.*4tt, siid acknowledged io niee Oat iit/she/tf#Wsigned it voluntarily for its stated purpose,.„ J� 4 ' • ' fiti � My Commission Bxpircrs: �� u0c` •F�•' „9��P ��': SUSAN t,i 4L I. AL LAIN NOTARY PUd110 -A *0d'' GOIA�Bpptl�l 4f Mift�pR1011Y yi '. My 0omm11118n 14 BARNSTABLE REGISTRY OF DEEDS 04/01/2016 05:05 FAX l�4Q1l002 y - Town of Barnstable Regulatory Services C12, _ Thomas F.Geller,Director EARMARM Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax; 508-790-6304 Installer, & Designer Certification Form Date: 1/03/06 v Designer: _Shay Environmental Services,Inc_ Installer: Robert Septic Services_ ,Address: P.Q. Box 627 East Falmouth Address: 5 Trenton Street. MA 02536 Yarmouth, MA On 9/04/05 Robert Septic Service was issued a permit to install a (date) (installer) septic system at 71 Elliot Road, Centerville,MA based on a design drawn by (address) Shay Environmental Services. Inc. dated March 10, 2005 (designer) XX I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. 1 certify that the septic system referenced above was installed with major changes (i_e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. ( taller' ignature) S (Designer's Signature) V (Affix Des& •dmp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. 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L C .-/ t C :(':\411 ..• -�C { ' . f' .? i aC.�i 1..,.� �! .. � 4 .L. .i.. %� a. :'Vi yt t# k,_�i'-C c:i.# i,i R t� 'r ' r# t - 7 ,'- r ,. }• t 13.- :z l :•t��' ss n f+ i *- _ .r t,.1 _a r•. .tf.. y f ... - y 5 J 4 A•.3 ', l.y :rL^t' '}..a-:M1,a .y tq��4Y . :,.. .I A.. -;14i 1`t 1' .x 3 r F :_:.,+ti; t e1.'S�. }f t r I f ;'� `F1 sty Q 1 5 #iy , T 4 „a { ,pc t>E ?� . .,j �1:.1 Y,''• . t.: 4 ,"�'• lA l .:1p rF• ,�:11.55 4A. M1:,f/ ;" a 1:,"-—:.I..-:..I I.-.-,...*1I:-..-�'-...':-�'[-�—:i,;I�I'+-I:1I.,;.:.1�I,.'..,.'I...im..Ia".....I.,'—,;�-.I-..II�..�-,�.�....-,.:�.,1+'':.�:I.f 1. ISf `'�- . 'l {. ,. T y .,!''r 1' air .^;J . ri*r4; .Y, r r. - t 4 S� y y r :{ :' T s II 1 1 1 - 71 Yd 7#r ALL OUTLET PIPES FROM THE t I: DISTRIBUTION Box SHALL BE SET LEVEL FOR AT LEAST 2 FT. 12' CONCRETE COVERt �-Y - r ...,.<...a... 2*NOTE. ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. ^ 1 J - s OUTLET 10' min. from VENT PIPE O Leoet 24 inches tall) ' L NEW Foundation house to septic tank Schedule 4� PVC w/Charcoal Odor Filter I ; '` { tcNoacouTs TOF ELEV >s 46.00 (NGVD) Septic tank covers must be I - - - s.s' ouTLET -, I t2' INLET Q• s 4, '�• within 6 in. of finished grade -- .� t; Or ovr Septic Tank - 98 SO -Gode over CI-Bo. - 9il.00 I I Q• I 't ,p t�@ / �nNM,Wash Oev H.00 I I �. '� 2 x x71 S 0.02 4" - SCH 40 To HOLE H-10 I Top orstet•m ocv 4too o� DIsT Box _ PLAN SECTIONCROSS-SECTION NEW 10' NEW -0 10 a Greotet S- 0.010' per toot _ ��- ATFROM0UNDION ' in 1,500 GAL. �0 10' GREATER t -4' Perforated P a.0 �'-t/B'-'i2" washed Store �k3r fSEPTIC OTANK o 0 2' nvet o.�.-4050 ¢�.