HomeMy WebLinkAbout0274 ELLIOTT ROAD - Health 274 ELLIOT ROAD
CENTERVILLE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
tx= M 274 Elliott Road, Centerville; MAc1r,
` Property Address,
Albert& Dorthy M Bertrand
A'Ouvner;` =:-Owner's Name '
nforrnation isZK
required for every Centervillel (� MA 02632 6/21/2018
page. *tyfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
.- key to move your
cursor-do not REID C. ELLIS
use the return Name of Inspector
key.
ELLIS BROTHERS CONSTRUCTION
Company Name
23 ENTERPRISE ROAD
Company Address
YARMOUTH PORT MA 02675
Cltyfrown State Zip Code
508-362-6237 S121891
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. 1 am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(31 MR 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ NeedsFurther Evaluation by the Local Approving Authority
Inspe or's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office°of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev-6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
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Commonwealth of Massachusetts
01 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�.. 274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is required for every Centervillel MA 02632 6/21/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
JA I have not fou d any information which indicates that any of the failure criteria described
In 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determi d" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years of *or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or ex iltration 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 th in 20 years old is available.
❑ Y ❑ N ❑ ND(Explainbelow):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 2 of 17
L.,
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
x. 274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy.M Bertrand
Owner Owner's Name
information is Centervillel MA 02632 6/21/2018
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
El Pump Chamber pumps/alarms not operation System will pass with Board of.Health approval if
pumps/alarms are repaired_
B) System Conditionally Passes(cunt.): fl�
❑ Observation of sewage backup or break out oi 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 H alth):
❑ 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 tin es 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 Bo of Health:
❑ Conditions exist which require further evalua on by the Board of Health in order to determine if
the system is failing to protect public health, afety or the environment.
1. System will pass unless Board of Heal determines in accordance with 310.CMR
15.303(1)(b)that the system is not functio ting in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc.rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owners Name
information is required for every Centervillel MA 02632 6/21/2018
page. City(rown State Zip Code Date of Inspection
B. Certification (cost.) -
2. System will fail unless the Board of alth(and Public Water Supplier, if any)
determines that the system is functioni 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 tributa ry 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 anc the SAS,is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other fa lure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
j
r
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
EEII due to an overloaded or clogged SAS or cesspool
El or
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:doc-rev.6/16 'title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.,. 274 Elliott Road, Centerville,MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is required for every Centerville) MA 02632 6/21/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy,is within 100 feet of a surface water supply or
tributary to a surface water supply.
[El 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_ his
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 systte� 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 Zoi ie II of a public water supply well
If you have answered"yes"to any question in Sectioi i E the system is considered a significant threat,
or answered"yes" in Section D above the large syste m 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 sy tem owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is Centerville) MA 02632 6/21/2018
required for every
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, al luding 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): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�,. 274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is required for every Centervillel MA 02632 6/21/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
r 0
it e4
i
Number of current residents:
Does residence have a garbage grinder? ❑ Yes (9 No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes [5/No
information in this report.)
Laundry system inspected? ❑ Yes 2r"'No
Seasonal use? ❑ Yes 2 No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes PrNo
Last date of occupancy:
�. Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): canons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 syc tem? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6116 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
M 274 Elliott Road,Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is Centerville[ MA 02632 6/21/2018
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: '" "
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? LI Yes ❑ No
If yes,volume pumped:
gallons �ww
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is required for every Centervillel MA 02632 6/21/2018
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:
Q�4t:.6t-r•Jl
Were sewage odors detected when arrivin t the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron 00 PVC ❑other :ex lain
( P )
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
e
Septic Tank(locate on site plan):
Depth below grade: feet
Mater al of construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
ASS
If tank is metal, st ag years /
Is age confi med by a Certificate of Compliance?(attach a copy of c/erti cater ❑ Yes ❑ No
Dimensions: ` 0/ J
Sludge depth:
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Coma pnwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
kM 274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is Centervillel MA 02632 6/21/2018
required for every
page_ Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
20
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
v
Distance from top of scum to top of outlet tee or baffle
v
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? -T-
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
-R/V k 9 /dS
Grease Trap(locate on site plan): ®�,4
Depth below grade: feet
Material of construction:
❑concrete ❑.metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee r baffle
Distance from bottom of scum to bottom of OL tlet tee or baffle
Date of last pumping: Date
t5ins.doc-rev.6116 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System-Page 10 of 17
I _
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is required for every Centervillel MA 02632 6/21/2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
�
Comments(on pumping recommendations, in et and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, eviden a of leakage, etc.):
Tight or Holding Tank(tank must be pumped i It time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑metal ❑fit erglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(req ired). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
r .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is required for every Centervillel MA 02632 6/21/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on i e plan):
(loc ,
Depth of liquid level above outlet invert J"0 N
Comments(note if box is level and distribution to outle s equal, any evidence of olids carryover, any
evidence of leakage into or out of box, etc.): 0
A4 A�ln 27A��- 8L
X Se, /L?
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, tondition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not
not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
r
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�a
274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owners Name
information is required for every Centerville[ MA 02632 6/21/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)�2 C 3� ��e ����,
Type: j�'i '�'vs P1bo %✓ 7—� , y,� ,�aats�l� r
❑ leaching pits number:
leaching chambers number: a�5
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
IF
042
LPG ��
��d �/
Cesspools (cesspool must be pumped as part inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6116 T ille 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
�.N 274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is required for every Centervillel MA 02632 6/21/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ��
Comments(note condition of soil, signs of hydra failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan): �4
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydrat lic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owners Name
information is required for every Centervillel .MA 02632 6/21/2018
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
wh a public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
S ❑ drawing attached separately
E A. '
A A`7. 0,
-gym i 7,
DPW-
>
C.. A 79 ! .
