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Home My WebLink About0209 ELLIOTT ROAD - Health 209 ELLIOT RD., CENTERVILLE A= M�i�iil�.M♦ 4�� '•`� � ".� ��`'� � � S �,, � s�, d 1 �+'Ss :x� � 'P,�� p, a �r a � 9 V� Q� - c r` a � � C7•� �✓� C S OA A S urma wo,�r ,lo lecib or Cr'r1 S .Q/ved ft ,07) I// C� /e k t xb No cos-_ q `I VHE,Ct7MMONWIF�ALTKOF MASSIACHUSTETTS BOARD OF HEALTH _ Jtn/' _ OF td�met� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construe ) Repair ( ) Upgrade ( ) Abandon ( ) ]Complete System ❑Individual Components , 1-� ,QocLol_ - ✓ /'-`�r/� �ynnd_raJ - o r 6L q (ca�'n f e�o_I Gl ��1 K(Yll�r's NarO 'KJ'VT /VCR Map/Parcel# 503 jai �O J / t pyri Te (pMer# C Yn V C [nstaIjglbl I IPST _ e i�ner'sN me D� �T'�"�T`jT� / ��G �^�Gx �hG��PA `V/� p 'Na S S�IJ Ad l� sd I� T 3 Q oo g" Telephone# Telephone# Type of Building: CZ C c.�.r�u-I�C.�� Lot Size W Sq.feet Dwelling—No.of Bedrooms — j5f&j,3r 3MS Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow( 'n.required) �+U gpd Calculated design flow +S gpd Design flow provided'14S+gpd Plan: Date _ 1.5- _) �_,15 Number of sheets - Revision Date Title �a i Cl.Y7 ® L 'l0� a - I l Description of Soil(s) Soil Evaluator Form No.�j 19 Name of Soil Evaluato Cr__ to of Evaluational DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and frurthnprogreos not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed �" Date l�� Inspections FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 --- - ------------------------------------------- - ---- --- ------- - ------ --- No. 2o®J !� THE CO MONWEALTH OF MASSACHUSETTS FEE [� �' e BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System;Constructe ),Repaired( ),Upgraded( ),Abandoned( ) has been installed in accordance with the provisions of 3 0 C R 15.00 (Title 5) and the approue'd es�l ns/a uilt plans relating to application No. f,1JS= 7/dated a 2 o.Sr Approved sign Flow pd) Installer Designer: s O Inspect Date The iss ante of this certificate shalAot be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. od 1 7t• etHE MMONW�ALTK-OF MASSACHUSETTS FEE IL BOARD OF HEALTH OF - 04l i APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construe`(+ ) Repair ( ) Upgrade ( ) Abandon ( ) �411g Complete System ❑Individual Components d" _ r� -1- Location f Owner's Name / Map/Parcel# � 1 +`fires/j i Lot,# Telephone# SCOW TOrrC'i �1I I tC l.s i'01 Y,-A" 1' - W c.L, Installer's Name" ,Designer's Name r Addre s Address _ f7 cc J ' . SCE F3�C� � �'� r . i Telephone# Telephone# Type of Building: I f' -1 G� �1.�� _. Lot SizeS`')i IrNltn Sq.feet _ Dwelling—No.of Bedrooms a.— fg-e f( Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) 4 q0 gpd Calculated design flow 'i:i gpd Design flow provided '�� gpd Plan: Date l`�l 3C Number of sheets - Revision Date Title a _ D 1 o-r-) O t L-o t id I re i l--` : rX Ck 1- 7C)` 1 r Description of Soil(s) C.eP gz> I OL '�---' i Soil Evaluator Form No. I I) C) I K Name of Soil Evaluator,=xu e-r'- f r J#-;'KA4_Date of Evaluation i DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed * Date yc, Inspections o a FORM 1 - APPLICATION FOR DSCP PEP APPROVED FORM 5/96 , No. voS - 7 THE COMMONWEALTH OF MASSACHUSETTS FEE ! S 80CD [.Q— BOARD-OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) Complete System If The undersigned hereby certify that the Sewage Disposal System;Construct"de -(J),Repaired( ),Upgraded( ),Abandoned( ) by: ++ G r ✓� has been installed in accordance with the provisions of 3 t0 C1n.R 15.00 (Title 5) and the approved design plans as built 1 plans relating to application No. dated .) Approved Des gn Flow y� VO ("gpd) ff Installer Designer:. L_M.S / Inspector Date The iss ante of this certificate shalt not be construed as guarantee that the system will function as designed. j FORM 3 - CERTIFICATE OF COMPLIANCE y DEP APPROVED FORM 5/96 No. 900-S^- 4 7( THE COMMONWEALTH OF MASSACHUSETTS FEE �I I (��,' "-tee-�— BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT 6 Permission is hereby granted to FConstruct K) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at Do 'I ►-( 0 T Xtjr r�/�O as described in the application for Disposal System Construction Permit No. 