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HomeMy WebLinkAbout0080 ENSIGN ROAD - Health L747 gn Road P 57 1 Owirford, NO. 1521/3 ORA 10% No. T '� ia�7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes gpptiLation for misp08al 6pstrm (Construction permit Application for a Permit to Construct( ) Repair(✓r Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �0 ���� � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Aa/ ,/ 4 a l-ex Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. C�' 44LK j/l-t Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures /� Design Flow(min.required) s�Q gpd Design flow provided �!� gpd Plan Date � —b 2/ Number of sheets Revision Date Title Size of Septic Tank �,d 0 d Type of S.A.S. � o 621 Description of Soil Nature of Repairs or Alterations(Answer when applicable) L mac..G it ,kAIA 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 aaArivt to plac system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date L `f71 Application Approved by V� Date C Application Disapproved by Date for the following reasons Permit No. �c i/ `'� � Date Issued No. '/ Fee 'THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓r Yes.CJ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for ]Disposal 6pstem Construction permit 81 r� Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Comport nts r� Location Address or Lot No. ��+ t�'G V Owner's Name,Address,and Tel.No. X In J J / ) � r Assessor's Map/Parcel tv r P < ! O'a/-ey Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. c p14^ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _ �7 gpd Design flow provided .;Id gpd Plan Date 7 —C — 2/ Number of sheets Revision Date Title t _ Size of Septic Tank /"D 06 Type of S.A.S. 1;.43 Ira 0 �l e, Description of Soil b i Nature of Repairs or Alterations(Answer when applicable) LeAl e._c ,p r L-ec-C A ,'A-4 J 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 offitle 5 of the Eh4ironmental Code and-not to placemthe system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date '/�" 3`71 r f Application Approved by �tsldi; f,1i Date F f/at� Application Disapproved by Date for the following reasons Permit No. QD—CL t / Date Issued ( J lr;L l- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifitate of Cornpiiante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( �� Upgraded( ) ` � Abandoned( )by K++ e �t4�.°-� n 0�p /-Q rt� at ,�<I A A/ f� t� has been constructed in accordance j with the provisions Aide 5 and th for Disposal System Construction Permit No. �r( dated Ll d� P Installer 1r 1I )VY 1AL die) b Designer r #bedrooms Approved design flow f�, gpd The issuance of this permit shall not be construed as a guarantee that the system will function a9lbsigned. Date Inspector No. )y a-k ` 3? FeeTHE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Misposal 6pst m Construction permit 10/ Permission is hereby granted to Construct( ) Repair(✓) Upgrade( ) Abandon( ) System located at Ar" { and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Const ctio /nmuust be completed within three years of the date of this permit. t-f Date 75 ! / 14 Approved by /11 1/7 � � . __ �.► ���'�—� i Town of Barnstable Inspectional Services Public Health. Division % BARNSTABLE, 0 p.. Thomas McKean, Director .as �� 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 / Installer & Designer Certification Form Date: #2-3j24 Sewage Permit# Assessor's Map\Parcel Designer: 1)cturA Coy.� Installer: � _� . R Address: iZyApf- P-A SWft Address: . (J)a u vn, 0 Z6 33 4- /'yI ozc3S' On ��20—Z/ I�• was issued a permit to install a. (date) (installer) f'o C—W s i 6Q IZ o based on a design drawn b septic system at g Y (address) ►yklr- dated (designer) /I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. 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 ro=enced above was constructed i with the to rms of e IW a th able) � WWI D. CGUGHANC?wR N (Installer's Signature) No• 1093 r CGISTF P (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. \\toa\depts\HEALTMSEWER connect\SEPTIC\Designer Certification Form Rev&14-13.DOC TOWN OF BARNSTABLE LOCATION U Si�n SEWAGE# 2( ' 37 VILLAGE ASSESSOR'S i��12 ASSESSOR'S MAP&PARCEL JY 7- o -7 INSTALLER'S NAME&PHONE NO. \O re_', SEPTIC TANK CAPACITY I, doo LEACHING FACILITY:(type) Z �PO 06' /�,?Q (size) /2 F O( 2 NO.OF BEDROOMS 3 OWNER 1yfWt01- 96.rdl e y PERMIT DATE: 7 s 2d- Z COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet 4G FURNISHED BY 0 C4' 2,1 2 u. 15, 3 � 2 2 y, ��.