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0058 ENSIGN ROAD - Health
58 Ensign Road A= 147 -05'4 Centerville S M E A D No.2-153L OR UPC 12534 •moad.com • Made In USA OcYcO 10A rMUS®Nrrupw UL71lf Commonwealth of Massachusetts as� Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 58 Ensign Road Property Address Kathi Souza Owner Owner's Name / information is required for every Centerville ✓ MA 02632 10/6/2020 page. City(rown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. l!}ling out forms:When - A. Inspector Informationa- filling out forms on;the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road � Company Address Teaticket Ma. 02536 Cityrrown State Zip Code r 508-280-3356 S13938 Telephone Number License Number I ` A,Asa B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes . 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority b 4. ❑ Fails f I 10/19/2020_ Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "3' V Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `............. !% 58 Ensign Road u Property Address Kathi Souza Owner Owner's Name _ information is Centerville MA 02632 10/6/2020 �'a required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: �)a This 3 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding (2) 500$gallon leaching chambers with stone. At the time of the inspection no visible failure criteria was foundry: 2) 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. _ a Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): ,n , t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form II; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): Git - ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health `a'pproval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ .ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): y J��y ❑ 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): y ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): a - ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below;-11-' 3) 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. a. 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 puhlic,health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form tii� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .;, 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. City/Town State Zip Code Date of inspection C. Inspection Summary (cont.) ❑ 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 b. 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 with n a,�� 100 feet of a surface water supply or tributary to a surface water supply. '�'" e, ❑ 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 anal sis must be attached to this form. ' ?` c. Other: t .� 4) 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 t5insP.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .; 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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 water supply - well. .w El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 god- El10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure, criteria exist as described in 310 CMR 15.303, therefore the system fails. The x, system owner should contact the Board of Health to determine what uv n%d necessary to correct the failure. "'W 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply .1 ❑ ❑ 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 Pro€eclion Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is Centerville MA 02632 10/6/2020 required for every �`•-! ". page. City/Town State Zip Code Date of Inspection "°Ah X,tw C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for aH inspections: Yes No Og` ® ❑ 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? r ® ❑ 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. 'T:tc•,,<,' 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i, Commonwealth of Massachusetts •Jjt , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments „ . .. 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 - _c�;.. .. DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plu8lGPD Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes'["No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes-0 No Water meter readings, if available last 2 years usage d town water �:..` Detail: In 2019 -55,000 gallons were used and in 2018-27,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Ye'§''❑ No page. Water treatment unit resent? No' p ❑ Yes_.�.:No_. If yes, discharges to: 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 occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ®,,No; If yes, volume pumped: "4 gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract �r.r.My ❑ Tight tank. Attach a copy of the DEP approval. �6:3. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: New Leaching in 11/2/2015 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): �:• ^'} Depth below grade: 21" feet - Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet town water Comments (on condition of joints, venting, evidence of leakage, etc.): x Water was flushed and came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallon Sludge depth: 4" v�. .. Distance from top of sludge to bottom of outlet tee or baffle 32" 2„ _--- Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? 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.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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): t: Dimensions: Capacity: gallons - . Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ I1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date v" Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of " leakage or solids carryover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 "tti - Commonwealth of Massachusetts �- Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY u— 58 Ensign Road Property Address Kathi Souza Owner Owner's Name - requir required is Centerville MA 02632 10/6/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): ' * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): i If SAS not located, explain why: Type. ❑ leaching pits number: ® leaching chambers number: (2) 500 gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �n =. Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 _. THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) Im A .CC DATA � >:. . \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Ensign Road Property Address Kathi Souza Owner Owner's Name information is Centerville MA 02632 10/6/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Ao Ay, 8Z`2Q 83 � s 3 , Ay=33%L' Ct v4p''. 2 ay: 38' A,y! 3.5, 3 13y�>33 { S �S drZy �Is�- ,ar• t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Ensign Road Property Address i Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar I t ® Shallow wells Estimated depth to high ground water: 12 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record v� If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) i ❑ 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: I augered a hole at a lower elevation and shot it with a transit. 3 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 t Commonwealth of Massachusetts vt,o _. ,p Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� 58 Ensign Road V� Property Address Kathi Souza Owner Owner's Name information is required for every Centerville MA 02632 10/6/2020 pager CityTTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: "5 ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �i 58 Ensign Rd. Centerville Property Address Kathy P. Souza r4 Owner Owner's Name information is r/ MA 02632 12-14-17 required for every Centerville, page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Darrell Stone use the return Name of Inspector key. Cape Cod Septic Inspection r� Company Name P.O. Box 1466 Company Address Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 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 sys em: ® P sses ❑ Conditio asses ❑ Fails ❑ e ds Furt r Evalu b ocal Approving Authority " 12-15-17 Inspector's Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if.applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Ensign Rd Centerville Property Address Kathy P. Souza Owner Owner's Name information is Centerville, MA 02632 12-14-17 required for every State Zip Code Date of Inspection page. City/Town B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If'not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whethermetal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. _ *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Ensign Rd. Centerville Property Address Kathy P. Souza Owner Owner's Name information is Centerville, MA 02632 12-14-17 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are,replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ lobstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i ,i •• it .L 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 , t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Ensign Rd Centerville Property Address Kathy P. Souza Owner, Owner's Name information is required for every Centerville, MA 02632 12-14-17 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r — Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VOy�. 58 Ensign Rd Centerville .Property Address Kathy P. Souza Owner Owner's Name information is Centerville, MA 02632 12-14-17 required for every page. Cityrrown State Zip Code bate of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate,nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems:*To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000'gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area'(Interim Wellhead Protection Area—IWPA)-or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 58 Ensign Rd Centerville Property Address Kathy P. Souza -- Owner Owner's Name information is required for every Centerville, MA 02632 12-14-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was,the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® 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 been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the'failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Ensign Rd. Centerville Property Address Kathy P. Souza Owner Owner's Name information is required for every Centerville, MA 02632 12-14-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: 3 bedroom residential dwelling 3 Number of current residents: 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)): Detail: Sump pump? ❑ Yes ® No ' Current 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.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Ensign Rd Centerville Property Address Kathy P. Souza Owner Owner's Name information is required for every Centerville, MA 02632 12-14-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes,or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts = 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r< 58 Ensign Rd. Centerville Property Address Kathy P. Souza Owner Owner's Name information is required for every Centerville, MA 02632 12-14-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2015 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 21 p g feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Apparent good condition Septic Tank(locate on site plan): 15" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon 12" Sludge depth: t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Ensign Rd Centerville - Property Address Kathy P. Souza Owner Owner's Name information is required for every Centerville, MA 02632 12-14-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" 211 Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? 