'D60 �Y/ 4- dated Provided: Const uction shall be completed within three years of the date of this' t.Alhlocal conditions must be met. Board of Health Date ��y<. ), jr i,t ! fl� _ I = FORM 2 - DSCP DEP APPROVED FORM'5/96 j FORM 1255 (REV 5/96) H&W HOBBS&WARREN rM PUBLISHERS- BOSTON r ; A. M. 22811 39-1 � e #209 63.5' ,1 PROPOSED ADDITION / N88°0 7'30"E L' INSTALED: BY JOHN CONDEN 97 90 CB/DH DATE., NO VEMBER 26,2005 FLOOD ZONE "C"_ SEPTIC CERTIFICA TION RES ZONE "Rc" TO WN.-CENTER VILLE SCALE. I "=�0' PL.REF.-331130 ELE V NIA I CERTIFY THAT THE ABOVE YANKEE SURVEY CONSULTANTS SEPTIC SYSTEM IS LOCATED P. O. BOX 265 ON THE GROUND AS SHOWN, UNIT 1, 40 INDUSTRY ROAD AND IS INSTALLED IN MARSTONS MILLS, MA. 02648 SUBSTANTIAL COMPLIANCE TEL: 428-0055 WITH .THE DESIGN PLAN FAX 420-5553 JOB BRUCE G. MURPHY, R.S. DATE.' 01=05_O6 NUMBER 53727SEP Town of Barnstable Regulatory Services Thomas F. Geiler,Director RMIX NAMPublic Health Division 1639.ram" Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Sewage Permit# Assessor's Map\Parcel Designer: SiJgVe: e �/�"Installer: Address: 46 3 96A-D Address: AS � /GLS, A4. 626 40 On was issued a permit to install a (date) (installer) septic system at ZD Ezz /p j F64j-) n based on a design drawn by (address) C9YV i�RIIIZZ6 r �qh/ �L2y�y�•vsv�rAi�Ts dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. .w.nnbZ A,�`��\, BRL JCCr �y (Installer's Signature) J G. `� A 1Ir No.749 1 (Designer's Si a ) (Affix Desi N tamp Here) &_Q� 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. Q:Health/Septic/Designer Certification Form 3-26-04.doc TOWN OF BARNSTABLE LOCATION 0 � �1.�-1� R3 SEWAGE##aOOsp �1 VILLAGE C�N��-V1L�.� ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. TO K'E-Y / SEPTIC TANK CAPACITY /S n LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: i 1 'a 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 � � Lxi�� iP�-�, f ` .ri � .`t � � �� C�-� �� -J` � v 'ems � Fr�o� COMMONWEALTH OF MASSACHUSETTS �.tL EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 209 Elliott Road Centerville, MA 02632 Owner's Name: Ari Ilomaki Owner's Address: Date of Inspection: September 13, 2005 Name of Inspector: (Please Print) Janes M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Ostervi 4 MA 02655-0049 Telephone Number: (508) 862-9400 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 Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Need urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: September 18, 2005 The system inspector shall sul 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. 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 6/15/2000 page 1 r� C Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Iloniaki Date of Inspection: September 13, 2005 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. 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. Answer yes,no 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 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. 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 Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari llomaki Date of Inspection: September.13, 2005 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 i Page 4 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following 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 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. 4 7 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 209 Elliott Road Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 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: Yes No ✓ _ 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: 209 Elliott Road Centerville, MA Owner: Ari Romaki Date of Inspection: September 13, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): n1a Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n1a Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 2 years ago-per owner Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 1 012 7178-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 Elliott Road Centerville,MA Owner: Ari Romaki Date of Inspection: September 13, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: To grade Material of construction: ✓ concrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present The liquid level was even with the outlet invert There did not appear to be any signs of leakage. NOTE:A new system was going to be installed- only the tank needed to be inspected(per Health Department) GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Cormnents(on pumping recormmendations, inlet and outlet tee or.baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Romaki Date of Inspection: September 13. 