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Home My WebLink About0415 ELLIOTT ROAD - Health 415 ELLIOTT Centerville A = 227 — 107 SMEAD No.2-153LOR UPC 12534 smaad.eom • Made in USA 440 11 w".9 1!B I1S®N liiS i11001K�l�E SFI DESR "` �� o Commonwealth of Massachusetts l6h4hr _ Title 5 Official Inspection Form as. - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell _ d, Owner Owner's Name -- information is required for every Centerville _ MA 02632 June 1, 2018 page. Cityrrown 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 I •2� �a on the computer, ST "J I use only the tab 1. Inspector: key to move your cursor-do not Patrick T Sullivan _ use the return key. Name of Inspector Read Rooter ooter ExcavtinVQ �_ Company Name PO Box 89 _ Company Address Forestdale MA 02644 City/Town State Zip Code 508-888-6055 _ S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the;Local Approving Authority �'_ _ June 8, 2018 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is Centerville MA 02632 June 1, 2018 required for every _ page. CityfTown 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 oldk or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or eifiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced vyrith a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspec bn if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank less than 20 years old is available. El Y N (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts l W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 June 1, 2018 - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled r 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 Require by the Board of Health: ❑ Conditions exist which require urther evaluation by the Board of Health in order to determine if the system is failing to prote public health, safety or the environment. 1. System will pass unle s Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sy em is not functioning in a manner which will protect public health, safety and the environ ent: ❑ Cesspool or pri y is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts g=- Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,u 415 Elliott Road _ Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 June 1, 2018 page. Citylrown 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 surface water supply. ❑ The system has a septic tank and SAS a n he SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS nd the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS d 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 we/a, alysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates abse presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided her failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ® or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 M Commonwealth of Massachusetts _ Title 5 Official Inspection Form _ — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °.0 V 415 Elliott Road Property Address Brian Covell _ Owner Owner's Name information is Centerville MA 02632 June 1, 2018 required for every _ _ page. CityrTown 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 withi 400 feet of a surface drinking water supply ❑ ❑ the system is w' in 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is ocated in a nitrogen sensitive area (Interim Wellhead Protection Area— IWP or a mapped Zone II of a public water supply well If you have answered "yes" to a y question in Section E the system is considered a significant threat, or answered "yes" in Section above the large system has failed. The owner or operator of any large system considered a signific t threat under Section E or failed under Section D shall upgrade the system in accordance with 10 CMR 15.304. The system owner should contact the appropriate regional office of the Dep ment. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell_ Owner Owner's Name information is required for every Centerville MA 02632 June 1, 2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on.- Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ��- Title 5 Official Inspection Form I=' _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V.c 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 June 1 2018 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No GPD Water meter readings, if available (last 2 years usage (gpd)): 2016=2017- 189 189 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy'. Current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based o/en 5.203), Gallons per day(gpd) Basis of design flow ( /s ft, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holdint? ❑ Yes ❑ No Non-sanitary waste dthe Title 5 system? ❑ Yes ❑ No Water meter readings t51ns.