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.): Grade to inlete cover 5" Outlet 15" Normal liquid level No sign of leakage Sch 40 tees Recommended next maintenance pumping within 1 year Recommended maintenance pumping every 2-3 years Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments ,M 58 Ensign Rd Centerville Property Address Kathy P. Souza Owner Owner's Name information is Centerville, MA 02632 12-14-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Ensign Rd Centerville Property Address Kathy P. Souza Owner Owner's Name information is Centerville, MA 02632 12-14-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) p � Distribution Box(if resent must be opened) (locate on site plan): 0° 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.): Grade to box 32" Cover 16" OK condition 2 outlets with speed levelers Normal liquid level No sign of leakage No scum No sign of failure 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.): * working orders stem is a conditional ass. If pumps or alarms are not In wor ng y P Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w , 58 Ensign Rd Centerville Property Address Kathy P. Souza Owner Owner's Name information is Centerville, MA 02632 12-14-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2 (500 gallon) Chambers with stone Grade to chamber 32" Cover 12" Bottom 62" Currently 2"of standing water on the bottom No sign of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Ensign Rd Centerville Property Address Kathy P. Souza Owner Owner's Name information is Centerville, MA 02632 12-14-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts u t W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Ensign Rd Centerville Property Address Kathy P. Souza Owner Owner's Name information is Centerville, MA 02632 12-14-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I � t o z 3 A B .2 c) 2�-g 3 29 10 33-6 4 33 5 6 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Ensign Rd Centerville Property Address Kathy P. Souza -- Owner Owner's Name information is Centerville; MA 02632 12-14-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells >5 Estimated.depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design Ian reviewed: 2015 g p Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Engineer certified installation Bottom of SAS ELV. 47.5 Bottom of test hole ELV. 42.5 Separation >5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Ensign Rd. Centerville Property Address Kathy P. Souza Owner Owner's Name information is required for every Centerville, MA 02632 12-14-17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 _. Ili No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes UBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Disposal 6pstem Construction Vermit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7,'a �lyish (�'rAerv;j1 Owner's Name,Address,and Tel.No. IW Assessor's Map/Parcel 5-8 613iih A Ct�^ ►•plc IMv►ss' Installer's Name,Address,and tel.No. ERI( S-TeIi0,5 Designer's Name,Address,and Tel.No. rM tr f S lt5 XhC• C000,c-)t f'095TIOMS MILLS I'hPr. OZ6ge fb. &X ?a E 5aK, -a% Masys, 6z539� Type of Building: Dwelling No.of Bedrooms Lot Size 3y g3d sq.ft. Garbage Grinder( ) Other Type of Building eg:5- - No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 5 Number of sheets Z Revision Date Title Size of Septic Tank SOW Type of S.A.S. ;S )- [' t, rSCZ) Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envirownental Code and not to place the system in operation until a Certificate of Compliance has been issue his Boar Si Date / /S Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued t No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS 0[pplitation for Bispo' sal 6pstem ConstCUttion i3ermit Application for a Permit to Construct( ) Repair(upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 58 £45,ib R,�. CprAer-,^N Owner's Name,Address,and Tel.No. ?-a. } � � .SV Cn5iih �. Cc,natw.�� 1L1WS5. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Pi Or 5:,-,5 SnC. �OX�I TAR5T0A)S MILLS mA. Oz(ag6 , Y 761 C 5c�w.cj MASS. 4z537 o 74 lei_t 11 Type of Building: Dwelling No.of Bedrooms Lot Size 3y g 3b sq.ft. Garbage Grinder( ) t Other Type of Building p No.of Persons Showers( ) Cafeteria( —P N Other Fixtures ` Design Flow(min.required) gpd Design flow provided 3 9 a ,Z$" gpd Plan Date 1 f(0 S' Number of sheets Z Revision Date Title Size of Septic Tank Type of S.A.S. !�nn u loPif S na Description of Soil i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued ... his Board eat . 141J Date Application Approved by // / � Date Application Disapproved byZY Date ` for the following reasons Permit No. Date Issued E ---------------------------- _______________-------- -------------- _________________ ________________________________________ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compriante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by ERN C 5rf v at has been cons cted in accor tad/ J with the provisi o Title 5 and the for Disposal System Construction Permit No. Installer �� r H�a 'STIIJEwjs Designer .ar So f #bedrooms ?j Approved design`flow, gpd The issuance of this p rmit shall not be construed as a guarantee that the system willfunctio as ''de gn d1 Date ) Inspector / k ✓ ---------------------------------------------------------------------------------------------- �,} No. 6U1 '�n Fee (J E COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS t BispoBal ,6pstem onstrnttion Vermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at S� S- sic i) 6 . Co v.�-e y�1!e YV114 i f 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. j Provided:Cons ct on mu it be com leted within three years of the date of this permit. Date , Approved by Town of Barnstable t HKE. Regulatory Services Richard V. Scali, Interim Director &UMSTABLE. 9�A MASS. �0� Public Health Division ren yg. °i Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 11 iw I� Sewage Permit# —313 Assessor's Map\Parcel 1417 L�t Designer: m'qe.' SM_s `ne, Installer: ` C b Address: I W 8W 6 0 / Address: Se - `� On �t� was issued a permit to install a date) ,1(installer) septic system at �j� 1`�Sl'�N VJP 6"kfV1aC based on a design drawn by (address) MvA,e.