' e
a
gP(�25
t5ins.doc-rev.6116 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
274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is Centervillel MA 02632 6/21/2018
required for every
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam: ,� f
❑ Check Slope AZT
❑ Surface water 141P Iv`
❑ Check cellar 04 ',7 1;7
❑ Shallow wells I-e7<
Estimated depth to high ground water. feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ . Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
274 Elliott Road, Centerville, MA
Property Address
Albert& Dorthy M Bertrand
Owner Owner's Name
information is required for every Centervillel MA 02632 6/21/2018
page. CityfTown State Zip Code Date of Inspection
E. Re ort Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
pection Summary D(System Failure Criteria Applicable to All Systems)completed
pstem Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
j
V
Tins.doc•rev.6r16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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� y
Iowa of narnstable
a Regulatory Services
# t 'I'liomtas F. Geiier, Director
eaus,
Public Health Division
Thomas McKean, Director
200 .Mwin Street,Hyannis, MA 02601
Office: 508.802.4644 Fax•,506-°'90-6304
Installer & DesigaIr Certificatign Form
Date: l i .Z
Designer: ...Sc _ r �t ere ':Co C _ _ Installer: ..C:cy ew,t'k ;j( ter�rtse_
Address: �t� �W C.cc�nb��:r ..__rtrtir�Kra _ Address: _.QC7-a,.VC7;03.---_
-- — — 622e3 Z
on 1 a—_ -20 0C, �a I e ( nS was issued a permit to install a
(
( )� installer)septic system system at ^.�7 yt..-i 1 i c r ll.co c1 --- based on a design drawn by
dated Pet.t:-r,be;- tl 1C<) ,-
/ (designer) -�---`-- ---
_�/_ Z certify that the septic system referenced above was installed sub,,3tantiall according e;
- Y l
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
greater than 10' lateral relocation of the SAS or any vertical relocations of any comportei:t
of the septic system) but in accordance with State & Local Regulations, Plan revision or
certified as-built by designer to follow.
�.
11i�0(
5 E.
(Desigttez'sSi e �Afti esigner's ampMere)
LEASE TU BARN ' L,E PU LIC HE T11 DIVISUM CERT JICATE
a ANCE AILL NOT B U ULLB TR S AS-
BUILT C IVED BY JUE 1L U CITYISION.
THANK Q.
Q: Health/SepticT)esigner C'ortification Fot�n
+.� - -—— -- i -s --- ►iT1J77AITnm7:1nr 1.1-4 g7 cj CiTkA7-7T—NHr
DEEP-OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture
Surface(in.) Soil Color Soil Other
(USDA) (Munsell) Mottling (Structure,Stones;Boulders.
on istenc % ravel
1-0�r3/I
iU -3C LS 10.Yrs�� _
M'CS 2,5YV6 1cc;e '5r 1
----- —.
DEEP OBSERVATION HOLE LOG Hole# z
Depth from Soil Horizon Soil Texture
Soil Color Soil Surface(in.) (USDA) Other
(Munsell) Mottling (Structure,Stone::,Boulders.
_QQnsistency.%Grave. l)
Fc'li
A LS to Yr 3/1
ii6-30 L5 ^
!o r s 4 —
3e'' 3z G N-CS a
Z,.Jr r flb
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil
Surface(in.) (USDA) Other
(Munsell) Mottling (Structure,Stones,Boulders.
Co i to 4' Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling
(Structure,Stones,Boulders.
Consi ten I
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes ._
Within 500 year boundary No_� Yes
Within 100 year flood boundary No ✓ Ye5
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? _ �e S
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on 10-27-97 (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,expertise and ex erience described in�10 CNM 15.017.
Signature -dimDate 12'12-4 9
QASBPTiC�P RCFORM.DOC
Town of Barnstable P#
Department of Regulatory Services
anxrtertisr,s, .
MAM
Public Health Division� U 9
200 Maio Street,Hyannis MA 02601 Date
Date Scheduled 1 d°�
Time Fee Pd, UU
Soil Suitability Assessment for Sewage
Performed B : ok ' gisposal
y c�nc>2l Qcme,�i�� tI7 esC
Witnessed By:
Location Address
LOCATION & GENERAL INFO
// RMA.TION
t`�Ol t Owner's Name ,all-.L t J J
Address 7 I /l'
Assessor's Map/Parcel: Z Z C7 j 0 '�,e
Engineer's Name �?to &Iv 1j4,
NEW CONSTRUCTION
REPAIR _ Telephone#F V711KL
Land Use Sle Fa,ri ty /restdenhw
Slopes
_ Distances from: Open Water Body Surface Stones
--�_ft Possible Wet Are
Drainage Wa a_�_ft Drinking Water Well ---_ft
-y
ft Property Line >1-6
Other ft
SKETCH: (Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetland
s in proximity to holes)
Se ocvt aw l C2-(t-bq
Parent material(geologic) oo�tUpS�n r�
. Depth to Bedrock 7 11.2 b5 S
Depth to Groundwater- Standing Water in Hole: -7 132 bBS.