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form /t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road_ Property Address Brian Covell _ Owner Owner's Name information is Centerville MA 02632 June 1, 2018 required for 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: Ready Rooter records: Pumped Fall 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? --- --- --- Reason for pumping: — — Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins.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 415 Elliott Road Property Address Brian Covell _ Owner Owner's Name information is required for every Centerville MA 02632 June 1, 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: System installed 04/01/1994. Certificate of Compliace on as-built in file at Health Dept. _ Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 - - feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/Afeet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 2 feet Material of construction: M 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: 8.5' x 5' x 4.5' 1000 gallons 1" Sludge depth: ---- -- t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form ' - — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;.W 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 June 1, 2018 - page. Cityrfown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 33" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 6 -- ---- Distance from bottom of scum to bottom of outlet tee or baffle 14'_ How were dimensions determined? Dip tube, mirror and tape measure. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet concrete baffle and outlet tee in place. Liquid level at outlet invert. Outlet viewed with mirror. Under retaining_wall. Riser brings inlet cover within 6" of grade. 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 o top of outlet tee or baffle Distance from bottom o scum to bottom of outlet 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M Iu 415 Elliott Road Property Address Brian Covell _ Owner Owner's Name information is Centerville MA 02632 June 1, 2018 required for 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 ❑ ibergIass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: g - — gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition o alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Ix - - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 June 1, 2018 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 011 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.): One inlet, one outlet. D-box located and inspected with camera from leach pit. Under retaining wall. No high water staining over outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump hamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required).- If SAS not located, explain why: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts o Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w y° 415 Elliott Road Property Address Brian Covell _ Owner Owner's Name information is Centerville MA 02632 June 1, 2018 required for every — — page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Type: 1-6' x6' w/2' of ® leaching pits number: stone. ❑ 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.): Liquid level 4' below invert at time of inspection. High water staining 3" above current level. Clean stone visible in sidewall. No sing of past hydraulic failure. Riser brings cover to grade. 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 i ow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts �G = � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 June 1, 2018 _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, si/fhydraulic 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 Commonwealth of Massachusetts �=F=_ = F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 June 1, 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System'. Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: M hand-sketch in the area below drawing attached separately A: 6 (5ins.doc-rev.6/16 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y rY I< 415Elliott Road R Property Address Brian Covell _ Owner Owner's Name information is required for every Centerville MA_ 02632 June 1, 2018 _-- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 --- 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: 1994 _ 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: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Slope to rear of property drops below base of leach pit. Test hole at neighboring property in 2010 found no ground water at a depth 5' below base of leach pit. Accessed local ground water contours and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form R, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 P Y �/ w 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 June 1, 2018 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form c®p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.� 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 ' page. Cityrrown State Zip Code Date of Inspection t b IK� Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms �j * f/?to/ on the computer, �/l � use only the tab 1. Inspector: key to move your cursor-do not Patrick T. Sullivan use the return Name of Inspector key. Ready Rooter Excavating Company Name P.O. Box 89 _ Company Address Forestdale MA 02644 City/Town State Zip Code 508-888-6055 S112843 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 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority January 5 2016 Ins`pector'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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•e. , 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 415 Elliott Road Property Address Brian Covell _ Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 page. CityrTown State Zip Code Date of Inspection B. Certification (cunt) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. i The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally 11 unsound, exhibits substantial infiltration or ezfiltration 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. J A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank less than 20 years old is available. ❑ Y ❑ N ❑ NO (Explain below): J l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break o�Vbr 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 replace ❑ 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): i i ; C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require furt� r 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 systen i/ s not functioning in a manner which will protect public health, safety and the environ ment: ❑ 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•3113 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 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 page. Cityrrown 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 sys�pm (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surfabe water supply. ❑ The system has a septic tank and SAS and the §AS 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: / "x This system passes if the well water ana 4s, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and t4/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 1h day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Pw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 415 Elliott Road _ Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is,within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system located in a nitrogen sensitive area (Interim Wellhead Protection Area—IV rs A) or a mapped Zone li of a public water supply well If you have answered"yes�o any question in Section E the system is considered a significant threat, or answered "yes" in Sect n D above the large system has failed. The owner or operator of any large system considered a si ificant threat under Section E or failed under Section D shall upgrade the system in accordance ith 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form o` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is Centerville MA 02632 December 30, 2015 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, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30 2015 page. CityfTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2014= 325 GPD* g ( y g (gp )) 2015= 235 GPD* Detail: *High water use during summer months due to irrigation. Sump pump? ❑ Yes ® No Last date of occupancy: Current 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., Grease trap present? / ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to 