-c 4 �S �vie dated I b � (designer�r-� am''J _M� tiv, 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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constru liance with the terms of the I\A approval letters (if applicable) tIA OF k, DARREN -Tffistal is ignature) Y (Designer's Signature) (Affix tamp Here) PLEASE RETURN TO BARi TABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Desia er Certification Form Rev 8-14-13.doc TOWN OF BARNSTABLE OCATION E1nS�_,►R {&- SEWAGE# Z6/5-- 323 VILLAGE ASSESSOR'S ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. Llef(- Srft gAM S02-? SEPTIC TANK CAPACITY 1606 qA1. LEACHING FACILITY: (type) 9�20cpAI C��u,��yZ)size) Zsy 13 NO.OF BEDROOMS OWNER s PERMIT DATE: 1/ 2/ COMPLIANCE DATE: ( 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY A,: io y AZ,ibr � SZs 2Q ' i A A3: Zq ' 83 ctV49 (� By; 38' t , AS% 3.3 3 B 33' ► ►i r� i ✓ ;os 00 I Town of BArnstable P# Department of Regulatory Services • Public Health Division Date� � twaretrt� * I KAsa. 16 y `�$ 200 Main Street;Hyannis MA 02601 aJ 3 �F fDIM Date Scheduled ` ' U ( Time (� Fee Pd.- w h / I Mtlt ,f oil Suitability Assessm'ent fop Sew e D. is osal t. � f c Performed By: 0a " t ��� Witnessed By: L/ VU ✓ �� c i - LOCATION & GENERAL INFORMATION location Address% I&P 5 t,(/ll ( Owner's Name � Z MO r&-A-19 I UL C- d �/ Address l f -AQ- (�I i Gam! O��S �ht✓ Assessor's Map/P4tcel: U S Engneees Name - X 50% 3U)'-'3311 NEW CONSIRUt2ON REPAIR Telephone# Land Use Pts l QwrI6 ( Slopes(vo) '�A - Surface Stones ' V ����� Distances from: Open Water Body ft Possible Wee Area ft Drinking Water Well �L_-Z�ft ft Pro Line ft Other ft Drainage Way Property SKETCH:($treet name,dimcnsiods of lot,exact locations of test holes&Pere tests,locate wetlands in proxitnity to holes) -YOf- Se D, ESI" Of, V, (b 1.(0 l , quru-. ._.... _ _ `� -` �.--a -r-.�.w.-�r...o..srt-:� -.s+.�•'.0`.s....c....f. -sue _� --.. - Y.f•�•+!F+'.� '- -.�� -♦ "".." i . - i I I • I ' I I I I - i t I . s� Parent material(ge(Jlogic) Depth to Bedrock Depth to Groundwatdr: Standing Water in Hole:' ri i Weeping from Pit PACs Estimated Seasonal i fth Groundwater 1 DtTERMINATION FOR SEASONAL HIGH WATER TA LI Method Used: I. ___in. Depth td Sall tttotths: In. Depth Ubperved standing in abs.hole: in groundwater Adjustment $. Depth tolweeping from side of obs.hole: i Adj. 7etoC,,, _._,.- Adj.Croundwater Level,"e Index Well# Reading Date vel Index Well le PERCOLATION T'E+ST . Datt: Inierr-.. Observation Time at 9" �7A -.--- Hole# ` . 11 Time at6" ..... Depth of Pere 663 ( Time(9"-6") -- Start Pre-soak Time.@ // -- ; 6 End Pre-soak I Rate MinJlnch Site Failed; Additional Testing Needed(Y/N) Site Suitability Assessment: Site Passed — Original:.Public Halth Division Observation Hole Data To Be Completed on Back-- — ***If percolaibn testis to be condracted within 100' of wetland,,you must first notify the Barnstable C4,#servation Mision at least one(1)wetsk prior to beginning. ,r� U DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon. Soil Texture Soil Color Soil Other .Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel �� r) � a/bl b � • DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel) tv DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from S ' orizon Soil Texture Soil Color Sol] Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Gravel) Flood Insurance Rate May: Above 500 year flood boundary No Yes , Within 500 year boundary No"' Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring p>rr ious material exist,in all areas observed throughout the area proposed for the soil absorption system? ' If not,what is the depth of naturally occurring ervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the require 'n' g,exp rtise and experience described in 3:10 CMR 15.017. Signature Date �® W Q:\SEPTICIPERCFORM.DOC LOCATION L©T 5 �IJS C�h.i P-oiA-� NO. n- _ VILLAGE CC-�'TS R-�/11_d. �- DATE t O ,� ► APPLICANT GP_EEIu(,Ra EC- OrE`/ COP P FEE `.. l ADDRESS TELEPHONE.-NO.'1"1 t- 3(04 (Non-refundable ENGINEER e(_bQepC.E �LICa►I.�E�Ra t TELEPHO N ".."115 22q.4 DATE SCHEDULED'• Se!p'1- I's 1C1%) (Applicant's signature) • • • • •.Y • • • • O • • • • • • • O O O • • • • • • • • O •-*•O • • •.• • • q.• O • • • • • • •�O • O • • • • • • • • • O • • • • • • • • O.• • • • • • SOIL LOG 3 SUB-DIVISION NAME • G,Q. �(b(��., .'DATE 9 0'S �`� f TIME �1 EXPANSION AREA: YES v""NO ir,&P_ (.3 ENGINEER: : TOWN WATER ORIVATE WELL BOARD OF HEALTH Jim Qf?SCZsL_L ( J,=H 1-i EXCAVATOR SKETCH: (Street name,etc.:,dimensions of lot ' ',exact location of test holes and percolation tests,jocate wetlands in proximity to .test holes) y/ NOTES �S4_ r� ]z . .►"EST +-�OL;� _ � INf ..,.... ....-... .. �.. ... .:Y+s• m¢+.+..anY-.'r s r.+ u.,.. r.t...Yr.0 tKH'..rauKu _tiy...i,i ,i.. a _. ... ', oP= Lc�-1' PERCOLATION .RATE: LE. SS I�`tA Q 'L TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 2` Na �Le AAA 1. 2O Ps)L+ 2 Y- 3 3 i 4 4 5 6 6 7 2� M 7 g g 9 9 10 10 12 4 12:. 13 w 13 14 14 15 151 16 16 SUITABLE FOR SUB-SURFACE 'SEWAGE:j '-• LEACHING FIELD LEACHIN PITS LEACHING TRENC S UNSUITABLE FOR SUB-SURFACE`'SEWAGE. REASONS. ` NOTE: ENGINEERING PLANS MUSST SHOW NUMBER ASSXGNED ,ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P. E AND TURNED TO BOARD OF HEALTH 4 COPY: • RETAINED BY APPLICANT r ; NoJ.' THE COMMONWEALTH OF MASSACHUSETTSA p P 0 V BOARD OF HEALaT+t+bj, C0r.'servatj0n Commission TOWN OF BARNSTABLE � Appliration for Disposal i0orkii TonA on intttt a,. Application is hereby made for a Permit to Construct or Repair (?o an Individual Sewage Disposal System at: ......... .....Ex 4s.\.r I ------------------------------------------------------ .4.4...... ................................. ...............11V .7 . ..... Loca .8Addross _k or Lot No. ......S '4............. .................IRS.C2<_ ......................... ..........7-------- ....................................................... Address ....................... ......................� ............................................. ... ... ... .. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons....._.__._..