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: - (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Romaki Date of Inspection: September 13, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pits were not located or inspected since a new systein was being installed CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13. .005 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. BAV k B i i O O B 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 209 Elliott Road Centerville. MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 15'+/ to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection andlor this report. 11 - TOWN OF BARNSTABLE LOCATI01� C 111 O 7 `\p l� SEWAGE,# �'.LAGE �n �,(v�1� ASSESSOR'S MAP & LOT �' 3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY V V l! G/1 ' LEACHING FACILITY: (type) P,T5 (size) NO.OF BEDROOMS BUILDER OR OWNER. PERMTTDATE: 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 leach' g facility) > Feet Furnished by J^s 1�Ats�� beck I 10 0 B a� a� :fc COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 209 Elliott Road Centerville, MA 02632 Owner's Name: Ari Romaki Owner's Address: Date of Inspection: September 13, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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 Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Need urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: September 18, 2005 The system inspector shall sul 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. 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 6/15/2000 page 1 • Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 209 Elliott Road _ Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 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. 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. Answer yes,no or riot 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 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. 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 Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 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 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,perfonned 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 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following 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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 209 Elliott Road Centerville, MA Owner: Ari Romaki Date of Inspection: September 13, 2005 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: Yes No ✓ _ 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)]. I 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 209 Elliott Road Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currentiv occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:. Pumped 2 years ago-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped detennined? 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 1 012 7178-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: To grade Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert There did not appear to be an�si ns of leakage. _NOTE:A new system was izoinQ to be installed- only the tank needed to be inspected(per Health Department) GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or.baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Romaki Date of Inspection: September 13, 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: -- (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 V♦ Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The leach nits were not located or inspected since a new system was being installed CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 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. 1 O O � a Pal B a� a� 10 Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 209 Elliott Road Centerville, MA Owner: Ari Ilomaki Date of Inspection: September 13, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately IS'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 s TOWN O ,BARNSTABLE 1 i C � �14� SEWAGE #. I-ArGE6 f �U��—�.