HomeMy WebLinkAbout0051 EMERSON WAY - Health 51 Emerson Way i
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� un 12 1512:03p ,•„�, p.1
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;
51 Emerson Way
Property Address
Silvio Carrieri `
Owner
Owner's hams / _-
rnforma Ifo a Centerville ✓ MA 02632 5-30-15
required for every
page. City/Town state Zip Code Date of Inspection CA
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. Genera) Inlformation
filling out forms
on the computer, / � \`��� `I(A OF�aqs
use only the tab ` / •y��• ""' •.-�q
key to move your 1. inspector: D Z? �+
cursor-do not James D.Sears JA MES
use the return Name of Inspector = —�
key CapewideEnterprises,LLC =* '
- • .. o
�y Company Name T•zRTIF .•:� ��.
153 Commercial Street '�. s INSVe X''z'�
Company Address l—o
Mashpee NSA 02649
Citylrown state Zip Code
508-477-8877 S1623
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
6-12-15
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-3H3 Title 5 ofridal Inspection Form:Subsruface Sewage Disposal System•page 1 d 17
Jun 12 1512:03p p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carried
Owner Owner's Name
information is Centerville MA 02632 5-30-15
required for every
page. CityFrown state Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist_ Any failure criteria not evaluated are
indicated below.
Comments:
Conn Pass-Tank Leaking.The system is a 1000 Gal.Tank- 1000 Gal.Pump Chamber-D Box and
three pipe field.
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 exfiltrabon 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):
151ns-3113 Ttis 5 Official hspediion Forth:Subsudece Sewage Disposal System-Page 2 of 17
un 121512:20p p.1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carrier)
Owner Owners Name
information
required for every Centerville MA 02632 3-30-15
page.. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpsfalarms 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 dishfbution box. System will
pass inspection if(with approval of Board of Health):
i
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
t -
t
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
Leacking tank - Need to reseal seam.
❑ 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 ❑ NO (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•3113 Tittle 5 Offidal hWedion Forth:Subsurtaoe Sewage Disposal System•Papa 3 of 17
Jun 12 1512:21 p p.2
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carried
Owner Owner's Name
information is
required for every Centerville MA 02632 5-30-15
page. CityfTown State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Q Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Z Liquid depth in is less than 6"below invert or available volume is less
than day flow A4Fi¢(2SIA.,G
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
4
{
Jun 12 15 12:21 p p.3
Commonwealth of Massachusetts
-- Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carried
Owner Owner's Name
information
required for every Centerville MA 02632 5-30-15
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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
i
❑ ® 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 formal.)
❑ ® 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 CUR 15.303, therefore the system faits. 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
I design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department
t5ins-3)13 Me 5 Official trspad en Farm:Subudke Sewage Disposal System•Pepe 5 of 17
{
Jun 12 1512:21 p p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carried
Owner Owner's Name
information is every
Centerville
wired for eve MA 02632 5-30-15
page_ CityrTown 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?
❑ 0 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
ti
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)1310 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
t5ins-3113
Title 5 Official IrapeGion Forth'Subsurface Sewage Disposal System•page 6 of 17
t
Jun 12 15 12:22p p.5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carried
Owner Owners Name
information
required for every Centerville MA 02632 5-30-15
page. C'itylrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank- 1000 Gal. Pump Chamber - D Box and 3 three pipe field
Number of current residents: 0
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
Water meter readings, if available(last 2 years usage(gpd)): 2013-166,000Gal
2014-70,000Gal's
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commemialllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.fL,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•3113 Tdle 5 Official Inspection Fenn:Subsurface Sewage Disposal System-Page 7 of 17
Jun 12 1512:22p p.6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carried
Owner Owner's Name
information is required for every Centerville MA 02632 5-30-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
i
I General Information
Pumping Records:
Source of information: 6/9/10 -
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
j
❑ 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
❑ Trght tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5im-3013 Tile 5 Official Inspection Farm:SuDsurtaoe Sewage Disposal System-Page 8 of 17
Jun 12 1512:22p p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carrieri
Owner Owner's Name
information is required for every Centerville MA 02632 5-30-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Approximate age of all components, date installed(if known)and source of information:
2005-
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'teat
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage,etc.):
Pipeing is 4" PVC SCH-40_
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:
14"
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
4"
t5ins•3M3 Title 5 Official Inspection Form:Subsurface Sewsp OLVwal System•Page 9 of 17
Jun 12 1512:23p p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carried
Owner Owner's Name
information is required for every Centerville MA 02632 5-30-15
page. Cityrrown 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 at bottom
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle 26
I
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? Asbuilt-T3pe
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank Level at seam,Tank leaking.Tank and covers at 14"below grade. in and outlet tee. Need to
reseal tank seam.
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
k5ins-3/13 Title 5 Offidal Inspection Farts:Subs urfaw Sewage Dlsposak System•Page 10 of 17
Jun 12 15 12:23p p.9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carried
Owner Owner's Name
information is required for every Centerville AAA 02632 5-30-15
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: pate
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3113 • Title 5 Official Inspection Fom:Subsurfac,Smwrge Disposal System-Page 111 of 17
Jun 12 15 12:23p p.10
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Emerson Way _
Property Address
Silvio Carrier)
Owner Owner's Name
information is Centerville MA 02632 5-30-15
required for every I,
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-14 below grade. Box is clean and solid w/3 lines out..2" inlet w/tee. No sign of
over loading or solid carry over.
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.):
Pump chamber is a 1000 Gal. Precast tank w/2'steel cover at grade on pump end of tank Chamber
is clean w/no solid carry over. one pump pump and alarm working.
" 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:
!Sins-W13 - - Title 5 Deal Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Jun 12 1512:24p p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carried
Owner Owner's Name
information is Centerville MA 02632 5-30-15
required for every
page. CityFrown State Zip Code Date of inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
15'x30'
❑ 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.):
Leaching is a three pipe field 15'x30'. ck D Box clean w/no sign of over loading. Camera out
Iines,Lines clean w/no sign of over loading or solid carry over.No sign of holding water in lines.
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
15ins.31Q Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17
Jun 12 1512:24p p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carrieri
Owner Owner's Name
information is Centerville MA 02632 5-30-15
required for every i
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note oondition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc,):
r
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•3113 Tnle 6 official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17
Jun 12 1512:24p p.13
Commonwealth of Massachusetts
Title 5 Qtticlal Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Emerson)Nay
►L—- ---- -----------
Property Address ---.-_�__ -------....
Silvio Carried
Owner Ownefs Name
information is
required for every Centerville MA 02632 5-30-15
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:
® hand-sketch in the area below
!� drawina attached seoarateiv
f
� I
i .
t5in -3113 - Tide 5 of lal Ltspecdon Form'Subsurface Sewage oisposal System-Page 15 of 17
Jun 12 1512:25p p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carrieri
Owner Owner's Name
information is required for every Centerville MA 02632 5-30-'15
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to igh 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: 11-9-04
Date
❑ Observed site(abutting propertylobservation 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:
T_H_on Design 11-9-04, no G.W. at W-6". Bottom of field around T below grade. Bottom at U-6"
above T.H.Depth.
Before filing this Inspection Report, please stye Report Completeness Checklist on next page.
t5im-3/13 Tide 5 Official bspedion Form:Subs&aca Sewage Disposal System-Page 16 of 17
Jun 12 1512:25p p.15
Commonwealth of Massachus
etts
Title 5 Official Inspection Form
'4 MW Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Emerson Way
Property Address
Silvio Carried
Owner Owner's Name
information
required for every Centerville MA 02632 5-30-15
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
II
t I
r5ins-3H3 Ti9e 5 Official Inspection Form:Subsurface Sewage Disposal Sy
stem•Page 17 at 17
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes r
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppliCation for Mispo8al 6pstrm Construction 3pErmit
Application for a Permit to Construct( ) Repair(1) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot l�jo.S i LM°'�0�WC'y Owner's Name,Address,and Tel.No.Lo C e r\D,
CtA\ef,,'- d � ® �CC(ie1(1% \G1S' VCyfnq-� M.L%rl4aorook-
Assessor's Map/Parcel 0011
Installer's Name,gddress,and Tel.No. Designer's Name,Address,and Tel.No.
�_5c,a�,4 -L i q
Type of Building:
Dwelling No.of Bedrooms Lot Size 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 Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �.Q pfAY j_,t,s&,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by t ' Board of Health.
ign ° 0 Date '� 1
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
S
,
r `
No. ._ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
21pplicatlon for 3.3I8tlosaf *pstem Construction permit
Application for a Permit to Construct( ) Repair(,/) Upgrade( ) Abandon( )' ❑Complete System ❑Individual Components
Location Address or Lot No.5 Owner's Name,Address,and Tel.No.LU f z C�a
C'e:\*eti,a- ,tAip 02 bD {C�eY, iCtiS Veya(Zv\ /o�u -lho�o�g�•
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
5kGyr- t_t_( Z)It Qo- n 1 ¢j
AA C�t1 <
o,
Type of Building:
Dwelling No.of Bedrooms Lot Size 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 Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Z o r)o,,,l C7 ; art, G�
o V �-
•
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
igned.le ° A 1, 1/'_ Date 2 1
Application Approved by �, f�� ,�� Date
V ,
Application Disapproved by Date
for the following reasons )
/ y-'
Permit No. Date Issued
------------------------v------------------------ r= �
THE COMMONWEALTH OF MASSACHUSETTS
A(rr BARNSTABLE,MASSACHUSETTS
�M Certificate of Compliance
Sr THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(f) Upgraded( )
Abandoned( )byat `-� ki has been constructed in acc•�
with the provisions of Title 5 and the for Disposal System Construction Permit No 4i ed
r
Installer 1 �_��L 5� Ll�. Designer
#bedrooms f Approved desi Ow\ gpd
\c d
The issuance of is rmit shall not be construed as a guarantee that the system wil�function as des ned.