'e Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road _ Property Address Brian Covell Owner Owner's Name information is MA 02632 December 30, 2015 required for every Centerville page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Ready Rooter records: Pumped yearly, 11/13/15 last Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 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 w e 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (coot.) Approximate age of all components, date installed (if known) and source of information: System installed 04/01/1994. Date of Compliance from as-built on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): — Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.6' x 4.5'x 5' 1000 gallons <1„ Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" (approx) Scum thickness <1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle N/D How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet concrete baffle and outlet PVC tee in place. Liquid level at outlet invert. Risers brings inlet within 6" of grade. Outlet under retaining wall. Viewed with mirror from inlet. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal /❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i Scum thickness / Distance from top of scum tg,, op of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 page. CityrTown 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): i Dimensions: / Capacity: / gallons Design Flow: ' /` gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No I 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): One inlet, one outlet. Camera used from leach pit to locate and inspect d-box. Unaccessible due to retaining wall. No sign of leackage or high water staining over outlet invert. Pump Chamber(locate on site plan): Pumps in working order: j ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump cha ber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. r Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•3/13 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 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Type: ® leaching pits number: 1-6' x 6'w/2' of stone. ❑ 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.): Liquid level 4.5' below invert at time of inspection. 8" of liquid in base of pit. High water staining 2.5' below invert at time of inspection. Clean stone visible in sidewall with mirror. Pit is H-20, 6' below grade. No sign of past hydraulic failure. Riser brings cover to grade. 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 j Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 415 Elliott Road Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 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.): i Privy (locate on site plan).- Materials of construction: Dimensions i Depth of solids Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 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 415 Elliott Road _ Property Address Brian Covell _ Owner Owner's Name information is required for every Centerville MA_ 02632 _December 30, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 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 C. _ 1t ' r ILI t 00 �i.. I t ' ,. t t5ins•3113 Title 5 Official Inspection Forth: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 415 Elliott Road _ Property Address Brian Covell Owner Owner's Name information is required for every Centerville MA 02632 December 30, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 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. 1994 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health explain: Test hole @#429 2010 ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Slope to rear of property drops below base of leach pit to wet land area. Test hole in 2010 at next door property found no ground water>5' below depth of leach pit. Accessed local ground water and topo contours. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 415 Elliott Road__ _ Property Address Brian Covell Owner Owner's Name information is Centerville MA 02632 December 30, required for every 2015 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 I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNnSTABLE LOCATION LI1 S , `�`o�` \ ;,d�C SEWAGE VILLAGE CG.n\L r V r`�,e ASSESSOR'S MAP&PARCEL ` % S IMTAttE1*'S NAME&PHONE SEPTIC TANK CAPACITY LEACHING FACILI.TY:(type) L.C�CkJ1 P` (size) C r k �f '_ NO.OF BEDROOMS J OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) ` Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) o� Feet FURNISHED BY E(e S L�C�aL�G 1� � 0 3a ` 3 , 30 ` 3' a� ` I �� 'L �j r•,eu� 4 «Dcy C_.socU C,...