__......_.._... Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow:...........................................gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank V Liquid*capacity-LM!Vgallons Length--- ...... Width.....T------- Diameter________________ Depth...._........_.. Disposal Trench—No..................... Width.................... Total Length_._..............._. Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.__..._.._.......... Depth below inlet.._................. Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---------------------------------------------------------................ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_.___.__...._........_.. IT4 Test Pit No. 2................minutes per inch Depth of,Test Pit___:..........____.. Depth to ground water......_____...__....___. 94 ......................................................I...................................................................................................... 0 Description of Soil............................................................................... ........................................................................................ W U ....................................................................................................................................................................................................... W Z ---------------------------------------------------------------------------------------------------------------------------------------------------------------S------------------------*-------- U Nature of Repairs or Alterations—Answer when applicable------ ------U�-------elpt. L................... --------------VAA4--nA -__.......0,6-0--K..................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar#of health. Signe ................ -- ---- .... ........ -7 ....... . ......... ........... ------------- ................, ...... Application Approved By ..0......ee�. �te................... .............. Application Disapproved for the following reasons: ........................................................................ --- ............................_-------------------------------------------.......................... ......................................... Permit 0. --------------- N .......................................... Issued ............;'�7?..�z------- ----------- Date Al-P/19W No.11 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ! f TOWN OF BARNSTABLE�7/_49 Appliration for Elhiposal Works Tonstrui `9nirrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ............... ------c'-2-------------------------- ............... ...................................................... L.,.ti.?n-Address or Lot No. ................. ......... kc L......................... ................. ............................................................ Own< Address ....................... ......... ->, \_vAk. ............................... .... ...... Type of Building Installer Address Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder aOther—Type of Building ------------------------_- No. of persons........_.__.........._.____ Showers Cafeteria!I1 Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank-\-Liquid capacity.Lf.2- Mons Length......... Width___...__. Diameter................ Depth............._.. Disposal Trench—No. .................... Width......_._...._...... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter....____._.......__. Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by-------------------- ...............Pit--_-____------_-_---*---------------- .... . ............. Date........................................ Test Pit No. I................minutes per inch Depth of Test Depth to ground water_.__.............__..... 0� Test Pit No..2................minutesper inch Depth of Test Pit.................... Depth to ground water........._.._._.....__.. 0 9 ............................................................................................................................................................. Description of Soil.------•------------•-•--------------•------••-----------.....--------.....----------............................................._................................. W -------------------------------:----------------*-------------------*--------------------------------------------------------------------I-------I------------*.......................................... ...1---------------------------------------------------------------------------...................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable._-__- ------ .................... .......... . ................................................................ .............................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boards of health. -7 Sid --- ---------- ------ igne, ..... . ................. ...............:7-- ------------ Daw Application Approved By ..c------- ..... .:Ii........------------------------ ----------- ...................................... ............................... p 4V"et�. r .... +/ Date Application Disapproved for the following reasons: .........................................................................................................I............................... ................. ..... .........................I.................................................................................................................................................................... .............................---------- Permit No. ......... ............. ........... Issued ............ ......�.;7 ...............Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE i(frrtffirate of Tompliance THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed or Repaired by............................!a L;A,�- C Installer CO-- ....................................... at ----------------------------- C ..............................................................................I............................... I has been installed in accordance with the provisions of TITLE he-; c- dated ......