— ASSESSOR'S MAP O _ V _ Go` P.ISTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY n00 0 LEACHING FACILITY: (type) (/1 (size) dam• .NO.OF BEDROOMS BUILDER OR OWNER °PERMITDATE: COMPLIANCE DATE: 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 fee:,of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Dec �� 3y LOCATION , vSEWAGE PERMIT NO. CFZ ram V ZP•-lO' VILLAGE f1 - l INSTA LLER'S NAME i ADDRESS .BUILDER OR OWNER DATE PERMIT ISSUED fa/42 DAT E. COMPLI-ANCE ISSUED �► , - r R b 1 fs f i 4 No je c, S . Cl Ven�' unCP�,r /l�(I�lec� -�5�ow �u /Q,� ✓ i � T Town.of Barnstable P#---T , oF•twE Department of Regulatory Services . ; Date Public Health Division 200 Main Street,Hyannis MA 02601 ram: )c�-� � Time )0 Fee Pd. / Date Scheduled_� `C> Foil Suitabili Assessment for Sewage Is osal , • S Performed By: 1" ✓"` :' Witnessed By: LOCATION & GENERAL INFORMATION Location Address /1 r qQ �j��Q L r� Owner's Name J ( j I f\ ` Address Assessor's Map/Parcel: C;)C,>LC? l 3(�-pd Engineer's Name NEW CONSTRUCTION L/ REPAIR Telephone# Land Use Slopes Surface Stones -.l• o y Distances from: Open Water Body ' 3 S ft Possible Wet Area 1 3 S ft Drinking Water Well ft Drainage Way ft Property Line "�0 `i ft Other ft a—*i,�01,o sZ SKETCH:(Street name,dimensions of lot,exact locan test holes&pert tests,locate wetlands in proximity to holes) PC— 4. rT /C �u 0 Parent material(geologic) C%IA�R�e(Z. Depth to Bedrock � '4 / Depth to Groundwater. Standing Water in Hole: g T�4' Weeping from Pit Face Estimated Seasonal}Iigh Groundwater i °r D9TERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: in Depth 6boerved standing in obs.hole: la- Depth to Sall tnatt199: Depth to weeping from side of obs.hole: in. Groundwater Adjustment t� Index Well# Reading Date: Index Well Levi l Adl.factor Adj.drouttdwater l-eVxl.` PERCOLATION TEST,,' Observation „ ^, Hole# Time at 4 , Time at 6" Depth of Perc ^ �v v� y.� e'• V. ®o �u „ „ Start Pre-soak Time @ __ . 'ISme(9 -6 ) d_ 305� End Pre-soak /6.M/ Rate Min./Inch Site Suitability Assessment:,Site Passed C/ Site Fa Additional Testi ng Needed(Y/N) ,;,, • Original:.Public Heath Division. Observation Hole Data To Be Completed on Back--------- r . ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\S EPTIC\PERCF�RM.DOC y DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Struc�ure,Stones,Boulders. Con stencv.%Gravel F C DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel tc,r�-c�• DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. , Consistenc Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consisten ° ravel ly Flood Insuranke Rate an: PA e,`$ L Above 500 year flood boundary No— Yes _ Within 500 year boundary No— Yes Within 100 year flood boundary No— Yes 'V Depth of Natually Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed fbr the soil absorption system? S — If not,what is the depth of naturally occurring pervious material? Certification I certify that on. (date)I have passed the soil evaluator examination approved by the Department of]Environmental Protection and that the above analysis was performed by Me consistent with the required training,a ertise and expe 'ence described in 310 CMR 15.017. Signature Date /� Q:\S.EPTiC\PERCMRM.DOC w -n fD 4PM b, COMMONWEALTH OF MASACHUSETTS s EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02632 Name of Owner ROBERT ELLIOT C/O MARGERET KOOMEY , Address of Owner: 28 NORTH ST.GRAFTON MA.01619 Date of Inspection: 2118/00 Name of Inspector: JOHN GRACI I am a DEP approved system Inspector pursuant to Section 15.340 of Tftle 5(310 CMR 15.000) Company Name: TITLE V SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET MA.02636 Telephone Number: 608-664-6813 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience i h n the proper function and maintenance of on-site sewage disposal systems.The system: X Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date:2/21/00 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection Is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not Imply any warranty or guarantee of the longevity of the septic system and any of its components useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE. I revised 9/2/98 Page 1 of 11 L � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02632 Name of Owner ROBERT ELLIOT C/O MARGERET KOOMEY