Weeping from Pit Pace 7 13 2 �D4S
Estimated Seasonal High Groundwater 71
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: check pbS¢c�otian
Depth Observed standing in obs.hole: 7 13 2
Dcpth to weeping from side of obs.hole: >t-z tn. Depth to soil mottles: 713 z
Index Well# — in, OrbundwulerAdjdstm — tn,
Reading Date: index Well Icvcl — ft.
--- AdJ,Factor _ AdJ,droundwater l..cvel
Observation PERCOLATION TEST
Dute 1? I Tlma t1A't
Hole S 1
Time at 91!
Depth of Pere
Time at 6"
Start Pre-soak Time @ w-0 AH "—
End Pre-soak W.-Ib A)l — ' —
Rate Min./Inch
Site Suitability.Assessment: Site Passed
Site Failed: Additional Testing N
Needed(Y!N)
Original: Public Health Division
Observation Hole Data To Be Completed on Back-----------
***If percolation testis to be conducted within I00' of wetland, you must first motif the
Barnstable Conservation Division at least one Y
(X) week prior to beginning. `
Q:\SEPTIC\PERCFORM.DOC /
y �
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
ImpoWhen filling
A. General Information.
When filling out
forms the
computer,
r,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
f� P.O.Box 763
Company Address
Centerville Ma. 02632
rerun City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
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
❑ eeds Further Evaluati n by the Local Approving Authority
10/29/2009
Insp or's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface(!wage Disposal System•Page 1 of 17
Ti
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 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.
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
'Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑' Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every 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 coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day.flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every 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?
® El available
as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1500 gallon tank,D-Box and leaching pit.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2007:46,000
9 ( Y 9 (gpd))
2008:57,000
Detail:
2007:129gpd 2008:156gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: 10/29/2009
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 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
274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville - Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How
o as quantity pumped determined? ,
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
'
Depth below grade: 1
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:
1500 gallon .
Sludge depth:
3"
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every 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
29"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 .
Commonwealth of Massachusetts
L, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 274 Elliott Rd.
' Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carry over.No evidence of leakage .
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 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
;M a 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil.Pit shows signs of hydraulic failure.Water level was 6" below invert at time of
inspection.Stain line observed up to ivert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
CGM , 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is
required for
Centerville Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): .
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. Cityfrown 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
Al' 20, A
WAO
31
ABI
3
l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�GM , 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
e
Check Slope
p
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LP 8'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how 9 you established the high round water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108 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
G1M , 274 Elliott Rd.
Property Address
Albert+ Dorothy Bertrand
Owner Owner's Name
information is required for Centerville Ma. 02632 10/29/2009
every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
No. Fee
. THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer:—Z
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplitation for Oispoisal 6pstem Construttion permit
Application for a Permit to Construct( ) Repair 6<) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Z 7q 6(kot( /2.0 P Owner's Name,Address,and Tel.No. A&,t 134,rr,nn d
Assessor's Map/Parcel `Z 2,1
Installer's Name,Address,and Te.No. Designer's Name,Address,and Tel.No.
Ga,Ozw;�e CnT�ryv�sje�
-/i 2f %10
Type of Building: t/
Dwelling No.of Bedrooms 7 Lot Size Z I sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date I ), I( " U a ci Number of sheets I Revision Date
Title 'ZZ L( O i &
Size of Septic Tank 5�L 4A 060 Type of S.A.S. s7 sg 12
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) °J1 i-p-n , W � i-) 3(
Date last inspected: D
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Heal
Signe Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
s
J a4 No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered incomputet:
,,PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4plicat on for'Mispo'sal 6pstem Construction Vertu
Application for a Permit to Construct( ) Repair'K) Upgrade( ) Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. Z-7,� E(lrb C1 /'�o�r� Owner's Name,Address,and Tel.No.q f(„r 13, r;;,�„d
Assessor's Map/Parcel 'L 21 b
Installer's Name,Address,and Tel.No. II Designer's Name,Address,and Tel.No. S--L k i
LJ26 k/o2FS t 3GZ e3z C z-� 3— 03 -17
LaNUC�f+a�a'
Type of Building:
Dwelling No.of Bedrooms / Lot Size Z z1 1 Z r t sq.ft. Garbage Grinder( )
Other Type of Building + No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided - gpd
{� Plan Date Q " ( t ` 20 y Number of sheets Revision Date
Title 17 61 t O6 H
Size of Septic Tank C•b ttt I,(w Type of S.A.S. STlr ss '
Description of Soil n ;
d//.�r, `` C `
C
Nature of Repairs or Alterations(Answer when
applicable)
® � + 4_,;
U� Wli
�—Z Za
Date last inspected: �,�19q
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health ,
Signe (iCI Date ( (y! j , Z-0 C'
Application Approved by Date,//
Application Disapproved by Date
for the following reasons
Permit No. ^' Date Issued f "�
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Jle) Upgraded( )
Abandoned( )by ,�, � by t C LLt
at 2'+' 113{fi //�l -r has been constructed in accordance
with the provisions of Title 5 arld the for Disposal System Construction Permit No. dated � C.� /�7
Installer (.A�,ti, f f l,%e_� (,.1. Designer T�c
4
#bedrooms Approved desi flow gpd
The issuance of his Trml
t shall not be construed as a guarantee that the system wi 11nct�n as designed?
Date i 12 �n Inspector
--------
------ --�- -- -- - - - -_- -- -- -= _- - -
No
`-~'=r� Fee C/
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION�-BARNSTABLE,MASSACHUSETTS
Misposal Opstem Construction permit
Permission is hereby granted to Construct( Repair V\ Upgrade_(. ) Abandon( )
System located at p� G 7 lb't jar r 14,, tom, k( W
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Cons vc�tio must be om feted within three years of the date of this permit.