JJ P c g Y �y g
Date 1p o i / Inspector
1
---- ---- ------------❑--------- ------------------------------------------------------------------------- ---- ------
No. Fee
// /------/2
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
30isposal 6pste Construction �ermit
Permission is hereby granted to Construct( ) Repai (7 Upgrade f Abandon(i )
System located at CIA
c
a
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:Construction must be completed within three years of the date of this permit.
r Date Approved by
TOWN OF BARNSTABLE
LOCATION k.,( ;i SEWAGE #
VILLAGE ASSESSOR'S MAP'& LOT__
INSTALLER'S NAME&PHONE NO. �_ 1 �Yr�('ir � �. . ' .� �✓'�, � '� _. �"y�
a'C
SEPTIC TANK CAPACITY J. Q'Q
LEACHING FACILITY: (type)n—LLA (size) 15 x Y)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDAi'E:.. L'� --COMPLIANCE DATE:
Separation_Distance Between the:
Maximum Adjusted Groundwater Table io the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
an 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
I i
I
i'
241
AN 6 r5
r �
o r � �
,..� Deck 10
r � �
r r 54'
BATH
DINING KITCHEN BEDROOM
ICJ
fV
'
LIVING-ROOM BEDROOM BEDROOM
LZ
54'
a-�6a 54'
LAUNDRY UTILITY
BATH
'2 Gar Garage r�.3
cv .
CV FAMILY ROOM
STORAGE
54'.
�\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address 14144,
ye ,
Owner
cyan ers Name
int rination is
required for el r1 —,P t1 I I
every page. Cdy/Town f)
State YP Code Date o Inspection
Inspection results must be submitted on this form,Inspection forms may not be akeredin any
'w. way.
knp
,M, i out A. General Information -
forms on the
computer,use 1. Inspector
only the tab key
to move your
cursor-do not
use the return Name of inspector
key. _
Company Name '
�-QMPanY AddressState
zip Code
Iempnone Number
License Number
B. Certification
I certify that I have personallyi
inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of St 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
r.
I is Sig e Q 9
Date
The system inspector shall submit a Copy of this inspection report to the
Approving
of Health or DEP)within 30 days of completing this inspection. If the syst m isa hared Syst m ord
has a design flow of 1 o,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 s
and Copies sent to the buyer,if applicable,and the approving authority. ystem owner
This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address hove,the s
F - the same or different conditions of use, lam will perform in the future under
t a
Si
;�. _ Titles(KFire1i....-..w.,..c__....._...
r
Commonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cons)
Property address
Citylrown state Tip code
e
Owner's Name Date of l
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
k1 have not found any information which indicates that any of the failure criteria described
m 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Answer yes,no or not determined(Y, N,ND)in the❑for the following statements. If"not
determined;please explain.
❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
t5insP•d=dw'03/2M Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
S. Certification (cont.)
J
Property Address
City/rown state Zip Code
owner's Name Date of Inspection
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static war level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaceow"
ND Explain:
f,
jF
f
❑ The system required pumpipg more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspectiigh if(with approval of the Board of Health):
❑ broken pipe(s are replaced
❑ obstructi0rf is removed
ND Explain:
C) F r Evaluation is Required by the Board of Health:
❑ ditions 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
tBiW.doc doc•032006 Tdle 5 Official Inspeifion Form:Subsurface sewage Disposal System-
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not.for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
Property Address
cityfrown State Zip code
Owners Name Date of Irmpection ,
C) Further Evaluation is Required by the Board of Health(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 aseptic tank and SAS and the SAS is within 50 feet of a private water
supply well.
r
❑ The systerh has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more fr qin a private water supply well".
` used to determine distance:
**This passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria i tcates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other
tsnsp.doc doc•09J M Trde 5 Offiaal Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
DA V',J�F'
Propeny Address
City/rown state MpCode
ownees Name Date
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
dogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or dogged SAS or cesspool
® Static liquid level in the distribution box above outlet invert due to an overloaded
or dogged SAS or cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less
than%day flow
❑ Required pumping more than 4 times in the last year NOT due to dogged 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.
❑ 9 Any portion of a cesspool or privy is less than 100 feet but greater than 5o 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 agent 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.
Yes No
❑ The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 16.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
t5insp.doo doc•03/2006 Trtle 5 o"bgxs c bw Form:Subsurface Sewage Disposal SysOem-
Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cunt.)
Property Address
Citylrmn State Zip Code
Owner's Name Date of Inspection
E) Large Systems: To be considered a large pystem 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"rW to each of the following,in addition to the
questions in Section D.
YES NO
❑ 0 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
❑ ❑ *system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answ 'yes'to any question in Section E the system is considered a significant threat,
or answered`fir In Section D above the large system has failed.The owner or,operator of any large
system cons' red a significant threat under Section E or failed under Section D shall upgrade the
system in ante with 310 CMR 15.304.The system owner should contact the appropriate
regional of the Department.
tSmp.doadw•03MM Titre 5 Offidal Inspection Fwm:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. Checklist
Property AMreie
cityfrown State Zip Code
t
owners Name Date of Inv4cironj
Check if the following have been done.You must indicate`yes'or"now as to each of the following:
YES NO
❑ Pumping information was provided by the owner,occupant,or Board of Health
❑ f�' Were any of the system components pumped out in the previous two weeks?
❑ ,ff 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?
-w 11 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)]
5insp.doc doc•03/20M Tdie 5 Offiaal Inspection Form:Subsurface Sewage Dial System
Page 7 of 16
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information
Propeny A&rm
cityfrown State Zip Code
owner's Name Date df insoection
Residential Flow Conditions:
Number of bedrooms(design): Is Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 3 0
Number of current residents:
Does residence have a garbage grinder'? ❑ Yes 2�'No
Is laundry on a separate sewage system?[d yes separate inspection required] ❑ Yes �lo
Laundry system inspected? ❑ Yes WNo
Seasonal use? ❑ Yes,AZ'No
Water meter readings,if available(last 2 years usage(gpd)): ^
Sump pump? ❑ Yes,' No
Last date of occupancy:
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 j ,jetc.): .
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:
Last date of pancyluse:
Date
Other(d be):
t5insp.dw.doc•03/2006 Title 5 Official lrq)edw Fom:Subsurface Sewage Disposal System
Page 8 of 16
r -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
Property Address
cltyfrown State Zip Code
Owner's Name Date Of 1 n
General Information
Pumping Records:
Source of information: A d A i C-o�G
Was system pumped as part of the inspection? ❑ Yes W 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/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
t&nsp.dw doc•t0.?OW rrtle s official 1 nspecWn Form:Subsurface sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cunt.)
0A,11>2-
Property Address
City/Town Stale Zip Code
Owner's Name Date of I
Building Sewer(locate on site plan):
e ..f-
Depth below grade: fed
Material of construction:
❑cast iron /A/40 PVC ❑other(explain):
Distance from private water supply well or suction line: i
feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
Septic Tank(locate on site plan): i
Depth below grade: fedJ
Material of constriction:
Aconcrete ❑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 [I Yes ❑ No
-------------------------------------------------------------------—------------------------------------ --------
Dimensions: �7 —� 2
Sludge depth: ��
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
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? M JaA, Lir
t5insp.doc doc-032006 Title 5 Official Iron Form:Subsurface sewage Disposal System
Page 10 Of is
I -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cunt.)
Property AcTdress
cayfrown State ZP Code
owners Name l
Date of i
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
�a
Grease Trap(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 o bet tee or baffle
Distance from bottom of scum bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pump)toloutlet
ecommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as relat invert,evidence of leakage,etc.):
r'
i
t
Tight or H ding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth low grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑polyethylene
❑other(explain):
t5insp.doc.doc•03/ M Title 5 Official i rupecZion Form:Subsurface Sewage Disposal System
Page 11 of 16
I -
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
y-
-hie,
Mdmw
Cityrrown State Zip Code
•� C n I,
owner's Name Date of lw*cfim
Tight or Holding Tank(cunt.)
Dimensions:
Capacity- gatlons
Design Flow: gales 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
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert f/W
Comments(note I box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.):
COS CFL/-,k-"/_ Jc'0.
Pump Chamber(locate on site plan):
Pumps in working order. Yes ❑ No
Alarms in working order. Yes ❑ No
t5insp.doc.doc•032006 Title 5 Official Inspection Form:Subsudaw Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cunt.)
Property Address
Ci rown state Zip Code
-:-;?-(t to
owner's Name Date of lrrsper�ion
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
- S
r
n i j-- _O ou +� 1 C t_ ko JL-4e_
loe
Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located,explain why.
Type.
❑ leaching pits number.
❑ leaching chambers number:
❑ leaching galleries number.
❑ leaching trenches number,length:
leaching fields number,dimensions: &2---- `�—s
❑ overflow cesspool number.
❑ innovativelaftemative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.): 2
t5insp.doc.doc•.03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not,for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (corn.)