I Date of inspection: 2/18100 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any Information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all Instances.If"not determined",explain why not. p/$ The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n& Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass Inspection If(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced Iva The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): broken pipe(s)are replaced _obstruction is removed i revised 9098 _ Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02632 Name of Owner ROBERT ELLIOT C/O MARGERET KOOMEY Date of Inspection: 2/18/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool 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 AND SAFETY AND THE 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 soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance m&(approximation not valid). 3) OTHER n/a i revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02632 Name of Owner ROBERT ELLIOT C/O MARGERET KOOMEY Date of Inspection: 2118/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Q. _ X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must Indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system Is within 200 feet of a tributary to a surface drinking water supply X the system is located In a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further Information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02632 Name of Owner: ROBERT ELLIOT C/O MARGERET KOOMEY Date of Inspection: 2/18/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X - Pumping information was provided by the owner,occupant,or Board of Health. X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note If they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X _ The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at Issue,approxir.'ation of distance is unacceptable)1 5.302(3)(b)] X _ The facility owner(and occupants,if different from owner)were provided with informallun on the proper maintenance of SubSurface Disposal Systems. i revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02632 J Name of Owner ROBERT ELLIOT C/O MARGERET KOOMEY Date of Inspection: 2118100 FLOW CONDITIONS RFS113ENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 1 Number of bedrooms(actual): Total DESIGN flow: 110 gpd Number of current residents:1 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate Inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COM M FRCIALlIN13USTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X Septic tank/distdbution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1978 Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02632 Name of Owner ROBERT ELLIOT C/O MARGERET KOOMEY Date of Inspection: 2/18/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 7" Material of construction: _ cast iron _ 40 Pvc X other(explain) Distance from private water supply well or suction line: n/a Diameter: 0" Comments: (condition of joints,venting,evidence of leakage,etc.) THE SEWER IS 20 PVC;THERE IS TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 1" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: L 8'6"H 6'7"W 4'10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 1" 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: 17" How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet Invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: - (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a 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 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet Invert,structural integrity,evidence of leakage, etc.) n/a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02632 Name of Owner ROBERT ELLIOT C/O MARGERET KOOMEY Date of Inspection: 2118100 TIGHT OR HOLDING TANK: - (Tank must be pumped prior to,or at time of,Inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n1a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:WA Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n1a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet Invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into.or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _ (locate on site plan) Pumps In working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 „ c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02631 Name of Owner ROBERT ELLIOT C/O MARGERET KOOMEY Date of Inspection: 2/18/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(2)n leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Aftemative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE SAS APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: _ (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: n/a Inflow(cesspool must be pumped as part of inspection)NO 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 revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02632 Name of Owner ROBERT ELLIOT C/O MARGERET KOOMEY Date of Inspection: 2/18/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes Into house) p�cl� AA AC- � gc 3y revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOS AL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 209 ELLIOT RD. CENTERVILLE, MA MAP 228 PAR 139-001 02632 Name of Owner ROBERT ELLIOT C/O MARGERET KOOMEY Date of Inspection: 2/18/00 NRCS Report name: n/a Soil Type: n1a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _ Checked pumping records Checked local excavators,Installers Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) GROUNDWATER WAS DETERMINED FROM TRANSIT AND STORY POLE I revised.9/2/98 Page 11 of 11 FIC31 No ---.._� 5..... *- . 5`.`. ........ THE COMMONWEALTH OF MASSACHUSETTS t4. BOAR® O.FHEAJ_TH _---..... ...........OF....... ..L �dr --------------------------- ApplirFa#ion for Dispvii al lftrks Toutitrnrtinn Vamit ,,Application is hereby made,for a Permit to Construct (A4""or Repair ( ) an Individual Sewage Disposal System at .....I .1.._...... - - t ----------------------- -----------•------ Location- dress or Lof No ..... La�k �Z O(r Address W --•---•-------C ---- ........................ --•--•-•---...................--•-••-•---••-•---------•-----------•---•-...I.t..L..�.L...:.�....t..R...I.-,-A-- Cr> � Installer Address Type of Buildi� Size Lot.:..........................Sq. f Dwelling—No. of Bedrooms.............3............................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a � Other,fj,Uures ----------------•------------------•-------------------------•---•--------------..........-----....---•------------••---•--------------...........__.. W Design Flow........S.s........................:----gallons per person per day. Total daily flow--- aO............................gallons. WSeptic Tank 4 Liquid capacity�id*dgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length ... Total leaching area....................sq. ft. Seepage Pit No.__. . Diameter______ ___________ Depth below�let.. C` Total leaching area-----._---__--sq. ft. Z Other Distribution box ( ✓f Dosing tank ( ) J'3 Percolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1-1 O Description of Soil-•---.a-" / �' .. J:a �� s_�.._�f?z!c' �.�� - 2 x U -------------- --- ---- W �-------- � �` . V- Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. ..........................................................--------------------------.......-........------------------------------.................................----............................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has issued by the b r of healt...V.Lt ................ ................................ Date Application Approved BY ��" �. - . . •G��f �i�------ -------•-------- � .m��'".7�" E %7 Date Application Disapproved for the following reasons----------- ------------------------------------------------------------ -----------------------••••-----•---•-- *111 Permit No.. .. Issued ...2 7...-- ate - ...-•---•--••----------- Date r Nc�.......: l:a ..... r FEB.... ." ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD` OF , HEA T " pptirFatilan for Bi Voii al larks (�omitrur#inn rrnt; it Application is hereby made for a Permit to Construct (r )'or Repair ( ) an Individual Sewage Disposal System at pp ... I `•� .. .............•.. .... . 1...------....... a.... -r" ....... r Locatio , ddr ss +� ``�� } r Lot N r Owner Address W Installer Address Type of Buildi a. Size Lot............................Sq. fe t., Dwelling—No. of Bedrooms-----------_5-----------------------------Expansion Attic ( ) Garbage Grinder ( j' 10k Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q+ Other-fiktures --------•-_---------_............................ w Design Flow........ ..........................._._gallons per person per day. Total daily flow_..,. _'.............................gallons. WSeptic Tank-I Liquid capacity/04 gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length._.__.. _.______... Total leaching area....................sq. ft. Seepage Pit No._.. ""'"._____ __. Diameter._.._.----------- Depth below i let._ r Total leac Ig aW.----•---_----•sq. ft. Z Other Distribution box (V). Dosing tank ( ) F;, `" , Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ = - --- P O Description of Soil...__ "__ .��I�1? 'x'►__9' _ -----------------• _-_--•••••............................... •--- "} U Nature of Repairs or Altefations—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— Tlie undersigned further agrees not to place the system in operation until a Certificate of Compliance.has 'b "e issued by rhe b I• of liealtl-k z Sne k ' ' _ -------------•--•••-• ................................ ' Date Application Approved By.•.. !r ...... r ---• --+ "/'` ' Date Application Disapproved for the following reasons:.....................................................---==------------------------------------------------••.... Date PermitNo........................................................ Issued....................................................... Date i THE COMMONWEALTH OF MASSACHUSETTS BOARD 9f HEA �"a d/��.............O F......... f.,�°.....�....... (9rdifiratr of Toutplinnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired:(:"") by- W---- --- ........................................ •-•-- ---- .......................................... ._..._... j q Ins ler r t?< has been installed in accordance with the provisions of of he State Sanitary Code as described jn tho ?�application for Disposal Works Construction Permit No....:........t.. --_______--__- dated... ................ THE' ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY: DATE................................................................................ Inspector -------•---.........•••..._..---------- THE COMMONWEALTH OF MASSACHUSETTS " BOARD O . HEAL�T . .... Cl"'� OF........... :..... No...................... z . FEE._........1st... , Digposttl Works Tonstrar#inn.- am Permission is hereby granted ............ :.. Al to Construct ( ,M air )• , Ind' i u Sewa e > "osal Sys ✓ ��_ �� 46 Street s as shown on the application for Disposal Works Construction P '"t No-" __. Dated.. ... % --------- Board of Health DATE ............................. .............................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS i i _ s _ t � � M J 2pfX. Lp CO � d J O � y J V v J � T Q- J U s I i ♦12" OUTLET PIPE ` GENTE INV.=1.98' i r AA a � Of pINE STREET i 70P OF WATER 6.15' v� �\A C''� A.M. 2281197 .' ��''�T-, - . `G,; s� IRUCE o S cJuc'� v MURPHY y Q A.M. 228/139-2 i 190.98 DOY,E No. 749 A19 ` j 51'22 E e � #37 s9 9F 0 Z o v N83° JF s .�c Q s cis E FORMED s�qAID g U R�iEyO�d• fcS ,4yIr,AR`pc� i \ POND v�e®d ) LOCUS ' `. TOP OF WATER = 6.2' WOODS (2123105) ��. •1�" --� A. M. 228/1 39-1 • PIPE c, G�A�A1 AREA=55,063f SF INV.=8.62' ♦ram � ./ 4'4 Oy0 40 MARSH , LOCUS MAP A.M. 227/005 A PLAN REF 331130 0,,41 (�� 1 DEED REF 144791251 — �.a MARSH UPOLE ASSESSORS MAP 228 PARCEL 139-1 � V / 32 - Z� � 1 s.3 I ZONING. RC � , TREE - 7-�_ 14 SETBACKS- 20-10-10 � 0 ' 18 ----4 ,J* I ^., f�T F�; i' ��-_ i�♦. - �� xs.s BENCHMARK \ � O EXISTING TOP OF TAGBOLT ON HYDRANT SITE PLAN OF LAND LEACH PI75 I CLEANOUT , I ELEV.=20.28' (N.G. V.D.) (TO BE REMOVED, � I LOCATED AT. #209 ELLIOT ROAD ' IWA1xoUT CENTER VILLE, MA. ry 17 i ILPREPARED FOR. oo , ♦l4�206 ARI & TA WNDRA ILOMAKI SEPTIC LOCATION Q O `J Q' ali.,,,.,,.,,,., . ,,,, ° ;4 NOTE.- Of" i SHOWN PER TIE CARD 4y �j I Q� :' ♦� ; A �� %%% L�I " '0� Q 5' REMOVAL IN ALL DIRECTIONSAROUND LEACHING TO RECEIVE SCALE: 1» , PROPOSEI �� cU �� / •� � CLEAN SAND FILL PER 310CMR 15.255 =30 ' >.. . 0 W O� I =__y_ / / REMOVAL OF UNSUITABLE SOIL TO - ADDITION •. � , �'' J •��y / 1 2.9 �`)y APPROXIMATE DEPTH OF 36'— ED. SAND (� I p /E TO EXIST. 'QQ ?;L,• '� Y �� TO BE INSPECTED BY HEALTH DEPT. MARCH 15, 2005 4Jl cS•� /O FUEE.EV'�►Q Q � I ��• � • �_„�...� � � PRIOR TO BACK—FILL � REV A UGUST 25, 2005 �♦ ;?e ,� 'po' j j`9 REV SEPTEMBER 1, 2005 VENT ,/I / 1 x�i' , 3.7 g 44 M i REV.