Date � Approved
o ! C
TOWN OF BARNSTABLE
/ � U
LOCATION �)4 c t l f o f rn/2 SEWAGE# Z C'a 9- ` Q
VILLAGE 1/1 &C ASSESSOR'S MAP&PARCEL d a 7- q y
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) a I+Re, 3l01(0 (size) F,S'Y go 9j'
NO.OF BEDROOMS
OWNER I-
PERMIT DATE: / - /7 - Z 0 a 9 COMPLIANCE DATE: !- / 2- 2 a t 0
Separation Distance Between the: 1
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ► )o U 0Lto l 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 Co k,(p f o S > L L C
A' as-®
�2 3
C3 a(o a
Cs 32.5
�3 23 � r
J4 �8
DS
�Og
I
r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS,,`
DEPARTMENT OF ENVIRONMENTAL PROTECTION' OCT /pet?
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 <0
TkUDY CO>J{E
emery
ARGEO PAUL CELLUCCI �� DA B.S I RUNS
Governor
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 274 Elliott Road, Centerville, MA Name of Owner: Joseph Dello Russo
Address of Owner: 14 Long Meadow Drive
Date of Inspection: October 13, 2000 Westwood, MA 02090
Name of Inspector:(Please Print) James M.Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 227
Telephone Number: (508)862-9400 Parcel: 090
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 in the proper function and
maintenance of on-site sewage disposal systems. The system:
✓ Passes
Conditionally Pas
Needs Further E ua'on By the Local Approving Authority
_ ails
Inspector's Signature: Date: October 19, 2000
The System Inspector shall submit 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
3
revised 9/2/98 Page 1of11
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 274 Elliott Road, Centerville,MA
Owner: Joseph Dello Russo
Date of Inspection: October 13, 2000
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
✓ 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.
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.
Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
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.
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
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
revised 9/2/98 Page 2of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 274 Elliott Road, Centerville, MA
Owner: Joseph Dello Russo
Date of Inspection: October 13, 2000
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 15.303(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 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 AND SAFETY AND
THE ENVIRONMENT:
The system has aseptic tank and soil absorption system(SAS)and the SAS is within 100 feet to 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 1 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 (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 274 Elliott Road, Centerville, MA
Owner: Joseph Dello Russo
Date of Inspection: October 13, 2000
D. SYSTEM FAILS:
You must indicate either "Yes"or "No"as to each of the following:
I 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
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow.
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 Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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. 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"as 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
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 H of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 274 Elliott Road, Centerville, MA
Owner: Joseph Dello Russo
Date of Inspection: October 13, 2000
Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health.
*✓ 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. (*The house was unoccupied)
✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. .
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
✓ All system components,excluding the Soil Absorption System,have been located on the site.
✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions 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:
✓ Existing information. For example,Plan at B.O.H.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)].
✓ _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 274 Elliott Road, Centerville, AM
Owner: Joseph Dello Russo
Date of Inspection: October 13, 2000
FLOW CONDITIONS }t
RESIDENTIAL:
Design flow: I10 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 4
Total DESIGN flow n/a
Number of current residents: 0
Garbage grinder(yes or no): n/a
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(gpd): 1999-30,000 gals.:1998-24,000 gals.
Sump Pump(yes or no): No ,
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: ead(Based on 15.203)
Basis of design flow
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
None on file-per treatment plant
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: Approximately Apr. 1986-per as built card
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 274 Elliott Road, Centerville, MA
Owner: Joseph Dello Russo ,
Date of Inspection: October 13, 2000
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 16"
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 1500 gal.
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle: 27"
Scum thickness:. 15"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 4"
How dimensions were determined: Measuring stick
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.) The tees were present The liquid level was even with the outlet invert. There were no signs of leakage.
Recommend pumping.-
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:
(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.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 274 Elliott Road, Centerville, MA
Owner: Joseph Dello Russo
Date of Inspection: October 13, 2000 :. .z
TIGHT OR HOLDING TANK: . None .(Tank must be pumped prior to,or at time,of inspection)
(locate on site plan)
Depth below grade:
Material of constriction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓ + . .'
(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was level, and there
were no suns of leakage or solids There were no sines of failure in the leach pit
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.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 274 Elliott Road, Centerville, MA
Owner: Joseph Dello Russo
Date of Inspection: October 13, 2000 Pw
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits,number: 1-6'x 6'(per as built card)
leaching chambers, number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
The pit was located but not dug up. There were no signs of failure in the D-box. The cover was 3'6"down and under a tree. Recommend
installing risers to bring the cover within 6"of grade. The bottom to grade was approximately 9'6".
CESSPOOLS: None
(locate on site plan)
11
Number and configuration:
Depth-top of liquid to inlet invert: t
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection).
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.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 274 Elliott Road, Centerville,MA
Owner: Joseph Dello Russo
Date of Inspection: October 13, 2000
Map: 227 ,
Parcel. 090
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)
r
F�OiCT"
A x
Al- 30
Tc W��1
/ - a1,�
n3-
93- 44a' a
3
revised 9/2/98 Page 10ofII
r .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 274 Elliott Road, Centerville, MA
Owner: Joseph Dello Russo
Date of Inspection: October 13, 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
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
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. Must be completed)
The bottom of the pit to grade was approximately 9'6". Using the Barnstable topographic map and the Cape Cod Commission
water contours map, the maps were showing approximately 23' +/-to groundwater at this site. Using the Cape Cod Commission
Technical Bulletin, the high groundwater adjustment for this site(MI W 29, Zone B, 8100)was 3.0'.