Property Address
c tyrro" State Zip Code
Owner's Narne Date of Inspection
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
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.): ;
Privy(locate on site plan):,`
Materials of constructi".
Dimensions 1
Depth of solids
Comments( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
t5hW doc.doc•032M Title 5 Offtaal Inspecbon Form:Subwrface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cost.)
i
Property Address
cityfrom State Zip Code
—7p it /no
Owner's Nme Date of 1
Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system including ties
to at least two peffnanent reference landmarks or benchmarks.Locate all wells within 100 feet.
Locate where public water supply enters the building.
eO
) V1
t5insp.doa doc•032M Title 5 OffkW Inspection Forth:Subsurface Sewage Disposal System
Page 15 of 16
TOWN OP BARNSTABLE .
LOCATION ) v .R SEWAGE #
VILLAGE an. ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE N0. .1 W JJ(-n MJ-)1L:ir :;�'��� �00 X�
�— R ----.
SEPTIC 'PANT{ CAPACITY
LEACHING FACILM? (type) :9 � (size) 15 X ?�o
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DA i s o ` n h �_COMPLIANCE DATE':
Separation Disvwce Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furtushed by
0.
' Ilya �'
'
s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cost.)
�6c^
Property Address
State zip Code
Owner's Name Date of lwilx ion
Site Exam:
slope i��► � Se
Surface water ��
Check cellar Of
Shallow wells A10 Lfr'
Estimated depth to ground water.
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: 1
Checked with local excavators, installers-(attach documentation)
❑ Accessed VSGS database-explain:
You must describe how you established the high ground water elevation:
• P
t5insp•�•�'03R006 Title 5 Official Inspection Form:Subsurface. Sewage Disposal System
Page 16 of 16
No. a00g,(—_ K? � ��✓i�v'�1.�. ��"U✓1�2.t�# I��-� �,��°'f''�e"
COMMONWEALTH OF MASS CH ETTS
Entered in computer:
THE
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppIicatiou for 301opooal &pztem ConMructiou Permit
Application for a Permit to Construct( , j Repair +,4)Upgrade( )Abandon( ) D Complete System ❑Individual Components
Location Address or Lot No. 1�4j r)15 Owwnner�'ss Name,Address and Tel.No.
Assessor's Map/P�l �� 4� ' ����n
1'6 W i UUU"'111111
Installer's Name,Addres ,and Tel.No. "I Wllm
n`Ina Desi ner's N an e,Address d Tel.N
Type of Building:
Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design.Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature o Re airs or Alterations(Answer when applicable)i(l 4xi 1 ?Q C-h OL M�f. k�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been ' ue y th' Bo d-af ealth.
Signed _ Date
Application Approved by pima gA=jj3 14f Date 2
Application Disapproved Vr the following reasons
Permit No. a U OS—_ 19,1W Date Issued 2 b
No. 0 OC (L /{v��2 Gfv✓� PC l a + �— r Fee b o —
V p
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
' Yes -
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
` Z(ppfication for Migoof 6peum C645truction Permit
Application for a Permit to Construct( )Repair(� )Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. 11K Owner's Name Address,and Tel No.
CZ) n `Pe,�-vr- �A)
Assessor's Map/Parcel � �t
41
Installer's Name,Address,and T*No. h Desi n�'s N e,Address and Tel.Np /�,.r 0)aj� ()377
YVI
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets f Revision Date
Title
Size of Septic Tank Type of S.A.S.
r.•
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) t n 4di 1 i V Yl`1 p ch&, k,�C t j)—y
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by I Board-of Health. /
Signe i Date 2 j
Application Approved by ru Date /?
Application Disapproved r the following reasons
Permit No. U U 0 V Date Issued z G `
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CER�Y, that the On-site Sewage_IDisposal System Constructed ( ) Repaired (X )Upgraded( )
Abandoned( )by J. ` • �( P C d O
4 L
Fjme bn)n Wi-w Criiij fa i how} «T'i.0j _—.._._—" been ccr:str,:cte� _:. ]r .a . o
with the pr visiLonis o Tits 5 and�th�e�for Disposal System Construction Permit No. 2 QLI. — 0(4& dated 3 ~11yv
Installer I`C)Lli1 rup 1.�.!1 I Designne-r _. 1
The issuance of this a shal not be construed as a guarantee that the sy% � ill' u c one as�sied.Date Inspto "No. Q o U S '0 /J Fee /U 0 —
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi!5pozaf *patent CCon6truction Permit
Permission is hereby granted to Construct( )Repair(Y\)Upgkade( 1 ss)ppAbandon( )
System located at ��I r_n J�,�, n t)fl.1) Cwl i iv
1
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: C nstructign must be completed within three years of the date of thiFf%-Mit.
Date: 1 .a a U Approved by t, r�
AM JCENGINER, SN,2% r' 508 273 0367 R. 02
l V1V)ll 0A Kral A.IIa6aMr.
Regulatory Services
Thusnas F.Geiler,Direetor
NAM Public Health Divia:Vn
�eaa
v
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 fax-, 508-990-6304
Installer& Designer.Certification Foam
Date: 01 G _
Dcsizner:_ Installer: .- , C :.1t)nc
Address: Address: Tn._h_QX CP
On 1 o ut 't�.�,,,...,..was issued Et permit to install a
ate (installer)
septic system at 5— �,v A I _ based on a design drawn by
(address)
dated
(designer)
(� I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system, ref-,:erns;ed above was installed with major changes (i.e.
xeat,�.d>an 10' JILteral reiocz6on of t'ie SAS or any vertical relocation of any component
Q►tae septic system)but in accordance with State & Local ,Regulations. Plan revision or
certified -boil -designer to follow.
! [NO
JOHN L.
� CMVRcURCMIt.I w
JR.
(Installer's Signatur j , c;,eor
� 41.
, p, esigner' amp Here)
Tesigrier's atu.re)
LEASE RETU TO BARNSTABLE PUBLIC HEALTH DIVISION. CEItT PICATE
COMPLI
OFCE ILL NO BC 15SUED UNTIL BOTH THIS FORM AND AS-
BYJILT CARD ARE REC IVE BY THE BARNSTAB)1 PUB IC EALTH DIVISION.
TH Yout
Q:Ilealth/Septic/Designer Certification Form
TOWN OF BARNSTABLE
j SEWAGE #
VIL AGE_ .4 j � ASSESSOR'S MAP & LOT J B ?
INSTALLER'S NAME&PHONE NO. -)-,I (' C d�, �' ,A VI J ".�G 'L
SEPTIC TANK CAPACITY ..10 C)0
LEACI-NAG FACILITY: (type)� (size)
NO.OF BEDROOMS ^°
!'UJLDER OR OWNER
PERMITDA E:_. -/a t COMPLIANCE DATE:
Separation_Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private.Weter Supply Well and Leaching Facility (If any wells exist
en site or w,:thin 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
4
Funiished by -
1
s ... I
� i
RECEIPT
Printed:03-04-2005 ® 15:12:11
BARNSTABLE LAND COURT REGISTRY
JOHN F. MEADE, REGISTER
Trans#: 73615 Oper:CATHY
Doc#: 995519
Ctl#: 1656 Rec:3-04-2005 ® 3:12:07p
BARN
DOC DESCRIPTION TRANS AMT
--- ----------- ---------
1 LEVIN, PETER J
RESTRICTION
Recording fee 30.00
Surcharge CPA $20.00 20.00
State Fee $20.00 20.00
Surcharge Tech $5.00 5.00
Document Copy -Man 1.00
Total fees: 76.00
*** Total charges: 76.00
CHECK PM 1686 76.00
Do•==99S s 19 03—iD4ORElY
BARNSTAP LE LAID C f��..
�P
DEED RESTRICTION
i
WHEREAS,Peter J.Levin of 598 Schoolhouse Road,Saugerties,New York and Anthony F.Levin
of 41 Johnston Ave,Kingston,New York is(are)the owner(s)of the laud together with the buildings and
improvements thereon situated at 51 Emerson Way,Centervill"assachusetts,and more particularly
described as Lot 25 on Assessor's Map 188 and shown as Lot 54 on Plan 24614-E(Sheet 2)dated
February 14,1958,drawn by Ed.Kellogg,Civil Engineer,and filed in the Land Registration Office at
Boston,MA,a copy of which is filed in the Barnstable County Registry of Deeds in Land Registration
Book 200 Page 97 with Certificate of Title No.26157. Said lot(s)containing 0.26 acres+-according to
town assessors records;and^WMER(1lS,6e�t.LtVtA i�a {PcTtc►awrt eEabout-a►entlened and
WHEREAS,I(We)as owner(s)of said Lot 54 have agreed with the Town of Barnstable Board of
Health to a restriction on the number of bedrooms that can be included in any home now existing or
hereafter constructed=on said lot as a condition to obtaining a disposal works construction permit for the on
site septic system repair/replacement/installation on said lot pursuant to State Environmental Code,Title V;
310 CMR 15,000 et.seq.;and
.WHEREAS,the Town of Barnstable Board of Health as a condition to granting the disposal works
construction permit is requiring that the agreement to restrict the number of bedrooms in any home now
existing or hereafter constructed on the lot be put on record with the Barnstable County Registry of Deeds
by recording this document;
NOW,THEREFORE, I(we)do hereby place the following restriction on the above referenced lot in
accordance with the Town of Barnstable Board of Health,which restriction shall run with the land and be
binding upon all successors in title:
1. Any home now existing or hereafter constructed on the above-referenced Lot 54 shall contain
V no more than three(3)bedrooms.