�cv�.0 MA 02-632 � a �onR— Ouec C� a� �yc woo n THE COMMONWEALTH OF MASSACHUSETTS P' $05— 1 BOARD OF HEALTH pyLe Appliratiou for Di-spoiial Works Tomitrurtiott ramit Applic n is hereby mad f a Per�}i to Construct K) or Repair ( ) an Individual Sewage Disposal System at: • .-• � ..�. a. ...... ........`_...f pa a27--7__......�..s�� -/ .......................•---•- Location-Address or Lot No. Q P°o° 22f}-7 -- r a.__ s _. -----------•-•----------- Iz.r..0 o Owner Address W --•.•. •.. .. �.......��..... -------------------------.....----... ...----------0.4..! ...F4.�M!f! f.... ......... Installer Address Type of Building Size Lot...... U Dwelling—No. of Bedrooms......-.1I.P'S-C......................Expansion Attic �) Garbage Grinder ( ) Other—Type T e of Building No. of ersons----------------_--_--.--- Showers pr yP g ---------------------------• P ( ) — Cafeteria ( ) p" Other fixtures .................................. W Design Flow.................................. --._gallons per person per day. Total daily flow............................. .....gallons. WSeptic Tank—Liquid capacity le _gallons Lengths Ll6.` Width l' (Qs.. Diameter................ Depth4�(v.�'._.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....Ox.w........ Diameter....../.c?....._. Depth below inlet....6............ Total leaching area.a47.....sq. ft., Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by....Le_v_,�f---- 1A f_jW%.,a,r ........... Date...Z`.•j1n._v...f`r`�: ..... ,.a Test Pit, No. I................minutes per inch Depth of Test it.---.--2!.......... Depth to ground w to <� .. •-••---:-.. L=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to groutt ?� A �' a' -_........ Description of Soil............•...1... ►- .L.. ------. ... ►'Y'+ — ce FX ALLYN res 1........�Z i '11'lc4aQ(c a±�_.Glc' s` -----------•----•---•---•................. .c�...... a1- ... U ex U�-tiCS 1V...... W - ••---•---••-•......................:.......•------•--•-•--•--.........._.........--•--•---•-•------.....................____._................ --•--- --5k3:-rtr�? .wP.F.......r3.... x 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 Environmental Code—The undersigned further agrees not to place the system in.operation until a Certificate of Compliance has bee sued by the bo d of,heal Signed --------------------.........--- - - ------ - --........... ............. ......... ..�� Application Approved By ......2fonllowing ..,e -+..� -- �eli tin Di a r ved or reasons: .... ...- .. Appca o s PP o f .. ................................ ............... .......................................................................... .....................................................................................:................................................................................. .. ........................' Date...... ................Date................ �j / Dare PermitNo. ......../ {.. ..........-------- Issued ............................................------------------...... � d No................_....... Fim..................._..... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .._........J..pw k,%..................0 F..........`Z�.r..n.S.Ix.64-.............................................. Appliratian for Diapasal Works Tanatrurtinn ramit Application is hereby made for a Permit to Construct (>< or Repair ( ) an Individual Sewage Disposal System at: .....1r.O.:T... ...+rr-Idlf.1 --R-G/•-•-��""w'f---4� ••.�k►1_�..... .........IC/l/i .............................. Location-Address or Lot 1No. ...Gt-ts+� � ................ ...Pr-Qt... $.!'k7.� �C�_y}LYu-dA ...................................... Owner Address W Installer Address Type of Building Size Lot.........Ot y!Q k�.Sq, 4eel. V Dwelling—No. of Bedrooms..........l.h c-----------------------Expansion Attic (Ah Garbage Grinder (AA Other—Type of Building .... No. of persons............................ Showers C4 YP g -------------•-•-------- P ( ) — Cafeteria ( ) Gw Other fixtures ...-•-------••-•--••-••------- d - ----------------------------- ----- ------........-------•--•.