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 fitture. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
' TOWN OF BARNSTABLE
LCCATION a� l I 16 f7 RJ SEWAGE #
`aLAGE roz-aev.16- ASSESSOR'S MAP & LOT 0 G
..INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) P,►7 (size) COX 6�
NO. OF BEDROOMS
�dS<n� I'd 6 R V S$O
BUILDER OR OWNER
PERMITDATE: y13 IFl6 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet F
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
+ � • t �
30,
� xx
A2�' a� 'WAI)
31 a
A3-
r33- N a"
3
q'o
No...... E .._.. g` Fims . d
THE COMMONWEALTH OF MASSACHUSETTS
d� BOARD OF HEALTH
ApplirFataon for Disposal Works Tontrnrtton rprmit
Application is hereby made for a Permit to Construct ()Q or Repair ( ) an Individual Sewage Disposal
S stein at: 0 2- y C ex TM\J p.�
. 1
-••. --•--•-----------------------•••-•--.......-----•-----•-----------•••-•-••-•-......_-••••-........
.- anon-Ad ess
y or Lot
�'`1�27 ....!�........f /�9 L /Z .0.,� ! !q e!!. �O .L4 __. .� 2Ne4°ff�tri�"
�►^A .
�q•*,�„D`��� Address
(.�......t.._�._..__._.... ............... . ._.....
Installer Address
Type of Buildings Size Lot_;4:tt Z2_------Sq. feet
U Dwelling—No. of Bedrooms...............3..........................Expansion Attic 04) Garbage Grinder (Y4
a`4 Other—T e of Building No. of persons............................ Showers
YP g ---------------------------- P ( ) — Cafeteria ( )
04 Other fixtures ......................... ----------------------------•---•--------------••--•-•---•-------•----•-••--------------------••-------•------•---------•--
WDesign Flow....................,2`�-. ..............gallons per person per day. Total daily flow--------- ...................gallons.
WSeptic Tank—Liquid'capacity_�.0.(7.gallons Length................ Width................ Diameter................ Depth-42.1/.4-rdiv 1 D
x Disposal Trench—No..................... Width....e.............. Total Length.................... Total leaching area............__.._.__sq. ft.
Seepage Pit No.____._._t....------- iameter.... ............ Depth below inlet..... ........ Total leaching area..•_6....sq. ft.
Z Other Distribution box (K Dosing ank (ell®) S''Ot9
"" Percolation Test Results Performed by...... AKT 6;n .... . J..Y_.6............. Date..._
�
Test Pit No. I.....�___-minutes per inch Depth of Test Pit-----1__4...._.. Depth to ground water-__�[_Q
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 .-•---•--------------- ---------------------•••--•-------•---•------............•--• ------
3 / � -
Description of Soil------ . f•--- .....................
------------------------------ . �. l Y------`Aw _........------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
1
---------------------------•-------------------------•---•--••--------------------•----•-•-...----•-------....----------------•-------------------------------------------------------•.....------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certifi to f Compliance has been i ed by't�he)�Dard li .
,�C.cf' e Sign .......... ...........
ate..............
iIt Approv d BY-----------•-
Date
Application Disapproved for the 4
lowing reasons-------------------------------------•-----------------------•---------------•-----------------------------•-•••.
.................•••---------••-•-----------•------••---•------••-----------------------••---•------•--••---------•----••--•--•-----•••-----------•---•--..............................................
Date
PermitNo......................................................... Issued.-•-----------•---••-----------_....
Date........................................................
n-+.............................................................................................................-
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7.0.�4.10..............OF .. �Z,.w=: 7..R..d -. ..................
Trtifgrat a of Tompltnnrr
TIWS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (}e) or Repaired ( )
byAl :.:..q_ ....._=: �. r�--------------------------------------•---------............---•-----------.........------......------•---•-----•---------
Installer
at a-tea... �. --! ......................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Coe s de- ribed in the
application for Disposal Works Construction Permit No.__....__ dated....... ............. _
�. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS,A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
qD4 ad
THE COMMONWEALTH OF MASSACHUSETTS
s BOARD OF HEALTH
...OW...10 10................
x, Applira#ion for Disposal Works Tonst'nrtinn . umit
A
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at: `7 '
.�-.........!......... L L!a..... .}.�....�?...,a---------------••- ..................................................................................................
^• Imli.n-A ress r Lot IQ
� / ��ijHvt ter>?iv ��.!✓ .... 1i2H�ur�} �c11j
Owner
..........
...� ......... �-- ... Address
.... ... ..........
Installer Address
Type of Building Size ......._Sq. feet
U Dwiling—No. of Bedrooms.:............. .._..Expansion Attic 410 Garbage Grinder (�
F-I .....---•-•----------- —
a`� Other—T e of Building ............... No, of ersons..........._.._..._......... Showers
Other—Type g ------------- p ( ) Cafeteria ( )
0 Other fixtures ----------•. ---------------------•--------------------------•----•----....---.--•-•-•-•--••--•-•--•............•--•
W Design Flow.................. ... gallons per person per day. Total daily flow.._.....3. ..v.....................gallons.
WSeptic Tank—Liquid capacity A ti ov..gallons Length................ Width................ Diameter................ Depth42_(L4,0 1 o
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit'No........I-----------.Diameter...G._ Depth below inlet.................... Total leaching area.�!.G.....sq. ft.