We agree that this shall be a permanent deed restriction affecting the above-referenced Lot 54 also known
as 51 Emerson Way,Centerville,Massachusetts as shown on said plan recorded in the Barnstable
County Registry of Deeds.This restriction may be released by the Town of Barnstable's Board of Health
should regulations change or sewer become available.
For our title see Deed recorded in the Barnstable County Registry of Deeds Certificate No.132389.
Executed as a sealed instrument this /5-th day of y ,2005
c
P r J.Levin Anthony F.Levin
I`Jr (Di 0��i��t
BELLE Lev I State of New York
to F•
ulster 'SS. S. (Date: �5 2005
�j1n'{�orre�/ �
Then personally appeared the above-named Ala�l p �V t and ac owl ge a foregoing
instrument to be their free act and deed before me.
_ otary Public
BARNSTABLE COUNTY
REGISTRY OF DEEDS (�
ATRUE COPY,ATTEST My commission expires:
JOHN F.MEADE,REGISTER Notary sPublic, Staley cif New York
yp
No 50011�547
BARNSTASLE REGISTRY OF MEEDS COPT1miS f lad yr xPif�¢'rs September iR1.CY4
I
LETTER OF TRANSMITTAL
JC ENGINEERING 4 > Telephone: 508-273-0377
2854 Cranberry Highway Facsimile: 508-273-0367
East Wareham,MA 02538
TO: Town of Barnstable DATE: 03/07/05 JOB NO. 756
Board of Health RE: Proof of Recording
200 Main Street Deed Restriction for
Hyannis,MA 02601 51 Emerson Way,
Centerville,MA.
WE ARE SENDING YOU: X Enclosed _ Under separate cover via X the following:
X Report X Plans _Brochures _Shop Drawings
Specifications _Copy of Letter _Change Order _Contract Documents
�s
Enclosed,please find a copy of the proof of recording the Deed Restriction for
e:rs
51 Emerson Way,Centerville,MA. =
co
C:)
THESE ARE TRANSMITTED as checked below:
X For Approval _Resubmit Copies for Approval
For Your Use _Approved as Noted _Copies for Distribution
As Requested Returned Approved as Submitted
Returned For Review and Comment For Your Information
REMARKS Please feel free to contact the office with any questions.
COPY TO:.. File:..:_ : ,.._.. .. r,, ....: _� _ --SIGNED:
Melissa Borges d
Town of Barnstable
DARMAD105 > , Board of Health
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Sumner Kaufman,MS
Wayne Miller,M.D.
January 21, 2005
Mr. John L. Churchill, Jr., P.E.
JC Engineering, Inc.
2854 Cranberry Highway
East Wareham, MA 02538
RE: 51 Emerson Way, Centerville A= 188-025
Dear Mr. Churchill,
You are granted conditional variances on behalf of your clients, Peter and
Anthony Levin, to construct a replacement sewage disposal system at 51
Emerson Way, Centerville, Massachusetts.
The variances granted are as follows:
PART Vill, SECTION 1.00: The septic tank will be located 66 feet away from a
bank, in lieu of the one-hundred feet minimum separation distance
required.
310 CMR 15.211: To install a soil absorption system 5.4 feet away from the front
property line, in lieu of the ten feet minimum setback required.
310 CMR 15.211: To install a soil absorption system 10.3 feet away from the
cellar wall foundation, in lieu of the twenty feet minimum setback
required.
These variances are granted with the following conditions:
No more than three (3) bedrooms maximum are authorized at this
property. Dens, study rooms, offices, finished attics, sleeping lofts, and
! similar-type rooms are considered "bedrooms" according to the MA
Department of Environmental Protection.
(2) The applicant shall record a properly worded deed restriction, signed by
the owner of the property, at the Barnstable County Registry of Deeds
restricting the property to three (3) bedrooms maximum. A copy of the
Q:WP/ChurchillLevin
96 A
recorded deed restriction shall be submitted to the Health Agent prior to
obtaining a disposal works construction permit.
`, 3) The septic system shall be installed in substantial compliance with the
submitted engineered plans dated November 29, 2004. .
(4) The professional engineer shall supervise the construction of the onsite
sewage disposal system and shall certify in writing to the Board of Health
that the system was installed in substantial compliance with the submitted
engineered plans dated November 29, 2004.
These variances are granted because the physical constraints at the site
severely restrict the location of the soil absorption system due to its close
proximity to the wetlands and small size of the parcel.
Since ely yours,
yn filler, M.D.
C airman
Q:WP/ChurchillLevin
oF�r
DATE:
�RN3rABI�,
FEE:
MABS.
i63q. ♦�
'O�'Fp�p�lA Town of Barnstable REC. BY
SCHED. DATE:
Board of Health
200 Main Street,Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Susan G.Rask,R.S.
Sumner Kaufman,M.S.P.H.
Wayne A.Miller,M.D.
VARIANCE REQUEST FORM
LOCATION
Property Address: < L:7wccson UJcay ^
Assessor's Map and Parcel Number: (� ' 25 O Z(o f{c ± -
Size of Lot:
Wetlands Within 300 Ft. Yes ✓ Business Name:
No Subdivision Name:
APPLICANT'S NAME• 500 n Cn ue C A(0 Q. 5 0 Z 7 r l l
Phone 3 0 3 7 _
Did the owner of the property authorize you to represent him or her? Yes X No
PROPERTY OWNER'S NAME t �
CONTACT PERSON N r—
(�i k Et' S. >I fl�th o'n c t n
Name:
Name: 50hn Clnurelni 11 P:�.
t
-- 1 C Et�Stnee citnq 1nC
Address: 51 C-fte-CS00 ay
CenF_2cvil 1epq 32--- Address: 265`f Cfpol�0(e-tf i13 Cw ,
HA 02539
Phone: 8`15- 33 9- 2 l I b
Phone: 500 -2.-13 -0377
VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed)
310 awa is,7-0 7,6 tuor,•5e4back Eron{ PL 10 ere . Leach. Eaciliiy S;-ze of 1eaelnc,1
5 (acililr 10 GHR 15, ( see jacl�ed elon
211 se{9,7 uor.� ta, Cel1o� wall 1u p,ap,�e ac_h_Foci I StZe 6 F It.(: in
� F'Vc.ilAt��ee aF+atCl�ec{ lan�__f0{�Chap.]Ij 5¢t{.31 `/,0 yar. se loocicQ,�-ank Fo w k1nnAS see AfIQclne_d OI Ctfl �—
;
NATURE OF WORK House Addition 0 ????? House Renovation 0 Repair of Failed Septic System
Checklist (to be completed by office staff-person receiving variance request application)
Please submit copies in 4 separate completed sets.
Four(4)copies of the completed variance request form
Four(4)copies of engineered plan submitted(e.g.septic system plans)
Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
Signed letter stating that the property owner authorized you to represent him/her for,this request
Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense
(for Title V and/or local sewage regulation variances only)
Full menu submitted(for grease trap variance requests only)
C:\Documents and Settings\decollik\Local Settings\Temporary Internet Fi1es\0LK3\VARIREQ.D0C
t-4 y ll M- �t �t�s
I
Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same
owner/leasee only], outside dining variance renewals [same owner/leasee only], and variances to repair failed sewage disposal systems
[only if no expansion to the building proposed])
Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED Susan G.Rask,R.S.,Chairman
MAIL-IN REQUESTS
NOT APPROVED
Sumner Kaufman,M.S.P.H.
REASON FOR DISAPPROVAL
Wayne A.Miller,M.D.
Please mail,the completed variance application form to the address below. Also include four
copies of engineering plans, house plans, authorization letter, etc (see check-list below). In
addition, please include the required fee amount (see fees at bottom of this page). Make $85.00
check payable to: Town of Barnstable. Our mailing address is:
Town of Barnstable
Public Health Division
200 Main Street
Hyannis, MA 02601
Checklist
Four(4)copies of the completed variance request form
Four(4)copies of engineered plan submitted(e.g.septic system plans)
Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
Signed letter stating that the property owner authorized you to represent him/her for this request
Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense
(for Title V and/or local sewage regulation variances only)
Full menu submitted(for grease trap variance requests only)
$85.00 variance request application fee (no fee for lifeguard modification renewals, grease trap variance renewals [same
owner/leasee only], outside dining variance renewals [same owner/leasee only], and variances to repair failed sewage disposal systems
[only if no expansion to the building proposed])
Variance request submitted at least 15 days prior to meeting date
FOR FAXED REQUESTS
Our fax number is (508) 790-6304. Please fax a completed application form.
Also, you must mail the required -$85.00 fee. Please make the check payable to: Town of
Barnstable. The check must.be mailed to the address listed above. In addition, please mail four
copies of engineered plans, house plans, authorization letter, etc. (see check-list below):
Checklist
Four(4)copies of engineered plan submitted(e.g.septic system plans)
Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
Signed letter stating that the property owner authorized you to represent him/her for this request
Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense
(for Title V and/or local sewage regulation variances only)
Full menu submitted(for grease trap variance requests only)
$85.00 variance request application fee (no fee for lifeguard modification renewals, grease trap variance renewals [same
owner/leasee only], outside dining variance renewals [same owner/leasee only],and variances to repair failed sewage disposal systems
[only if no expansion to the building proposed])
DATE:
FEE:
REC. BY
SCHED. DATE:
Variance request submitted at least 15 days prior to meeting date
For further assistance on any item above, call.(508) 862-4644
Back to Main Public Health Division Page
C:\Documents and Settings\decollik\Local Settings\Temporary Internet Files\OLK3\VARIREQ.DOC
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LETTER OF TRANSMITTAL
JC Engineering Inc.