------------...... ... W Design Flow....................................S,s_.gallons per person per day. Total daily flow.............................3.3-0--...gallons. WSeptic Tank—Liquid capacity../Ox=gallons Length..8.4:6''. Width--C -1A-"-. Diameter---------------- Depth.5�4t*.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No......Oyu?------ Diameter......../,o'..... Depth below inlet.....G..____.____ Total leaching area..,,2.&.?...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by..... .y_...£:J", c...Lr1��,�,�,........... Date....1!_./0,a..... l.�irr.3... Test Pit No. 1................minutes per inch DepA of Test PIt-------!7.......... Depth to ground water.. ............ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r...-•---•--•------•--•-•--•-- ------•• ---•...--•......................................................... ..-'------ O Description of Soil..........0.-.1.�..' 1 u W ...............................•-•-----••-...---...------•-•--.-_... ._ .. �,_.._ TFp�r�r �^ *. .. U Nature of Repairs or Alterations—Answer when applicable...................................................61 MRs. .................._...� .:_ ....••-•••'•--•-•-----•-----•••......................•-•--•-••---•--•-•••-••-...._............•.....-••-----------••------------.........-••-------... WI�c n Agreement: ^ U s, ,emsyt'��13 The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys r,Iha rd :nce"with the provisions of TITLE 5 of the State Environmental Code—The undersigned further age,notto place the system in operation until a Certificate of Compliance has been issued by the board of health. ' Signed ................ ....... ...................... .................................................. ........................................ Dare ApplicationApproved By ............ ..................................................... ........... ................................................................ .....................ce................... � Application Disapproved for the following reasons: ...................... ............................................................................................................... ...................................................................................:........................... . ............................... ...................................................... ........................................ Dare PermitNo. .................................................................... Issued --------..................------------------------..........-------- Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT ... ... .... OF .... ll/1s��,�... .... .. ... .......................... CPrttfirate of 101'ampliart.CE THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ------------------------------------- —`-{�. � �t --&151Z,e----------i............-------..........--------...............-----..........................-----------------------.............. caroller at .............. ..... ... .. -` � �� --------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental C e as desc ibed in the application for Disposal Works Construction Permit No. 5.9...1-471��r............ dated .. �. .�.. HALL NOT BE CONSTRUED AS A GUARANTEE THAT THE THE ISSUANCE OF THIS CERTIFICATE��gS SYS�M WILL FUNCTION SATE= CTORY. c� �t --''-- Inspector .......... DATE....... ..:............... .... ...----........---- -...................... P -..... .................... ...--------------.. ...-----.-------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................O F..........---........................................................................ Disposal parka Tunatrnrtiun trrmit Permission is hereby granted........................................................................................................................................ _.... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Street as shown on the application for Disposal Works Construction Permit No........ ........... Dated.......................................... ............ ......................................._ DATE------- ----'•-------- Form 1255 CH&W Board of HOBBS&WARREN Publishers TOWN OF BARNSTABLE t LOCATION r--LL SEWAGE # VILLAGE CC---&J=127 E ASSESSOR'S MAP & LOT ��- f 6� INSTALLER'S NAME & PHONE NO. �p,,4,,.J SEPTIC TANK CAPACITY loco Gs'i A A,x LEACHING FACILITY:(type) P R-EC,g S-r (size) loco c L,4 NO. OF BEDROOMS 3 CQ2 PRIVATE WELL OR PUBLIC WATER ' ow j BUILDER OR OWNER IJ 2 .J CcocLL DATE PERMIT ISSUED: � ��, DATE COMPLIANCE ISSUED: t�''' �"�4¢' l VARIANCE GRANTED: Yes ) No J - 30, \\ {_ 5-4z 20' MINIMUM OR AS INDICATED ON PLAN NOTES: PINE STREET 10' MIN. 