� era II H-, r, 3 HOLE H-10 DISTRIBUTION BOX j Or eelM a0 ^ J/4'-ik' washed Stone 6 Bottom of Leash Facility Elev..38.50 CONCRETE FULL FOUNDATION) s' II O p I NOT TO SCALE �NO. '� > u •a a $ I- "'7' -+ �tow Rad>ItA�r a;�n,.a-,�lac 4ovTEo c ' U u II Note: All leach Imes to be capped of ends wl" cep° s PROVIDED - - SYSTEM PROFILE s n.omp ted stone 1/2. LEACH TRENCHES CROSS-SECTION ( TOTALS GENERAL NOTES composted atone j u � LEACH TRENCHES Batten of ie.t Hde + Elev._8750 Not to Scale - (2 TOTAL) 1. Contractor*is responsible for Digsafe ratification `-a N1di and protection of all underground utilities and pipes. 6 in of 3/4'-1 1/2' 1 2. The septic tank anq distribution box shall be set compacted atone NOTE: ALL COMPONENTS MUST HAVE RISERS ' WITHIN 6" BELOW GRADE °''/e-'/� level On 6" of 3/4 -1 1/2" stone. - Washed Sten• 3. Backfill should be clean sand or gravel with no Ma. stones over 3" in size. 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. PERCOLATION TEST ' -'a•mpxt m Nan.Stool 5. The contractor shall install this system in accordance •d 4' p•rf-ted Pv.6 pp with Title V of the Massachusetts state code, the approved plan Date of Percolation Test: SEPTEMBER 10, 2604 NOT TO SCALE and Local Regulations. Test Performed By. CARMEN E. SHAY, R.S., C.S.E. 6. If, during installation the contractor encounters any oil conditions or site conditions that are different SHAY ENVIRONMENTAL SERVICES,,Results Witnessed By. DONNA M (BARNSTABLE B.O.H.) soil Calculations from those shown on the soil log or in our design INC.NC. TYPICAL 1500 GALLON SEPTIC TANKinstallation must halt & immediate notification be Percolation Rote: Less Than 2 MPI ® 36" Number of Bedrooms: 1 Equivalent to 110 Gal./Day Garbage Grinder: No NOT TO SCALE mode to Carmen E. Shay - Environmental Services, Inc. Leaching Capacity Required: 330 Gal./Day Minimum per Title V. 7. No vehicle or heavy machinery shall drive over the Septic Tank - 2 x 330 Go!,/Day - 660• USE NEW 1,500 GAL. Septic Tank. 3-24' DIAM ACCESS MANHOLES (H- 10 LOADING) septic system unless noted as H-20 septic components. I SOIL ABSORPTION AREA: Jsin percolation rate of <2 min. inch 1a _6. 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. j Test Hole 9 p /' , No. 1 Proposed Leaching Trench Dimensions: 2 TRENCHES -4' Wide by 27' Long by 2' Depth EACH. f �'y .:.'.�" _ 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. DEPTH SOILS ELEV I Bottom Area: 0.74 gal/sq. ft. x 216 sq. ft. = 159.84 gallons 10. All solid piping, tees & fittings shall be 4" diameter 0 44.00y Sidewou Area: 0.74 gal./sq. ft. x 232 sq. ft. = 171.68 gallons Schedule 40 NSF PVC pipes with water tight joints. Loony Providing: = 331.52 gallons INLET 1 1 1. Municipal Water is Connected to ALL OF The Residence and Abutting Sand Use: 2 TRENCHES - 27'L by 4'W x 2'D INLE THE PTIC TANK, Properties Within 150 Feet. +0 r 3/2 I DISTRIBUTION BOTHE ACCESS X ANDOLE CHING COMPONENT i SHALL BE RAISED To WITHIN 6' OF THE PROPERTY LINES ARE APPROXIMATE AND 'oomy I \ 6' ,- •_ *_ 1 