Civil&Environmental Services
2854 Cranberry Highway Telephone: 508-273 0377
E.Wareham,MA 02538 Facsimile: 508-273-0367
TO: Town of Barnstable _ DATE: 11/30/04 JOB NO. 756
Board of Health RE: BOH Variance Package
200 Main Street 51 Emerson Way,Centerville
--- - - - -
Hyannis,MA 02601
WE ARE SENDING YOU: X Enclosed _ Under separate cover via X the following:
Report _Prints _Brochures Shop Drawings
Specifications —Copy of Letter —Change Order Forms
Please find enclosed the following for your review and approval: 1 ) four copies of completed variance
request form 2.) four copies of septic system design plan dated November 29 2004 3 )four copies of
labeled dimensional floor plans 4)one signed representation authorization letter, and one check for$85
(variance request fee).
THESE ARE TRANSMITTED as checked below:
X For Approval _Resubmit Copies for Approval
c= -:7
For Your Use Approved as Noted ="
_ PP Copies for Distribution _
i7l
As Requested _Returned Approved as Submitted
Returned _For Review and Comment For Your Information
REMARKS Should you have any questions,please feel free to contact our office.
Also,we understand the hearing date and time is scheduled for December 21 2004 providing that abutters
receive notification of the hearing at least ten days prior to hearing date. Please call our office to confirm
Thanks.
COPY TO: File(1) SIGNED:
Michael Pim nt I, E.I.T.
Peter J. Levin
51 Emerson Way
Centerville, MA 02632
November 16, 2004
Board of Health
Town of Barnstable
200 Main Street
Hyannis, MA 02601
RE: Declaration of Authorization
Dear Members of the Board:
Let it be known that,I, Peter J. Levin, do hereby authorize JC Engineering, Inc. of East
Wareham, MA 02538 to represent my interests regarding the upgrade of the sewage
disposal system located at 51 Emerson Way, Centerville, MA in meetings both public
and private.
Sincerely,
Peter J. Levin
W:UOBS-ACTIVE\756-51 Emerson Way(Levin)\Board of Heal th\AUthorization Letter.doc
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A ,ignat
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. 7�F3eceived b (P'n d Name) ECI. Dajte�o"eli e
■ Attach this card to the back of the mailpiece, p ; ,14 1-2,
or on the front if space permits. L
D. Is delive ddress different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑ No
t,
Cheryl Heinzmann
39 Emerson Way 3. Service Type
Centerville, MA 02632 ❑certified Mail ❑Express Mail
❑ Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number i i i 7 0�j4 1 6:..i p`p p 3 7 3 711�6 6�r 7 9 �58
(Transfer from service label)I s
PS Form 3811, February 2604 'Domestic Return Receipt 102595-02-M-1540
I
UNITED STATES POSTAL SE E,1� � lrst_Cl s
� U -
�\' �r� , 'gPostagez&..Fees Paid
c a_ x=• =Permit No G-10°
I • Sender: Please p'M t. 6&name, address, nd-ZTP+4-unrthis'b6x'
I I
I �
i
I
I )C Engineering,Inc.
E 2854 Cranberry Highway
East Wareham,Ma 02538-1314
.ia►l:tiii•[Fa►[r6ilit[i�if[1I:IIIFi14f.46li1llft[1[[i.![i,a%{si)
COMPLETE /N COMPLETE THIS SECTIONON DELIVERY
5A. ignature
■ Complete items 1,2,and 3.Also completeitem 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse /1i ❑Addressee
so that we can return the card to you. ived by( rinted Named C. Date of Delivery
■ Attach this card to the back of the mailpiece, oG"
or on the front if space permits. Snt u0 17"
D. delivery address differentYrom item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
i�t I
Jan Malaspino
-, ong
88 Longfellow Drive
a
Centerville, MA 02632 3. Service Type
❑Certified Mail ❑Express Mail
l ❑ Registered ❑Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number I s;; `; Tom"--
(Transfer from service fa' 1'!: 7 0 0'4!i 11+6 0 t 0 0 0 3' 7 3 7y1 ;6 7'd 9"
PS Form 3811;February 2004 j 1 ,Domestic Return Receipt 102595-02-M-1540
■a.
UNITED STATES POSTAL SERVI Q MAI O ^--
�'
o t ,
• Sender: Please priat'"Z e, address, and ZIP+4 in this box •
!C EAgineeriem Imei.
2854 Cranberry MOM
East Wareham,Ma 02538.1314
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. X ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. Received b Printed Name) C. Date of Delivery
■ Attach this card to the back of the mailpiece, e O /J
or on the front if space permits. /y
._ D. Is delivery address different fro item 19 ❑Yes
1. Article Addressed to: If YES,enter delivery addFesskelow: ❑ No
w
IEBox200
Kdaren Rodman r�
' 3. ServiceTypee, MA 02632 ❑Certified Mail Cpt
❑Registered et Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number. }
(rransfer from service label)4 { t 7 0 0 4 [1, 0 j Q 0 3;(7�3 71 i E?6 8 6 j i j 17B44/
BPS form,381{1',tFeb�uary 2004Form,381{1',tFeb�uary 2004 { Domestic Return Receipt _to25s5-o2-M-t54o
UNITED STATES POSTAL SERVICE First-Class Mail
I Postage&Fees Paid
LISPS
Permit No.G-10
E • Sender: Please print your name, address, and ZIP+4 in this box •
I
I 1C Engineering,Inc.
2854 Cranberry Highway
East Wareham,Ma 025384314
I
I
I
I
I
I
I
I
COMPLETETHIS SECTION • • ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. gent
■ Print your name and address on the reverse X C ❑Addressee
so that we can return the card to you. fReTived by(Printed N e) C. Date of De ivery
I ■ Attach this card to the back of the mailpiece, JLif Liti ������ �,
or on the.front if space permits.
D. Is delivery addrLKs different from item 11 ❑Yes
i 1. Article Addressed to: If YES,enter delivery address below: ❑ No
I _
James A. Jenkins TR
Jenkins Nominee Trust
I227 Pine Street 3. Service Type
❑Certified Mail ❑Express Mail
West Barnstable, MA 02668 ❑ Registered ❑Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
I 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number r
(Transfer from service/abe!)� j (� 7 p 4t j 1`16 0;j0 0 03 17 3 f71j 6 91',4 [�j� � i � �p�.
PS Form 3811;February 2004 Domestic Return Receipt 102595-02-M-1540
I
UNITED STATES POSTAL SE pq
� k»Cdaeshl�ih
7�3
gos11S'1s -Fees Paid
Permit N.O.G-10
• Sender: Please print,your pane, address, and ZI04in this box •
I
I
_ I
I
• JC�ngia�ring,9nt' I
-2. 854 Cranberry Highway
'68t Wareham,Ma 02538-1314
I
I
1�{tflli�t�P�I�Itf��f�l!li71l11{Il�ilff�ii'=Ilf�lllflld�l�t9�l
COMPLETE •
■ Complete items 1,2,and 3.Also complete A. Sign t S
item 4 if Restricted Delivery is desired. X �O Agent
■ Print your name and address on the reverse ddresse
so that we can return the card to you. nt Name) C. Dated{Delivery
■ Attach this card to the back of the mailpiece, d
or on the front if space permits. VT
D°Is delivery address different from R ❑Ye
1. Article Addressed to: "}" If YES,enter delivery address below. �/ ��d_
ta:"bS " e
;r
Richard J. Ryan TRS F=
Peter E. Ryan Trust
54 Westlake Road ` 3. service Type
� 1 ❑Certified Mail ❑Express Mail
I Natick, MA 01760 ❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
dl}►gv?ice lafm L1,I
E 0 4 1 -0 _- 7 7 6808 k3d
PS Form 3811,February 2004 k+ Domestic Return Receipt 102595-02-rot-1540
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
• Sender: Please print your name, address; and ZIP+4 in this box •
IC Engineering,Ina.
2854 Cranberry Highway
East Wareham,Ma 02538-1314
i
I
I
I
Qi III#Iitdifil`iifif11111 ills I flit'flit if III III iit)iIs1111fiiii
0
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
FAILED INSPECTION RECEIVED
SEP 2 12004
RNSTABLE
TITLE 5 TOWHE�ALTBH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: J ,v, -Qr1ovj Lze.v4 MP �C
e
Owner's Name: L e,v1&i DARCEL,
Owner's Address: AA ✓ 00--ro wo► rJ" e
Date of Inspection:
Name of Inspector.(please print)
Company Name: &*Vi o—
Mailing Address: io,x /a qy
EA,! o► t�6��
Telephone Number{ a cftf
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on tray
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 15.0001 The system
Passes
CondifiGnally Passes
Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: o Date: 9 a- O
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,M0
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments /
6?
hex he-dam /
****This report only describes conditions at the time of ins
pection at that
time,This mvpttgn does gotaddreis how the vy!ctem will perform m 6e future under under the 'th�.name s of �r different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR-VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 4�57rv'td-4 C-ra
Owner: Z—C vi
in
Date of Inspection:
Inspection Summary: Check A 4C,D or E/ALWAXs complete all of Section D
A. System Passes:
&/`l'
have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 pr in 310 CMR 15304 exist.Any failupe criteria not evaluated are indite below.