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. GpJaC� MASONRY EXTENSION TO 12' TITLE 5 ; THE TOWN OFZoar�1J RULES AND BELOW GRADE BACKFILL NTH �O ° REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE; S� BROKEN Po TOP OF FOUNDATION e' MIN CLEAN DIKE WAY Q� O G MASONRY EXTENSION TO 12' AND THE REQUIREMENTS OF THIS PLAN. -'t'� 80.0W GRADE ~ 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO Z WITHIN 12" OF FINISHED GRADE. 4' SCH. 40 PVC PIPE _ N. PITCH 1/B' PER FT. N 3. ALL MASONRY UNITS USED TO BRING COVERS TO GRADE SV�' 2' LAYER OF SHALL BE MORTARED IN PLACE. 1 4 P� FT FLOW LINE 1/8' - 1/2' 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE G�� O� ' 0 RUH 10' TEE Wt /000 WASHED STONE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR 13 3' MIN. GAUON WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING2' MIN. LEVEL I±i LEACH4'- 27, r PIT SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR J, MIN. w 3/4' - 1 1/2- WASHED STONE PARKING. L.EvEL DISTRIBUTION BOX y 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEED RESTRICTIONS OR ZONING REGULATIONS. OWNER/APPLICANT SHALL OBTAIN SUCH DETERMINATION FROM THE APPROPRIATE AUTHORITY. LOCATION MAP /LL,.') GALLON SEPTIC TANK Z 6. HORIZONTAL AND VERTICAL CONTROL, SEE LEVY, ELDREDGE �_��l 1�.q ASSESSORS MAP _277 PARCEL 7 L -� Vcr+,C! & WAGNER FIELD NOTEBOOK # -L 12--. LIQUID DEPTH IN SEPTIC TANK DEPTH OF OUTLET TEE BELOW FLOW LINE cl c«n,r<-e G I, 4 FEET 14 INCHES AA USGS PROBABLE HIGH WATER LEVEL 5 FEET 19 INCHES 6 FEET 24 INCHES CURRENT ZONING INTERPRETATION: DESIGN CALCULATIONS SEWAGE DISPOSAL SYSTEM PROFILE MIN. FRONT SETBACKS FEET NUMBER OF BEDROOMS 117rrG NOT TO SCALE MIN. SIDE SETBACK ; o FEET GARBAGE DISPOSAL UNIT /;v TOTAL ESTIMATED FLOW EOFL WITH A MIN. REAR SETBACK io FEET ( GAL./BR./DAY X 3 BR.) =''o GAL. /DAY 1.5' BERM - - - - REQUIRED SEPTIC TANK CAPACITY GAL. _ - - (15' WAY- _ _ _ ` _ - - ACTUAL SIZE OF SEPTIC TANK /06� GAL. _ - - _ LEACHING AREA REQUIREMENTS - - _ _ - - _ _ _ - - _ _ _ PERCOLATION SOIL TEST ( F- eo5�) � GPD./S.F. BOTTOM AREA /' a GPD./'S F . ��, ? �� a DATE OF SOIL TEST 11 fri I i9 .3 SIDEWALL AREA 2-..- SIDEWALL 27TT( iO /2)(�)SF x GPD/SF = 47/ GAL/DAY i sy I I 13s3 �' r. a.. .✓ b< �S cei—+ c e 4 ) ( / ) GPD/SF = 7 y GAL/DAY y v TEST BY C. zculd / G�' WITNESSED 8Y BOTTOM TT / 2 2 SF x / r I 7. L.J�Inn�ifn , ! ; ,,h,E of u,�t �s �`"5�� PERCOLATION RATE I-Len MIN./INCH SF ��O GAL/DAY TEST PIT #1 TEST PIT #2 1� +13 BREAKOUT CALCULATION: _ _. ELEV.- ?_3 ELEV.-- C P- 4., r I 88) LLY TREE` -0.00 -0.00 ,� � �/I � , \ 1 � •,bsa. f S.-boo, G�nerok ►v'Va+e 766,1 1 / j / r I �Q I• Aii rpe} LEGEND fed G.,.,.I 1/ @ � � 1 � ` �/ Li,.•+'.t- o� wcrlt -5 A* IJlt .sfti;n/�'i.•-�- J. I �'r�-�/ �� c.. .-�� ibl��fh� g EXISTING SPOT ELEVATION 00.0 X j , �,«s EXISTING CONTOUR-------00--- i� FINAL SPOT ELEVATION 00.0 s J. //// i�•ss•.j �.�dt shy/r a� . ecu*f FINAL CONTOUR LOT #5 `'� °o. �� -��a-•/ /�/�W tears ("J !% �r eorro�l OF TEST HOLE SOIL TEST PIT LOCATION OR WATER ELEV. OR WATER ELEV. TOWN WATER W W 100 3r fiocid 1 / ` �• �` SEPTIC TANK o 0 Zone A 10 / � DISTRIBUTION OING PIT 0 WATER LEVEL ADJUSTMENT: PRIMA "° RESERVE LEACHING PIT �R� TEST DATE i; /i/irk ! WATER LEVEL I? / 4 q/ / _l 'e4L�`s"i '710u" `LSr.•f7c-" . w�f-IenCIS SF 3- 1'753 INDEX WELL w-�5 , 29/�_' Rcu / Ccosh►/ /3o./c c,., t f 4,b.k f.rFi. t�, , t 27/92 i-I4,1 4jc...1i/ d— L- l -I,' 4/.//1<,:.r7N'"li ...19C2,1 WATER LEVEL RANGE ZONE LB, 1 INITIAL ISSUE .=�tl- DEPTH TO WATER LEVEL FOR INDEX WELL N0. DATE DESCRIPTION BY FOR MONTH OF: WATER LEVEL ADJUSTMENT /,� SITE PLAN & SEPTIC DESIGN DEPTH TO HIGH WATER 71A, LOT 5 ELLIOT ROAD NOTES: IN 1. Previous file number for this site; SE 3-1753, CENTERVILLE, MASSACHUSETTS Order of Conditions expired Feb. 22, 1991. � /'�a FOR 2. Datum — NGVD y1`L pp D T T7�T T 3. Topography taken from a plan t�t�980 1� 3TEPNL� £' - BRIAN CO V �,LL prepared by Baxter do Nye for APPROVED: BOARD OF HEALTH A' oN Dr. Allen Morrisey, dated Dec. 28, 1987. fij1�'' {y WtL. I , 20 SCALE: 1 = 40 JOB N0. 1679 / 1679 SITE PLAN DEP File No.; SE 3- 266Z DATE AGENT Order of Conditions Issued; LEVY, ELDREDGE & WAGNER ASSOCIATES INC. v + t PERMIT # §421M LiUM IBC91]M PLO= UXD SWORS co 586 STRAWBERRY Hal RD. CENTERVa E MA 02632 /VfW ENGLAND REPROGRAPHICS&SUPPL r C0 20' MINIMUM OR AS INDICATED ON PLAN NOTES: PINE STREET 10' MIN. 