• \ 'PROP. It �4 ,' �, o_ � '' � A.M. 248/57 003 ��. �. 5 ,`` oo +- ;t ,a ;� gwcw i YANKEE SURVEY CONSULTANTS SAUNA; 4w•y,1��r�sd';�� t , UNIT 1, 40B INDUSTRY ROAD N \ �� ;'ti '1�Cj�8•.�Q. , I/ G+��7��♦ h, P. 0. BOX 265 0 , z3.7 f w MARSTONS MILLS, MASS. 02648 "A ,1Q2' gg ; BENCHMARK �4V TEL 428-0055 FAX 420-5553 / R � •- TOP OF rONCRE TG BOUND �Y 1 \ _/ /� ,♦ / L 92�o ELEV.=20.84' ( D) cH \,I�.w 023.4- cn ��` i SHEET 1 OF 2 JOB # 53727 CM ° 7'30"E —97. 90' s�---------------18.8 19.9 21.6 ti EL. =24.5 719P OF FOUNDATION 20' MIN J ` 10' MIN. CONCRETE COVERS 4" SCHEDULE 40 P.V.C. VENT MIN. Pl7CH 1/8 PER FT. 2"LAYER OF EXISTING CONCRETE COVERS WASHED1S719NE CONCRETE COVER 16(PROP.) wAcxouT ' ' 16 PROP.) SLAB EL=1R2 6"M/N. 6iV/N. r r r ♦ ♦ / / r —T ' ♦ r r r r i ♦ / i ♦ i r r i / /� r r r r r r r r i 16.5 6itllN. J EXIST A17N 6" MAX �6" MAX CLEAN RISER r o l SAND 9itflN. FLOW LINE EL=14.6 t' EXIST. 1Z N 14" FLOW LINE o J,?5 INVERT CAS �lNMUSRT , 1M N. 14" INVERT LEVEL o 0 o a o 0 0 0 0 0 0 0 0ra t',I7S'7,J INVERT BAFFLE _ 1515 6" SUMP o 0 0 0 0 0 0 0 _ 11.8 (PROP.) EL.---• ADD CAS EL.=14:5 INVERT INVERT o 0 0 — EL.=15. 4 BOTH RAPPER -- R.= 14_15_ H 20 EL.=13.9 — INVERT 4 INVERTS DISTRIBUTION 4' H-�O ,2I. 0' EXISTING EL _ 14.8 EL.=Zc��_ INSTALL THREE (3) ACME 1,000 GAL. TANK -- PROPOSED BOX 500 GALLON LEACHING CHAMBERS 1,500 GAL TANK G TO BE WATER TESTED -33 5' X 12.B' TRENCH FORMA TIO H-,20 ��t1'� IF MORE THAN ONE OUTLET NEW 10' MIN F, �� PLACE ON 6" S719NE SOIL ABSORPTION WALKOUT w V 3/4" 710 1-1/," `- SLAB EL=172 DOUBLE WASHED S719NE SYSTEM (SAS) 4" CH40 PVC PIPE NOTE.' (ORSEQUALj MINIMUM �o0 5' REMOVAL IN ALL DIRECTIONS PITCH 1/4 PER FT AROUND LEACHING 719 RECEIVE TOP OF STANDING WATER IN POND IN REAR OF LOT (2/23/05) ELEV.___6.2 _ CLEAN SAND FILL PER 310 CMR 15.255 OBSERVED WATER TABLE (2123105) ELEV.=__6 2__ REMOVAL OF UNSUITABLE SOIL 719 INVERT APPROXIMATE DEP OF 36"—MED. SAND EL =152 CLEANOUT TH CULVERT OUTLET (2123105) ELEV.= 1_9__ TO BE INSPECTED BY HEALTH DEPT. PRIOR 719 BACK-FILL OBSERVATION HOLE 2 ELEV=_15.2 _ OBSERVATION HOLE I ELEV.=1_62-_ PERCOLATION RATE 2_ MIN./ INCH AT _4Z_ INCHES PROFILE O F DEPTH RORIZ TEXTURE COLOR 07T OTHER DEPTH HORIZ TEXTURE COLOR OTT. OTHER 0-12" A SANDY LOAM 10YR 4/2 0-12" A SANDY LOAM 10YR 4/2 SEWAGE DISPOSAL SYSTEM 12"-36" B LOAMY SAND OYR 5/6 12"-36" B LOAMY SAND OYR 5/6 I NOT TO SCALE 366"-120 Cl MEDIUM SAND IOYR 6/6 PERG "-132 ClCI MEDIUM SAND lOYR 6/6 GENERAL NOTES WATER ENCOUNTERED 9 120"= EL 6.2 WATER ENCOUNTERED 9 108"= EL 6.2 1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM 719 D.E.P. SOIL TEST P# 10,918 TITLE 5 AND THE TOWN OF -BARNSL BLE--__ RULES AND SOIL TEST DONE BY: BRUCE C. MURPHY, RS. REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2) TWO COVERS ON SEPTIC TANK SHALL BE BROUGHT TO DATE OF SOIL TEST: 0212312005 WITHIN 6" OF FINISHED GRADE WITNESSED BY: DON DESMARAIS 3) ALL WITHSTANDING H-10 LOADING UNLESS THEY R UN ER OR WI WITHIN DESIGN CALCULA TIONS.- 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. NUMBER OF BEDROOMS . . . . . . . . 4 4) ANY MASONARY UNITS USED TO BRING COVERS 70 GRADE SHALL GARBAGE DISPOSAL . . . . . . . . . NO BE MORTERED IN PLACE. TOTAL ESTIMATED FLOW 5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH INSTALL THREE (3) ACME 440 GAL/DA Y DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO 500 GALLON (H-20) LEACHING CHAMBERS ( 110__CAL/BR./DA Y x _4__ BR.) OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. WITH FOUR FEET OF DOUBLE PROPOSED SEPTIC TANK CAPACITY 1500 CAL 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR WASHED STONE SIDES AND ENDS IS 719 CALL 'DIG- SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS 33.5' X 12.8 SOIL CLASSIFICATION . . . . . . . . I PRIOR TO COMMENCING WORK ON SITE. DESIGN PERCOLATION RATE . . . . . < 2 MIN./IN.. ,�• 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS EFFLUENT LOADING RATE . . . . . . .74 CAL/DA Y/S.F. ` SITE CONDITIONS PRIOR 719 COMMENCING WORK ON SITE. * NOTIFY YANKEE SURVEY 24 HOURS LEACHING CAPACITY (AREA X RATE) 454 CAL/DAY 8) PARCEL IS IN FLOOD ZONES__A, a&C" . PRIOR TO INSPECTION RESERVE LEACHING CAPACITY . . . 454 GAL/DA Y 9) LOT IS SHOWN ON ASSESSORS MAP _928 AS PARCEL _139=1 (33.5 X 12.8 X . 74)+(33.5 + 33.5 +L2.8f12.8 X . 74 X 2) SHEET 2 OF 2 JOB NUMBER__ 53727