Comments:
H. System Conditionally Passes:
�Oae or more system components as described in the"Conditional Pass"section need to be replaced �
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will
pass.
Answer yes,no or not determined(Y.N,ND)in the for the following statements,If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltmtlon or tank failure is imminetit System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Hoard of Healthh.
A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box doe to broken or
obstructed pipe(s)or dare to a broken,settled or uneven distribution box.System will pass inspection if(with
of Hoard of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
G
page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(comwued)
Property Address: S� 5(/yj?, J, vvLL__
Owner: Levi h
Bate of Inspection: q t
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to d
is failingio protect public-health,safety-or the environment. etermme if the system
L System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is"functioning In a-manner which will PJWW public,he&h,-safety aed the environment:
_ Cesspool or privy is within 50 feet of a surface water
— Cesspool Of privy is within 50 feet of a bordering vegetated wetland or a sak marsh
2. System will fail unlem the Board of Health(and POW 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)aad the SAS is within t00 feet of a
surface water supply or tributary to a surface water supply.
— The system has aseptic 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 WOW laboratory,for coliform
bacteria and volatile organic compoundsindirates that the well isfree from
of ammonia nitrogen and nitrate nitro
the presence pollution from that facility and
failure criteria are tri reel,A c ���to or less than S PM provided that no other
copy of the analysis must be attached to this form
3. 9ther;
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: J� �N 0�I W�i 1�
Owner: v'h
Date of Inspection: 9 d
D, Sy0em Failure Criteria applicable to all systems;
You must indicate`yee or"no"to each of the following for all inspections:
Yes N
-� P,of sewage into facility or system componentdue— — or n urf
to overloaded or clogged SAS or cesspool
po ding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
c liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
�ol
qWj�dpth in cesspool is less than 6"below invert oravailablevolumeisless than�/1�1�8 more than 4 times in the last year NOT due to clogged or z day flow
V/ of times P mped °� o �PiPe(s).Number
—!C M'lmIMY�ion of��cesspool m PM is below high ground water elevation
cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
- �ater supply.
portion of a cesspool or privy is within a Zone 1 of a public welL
— portion Of a cesspool or pdvy is within 50 feet of a private water supply
_ T Any portion of a cesspool or privy is less than 100 feet but well.
supply well with no acceptable water lk�ter than 50 feet from a private water
quality analysis.JTWS system passes if the well water analysis,
performed at a DEP certified laboratory,for coldorm bacteria and
indicates that the well is free from pollution from that f n volatile organic compounds
ac�7ity and the presence ammonia
nitrogen and nitrate nitrogen is equal to or legs than 3 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this for aLl
illy es/No)The system tl,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 1A,01lq gpd to 15,4(NI
bPd
You must indicate either``yes"or"no"to each of the following;
(The following criteria apply to large systems in addition to the criteria above)
yes no-
-
the system is within 400 feet of a surface drinking water supply
_, the system is within 200 feet of a tributary to a surface dunking water supply
system is located in a nitrogen sensitive area(Interim Wellhead protection Area-IWPA)or a mapped
7.one It of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a si
"yes" in Section D above tb-c tar pe scant threat,or answered
large system bps failed The owner or o rator of any large systertt considered a
significant threat under Section E or failed under Section D shall u
15.304.The system owner should contact the a Pfrtc the system in accordance with 310 CMIt
appropriate regi Va office of the Department.
Page 5 of It
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: -P �i1�12rSo.1 q
Owner. v�
Date of Inspection: p
Check if the following have been done.You most indicate es"or"no"as to each of the followin
Yes No /
— — PumPing information was provided by the owner,occupant,or Board of Health
ere of the
a°)' system components Bumped out in the pnwious two weeks
— —vel Fia.
system received normal.now&is the paevious two week period
®cvolmea�arafer-been-i ced to-thesystem nexntiyaraspartofIbisinspection— built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signsof sewage
back up
Was the site inspected for signs of break out
7 Were all system components,
excluding the SAS,located on site
Were the septic tank manholes uncovered, and the'
Of es or tees,material of co o�n�' interior of the tank inspected far the c�nditien
v dimensions,depth of liquid,depth of sludge and depth of scam
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsuiflicc sewap disposal Sys=
The size and locadon of the Sal Absorption System(SAS)on the site has been determined based on
Yes
&1:ldsting information.For example,a plan at the Board of Health
L — Determined in the field(if any of the faihue criteria related to part C is at
is unacceptable)P 10 CAjR 15.302(3)(b)] rssrre approxunaUon ofance
7.
page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
G
Property Addmn: rG►y lPerO" (WA
�ef--nzee a va s
Owner.
Date of Inspection: ,Z
$ESIDLNITAL FLOW CONDITIONS
Number of bedrooms(design):'? Number of bedrooms(actual):
DESIGN flow based.on 310 CMR 15.203(for example: i to gpd x#of bedrooms): 3�T�
Number of current residents: / _
Does:+esidenoe have a garbage grinder(Yes or no):
Is laundry on a separate sewage system(Yes no):-&[if yes separate inspection
Laundry system inspected(yes no): l
Seasonal use:(yes or no):
Water meter readings,if a(last 2 years usage(UM)
Sump pump(yes or no): XIA
Last date of occupancy:
COMMERCULANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): and
Basis of design flow(seats/personstgketc.):
Grease trap present.(Yes or no):—
Industrial waste holding tank pmSent(yes or no):
Non-sanka y waste discharged to the Title 5 system(yes of no):_
Water meta readings,if available:
Last date of occup o yAm:
OTHER(describe):
Pumping Records. GENERAL INFORMATION
Source of information: A/
Was system pumped as part of the Wection(yes or no):
If yes,volume pumped:�jlons-How was
Reason for
quantity Pumped determined?SYSTEM
tank,distribution box,soil absorption system
Single cesspool
—Overflow cesspool
—Privy
_.Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and fiance contract(to be
obtained from system owner)
--Tim tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components date installed(if known)and source of i on:
X1%
Were sewage odors detected when arriving at the site(yes or no):1/v
P
Page 7 of It'
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
✓i i,�r lt� i4 Od'��
Owner. Lev,
Date of In ,p
BU&DI NG SEWER(locate on site plan)
Depth below grade: �Lc Materials of constnutio _castron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting evidence of leakage;etc.):
SEPTIC TANIG_(locate on site plan)
Depth below grade: f a-
Material of suction: _metal fiberglass_polyethylene
—other()
if tank is metal list age:_ Is age confirmed by a Certificate of
certificate) 1, Compliance(yes or no):_(attach a copy of
Dimensions:
Sludge depth:
r
sf from top of slndIF to bottom of outlet tee or bale:
Scanr thicimess: A
Distance from top of scum to top of outlet tee or baffle: �o
Distance from bottom of scum to bottooutlet tee or bale:
How were dimensions determined; A a -t/i C�
Comments(on pumping recommendations,inlet and outl tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence lea?C,etp,);
Z
// G o�'nehr,, 11
Ore ��✓hrTi^f 4o +hiJ 4o.�+`✓
GREASE TRAP: on site plan)
Depth below grade:_
Material of comstructiom:_concrete metal_ � polyethylene_other
(explain): —
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or bale:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping
Comments(on pumping recommendations,inlet and outlet tee or battle condition,Anictural integrity as related to outlet invert,evidence of leakage,etc.): lh',liquid levels
1 Y /
page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: / Eivr.s oh ovC4
Owner:
Date of Inspection:
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_polyeftlene der( n).
Dimensions:
Capacity: �llons
Design Flow: aalla+dday
At present(yes or no):
Alarm level: Alarm in working order(yes or noy
Date of last pumping:
Commends(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: E/of( present must be opened)(locate on site plan)
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: oogte on site plan)
pumps in working order(yes or no):
Alarms in worldng order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: r 0 cn L✓`G t
Owner:
n—&
Date at Inspection: 9
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not require
If SAS not looted explain why:
Type
leaching pits,number:
leaching b a i ,member:
1 galleries,number.
benches.member,laq*
leachmgfields,mmAw,din� caoxJo �(
overflow cesspool,num>rer:
imavadvelaltern'&e stem Typethame of technology:
Comments(note condition of soil,signs of hydraulic failure,level of n
eta): PoP mil,condition of vegetation,
"� „mil So,' Cr'euti col �r /L0
CESSP0013:-IL(cesspool must be pumped as part of inspection)0ocate on site plan)
Number and configuration:
Depth—top of liquid to inlet imvert:
Depth of solids layer.
Depth of scum layer.
Dimensions of cesspool:
Materials of consdniction:
Indication of groundwater inflow(yes
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:&O`ocate on site
plan)
Materials of conyuuction;
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
f
page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continuo
property Address: 5� z-�,Vrf-o,-q
Owner: Levf�l '" .q
Date of Inspecdon:
SKETCH OF SEWAGE DLSPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building,
�L
V
r r
< r I(
r t
r t
SEW A-CAE-RE-R MIT M-O.-
�-U 1_L_D=E-R-S--�/��►v-1 E:---ADD-R E-SS
DATE PE-R-"--1T-1_SSUED
D AT_E-CO M.P 1.l_Q,.1`1 CE-i_SS-U-EFL:- � -
r7
f
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C.