Z Other Distribution box (� Dosing tank (A/o) `� 6A1-/D A,
'~ Percolation Test Results Performed by........ . .x.- r2......4.. .(.`/ ............... Date.........................� _._..
Test Pit No. I......Z :..___minutes per inch Depth of Test Pit----(-4.12 1'Depth to ground water.._A4-U�4....
t tiL
f=, Test Pit No. 2................minutes per inch Depth of Test'Pit.-___'-_..__.._Depth-to ground water........................
............................. ` mow ............... .....-......�-•-•--.-.-------•-----------
O Description of Soil••-•Q..:-.1-•--• O n' ' ��/�_'mot__• '�------------------- ,
.-.-----
� /G ,/ ,-- —rho/G_
..............................................._..........._Z_.2...' ---•--•----------------•----•--------------------•-----------------•-•--.---•-•......--•-•--••---•••-
U Nature of Repairs or Alterations—Answer when applicable................................................................................................ .
..---•-••-•---•-••-•---•••--•••-•---••......--••-•--••••...................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certifi t of,Compliance has been O's'pled by the oard of he h.
qIDate
ic� Appro d By ---- P =� 1 '�-------------------
Date
Application Disapproved for the f Bowing reasons----------------•---------------------------------------•------•---------------------------------------..........
' -•.........................•-------------.....------------------------------------------....--..........................................................
....--------------------------------------------
Date
Permit No......................................................... Issued._..-------------- r
--------------- ••--• -------------...---------•--•-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TQ.............................OF ....................................3 ... ................----
f�rr�if irtt#�e ,af �unt�rli�tnre ,_
T .I IS TO CERTIFY, That the Individual Sewage Disposal System constructed (7C) or Repaired ( . ) y
= -.
Installer
_ _. /
at_ `� --... .r-•••.•-L .... I v '� - ......... 2�-; Z rL I!_•
-------------------------------------------••---••--•-
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... /n -
'- `_� dated h -� ='-------------
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE t
SYSTEM WILL FUNCTION SATISFACTORY.
G
tDATE................................................................................ Inspector................-------------------------------- t
�1 THE COMMONWEALTH OF MASSACHUSETTS
` 1J I �� -=.0
BOARD OF HEALTH
I�•��v ��n ,�I•Z r_ .........'..........�.....J................OF....... ' l
�.
FEE.... —
No.S6....... .. _ .,z
Disposal l arks Tllnstrmnott rranit
Permissionis hereby granted..... ........................................................------.......----...--------------------................-------•---.....:.... {
to Construct (jV or Repair ( ) In Individual Sewage Disposal System
at No..1-!r3 7 .;2------- U/ ............. . e...........
..:.....
Street 2 r
as shown on the application for Disposal Works Construction Per t No.........�ealth
ated.._...` _ _ ..�__ �......__......
/ .. /~
----- -- t _
DATE..........
� � �a.t.. z�``r_......--- -- 1
FOPm 1255 A. M. SUL 1N, INC., BOSTON 1 '
'LOCATION SEWAGE- PERMIT NO.
P I L L AA)G E
(� &TPIL�
INSTALLER'S . 'NAME. A ADDRESS
' dui1 e d
R U 1 L D E R OR OWNER
's
DATE PERMIT -ISSUED
DATE .. COMPLIANCE • ISSUE-D
66�,t� �+
31 ('lr
4 "
t \ll
I
i
- PROVIDE PRECAST CONCRETE o PROPOSED VENT WITH CHARCOAL n
`-T.O.F. EL.= 23.2' ± EXTENSION RISER WITH CONCRETE INISH GRADE OVER D-BOX= 24.2'± 4 SCHEDULE 40 PVC MIN. SLOPE 1 /o FILTER TO ABOVE GRADE FINISHED GRADE OVER BIODIFFUSERS = 23•0' - 2,4.5' GENERAL NOTE S
l COVER TO WITHIN 6"OF F.G. OVER SLOPE @ 2/o MIN. 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION
f INLET AND OUTLET COVERS. REMOVABLE WATER-TIGHT COVER OVER INSPECTION PORT WITH METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
FINISH GRADE RISER TO WITHIN 6"OF FINISHED GRADE "OF F.G. BOX PER
WITHIN CODE AND ANY APPLICABLE LOCAL RULES.
@ FND. EL, 22.0± FINISHED GRADE OVER TANK EL. = 22.0' - 23.5' 5"DIA. OUTLET(S) 3 OF F.G. (ONE PER ROW)
1 - - --- 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
_---..__-_ -.-__-- -- I DESIGN ENGINEER.
PROPOSED 4" 54"MAX. 67.2" MAX. 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
---EXISTING 4" �. PVC SEWER PIPE SEE NOTE 21 SEE NOTE 21 TOP OF SAS/B.O. = 18.90' SYSTEM UNLESS OTHERWISE NOTED.
SEWER PIPE 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
--=_ 3"DROP MAX „ PROVIDE WATERTIGHT ELEVATION = 18.90' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A
2" DROP MIN 3 9 MIN.SLOPE @ 1% JOINTS TYP.