� J 3 30 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS W DEPARTMENT OF ENVIRONMENTAL PROTECTION � ly SOW 7 SyO� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 80 Ensign Road Centerville MA 02632 .Owner's Name: Joe-Almeida Owner's Address: Same Date of Inspection: February 7,2007 Job#07-16 tV r Name of Inspector: PATRICK M.O'CONNELLt = Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 cc Telephone Number: 508-428-1779 w ,— CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: "" `•�, X Passes + Conditionally Passes i Needs Further Evaluate{ by the Local pp Ning Authority a � � Date: 2/7/07 Inspector's Signature: . 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. Notes and Comments: Leaching pit has'3-4"of effective leaching, recommend pumping tank in next 12-18 months. ****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. I Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Ensign Road,Centerville Owner: Joe Almeida Date of Inspection: February 7,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: I Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 80 Ensign Road,Centerville Owner: Joe Almeida Date of inspection: February 7,2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh . 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water.supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: f Page 4 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 80 Ensign Road,Centerville Owner: Joe Almeida Date of Inspection: February 7,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _X Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _X_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone 11 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. i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 80 Ensign Road,Centerville Owner: Joe Almeida Date of Inspection: February 7,2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks '? _X_ _ Has the system received normal flows in the previous two week period '? _X_ 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) X Was the facility or dwelling inspected for signs of sewage back up'? Was the site inspected for signs of break out Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.3,02(3)(b)] f Page 6 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 80 Ensign Road,Centerville Owner: Joe Almeida Date of Inspection: February 7,2007 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents:3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Information not available from water dept. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): _ Industrial waste holding tank present(yes or no): _ Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped two years ago. Source of information: Owner Was system pumped as part of the inspection (yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 6/25/82 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Ensign Road,Centerville Owner: Joe Almeida Date of Inspection: February 7,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: V Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: V Material of construction: _X_concrete_metal_fiberglass__polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): —(attach a copy of certificate) Dimensions:8.5'long x 5.2' wide—1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Baffles are intact and clear,liquid level at bottom of outlet invert Recommend pumping tank within next 12-18 months and every three years thereafter. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): i Page 8 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Ensign Road,Centerville Owner: Joe Almeida Date of Inspection: February 7,2007 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): Box has no high stains and liquid level is at bottom of outlet invert. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Ensign Road,Centerville Owner: Joe Almeida Date of Inspection: February 7,2007 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits, number: One 6x6 pit. leaching chambers, number: _leaching galleries, number: leaching trenches, number, length: _leaching fields,number, dimensions: _overflow cesspool, number: _innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit has 3-4"of effective leaching above current liquid level. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Ensign Road,Centerville Owner: Joe Almeida Date of Inspection: February 7,2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 29 16 16 35 t 54 Water Service 65 Driveway Ensign Road Page I I of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Ensign Road,Centerville Owner: Joe Almeida Date of Inspection: February 7,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water : More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: X Observed site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Health-explain: _ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Low area to rear of property is considerably lower than bottom of SAS. L _ TOWN ON BARNSTABLE LOCATION SEWAGE# ✓��P VILLAGE OwTvu 3 Xe- ASSESSOR'S MAP&PARCEL 9+9+A++7SRS NAME&PHONE NO. k- C 1 i(YnK1 4-0&lrl.?J SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �L*� (size) NO.OF BEDROOMS OWNER 00 P— PERMIT DATE: Can DATE:-70.!