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. GOJ�'Ct MASONRY EXTENSION TO 12' TITLE 5 ; THE TOWN OF RULES AND BELOW GRADE BACKFILL WITH REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE; So BROKEN P15) TOP OF FOUNDATION e• MI"• 30 C AN BELoW R EXTENSION AODE TO t2, AND THE REQUIREMENTS OF THIS PLAN. DIKE WAY 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 12" OF FINISHED GRADE. 4' SCH. 40 PVC PIPE s 3. ALL MASONRY UNITS USED TO BRING COVERS TO GRADE MIN. PITCH 1/E9' PER FT. � Sv YER SHALL BE MORTARED IN PLACE. 1 4 PER FLOW LINE 1/su- 11/i 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE 10' TEE WASHED STONE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR 28,o r MI". 27 ' 2'-0' G,u�a+ WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING 9 2' MIN. LEVEL �i LEACH 10 +'-0' 27 ; PIT SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR 9os 7. MIN. .� !o �+ 3/4" - 1 1/2' LEVEL DISTRIBUTIONS y WASHED STONE PARKING. LEVEL Box 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEED RESTRICTIONS OR ZONING REGULATIONS. OWNER/APPLICANT SHALL OBTAIN SUCH DETERMINATION FROM THE APPROPRIATE AUTHORITY. LOCATION MAP /oo�� GALLON SEPTIC TANK z_ 6. HORIZONTAL AND VERTICAL CONTROL, SEE LEVY, ELDREDGE & WAGNER FIELD NOTEBOOK ASSESSORS MAP _�� 7 PARCEL / 0 LIQUID DEPTH IN SEPTIC TANK DEPTH OF OUTLET TEE BELOW FLOW LINE I cI c.r+rr Eli, 4 FEET 14 INCHES � 5 FEET 19 INCHES 9R USGS PROBABLE HIGH WATER LEVEL 6 FEET 24 INCHES CURRENT ZONING INTERPRETATION: DESIGN CALCULATIONS SEWAGE DISPOSAL SYSTEM PROFILE MIN. FRONT SETBACK o FEET NUMBER OF BEDROOMS It7r-c NOT TO SCALE MIN. SIDE SETBACK /o FEET GARBAGE DISPOSAL UNIT i,U TOTAL ESTIMATED FLOW EOFL WITH A MIN. REAR SETBACK /o FEET (i/o GAL./BR./DAY X __�L_ BR.) GAL. /DAY — — _ 1.5' BERM - _ _ - - - - _ _ _ _ REQUIRED SEPTIC TANK CAPACITY -12-S_ GAL. (15' F)'AY - _ - _ _ _ ACTUAL SIZE OF SEPTIC TANK /fin GAL. �Ilk — _ _ _ _ — — — — — _ _ PERCOLATION SOIL TEST � P- 8051) LEACHING AREA REQUIREMENTS _ _ _ SIDEWALL AREA 2:- GPD./S.F. BOTTOM AREA /, 0 GPD./S.F. ��, E % 735? J Q _ _ DATE OF SOIL TEST J► m,gY 1493 SIDEWALL 2TT j° 2 SF x GPD SF = 47% GAL DAY g� I I `� / �c;y C9,:_�, a,� - tt�,i 6� �:��s �,� ( ce/-�. ca4 TEST BY C. F,,/c� ( / )� ) / / G � 7' ( BOTTOM TT ( /2) SF x %� GPD/SF = 7 7 GAL/DAY /, - WITNESSED BY T. )un,i n t / �` i f� a `�+ /_, fi, y�.-� �� «�s ��.�� (cc -�►:c 9 � PERCOLATION RATE b MIN./INCH aa G 7 SF n GAL/DAY JEST PIT #1 TEST PIT #2 3 BREAKOUT CALCULATION- ELEV.= ?- 3 ELEV.= � P- � :�, , peg; -0.00 -0.00 Tcaj � �vnrsG Lo„ isl -s•' s.S bay, ( c 4 �` "�7F' ! , � I � ( /� � � \� �jcn��alf ►.brew. 1�'Ic/i�..r G/c. ; c, 7 / �- i •� � l / I � I, A i roa{- I c a.,,A._,-s to he co..• cs+r d: C/ta ti 411 /. „. LEGEND : �� fit .C5 elr�vr�ells _ I I ./ e � J / / s,l, AV A, ht�• � i+dJ. C�.UU / t �: �// �� „�.h hos -a< An hd. s /„ i �/ iq_, _ _ _ _ EXISTING SPOT ELEVATION 00.0 X �� G.LO (mod c�.bk,•� EXISTING CONTOUR-------00----- FINAL SPOT ELEVATION 00.0- -" - �f FINAL CONTOUR TP LOT #5 ! c� pp- a,.GO .,�b��.�o��-c✓ it �rsc Ks <M� ��d� BOTTOM OF TEST HOLE SOIL TEST PIT LOCATION % -OR WATER ELEV. z OR WATER ELEV. TOWN WATER W===W 1O° y �"°rj �° / SEPTIC TANK Zo rt& A i 0 / j� "? r / DISTRIBUTION BOX ❑ WATER LEVEL ADJUSTMENT: PRIMARY LEACHING PIT O "0 �R;�, RESERVE LEACHING PIT / �:r-_- �• , ,g I„�,r . �• TEST DATE _ 1i ilj/r� � i-s;_- WATER LEVEL �1 / 4 "' / a n CJEES ' S� 3- I� S' .'', 7 u 9/%? 'rc v,c.•s1 Ccc rs/ /�o.•tc _ �,,.,,t -f 4.t_:./c SriC..j > INDEX WELL 2 7 Z7/9_�- .7 J.`' Lvc.. ^a/ 13on LG 1 <: </d•�,/�" v/ir�c�.h64'7s _,yg(.t) WATER LEVEL RANGE ZONE - INITIAL ISSUE DEPTH TO WATER LEVEL FOR INDEX WELL NO. DATE DESCRIPTION BY o'r FOR MONTH OF: WATER LEVEL ADJUSTMENT /1.21 SITE PLAN & SEPTIC DESIGN DEPTH TO HIGH WATER 7• LOT 5 ELLIOT ROAD NOTES: IN 1. Previous file number for this site; SE 3-1753, CENTERVILLE, MASSACHUSETTS Order of Conditions expired Feb. 22, 1991. FOR 2. Datum - NGVD 0 I 3. Topography taken from a plan Ft% 1- �':� BRIAN CO VELL prepared by Baxter & Nye forp APPROVED: BOARD OF HEALTH 'S STEPH N Dr. Allen Morrisey, dated Dec. 28, 1987. �ii, ALLYIU ` WILSON SCALE: 1 " = 40' N �oz1�,��: o JOB No. 1679 / , 679 SITE PLAN DEP File No.; SE 3- 2G67 DATE AGENT Order of Conditions Issued; LEVY, ELDREDGE & WAGNER ASSOCIATES INC. PERMIT # wr�y3 DOS LiMISCO A)IiCHIf1�t,TS PIAKM 1AND SORP6i IS co 586 STRAWBERRY EMI, RD. CENTERVHIZ MA 02632 NEW ENGLAND REPROGPAPH/CS 6 SUPPLY CO