..,/ /SYSTEM INFORMATION(contim,ed)
Pr%mty Address: CV64 )
Owner: 4tvj n
Date of Inapection:
SITE EXAM.
Slope
Surface water
Check cellar
ShaIIow wells
Estimated depth to ground water_✓_:z feet
Please mdkwe(check)all methods used to determine the high wound water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed
rp Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Healtl"Vlain:
Checked with local owavators,installers-(attach documentation)
Accessed USGS database-explain:
You 1sd desgn how you establishthe high ground water elevation /
L/N a �F N . eo N 11C' 1✓4 ✓.
0 0
Oi f 9 S is Ae&
4NVO?9 ot �0
3� Al
EXISTING GENERAL NOTES
C.I. PIPE PROVIDE PRECAST CONCRETE EXTENSION FINISH GRADE OVER D-BOX= 103.5'±
1. UNLESS OTHERWISE NOTED ALL SYSTEM COMPONENTS AND CONSTRUCTION
TOP OF FOUNDATION = 103.3' RISER WITH CONCRETE COVER TO WITHIN o FINISH GRADE OVER LEACHING FIELD= 102.8' - 104.0' METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE 6"OF FINISH GRADE OVER OUTLET COVER REMOVABLE COVER TO 4 SCHEDULE 40 PVC MIN. SLOPE 1 /o °
2"SCH.40 WITHIN 6"OF GRADE SLOPE @ 2/o MIN. OVER SYSTEM ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES.
FINISH GRADE @ FND. EL.= 100.3' FINISH GRADE OVER TANKS EL.= 99.3' TO D-BOX 5" DIA. OUTLET(S) 3/4"TO 1-1/2" DOUBLE WASHED STONE TO CROWN OF PIPE 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD
20" MIN. ACCESS COVER I 1 2"OF 1/8"TO 1/2" DOUBLE WASHED STONE OF HEALTH AND THE DESIGN ENGINEER.
13FE=100.0'± (TYPICAL FOR 3)� ss•MAx. 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL
BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED.
- 4"SCH. 2"PVC TEE 36"MAX. 4" PVC PERFORATED PIPE 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
LLLi- 3 3' 40 PVC SLOPE AT 0.50% TOP OF S.A.S. = 101 .83 - 101 .98 9"MIN. ELEVATION = 102.48 FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS.
[- N z36' MAX. UNLESS A 40 MIL GEOMEMBRANE LINER IS PLACED AT LEAST FIVE FEET FROM S.A.S.
SLOPE 1%min. '
o - L=5't _ 4" PVC OUT TO 101 .33' AND THE TOP OF THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
I, END CAPS 1 0°/
LEACHING FACILITY
INV(Out)= ALARM ON I tir.. },- -
T 5. SLOPE ALL SOLID PIPE AT o MINIMUM.
EXIST. Cl PIPE I LIQUID 4
0 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
LEVEL 96.$8' --� INLET TEE �'` ` 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO 96.80' UMP ON o '
INV(in)= N I6° 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BACK FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR
97.45` - L � 92.55 P�F�
101 .69' 101 .52' i INSPECTION. SYSTEM IS NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING
ITOUTLET TEE INSTALL " o 0 96.55' Na� 6"CRUSHED STONE ._ I v. 6" EFFECTIVE DEP H g. AOT ONS BASED ON ASOSUMED DATUM OFS1 0 OONOBTAINEO FROM A
APPROVAL
1 .
_ ELEV
GAS BAFFLE 6 CRUSHED STONE o OVER MECHANICALLY
NAIL IN PAVEMENT ON EMERSON WAY AS SHOWN ON PLAN.
22 ZABEL FILTER 101 .48 BOTTOM OF FIELD TO BE LEVEL EL. _ "100.83' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
OVER MECHANICALLY `- `- COMPACTED BASE
MODEL#A1801 HIP (GAS BAFFLE
BAFFLE ON BOTTOM COMPACTED BASE 5'.
1.5' 6' 6' 1
5 OUTLET DISTRIBUTION BOX THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE
EXISTING 1000 GALLOi i a i� i ;-ANK 1000 GALLON PUMP CHAMBER TO BE INSTALLED ON A LEVEL STABLE 30' 15' AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY
BASE. FIRST TWO FEET OF OUTLET
DISCREPANCIES TO THE DESIGN ENGINEER.
* MOLD PRECAST TANK WITH RUBBER PIPES TO BE LAID LEVEL. GROUND WATER GASKET FOR INLET AND OUTLET ELEV.= *95.83' 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE
PUMP CHAMBER SHALL BE INSTALLED ON A LEVEL STABLE BASE STRUCTURES SHALL BE MADE WATERTIGHT.
KNOCKOUTS. INSTALLER TO ALSO 5' MIN. 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR
EXISTING 1000 GALLON SEPTIC TANK & USE HYDRAULIC CEMENT AT JOINTS CROSS SECTION VIEW TYPICAL FIELD PROFILE ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH
PROPOSED 1000 GALLON PUMP CHAMBER TO ENSURE WATER TIGHTNESS. DISTRIBUTION BOX DETAIL FIELD DETAILS FIELD END VIEW
USED CAPE COD COMMISSION DETERMINATION FROM APPROPRIATE AUTHORITY.
NOT TO SCALE NOT TO SCALE
CORRECTION FACTOR OF 5.50' 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
(SEE TEST PIT DATA BELOW) LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE
♦ r • r THEY SHALL BE WITHSTAND H-20 LOADING.
NOTE: DESIGN DATA . • � , - . ' TEST PIT DATA 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND
N. ENTIRE PROPERTY IS NOT LOCATED WITHIN A DEP APPROVED ZONE II + '+ • FINES.
AND IS NOT LOCATED WITHIN TOWN DESIGNATED ZONE OF CONTRIBUTION. ; II IS ram„ . . _1� AGENT: David W. Stanton, R.S.
NUMBER OF BEDROOMS (DESIGN) 3 ' • ' / ♦� 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND
DESIGN FLOW 110
Jr MafC , EVALUATOR: Michael Pimentel, E.I.T. UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF
GAUDAY/BEDROOM November 9 2004
TOTAL DESIGN FLOW 330 GAUDAY D ++ • • DATE: LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN
`"�"� ' • TEST PIT#: 1 COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN
DESIGN FLOW X 200 % = 660 GAUDAY • • +•M • ACCORDANCE WITH 310 CMR 15.255(3).
w.<y E. • ELEV TOP= 100.00,
USE EXISTING 1000 GALLON SEPTIC TANK • 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
0. r
A * # • ❑ I ELEV WATER= 95.83' SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
INSTALL 15' x 30' LEACHING FIELD ron • f PERC RATE _ <2 min/in 16. PROPOSED PROJECT IS LOCATED WITHIN:
U) MAP 188 MAP 188 a . ASSESSORS MAP 188 PARCEL 25
LLI PARCEL 16
PARCEL 14
'IT N/F -N/F RYAN DEPTH OF PERC= 32" 50"
� NlFMALASPINO SIDEWALL CAPACITY .�_ � • 8n r
r OWNER OF RECORD: PETER J. &ANTHONY F. LEVIN
cc NO SIDEWALL AREA CREDIT TAKEN . •
N TEXTURAL CLASS: 1
MAP 188 ADDRESS: 51 EMERSON WAY
d PARCEL17 BOTTOM CAPACITY CENTERVILLE, MA 02632
S J N/FKELLEY LENGTH x WIDTH 74 GPD/S.F. = GAUDAY 0 ♦ • gyp~ 0 Loam 100.00'
( ) (� ) 0 0 • 4" 99.6T FEMA FLOOD ZONE C
C?J (30'x 15') (.74 GPD/S.F.) = 333.0 GAUDAY • •• "� ( 8" Fill 99 37' AS SHOWN ON COMMUNITY PANEL# 250001 0015 C
MAP 188 , • • „ • • Y 17. PLAN REFERENCE:
PARCEL 15
TOTALS. A
" Sandy
10YR 3/6 m
13 98.92' 1. 24614-E (SHEET 2)
♦ • " •
N/F O'NEILL w
EMERSON WAY CONTRACTOR TO VERIFY LOCATION OF TOTAL NUMBER OF LINES: 2 • , �� B Sandy Loam ,18. DEED REFERENCE:
EXISTING WATERLINE AND MAINTAIN 10' TOTAL LEACHING AREA: 450.0 SQ.FT. ` 10YR 5/6 1. DOCUMENT#132389
(40'WIDE LgYOUT) `� 20'� Coarse Sand 98.33' 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
MIN. FROM PROP. LEACHING FACILITY. TOTAL LEACHING CAPACITY: 333.0 GAL./DAY
B.M. v ' C-1 2.5Y 6/6 20. PROPERTY LINE INFORMATION IS APPROXIMATE, ONLY. THIS PLAN IS TO BE USED ONLY
Nail in Pavement I _ - - � 10%gravel
Elev. = 100.00' EXIST. DMH ❑ _� ____ _� �,;�, 32" 97.33' FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
EMEND - 1- sHRuss ❑ SHRUBS DOSING & STORAGE REQUIREMENTS Q Perc :rJ FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE.
pA a . . �, Adj. GW Elev.@50" .. . ,
(Assumed) ,,, R 15.431 THE iFOLL.VAYING LOCAL UF'GRAD2
QGE�% � W A R=255s3REF � � / DOSING REQUIRED: 4 Y 330GPD p � � o - �` 50 4�i Rom' `.� I. C�•�* r r • ••• F i-.