-?P 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 3 j/ y35 \ . . Water . m¥a ' \\ Ensign Road \ » � I i�C} ' COMMONWEALTH OF MASSACHUSEM ERF.CU'IIVE OFFICE OF ENVIRONMENTAL AFFAIRS DwART=m of EwntomzNTAL PROT ox RECEIVED MAR 1 2 2003 TOWN OF BA,tiNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A r CERTIFICATION Property Address: Owner's Name:,�o&�umcrP Owner's Address: Date of Inspection: C,)L-al-1- 0-5 / Name of Inspector:(please print) Company Name: MAP van Mailing Address: 1/40 yrae-Ps PARCEL ; k) S_?�cf.MovT� /f14 ca6&q _. Telephone Number. .S - Zqt — �/Sg�� LOT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310.CMR 15.000).The system: ✓Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date:10 a a ' 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, 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 repot to the Mxgx iate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of time.This inspection does not address how the inspection and ceder the conditions of use at that conditions of use, inn w�perform in the future under the same or different Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t CERTIFICATION(continued) Property Address: Owner: Date of Inspection: _ , '� Inspection Summary: Check AAC,D or E/ALWAYS complete all of Section D A.��T`117. �. f' und any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N b D)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exsiluation 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 struch> ny sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed plpe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: 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—MX1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fumctioning 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 Zane 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within.50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 90QC� Owner: Date of Inspection: - -6 D. System Failure Criteria applicable to all systems: You most indicate`des"or`W to each of the following for aD inspections: Yes No _ of sewage into facility or system component due to overloaded or clogged SAS or cesspool 'scluarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or coed SAS cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or 'PenPoo1 ^ L" d depth in cesspool is less than 6"below invest or available volume is less than%a day flow — :Z ' uired pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s).Number rimes pumped any portion of the SAS,cesspool or privy is below high ground water elevation. L-, Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface er 94 SuPPIy. /►ny portion of a cesspool or privy is within a Zone 1 of a public well. portion ofa cesspool or privy is within SD feet ofa private water supply well. !/Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet fioom a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria kozo)' riggered.A copy of the analysis mast be attached to this form.) 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 most serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`des"or`ono"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface driniang water supply _ — the system is within 200 feet of a tributary to a surface drinicing water supply — — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zane 11 of a public water supply well Ifyou have answered"yes"to any question in Section E the system is considered a significant threat,or answered `des"in Section D above the large system has failed.The owner or operator of any Iarge system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CW 15.304.The system owner should rnntw the appropriate regional office of the Department. i Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: U �C1� Owner: - -O Date of Inspection: Check if the following have been done.You mast indicate or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Hoard of Health X 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 T 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 oamipants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems,? 11ie size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ E;xdsting information.For example,a plan at the Board of Health Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J Page b of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: O Owner: C �� Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):3�0 Number of current residents:_? Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):�j[if yes separate inspection required) Laundry system inspected(yGs or no):_ Seasonal use: (yes or no): V�J(� Water meter readings,if available(last 2 years usage(gpd)): Sump pump Cyes or no):]AD Last date of occupancy:__L73�0-03 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/pmvxis/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of info mion: CUSlQZ, Was system pumped as part of the hVw ion(yes or no):Kap If yes,volume pumped:Alum—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ,-Ncf Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy —Shared system(yes or no)Of yes,attach previous inspection records,if any) _InnovativrJAltemative technology.Attach a copy of the ciirreiit operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DE.P approval _Other(describe): Approximate age of all components,date' ]led if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICL4L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM HODRMATION(contimied) w�1� `Y Property Address: -6\ Owner: f Date of Inspection: a- � -a BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron t- PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_,_,(locate on site plan) Depth below grade: Material Of construction: p/concxete metal fiberglass_polyethylene _. _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):,(attach a copy of certificate) Dimensions: V'(0 .Y Sludge depth: (6 Distance from top of sludge to bottom of outlet tee or baffle: 0 — Scum thiclmess: Distance from top of scum to top of outlet tee or bale: Distance from bottom of scum to bottom of outlet tie baffle: How were dimensions determined: K Q AQ Comments(on pumping recommendations,inlet and ondet tee or baffleamidition,structural inteigrity,liquid levels as related t outlet invert,evidence of 1 etc.):CC\ C I �1 J "�C a U,6\ GREASE TRAP:(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thiclmess: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C Owner: � Date of Inspection: Q pA a 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: f;allons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on she plan) Depth of liquid level above outlet invert: Ok C6-D \1 A.. 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. : \, zr.)C \ (1u c p -- PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): a Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY�IOASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM N FORM PART C SYSTEM INFORMATION(continued) Property Address: res Owner: Date of inspection: - L SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. T leaching pits,number: leaching chambers,number: leaching galleries,number' leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativeJalternative system Type(name of technology. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): V 1JcQ.. 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 or no): 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.): i Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM UgMRMATION(continued) Property Address: Q(� Owner, �� ;A ,aw& � u�l�e Date of Inspection: ��c� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the wwage 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. 6 A z> 3s� RE & p A F a q' L Page i t of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: & ` Owner: G&nvrVZ _ Date of Inspection: f� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater,0 Beet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from Mtean design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,instailem-(attach documentation) Accessed USGS database-explain: You mast describe how you established the high gromd water elevation: s 1 No.....f ....7,05 y FEa........... ............... THE COMMONWEALJ,i OF MASSACHUSETTS BOAR® OF HEALTH /��' DS �� .._ ..(� ..............oF........:..: . .� -fz. .s I : -.. .............._........ Appliration for Dhipoii al Works Tomitrurtion mi# Application is hereby made for a Permit to Construct� or Repair ( ) an Individual Sewage Disposal System at ..a� Ce.,,i._) *p. ..............Lot ...........C-7.k�LQ).. R Location- dress or t No. _._.. .........C.0i Its WN Owner Address W �_h! �._S C��...-- Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic (4/� Garbage Grinder pa,, Other—Type of Building ............................ No. of persons................_----------- Showers ( ) — Cafeteria ( ) 04 Other fixture�=----------------------------------- - W Design Flow....................5....1..........gallons per person per day. Total daily flow..................�.J'o...............gallons. WSeptic Tank—Liquid capacity..6$_0.gallons 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 (e-)-l' Dosing tank ( ) '~ Percolation Test Results Performed by.............. Date..........I//{�. �._.. as Test Pit No. Lj�7 S S____minutes per inch Depth of Test Pit.....