FINISHED GRADE. sand \ 99.82' COMPILED FROM THE SURVEY PLAN GENERATED BY STEEL REINFORCED PRECAST CONCRETE INSTALL TIJF-TITE GAS BAFFLES OR EQUALS 42" E PLAN VIEW ON ALL OUTLET TEE ENDS BAXTER & NYE, INC. OF OSTERVILLE, MA ENTITLED I •D rR S/6 85d 19' I 9"-28' Be 41 501,' I 1 \ S "SUBDIVISION PLAN OF LAND IN BARNSTABLE, MA - HARRY PETRIDIS" Med. 46 --_ 3-24' REMOVABLE COVERS-1 r I Sono I DA,ED DUNE 3, 1982. PLAN BOOK 365 PAGE 78) 2 s r 7 • ! -_27• 4 , TEST HOLE 1 ' t t IT SHOULD BE USED FO NO PURPOSE 28"- 1aa C, / 32.00 �' , . 4 = q•5.5(� .• .- T- OTHER THAN THE LLATION r O E E SEPTIC SYSTEM INSTA ''�•--'L 1' '�'' '�7' I J min•claaranc° - +ER✓' •••'�" 1 Y i INLET InNt to outlet - t3� T ' I T RESERVE _ _ _ e i \ E AREA "�f �= o"�mk `Ia 0 '° OUTLET 1 �}- NOTE: WETLANDS ARE PRESENT WITHIN 200 ^EET OF PROPERTY AS SHOWN. �� J LJ RESERvE AREA 7.4' cv) s -r ; i 1 I � -- I s. _,. \ ES HOLE \1` - � o oe.00! 1 .-D' min ASSESSORS MAP - 248 LOT - 285 __ ._ -_ = _/ di % .ieuw depth I- - O �\ LE V 44.00 2Ir 00 �9 A s I ZONING RESIDENTIAL \ O \ NEW 1500 gal I ~ l Septic Tank t 1 i FLOOD ZONE C 11 li \ „,o•_O• S'.-6' 'H '`F.. PROPOSED ` DL I f ERE ARE NO WETLANDS LOCA A N DECK \ ---- 11 CROSS SECTION END-SECTION OF THE SITED SEPTIC SYSTEM _ Perc #1 0 i O 1L � I�I . Depth to Perc: 36" to 54" 3 #71 r b Perc Rate= 2 MPI PROPOSED PROPOSE / Groundwater Not Observed \ FOUNDATIOA' FUTURE _ r r' NOTE: SITE IS IN A ZONE OF CONTRIBUTION - REQUEST A 1 BEDROOM PERMIT ONL DENOTES PROPOSED No Observed ESHWT 38- 1 , GARAGE I ; i 104X(� ADJUSTED H2O Elev. = rr r r None TOF = ELEV 46.00 SPOT GRADE \ 0 ESMNT FLR 38.00 x 104.46 r DENOTES EXISTING 1 = �\ � � .� � - o \ FNSH FLR = 47.00 � 5.25�1� r I � SPOT GRADE 6, t i i• i O PL PROPERTY LINE _ ' I -0 44 Test Hole h, I 4 \`t i ' 1ti �1 LOT #1 3 4� PROPOSED CONTOUR No. 2 1 0 2 �- 0 ' ') 111 I 1\ - - - - - -97 DEPTH SODS ELEV 34- 40 EXISTING CONTOUR 0 45.501 ° Loamy DEEP TEST HOLE & sand I f� ^� tt 0 PERCOLATION TEST LOCATION 10 r 3/2 -I I �� \ 0"-10' A 44.601 �'�� ', ' e i 11 \v p e- 6 FOOT STOCKADE FENCE C, I Loamy 0 32_, Sand 10 rR 5/6 10"-36" Bs 42.501, Med L 0 PLAN Sand AV L A I I �J. I 1 2.5r7/4 36"- 144 I33.50 LOT # �, , s OF PROPOSED SEPTIC SYSTE!V1 13,040 Square Feet +� ' �,T`� iAR �, gal 1ts� P OJECT BENCH MARK 8c FOUNDATION LOCATION °oos; I ��.. K NAIL SET PREPARED FOR �R/Vf �� `\`� �, \ LEV. = 54.00 (NGVD) >o �, w !� � ; >s'�I�s'r �T Bo oo. C RA I IS V I L_L E REALTY ISO �� AT # 71 ELLIOT ROAD y C.: ' .92r`�� °a\ - '/ CENTERVILLE MA o� LOT #2A � a\, ; PREPARED BY: �DepthPerc #to Perc: 50" to 68" y \\ CARM�'N E. >`SHA Y Perc Rate= 2 MPI J cp �tNOF04V1Groundwater Nat Observed / Q 20 40 50 4)' IGr Observed ESHWT �� ENVIRONMENTAL SERVICES, INC. GILR'_`�l S•ADJUSTED H2O Elev. None 37 '1' T� T 1 F`' P.O. BOX 627 r t T EAST FALMOUTH, MA 02536 TEL/FAX : 508-548-0796 SCALE: 1 "=20' �a,�,��j' SCALE: 1 "=20' DRAWN BY: CES DATE: SEPT. 13, 2004 PROJECT#SD634 FILENAME: SD634PP.DWG SHEET 1 OF 1