EXIST. DMH E • APPROVALS ARE REQUESTED:
Q CYCLES /DAY
--100- HRUBS N t ' ❑ 0' PROPOSED PVC VENT 330 GPD/4 =82.5 GAUCYCLE , -- C-2 Fine Sand (1.) A 4.6'VARIANCE (10'-5.4')FOR THE SETBACK FROM THE FRONT PROPERTY LINE
W a ,�u 2.5Y 3/6
�'THE ��, � `,, qQ .. I~. TO THE PROPOSED LEACHING FACILITY.
I , PROPOSED 15' x 30' LEACHING FIELD. CONTRACTOR SHALL - -
I a , ° �-' DISTANCE REQUIRED BETWEEN PUMP ON AND + , . . , (2.) A 9.7 VARIANCE (20 - 10.3') FOR THE SETBACK FROM THE EXISTING CELLAR WALL
EXIST. CB � � ❑ i4•oAK m RESTORE EXISTING LANDSCAPING AND/OR SPRINKLER - ( TO THE PROPOSED LEACHING FACILITY.
® O TP 1 U � 3 '' �� SYSTEM TO ORIGINAL CONDITION OR BETTER. PUMP OFF FLOATS: � ... � �'`�� '�� �.ak._ 1. Standing Water 116„
\ 30.0' 116" 90.33'
O 100x0 W 3��,0 ❑ ih 82.5 GAUCYCLE / 250 GAUFT = 0.33 FT/CYCLE " 22. THE FOLLOWING LOCAL VARIANCE IS REQUESTED:
�\ ' o� '� o PROPOSED DISTRIBUTION BOX (USE 0.40'TO PRDVIDE FOR 12 GALLONS OF BACKFLOW) ( 120 90.00' (1.) A 34.0'VARIANCE (100'-66') FROM THE MINIMUM SETBACK OF 100' FROM THE
\ m a0p°' 4� �• AK --PROPOSED GEOMEMBRANE LINER (40 MIL) ' PROPOSED SEPTIC TANK TO EXING WATERCOURSE_ USGS LOCUS --- --_IST T OURSE(i.e. EDGE OF BANK).
---- - ---
STEPPING STONE (TYP) \ USHRUBS #51 c -2-FT OVERHANG STORAGE REQUIRED ABOVE WORKING LEVEL: 330 GAL. *Used Cape Cod Commission Correction Method LEGEND
w STORAGE PROVIDED ABOVE WORKING LEVEL: 650 GAL. SCALE: 1" = 1000'
EXISTING 100' BANK OFFSET 1.) Measured depth to water table=9.66'
� 3-BEDROOM „ S€- - 50 - EXISTING CONTOUR
EXISTING GAS METER \ N 2A.)Approximate Index well=MIW-29
GARAGE--. -"' DWELLING s - 2B.)Water-level range zone=D
W/LOFT TOF=103.3' MAP 188 ,� 3.) Depth to water level for index well=9.04(10/04) 50 PROPOSED SPOT GRADE
EXISTING WATER METER 4.) Water-level adjustment=5_5'
� ABOVE BFE=100.0 NSTALL 1-1/4 PVC TO HOUSE. JOINTS TO BE MADE E03 PROPOSED CONTOUR
� PARCEL 24 5.) Estimated depth to high water=4.16'
ECK N/F RODMAN WATERTIGHT. WIRE PUMP AND FLOATS TO SIMPLEX
MAP 188 NpER�GK CONTROL PANEL No. 1-CC2 NEMA-1 MFG. HOOVER E/T/C EXISTING OVERHEAD UTILITIES
PARCEL 26 NSTRUMENTS.
N/F HEINZMANN 16"OAK
WALK �niSTING 1000 GALLON SEPTIC TANK TO BE W W - EXISTING WATERLINE
NEMA 4 JUNCTION BOX CORROSION RESISTANT HOISTING CABLE 7 x 19 STAINLESS STEEL
I9°OAK T00� UTILIZED AS PART OF THIS SEPTIC DESIGN. & LIQUID-TIGHT CABLE CONNECTORS 1/8"DIA./ 1,760 LB. STRENGTH
E}<IcTl�'G SHED !z"'('!FR I�FCK ° 40 FM GAS EXISTING GASLINE
2" SCH, SUPPORTED CONNECTORS SUPPORTED BY 1-1/4"
PVC CONDUIT, JOINTS TO BE MADE WATERTIGHT 2"BALL VALVE w/ UNIONS SCH. 80 PVC TEST PIT LOCATION
EXISTING CLOTHES LINE POLE PROPOSED HAYBALE LINE GEORGE FISHER CO. MODEL NO. 560
- Cn lo n O EXISTING 1000 GALLON SEPTIC TANK
PROPOSED 1000 GALLON PUMP CHAMBER -916 MAP 188 �98� EXISTING 20' x 30' LEACHING FIELD (LOCATION PER ASBUILT - 3.. __� 2"SCH.40 TO D-BOX
cor 13"OAK � ON FILE WITH THE BARNSTABLE BOARD OF HEALTH) o � o
F O PROPOSED 1000 GALLON PUMP CHAMBER
PARCEL 25 -' OLD PRECAST TANK WITH RUBBER
� cfl k0 ALARM ON
11,325 S.F. + 13 OAK 25" OA °' N GASKET FOR INLET AND OUTLET 4"SOLID SCHEDULE 40 PVC PIPE
d UMP ON o KNOCKOUTS. INSTALLER TO ALSO USE 2"SOLID SCHEDULE 40 PVC FORCE MAIN
04
HYDRAULIC CEMENT AT JOINTS TO ENSURE
�g6 L=50.36 _= N88°20'10"W L=` 5 90, PUMP
I o 1 WATER TIGHTNESS. -
4„ PERFORATED SCHEDULE 40 PVC PIPE
R=205.24 40.15' R=128.23
�96- (2)WIDE ANGLE CONTROL FLOATS "SCH. 40 TEE w/CLEAN-OUT CAP 13
DISTRIBUTION BOX
MAP
(BARNES 073618) o v 2"BALL CHECK VALVE SCH. 80 PVC 100 i
R L 45 1: PUMP ON/OFF 120 ACTIVATION P.S.I. FLOWMATIC MODEL No. 208S EXISTING LIGHT POST
}
N/FJENKINS - 1-94' 2: ALARM ACTIVATION 1/4"WEEP HOLE IN DISCHARGE PIPE OD EXISTING DRAIN MANHOLE
TkNK TO BE WATERTIGHT CERTIFIED BY 2"SCH.40 PVC DISCHARGE PIPE ® EXISTING DRAIN CATCH BASIN
_ -92---- MANUFACTURER (ACME PRECAST OR BARNES SE411 PUMP, 0.4 H.P., 115 V, 1750
EDGE OF B� =0==- -O- ----4� A�ROVED EQUAL). RPM, 2" DISCHARGE PASSING 1-1/2"SOLIDS REV. DATE BY APP'D. DESCRIPTION
EDGE OF BANK FLAGGED BY HORSLEY WITTEN BANK 04 BANK 05 BANK 06 _._ _
�'9 ANK 03 (IMP. DIA. 4.25")OR EQUAL -
GROUP COMPLETED ON OCTOBER 12, 2004 PROPOSED SEPTIC SYSTEM UPGRADE
��,,� i BANK 02
i
PREPARED FOR:
BANK01 1000 GALLON PUMP CHAMBER PETER J. & ANTHONY F. LEVIN
_,.,--EXISTING ACTIVE CRANBERRY BOGS_ - - - -- - - - LOCATED AT
BUOYANCY CALCULATIONS RESERVED FOR
BOARD OF HEALTH USE 51 EMERSON WAY
H-10 1000 GALLON PUMP CHAMBER: CENTERVILLE, MA 02632
HIGH GROUNDNATER EL.= 95.83'
BOTTOM OF PUMP CHAMBER EL. =92.30' j SCALE: 1 INCH = 20 FT. DATE: NOVEMBER 29, 2004
WATER DISPLACED =(95.83'-92.3')x 4.8'x 8.5' = 144.02 C.F. i 0 10 20 ao so FEET
WEIGHT OF DISPLACED WATER= 144.02 C.F. x 62.4 LB/C.F. =8,987 LBS �� �"OF�`" �
WEIGHT OF H-10 1000 GAL. PUMP CHAMBER=8,300 LBS. •? JOHN L. PREPARED BY:
WEIGHT OF SOIL= 8.5 x 4.8 x 1.3'= 53.04 C.F. x 110 LB/C.F. =5,834 LBS CHURCHILL' CIVIL
RJC ENGINEERING, INC.
WEIGHT OF SEPTIC TANK+WEIGHT OF SOIL=8,300 +5,834 = 14,134 LBS NO 41so� 2854 CRANBERRY HIGHWAY
14,134 LBS > 8,987 LBS (ACCEPTABLE)
SITE PLAN EAST WAREHAM, MA 02538
508.273.0377
SCALE: 1"=20' t Z°llrol Drawn By: MCP Designed By:MCP Checked By:JLC JOB No.756