�� t 'Environmental Code as d c�bed IA the application for Disposal Works Construction Permit No. .......I................... /........*--—-------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE -SYSTEM WILL FUNCTION SATISFACTORY. DATE------------- Inspector .............................. ------------4(�. ... .. ................................... --------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ............. ....... No.... FEE...5'C'7—.. Disposal frrnfit - Permission is hereby granted......__.._ .. ..................................................................... ..................(..... .. to Construct or Repair (LYan Individual Sewage Di al System ��5�;A�.. Isr ..........V4A at No...................................... ... ........ ( e. ................. .. .......U5............................................. Street as shown on the application for Disposal Works Construction Permit ated....... .............. ---------- --DATE_ ........ ........... Board o f Health .......... ......................... FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS TOWN OF BARNSTABLE LOCATION SEWAGE IVILLAGIE ASSESSOR'S MAP & LOT 0J4 INSTALLER'S NAME & PHONE NO. C� (A.Pe SEPTIC TANK CAPACITY C. LEACHING FACILITY:(type) �T`t (size) law lo NO. OF BEDROOMS 3 PRIVATE WELL O UBLIC W R BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r �� �� �� �C ���ra�-t�-� �" N-ew +�-�;aX a ���sz tiv� p,� S�- • THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ApplirFation for UhipwiFal Works Tnnitrnrfinn Famit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: - - ................_L.0.1.............•- -••..............�•�..5..! 1�... .................................................................... Location-Address or Lot No. a Own. 2c Address C ................. ....... 4------ ---------------------- ................................................. J .....-- - ' Installer Address � Type of Building Size Lot..I..1j....Y�_ C)Sq. feet Dwelling—No. of Bedrooms.._____._..........................Expansion Attic (�� Garbage Grinder (Mo aOther—Type of Building ......................:..... No. of persons............................ Showers .( ) — Cafeteria ( ) Q' Other fixtures ...................................................... W Design Flow..................... ...........gallons per person per day. Total daily flow.............1-_ 3--0...............gallons. WSeptic Tank—Liquid capacityf.DD-Qgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) ~' Percolation Test Results Performed by...............................%�-: `..__ �`..._ ����-_ Date...... 5 � � __..SS�. ---•---- - - - �a Test Pit No. 1 L-tJ.�_.minutes per inch Depth of Test Pit.......-L:? Depth to ground water.._ (i Test Pit No. 2:�:1r,---minutes per inch Depth of Test Pit-------/------------ Depth to ground water.•e,wGae.r..... 11 O .................. I................ ...._. _...__.............---------------------..........•--•-----•-•---••---•-•--•---•---•-----------... x Description of Soil.•-•--•--•-•--•-•-•-- Y= - -...�� S•'D I• ' U -------------------•---••--------------•--•------------Z 1.�...__------WI-- C_ -- :!g .b -----------•-----------....---...----••---....-------------- W •••••-------------------------•-----••-•-•---......------------•---•--••••...__.....-•-------•--••------•-•---•-----••------•-••-----••-•-----•--••-•----•-•----•------••-••-•-••••-•-----------•---•-•- UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ----------------------------------•-----------------------•------------------------.....•••........•--------•------------•-----••-•-•--• .............................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T:'1:,-. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board healtily. Signed G% � ...................... ..Z�. ..r .�' _ Da t Application Approved By......... p...-•---..•. - --------------------------•• �a... Date Application Disapproved for the following reasons----------------------------•--------•------•------------------------------------•---.....-------•---------...... -•------------------------------•----•-------------••--------•--------....--------------------------...--•----•••-•-.....-----------•-••----••------•-•--•-------•-----------•----------•--••••--------. Date PermitNo......................................................... Issued....................................................... Date 1 FER-3.s- ': :........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH P 9 1, A C1 31 Y) 5 / Al 5 Z_ ...........OF.......................................................................................... Appliration for Disposal Works Tonstrurtion "ermit V Application is hereby made for a Permit to Construct ,('I or Repair an Individual Sewage Disposal �� System at: �1 —, : . ..................�E./ r..... .-..)..... I ------------- ---- Location -- -Add V C or Lot No.C/Z Fss ................................................. .................... Owners Address ................... r � "0 . ......................... ............................. ............................................... ...............3 Installer Address Type of Building Size Lot.!_..f 2'�(-)Sq. feet Dwelling—No. of Bedrooms........:a..........................Expansion Attic 41/1) Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Other fixtures .........................------_-----_------------------------ ..................................................................... .............. Design Flow................ �;_15__ ............................gallons per person per day. Total daily flow.............. ...22. ................gallons. Septic Tank—Liquid*capacity'.1,DU_gallons Length................ Width................ Diameter---------..---.- Depth................ Disposal Trench—No..................... Width_...