( ) 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF
10" 4-PVC]FROM 1.33 f16" THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
44" �*19.6'± SEPTIC 4" PVC OUT TO (TYP.) tLEACHING FACILITY0.90, 10.75"(TYP) 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
�� 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
CONTRACTOR CONTRACTOR SHALL OUTLET TEE 18.77' MIN. 6 18.60' 18.47� 17.57' (laid flat) 2.875'(34.5")_ - (STONELESS SYSTEM) 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
SHALL VERIFY SIZE 48" VERIFY CONDITION OF
5.0' (n'P') FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
AND CONDITION OF EXISTING TEES 22"ZABEL FILTER 6" CRUSHED STONE aNOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
MODEL#AlA1 801-4x22 EXISTING SEPTIC AND REPLACE AS MECHANICALLY ( YP. 5'MIN.)
COMPACTED BASE 8.625'
TANK NECESSARY AND DESIGN ENGINEER.
VARIES (SEE PLAN)
cJ 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 30.00' ESTABLISHED ON TOP OF A
OUTLET DISTRIBUTION BOX HYDRANT BONNET BOLT(BENCHMARK 1)AS SHOWN ON PLAN AND ALSO BASED ON
BASE. FIRST TWO FEET OF OUTLET
TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV= < 12.00' APPROXIMATE M.S.L. DATUM OF 25.70' ESTABLISH ON TOP OF A STAKE AND TACK
(BENCHMARK 2)AS SHOWN ON PLAN.
EXISTING 1,500 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. 25 - BIODIFFUSERS PROFILE BIODIFFUSER END VIEW 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
CROSS SECTION VIEW THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
CONTRACTOR TO VERIFY EXISTING ELEVATION PRIOR
SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL (H-20) 25 - ARC 36HC (#3616BD) H-20 BIODIFFUSERS 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES TO ANY WORK & NOTIFY ENGINEER IF DIFFERENT, NOT TO SCALE NOT TO SCALE NOT TO SCALE TO THE DESIGN ENGINEER.
10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT.
11 i • l . ,ire• : , ql TEST PIT DATA 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
,. \t • • • Eli: .' • PERC NO. 12779 I REGULATIONS. OWNERIAPPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
• • • �� ' • ' `� �' INSPECTOR: David W. Stanton, R.S. APPROPRIATE AUTHORITY.
EVALUATOR: Michael Pimentel, E.I.T. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
• ' • i •. �� • , C.S.E. APPROVAL DATE: Oct. 1999 LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE
•• i .
• • N . • THEY SHALL WITHSTAND H-20 LOADING.
• . ri C3 •�` '` DATE: December 4, 2009
+ • • ' . `�T• 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
�� • • • - TEST PIT#: 1
• • , • 0 ' • ' 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
ELEV TOP= 23.00' MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
,�� / • . r ( ` ELEV WATER- < 12.00' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
�,• `�- FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
M •
w ��/ ; •* PERC RATE _ < 2 min./inch 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
c� O ZONE 2 SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
a w DEPTH OF PERC = 30"-48"
�O ��o j� :, 16. PROPOSED PROJECT IS LOCATED WITHIN:
N MAP 227 TEXTURAL CLASS: 1
o
<✓ • : • ASSESSOR'S MAP 227 PARCEL 90
Z PARCEL 91 /� ` • ' • • PREVIOUS OWNER OF RECORD: ALBERT& DOROTHY M. BERTRAND
o o LOCUS "
�O ^ ' • • • 0 23.00 ADDRESS: 274 ELLIOT ROAD
Fill 22.50' CENTERVILLE, MA
�N f . . •�i:11 , . A 6" Loamy Sand
�� O 1 �`� `SSS" ; Ile u '" +� 10Yr 3/1 FEMA FLOOD ZONE C
' 235�„ • 10" 22.17' COMMUNITY PANEL# 250001 0008 D
�S000, F MAP 227 4�u ,_ • '
. O ` a B Loamy Sand 17. DEED REFERENCE: DEED BOOK 13399, PAGE 50
F PARCEL 19 r � • • ' 10Yr 5/6
Benchmark 1 20.50' 18. PLAN REFERENCE: PLAN BOOK 239, PAGE 131
30
Hydrant B.B. / ti ` ti,- c • • • -�
Elev. =30.00' '• • •' " f� • Perc _ 19_ ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
Approx. M.S.L. !, �L B 48" 19.00'
/ `y •r �a}' " ' •• �. , 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY
°j �11 ��� • •• • FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
h� "'� `L�`/ •'• .�� _? '`� • • to FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE.
Lp •, rp• 1 A Medium-Coarsk�Sand
EXIST. LEACHING PIT TO BE "Q!� �- j :;• • f ` • . S� 0 � C 2.5Y 6/6
21. IN ACCORDANCE WITH 310 CMR 15.401 - 15.405, THE FOLLOWING LOCAL UPGRADE
PUMPED AND FILLED WITH 'R a l•11 • j (loose; 5%gravel) APPROVALS ARE REQUESTED FROM 310 CMR 15.221 (7):
CLEAN COARSE SAND-- ( f. • . Jts �l.l11177 I (1.) A 2.6'WAIVER(3.0-5.6') FOR THE MAXIMUM COVER OVER THE LEACHING FACILITY.
(2.) A 1.5'WAIVER(3.0 -4.5') FOR THE MAXIMUM COVER OVER THE DISTRIBUTION BOX.