--.............. Total Length.................... Total leaching area....................sq. f t. Seepage Pit No..................... Diameter...........;........ Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by....................._t7J!—_.()11.r.4_'e......C_ ......&. Date....... Test Pit No. --_minutes per inch'-. Depth of Test Pit------- .. Depth to ground water..J.�alO'�_._ Test Pit No. 2-MIK ..minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------- -------------------- T- ---------------0 Description of Soil........... 7--------- ............................................................................................................ ....................................T n� .................. ......... ................................................................... U ........................... -------------------------------------------------------- ------------------------------------------------------------------------ —.------------------------------............ U Nature of Repairs or Alterations—Answer when applicable................................................. ....... ...................................... .................................................................................................... .............................. ............................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of IT'12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of lie�aalth. Signed........................................ ........... .............. ......f...(................ Date ,. —--------Application Approved By......... 2 e -------—,5 7- -e--4-V------------------------ ----- Application Disapproved for the following reasons:......... .............................................................................................. ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS I BOARD OF HEALTH. 7 .............:.....`.`.............OF..................�9 4m) ........... ...................... C�rrtifiratr of Tompliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed SA/) or Repaired ..........................._�-4 ,- b ............. ... ................. y A --------- ---------------------------------- Installer iffe- at........................ _L, IL .... ..... ........... :.�---------------- ------------------ --------------------------------------------• - has been installed in accordance with the TITLE .provisions of 5 of fhe State Sanitary Code as described in the application for Disposal Works Construction Permit No.. -------------------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................. ........................... Inspector....... ......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N --- ........ FEE.- ........... Disposal Works 'Unstrudion ramit Permission is hereby granted......................... 1444 r, �5 "o/(- �,- .1,�// .............................................................12�.................................................... to Construct) or Repair L) an,Individual Sewage Disposal System I ............. r— ...I -�"e. .11� (i at No.............................. .............. t a/.. !..............................................t Street - r ......... as shown on the application for Disposal Works Construction Permit No..................... Dated.........................._............... .... --- ---- ........................................ DATE............................... ........................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS *OCATIOJ SEWAGE PERMIT NO. NULA6E� 1 ST:, LLEIt's ME i ADDRESS c 6UIL0EIt OR OWNER DA T E P ERMIT ISSt'U E W-L"` , DATE COMPLIANCE ISSUED .. \©� �� f W li THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) M A�C(- I DATA .. �- �J•, i.Y. r1YA..Y'ei.+.wb,d'E4.'h:w ..+n 4v.•-.. +... - ... 15,}^ yzvifJ 14 �9N 4� _ •l S�.1. {.... d - � �� �... let, a t` zxz 1. K a.� 10, F S •,+� n� tea^-- ,. � e` n eta. 07 • t �+_�'a,"'•j t � i.'x^�` .w'4C �.: ..i ka -. c<ty.,,.., .,w. e z racw� +W'+c»�tw�,�..y�wr",.ryY.r.. sox t� + heir a s m rc • m ?' t sF".' f :w '�•at y r_�'z "� ,r 7r' r^ Was R A m?x�', is lY m -sF w.''€a• v ,,. , S - m, "' 4 .n"v`,r +. a .tY tY # t• }r] .., # k k o dP i .a; 7G �* +✓ �.�'rvs w.. �. y. ,.,.r ,o..+ 1�• �,,�,,,_,+��wx�.f:t+"4♦ 9x`.u,,�.,k,�¢�,_t :? 4. _ �t _.�5 f �r. �¢.+. y �y -. mait, m# !" L „. n - .,^ .e+ v.*a -.was '�. yi"• X�' r$� i V f j+ i. sR•M_+.€ 7V,_'L t t F.i1; •�- µ .; - ra�t� :- '"`' . -, P ?Am ? a 4 aix•.% # '£r?", ROVE". ? 'r 4 •i„ - >r '.aa4a^ �e5 -.k''.m yn' i�''"^,k� 'i 7 ¢q�# �n v .+_^ t { ..+., ,} a .; 7p., s.a+ � x�r•F e r�.r^,P^Fa y ? 4. � t.. Y': - + ,; ��, r d`.a �y:,n _ �t..,,.^ _ '�vrr^',s�,•ix-� ,n�.. .a.:y+'.M'r •zr�rro' ' "' ,. '�+,+im SL. �m ":m,:µ"+..�P•. 2 f 3-. t ;'�.. t� y.. ..:7 .+.r a� _ n "�� c'.":�, _a'. vti� y+: _. ...r atv- �.q't^,-., "3°.�.r _°"-,:. M�m-.�,. �m�.:r➢:. -.-c, ..� .+..�a r•�'.. +s'- -r.� ^.,�, _ +.. "`�...�so.s /VOTE /F E/TNER TANK OR . Z.Ei4CN/NG P/T ARE MORE T/,HA:'/./2BELOJN • /p � /rf/N. ::rr?AOE� �1 24'O/AMETER CONCRETE COVER q'Pvc Pier SRALL BE B.PouGNT To G�gAoE.�,-;,✓ EXTRA CONCRETE h'E>4VY CAST /ROIV COVER Sli qLL 3E USED - M/N. PITCH �•., EL= IDO:o COVERS �B•PF.QF7 IF/N DR/VEJ1/Ay 2 'J. MiN. CO/VGRL�'T..E A • G AOE COVER CZ EAN -FA N 1O t> 4"CAST 2'LAYER ft b� IRON P/PE I O OO MIN.P/TG/f/ G/IL. ' a I • • • • . • • • e • ° %4•PER t'T. .SEPTIC TANfC B X ° • s • • • • • • • N/A SHFO 5727NE • - .� D r • •EFFECT/VE � � � ` 3�4'— I �2 • ° • O!<PTH ! • • v IYASRAF.0 STONE Q • • •' • • • • • 1 • o • •.� i • . • • • • • • p . v p,?E445T SEEPAGE lNYB CLEV.4T/GNS IW.S x 2,5 = 411 G/'D , • .� , • . . . . • • e •o P/7 OR ZV411V, i INYERT AT OU/LD/NG. 019.0 FT. 6� AM~ INLET SEPTIC T.4AW 97.Q FT. PIT CAP�iTY 549 G%D }� IO FT. VIA iW. . 11 C SEE TflBULATION> OUTLET SEPTIC TANK 7.