MAP 227
\� PARCEL 18 LOCUS PLAN
#2 I
`J `� EXISTING SCALE: 1" = 1000'
LEGEND
a 4-BEDROOM 132 12.00
DWELLING SWING-TIES
U No Mottling, Standing or Weeping Observed
N TOF = 23.2'± O� SCALE: 1"=20' _ - _ __ __-- 50x0 EXISTING SPOT GRADE
DESIG( DATA TEST PIT DATA
/ N HC-1 HC-2 - 50 - EXISTING CONTOUR
DESCRIPTION
----INV.=20.4'± PERC NO. 12779
Benchmark 2 - MAP 227 BIODIFFUSER CORNER(1) 31.8' 31.1' I INSPECTOR: David W. Stanton, R.S. F-501 PROPOSED SPOT GRADE
Stake&Tack ,�
Elev. =25.70' a \ ( PARCEL 90 o M BIODIFFUSER CORNER(2) 23.6' 23.4' NUMBER OF BEDROOMS (DESIGN) 4 EVALUATOR: Michael Pimentel, E.I.T. -r 50 PROPOSED CONTOUR
\ ° 22,929 S.F.± �o 0 110
Approx. M.S.L. �. � / � � DESIGN FLOW GAUDAY/BEDROOM
b �' ! ti" O ' C.S.E. APPROVAL DATE: Oct. 1999 E/T/C EXISTING UNDERGROUND UTILITIES
BIODIFFUSER CORNER 3 58.2' 38.6
EXISTING 1,500 GALLON SEP 11C TANK TO 0 0 101, TOTAL DESIGN FLOW 440 GAUDAY N 6" � DATE: December 4, 2009
BE UTILIZED AS PART OF THIS DESIGN 10" N �_ -- �- a BIODIFFUSER CORNER(4) 57.6' 40.0' o _ 880
` TP 2
DESIGN FLOW X 200 /o - GAUDAY TEST PIT#: 2 -X-X-X-X-X- EXISTING FENCELINE
10" 23.0 22-
so, /
24� 6' g"6 USE EXISTING 1,500 GALLON SEPTIC TANK
r3
ELEV TOP= 23.00' W W---- - EXISTING WATER LINE
T3.0
PROPOSED DISTRIBUTION BOX (H-20) 24- J ELEV WATER= < 12.00' TEST PIT LOCATION
0.0, 24 N MAP 227
PERC RATE _
PROPOSED TOTAL 25 ARC 36HC (#3616BD) H-20 10 0 %� PARCEL 17 EXISTING INSTALL 25 - ARC 36HC (#3616BD) H-20 BIODIFFUSERS LP#274 EXISTING LEACHING PIT
BIODIFFUSERS IN FIELD CONFIGURATION ---- --26-"'" DEPTH OF PERC =
4-BEDROOM
Ni&. 1011 _ DWELLING SYSTEM CAPACITY TEXTURAL CLASS: 1 o EXISTING 1,500 GALLON SEPTIC TANK
J �� 26r-- /
PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE
(TOTAL L.F. OF BIODIFFUSERS)(4.8 SF/LF)(0.74 GPD/SQ.FT.)= GPD
1 -2g
(125.0')(4.8 SF/LF)(0.74 GAUSQ.FT.)= 444.0 GAL. LEACHING/DAY 0" 23.00' 13 PROPOSED DISTRIBUTION BOX(H-20)
i 6"/ HCA Fill
- - 22.50'PROPOSED INSPECTION PORT WITH Loamy L Sand
j Q PROPOSED ARC 36HC(#3616BD) H-20 BIODIFFUSER
f } ACCESS BOX TO GRADE (TYP OF 3) HC-2 q TOTALS: 10, 10Yr 3/1
22.1 T
i
PROPOSED 4" PVC VENT PIPE; (2 TOTAL NUMBER OF BIODIFFUSERS: 25 B Loamy Sand
10Yr 5/6
l EXACT LOCATION PER OWNER TOTAL NUMBER OF COUPLINGS: 0
TOTAL LEACHING AREA: 600.0 SQ.FT. 30" 20.50'
(1 (3� REV. DATE BY APP'D. DESCRIPTION TOTAL LEACHING CAPACITY: 444.0 GAL./DAY - -
PROPOSED SEPTIC SYSTEM UPGRADE
o
oo� �� (4 NOTE: Medium-Coarse Sand PREPARED FOR:
EFFECTIVE LEACHING AREA OF 4.80 SF/LF OBTAINED FROM THE C 2.5Y 6/6 CAPEWIDE ENTERPRISES
MAP 227 DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER (loose; 5%gravel)
MAP 227 "MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO
- - _ ------ _- - _ LOCATED AT
PARCEL 89 PARCEL 16 ADVANCED DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003(LAST
NOTES: MODIFIED JUNE 30, 2009). TRANSMITTAL NUMBER=W000052. 274 ELLIOT ROAD
CENTERVILLE, MA
1. MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE . -
) � SCALE: 1 INCH = 20 FT_ ._- DATE: DECEMBER 11, 2009
OF EACH SEPTIC SYSTEM COMPONENT.
132 12.00 0 10 20 40 80 FEET
No Mottling, Standing or Weeping Observed �'N"CO)J7
2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF - - - - ��°r Jo L. °s� PREPARED BY:
THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH RESERVED FOR BOARD OF HEALTH USE l CH JR HILL JC ENGINEERING, INC.
TEST PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL CIVI 2854 CRANBERRY HIGHWAY
o ,
BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. EAST WAREHAM, MA 02538
SITE PLAN 3.) ENTIRE PROPERTY IS LOCATED WITHIN THE ESTUARINE WATERSHEDS 508.273.0377
SCALE: 1" =20' Drawn By: MCP Designed By:MCP Checked By:JLC JOB No.1730