(� FT. //VLET D/ST/g/8//T/ON BOX 9,7.4- Fj GROUND W,ITER TABLE _ .SECT/O/V O F ~ o/JTLETD/STR/BllT'/ON BOX �1-i•'L' FT SEWAGE O/SPOSA L SYSTEM //VCET L.EACN/A/G PIT 97.O /�'T. LEACH//VG PIT TABC/LATlON DES/GN CRlTER/A $CALF : %" _ /= v" D/ME/1/SIoN A � D/LIENS/ON $ FT. NUMQER OF BEDROOMS 3 D/HENS/CN a 4 FT to GA R6AGEDISP0.5.4L, UNIT NO*11 SO/L Z-06 TEST TOTAL E1TIIyKTED FLOW 33 GAL.IDAY SO/L TEST #/ SOIL 71=STje2 j.l NUMBR �acvv Pj f^Et�Y. gg•Ca ^-ELFY 1 . PATE ac- SO/L TEST /IV S PT. t5 19 S/OE LE4C,HG P PER /T I?g rr Sq t BOTTOM LE,4CN/NG PER P/T 7g RESULTS �V/TNESSEO BY S4. FT 0-2� 70NOt— PtRCOLIIT/ON RgTE , / L !+�/N 1NCN TOT.41- LEACHING AREA SQ. FT. FLFteC0IAT/ON RATE Ik2 .QESERvEZEACYIJVGAREA 2�0�o SQ. FT.. �7 /L•O OF M� DF��a'4 . / / MEQ JOHN g �\ I C�tJTI=�V I LL-E i o MORSE 4 J G. 14. No.10951 O •: �a ENGINEERING CIO INC. } ✓ I$TE� pQ` 9pG/STEQ �\�Q. EL ��o•�0 71Z MA/N ST. , A'YAN/V/S. N/,qS- + O SURD FSS�oNA1 Ea ® No GROVNO LVi4TER E/VCOU1VTER..5�z> A GROUNO,J.VATER AT ELEL! _ CL/ENT:6 i�gQ,�(` DRTE OIL(3 8�- ./06 /VO: �1023 SHEET 2 OF '1- i._ MARSTONS MILLS LEGEND �pP� PROPOSED CONTOUR ® PROPOSED SPOT GRADE pJ —— 98 —— EXISTING CONTOUR p F P� p55 LOCUS n + 96.52 EXISTING SPOT GRADE p� 58 ENSIGN ao_ 0 BENCH MARK W— EXISTING WATER SERVICE LUM * ® TEST PIT POND RT PAINT SPOT ON STEP CORNER EXIST. 1,000G 54 l ABLE GI DATu SEPTIC TANK BARNS 53 pq N� 0 52 R o o f\ OUTE 28 \, h LOCUS MAP �o I I 54 S-\oN �� `` CQ) LOCUS INFORMATION s3 I TITLE REF: 7574/328 PARCEL ID: MAP 147 PAR. 054 \ POOL FLOOD ZONE: "X" O \� LOT rJ \ \ COMMUNITY PANEL: 25001CO542J DATED:07/16/14 2 I AREA = 34830 sf+— 30. PLAN BGOI•: 293 PAGE 28 SEPTIC SYSTEM ASSR MAP147 PCL 54 X REPAIR PLAN - - �^2 fQ 52;, \ \ \� \ -51 O � - LOCATED AT: " G CONCRETE , � /'� 58 ENSIGN ROAD ORE i , CENTERVILLE, MA PREPARED FOR SOUZA 66.00' - OCTOBER 26, 2015 OF \ o D RRY M. y N t� 1 $TER`'� 2O4' QN I TAR\p� " o MEYER & SONS, INC. \ / P.O. BOX 981 PLAN EAST SANDWICH, MA. 02537 SCALE: 1 in = 30 ft PH: (508)360-3311 0 30 60 FAX: (774)413-9468 meyerandsonsinc@gmail.com 0 10 20 30 60 SHEET 1 OF 2 Ji 01743 ELEV. TOP FOUNDATION NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (53.5) = 56.02 -1� F.G.EL: 55.0 F.G.EL: 54.8 F.G. EL:, 54:0 a� � MAINTAIN 2% MIN SLOPE OVER LEACHING AREA 2" OF 3/8" DOUBLE WASHED " F.G.EL: 53.50 STONE OR FILTER FABRIC DOUBLE WASHED STONE 6" 3„ 4" SCH 40 PVC 101 ®®®® p ®®®® A: 14' 6 S= 1 (MIN. E 3E313®®®®® 4EESCHR40 PVCE INV.51 .50 �2EF. DEPTH �8EEEEE0EE0 Q•"•� � � INV.52.20 INV.51 .30 4' 2 X 8.5' 4' 1r GAS PROPOSED DB-3 EXISTING OUTLET BAFFLE EFFECTIVE LENGTH = 25' :. .. .. ., .,;.. :. � DISTRIBUTION BOX 0j INV. 52.45 INV. ELEV.= 49.50 EXISTING 1 ,000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON P��� 0F 4f4 Ssa BREAKOUT OUTLET TEE AS MANUFACTURED BY �`` ELEV.= 50.5 TUF-TITE, ZABEL, OR EQUAL D RREN M. �, / TOP CONC. ELEV.= 50.50 YER r--- _ NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING N b14 INV. ELEV.= 49.50 �E3 E3 PIPE INVERTS PRIOR TO CONSTRUCTION E3®®®®®® 2) D-BOX SHALL BE SET LEVEL AND TRUE TO �£�/Sj � ®®®®®®® GRADE ON A MECHANICALLY COMPACTED SIX S4NITA0 BOTTOM EL.= 47.50 ®®®®®®® INCH CRUSHED STONE BASE, AS SPECIFIED IN \ 3.75' 5 FT. 3.75' 310 CMR 15.221(2) V \ 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK �� �\" SEPARATION 5.00 FT. EFFECTIVE WIDTH = 12.5' WITH 1,500 GALLON SEPTIC TANK IF FAILED, DAMAGED, OR UNDERSIZED, INSPECT AT TIME OF INSTALL SEPTIC SYSTEM PROFILE SOIL ABSORPTION SYSTEM (SECTION) 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 42.50 r GAS BAFFLE AS REQUIRED (500 GALLON LEACH CHAMBER) GENERAL NOTES: DESIGN CRITERIA : 14852 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL LOGS p# NUMBER OF BEDROOMS: 3 BEDROOOM BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: OCTOBER 8, 2015 SOIL TEXTURAL CLASS: CLASS I (0.74 GPD/SF) OF THE RULES AND REGULATIONS.CODE. TITLE V. AND ANY APPLICABLE SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614 DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 110 G.P.D. X 3 BR DESIGN FLOW: 33o G.P.D. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR WITNESS: DAVID STANTON, BARNSTABLE B.O.H. = TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE GARBAGE GRINDER: NO (not designed for garbage grinder) DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING Elev. SEPTIC TANK: 330 gpd x 200� = 660 gpd, USE EXIST. 1,000 GAL. SEPTIC TANK FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN TP-1 Depth Elev. TP-2 Depth ENGINEER BEFORE CONSTRUCTION CONTINUES. 53.60 0" tf LEACHING AREA REQUIRED:53.50 0" (330) = 445.94 S.F. q 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. LOAMY SAND A LOAMY 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 10YR 3/1 1M SAND D 74 HEALTH FORTHE CTOR OR OWNER T PROPER INSPECTIONS DURING CONS THE LOTRTRUCTION.BOAR OF 52.9 s" 52.83 s" USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS W/ 4' 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. B B STONE ON ENDS & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED LOAMY SAND LOAMY SANG BOTTOM AREA: 25 x 12.5= 312.5 SF TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 10YR 6/8 10YR 6/8 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE 50.27 40" 50.17 40" SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING PERC ® EL. 48.7 C C CONSTRUCTION. TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. MEDIUM SAND MEDIUM SAND DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25. G.P.D. vs. 330 G.P.D. req'd CE 12. THIS PLANNS� R ENGINEER TO BEUSEDFOR SEPTIC FICATION 2.5Y 6/4 2.5Y 6/4 SYSTEM PURPOSES ONLY PROPOSED SEPTIC SYSTEM UPGRADE PLAN AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 42.60 132" 42.50 132" Q 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. 5CJ ENSIGN ROAD, CENTERVILLE, MA 15. ALL PIPING TO BE 4" SCH 40 0 1/8"/FT (UNLESS SPECIFIED) PERC RATE <2 MIN/IN. ("C HORIZON) re pared for: Souza NO GROUNDWATER OBSERVED Engineering and Survey by: SCALE DRAWN DATE • 1, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 MEYER&SONS,INC. N.T.S. DMM 10/26/15 to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO BOX981 requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October, 1999. EAST SANDWICH,MA 02537 REV. DATE SHEET NO. 50"62-2922 2 of 2 i