-/.:� ..... Depth to ground water.... 44 Test Pit No. 2_.-414,4-p minutes per inch Depth of Test Pit..._!.............. Depth to round water----- P P P g -E?sarE prrr�T1 t x ------------------ = r .....,•- Descriptionof Soil................... . -•--- — ® ._S..f01................................................................................................. U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------.................................. --------•-------------------•-----------•--•---------------•---•------------------------•-•----•---------------------------------------------.......................................................... Agreement: . . The, undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board iealth. / Signed............ �f --------_------------- ---- e- -� Date Application Approved By.................. ........................... .-------------- Date Application Disapproved for the following reasons-------------------------------------•------------------•----•-------------------------..._.........••----....--- ..............•-•---•------...--•-••----------------------•------•--------------•-----.....•-•---••--••-•--------------•---•----... Date PermitNo......................................................... Issued.------....-------•---------------••--•-..._at........ Date »>111 G No..... � Fps....... . .. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4�1� fs.. .....__....OF............. - �. .. -_..* � . ..._.........._.....__. Appliration for Bispoii al Works Tnnitrnrtion ramit Application is hereby made for a Permit to Construct_(A,-) or Repair ( ) an Individual Sewage Disposal System at: 7 / .................... _ f Location-Addrrgss r+ f (.n- ..........................................,r' f ``'K�a R j "j �� or Lots......................_... •' v^ f.._ Owner �y Address ........................................ _` �r ............................... — -•-•- ---.....----..........--•---....-----..........................----- P� Installer Address Type of Building - Size Lot...........................Sq. feet Dwelling—No. of Bedrooms........-.......................___________Expansion Attic ( f Garbage Grinder (41jo aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures,................................ W Design Flow...................._�_}...--�..........gallons per person per day. Total daily flow.................: O?..............gallons. 1:4 Septic Tank—Liquid capacityi.hM.gallons 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. ft. Z Other Distribution box Dosing tank ( ) l a Percolation Test Results Performed by................................ __ �: Date.......... F �l'�,t n. a Test Pit No. 1.('''?A...minutes per inch Depth of Test Pit.....,?_ ?_. Depth to ground water........ Test Pit No. 2_.__e .©.minutes per inch Depth of Test Pit.................... Depth to ground water..... A'.c Q+ .............. °== ----------------------------- ----------•--•--•------------------------------------------- - O Description of Soil....................0--�-�---s:__._f.:.:....-Y-....,. :..� ._ ��.� _____..._�.................................. _ `Y ___.________...______........_...._..__..____ W ........................................................................................................................... ------------­ 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 TT f:,. p 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•'health. g Date Application Approved By.................... --- '' _ ��e�' ---------------------- Application Disapproved for the following reasons---------------- -------•----------•--•-••--•-•--•---•----••--------------•••-•----•-----••. --•-...------•_... -----------------------------•---•--•-------•-----•---------------------------------....--••------------- Date PermitNo......................................................... Issued--------•••---.........•--- ^ ^----- •---•-- --••--•---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .' '.'...................OF............ -:<' :.... ', ',f„........................................ ............................... TE.rdifiratr of Tnntplittnrr THIS IS TO CERTIFY, That tIndividual S wage Disposal System constructed (,;`)or Repaired ( ) ............... s...e.5.r_.QZ..----------..._......r..................................by.......................... f �> t. ..— �' installer t✓� r�� fPI�..• i✓f .. }} . has been installed in accordance with the provisions of TITLE j of The 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.........................................691/?.//6/��----_. Inspector............ ............................................ �... .. y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �. .........lr... ....... .......OF..............�.:�:r* 1.. .'.. .... '/ •-'.Y.:.: e.`.".'.`.�:::........ No. FEE.......j :::.:..... Disposal Works Tnnotrnrtion motif ... Permission, is hereby granted h ?. ..f:r!. = ..................................... to Construct.•�,�'<) or Repair )fin Individual Sewage Disposal $ystem,, I Street I as shown on the application for Disposal Works Construction Permit No..................... Dated......................................... ••���;=�•,�--�af}j ........--•------•-----------------•------ DATE fy-'rGz_ F; ------ ----------------FORM 1255 HOBBS & WARREN, INC., PUBLISHERS fI 8' �u�a. tot °X(,,A f" A. tl ij/ bq f oP `✓n a 1 5A i 7 i 4 � P6 of _ 4`� - 5' IJ6tE : ALL N,4 tuQ c-,C 4 L owM �rsc �! 9 °� 10'12EMA w u N n 1 Sry Q E ED 2'VE Q u N L.ESS A Nc)-ncC / A�c►f - �1 � dF tN1ENT IS (�11-E1') L�'E,' 13ASIN . �. o ST 'f� WE-Tt„A�1DS Acr �0 _ �ytH OF M4ALE: s p :,, c I MATE A APPO a n ��p PLA tJ y f3 ;�tiia 29874 o rh �(I<sAr� FLcxD / E �Y � 019 Slit °,y ' N �- i b-7 2. F. LEGEND 'EA gS , CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION OxO �� oy G EXISTING CONTOUR --- 0 -=� o LBERTN �J�- b. � ,,,,,s, _,,,,. •, . FINISHED SPOT ELEVATION - FINISHE,D CONTOUR 0 ` Lf No.1.D951�O IN a�P'F`RVV[.V° :SCAKv Or P1R.AL1 NAL .9WitJ\l S VA AS DATE AGENT SCALES / -v-0 ' DATE .3 L DREDGE ENGINEER/NG CO. IN CLIENT I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. 8io23 BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINEER SURVEY R DR.BYt OF BARNSTA LE , ASS. 712 MAI N STREET CH. BY HYANN I S MAS 04 O - .._... . .•-.�, ' S. SHEET_.L_ OF �- DATE 5,EG. LAND SURVEYOR 20 FT. M/N. N07, TANK OR _EACAV11VG ?/T ARE MORE 7'14.9,-V /Z"BELOJN /D PT. MAV: A 24 'O/AM AFTER CONCRETE CORER rE--- SHALL BE BQOuaHT To GRA oE. �,-�,r .E,rT,e,a EONCRCTG 4rPYC P/PE /yEgVY CAS7- Cal PAMS /B�oFR FT IF//v ORI VIF WA Y 2 ff. MiN. CD/VC,pE TE CC) YER CCEAN .SAND 'LAYER A M/Al.P/TGII GAL. • • . . . . . • • o • (; _a %g"Rom . SEPTIC TA/V/< D/sT, • • • • • • e a WASHED 57rNE BMX v • • B • . • • • r .•• e- � �. _ - , • v�n r r •EFFECT/YC �F * • ,� 3�4 - � �2 r • • pEPTH • • r • WASNAF0 STaNE �ioff e • 0 f� O 1 D•!T G�-PIA C l T� �o. � r • • • • • • • • p ••p PREG45T SEEPAGE INY-A-r GLRVAT/DNS l Fr� x Z,�. = 4706 ?D a �•' r • • . . • • .a o �L P/7 OR EQL!/Y. /NYERT AT OU/LD/NG 9 4,3 INLET .SE��T/C TANK 94 d F•T / .5-48 L p F7 01AI 9. C SEE TABULATJON�. 0UTLET SEPTIC 7AN.- 9 3',y FT. r _ INLET p,,STR/BUT/GN BOX FT. GROUND W,47ZW 7.48LE OuTLErD/STR%BUT/ON..BOX 93, FT SECT/ON OF eVLET LEACH/NG PIT: 9.3.3 FT. SEWAGE O/SPO%SA.L SYSTEM LEA PIT TAdIJL.AT1ON EACH//V - sc.�tLE : / .. _ /•_ a» OMENS/ON A DESIGN CR/TER/A �4 D/�f.FNs/ON 8 & FT. N[/MBER OF BEDROOMS 3 - D/HENS/ON C�_FT./'`'1�N• 6AR4SA6E D/SPOSAJ- UNIT NONE SOIL L D.G TOTAL E.?TI/rfA'TEO FLGH/ 33 OGAL.�DAY SO/4 TEST / $OIL TEST c2 SOIL TEST NUMBER OF 40ACHIMa P/TS_ 1( EL EK 9 S 3 A- F /0 y/ ` S/OLD LGAG'HING PER P/T �S yrZ PT � � .DATE OF SO/L. TEST 9� '. BOTTOM LEs•ICN/NG PER P/T 7� — d — ' RESULTS J�//TNESSED BY✓'�� C/FF0.20 S4• FT f'ERCOLAT/OJv �IRTE / LES 5 Tv/>SL'/L ~„ >TOT.4L LEACH/NG AR,--.A -�SQ. FT. AE.eC04AT/ON RA7WA �'~ RESERVE GE,4CN/N6 AREA {'b SQ. F T. f^ !Z -tVk OF�As f M ED, o Mgss'�yLOT 8 �-,pis%G o✓ R o q-r� o ALBER , N CC/V�C. �// 4- L 4�o p No.10951 o�� EL R OEDGE ENGINEERING C9,INC. ' r� Q/STEM pQ' 90 FG/STEM R3.3 7/2 ",1/N ST. IY.gNNiS, "A:;". h0 SUR��'y FFSS/ONAL�a�\ ® V001TOUNO LN,4TCR ENCOUNTERED CL/EN Q GROUAI0 LS/ATER AT ELE(/ DRTE � 3/zg /� z .JOB NO: Z.o // SHEET Z OF LOCATION " JAG E PERMIT NO. VILLAGE I N S T A tLE NAME ADDRESS , GUILDER &QrR Ow R WATE PERMIT ISSUED DATE COMPLIANCE ISSUED �'', � �®T� i �p .� � b� - �® LOCATION STGE PER _IIT NO. f l I VILLAGE (a -\�J I L4 I N S T A LE NAME ADDRESS SUILDEIII OR OW R CA1✓_ DATE PERMIT ISSUED 1. I DAT E COMPLIANCE ISSUED 1 i C4 i oor CENTERVILLE MA EXISTING LEACH PIT +TO BE PUMPED AND REMOVED. REMOVE ALL ASSOCIATED CONTAMINATED SOILS AND t THIS IS A REPLACE WITH CLEAN MEDIUM SAND PER TITLE 5. COLOR ✓' PLAN / USE COLOR PLAN ONLY FOR INSTALLATION �� a o FULL DETAIL IS BEST a - VIEWED IN LEGEND �� q� E GIS DA FULL COLOR SEPTIC COMPONENTS p� e5Spg1TUM \ EXISTING ELEVA TION ;l t 1000 GAL h_ 4 4. 3 9 "M )ut GARB G ,rz, , SEPTIC TANKE79 TOP OF FOUN�P oT � ® „ . �r� G�i rq EXISTING --- -- .. ,,. ��� �._� LEACH PIT/ OWED CESSPOOL x. k',- / DISTRIBUTION BOXER TEST PIT \ Q JF /PROPOSED SOIL 44 43 / 42 0 ABSORPTION MINIMAL / 1Q GRADING SYSTEM PROPOSED / I/ 40 \ -SEE DETAIL / G t • ON BACK0 I 46 VENT r 12 in PIPE OAK ` I I L Oo T D AREA = 20625 sf+- ` 44 DR off PLAN BOOK 293 PAGE 28 ASSR MAP 147 PCL 57 2 07, 43 ,� kw o VARIANCES REQUESTED 'QO MAY BE GRANTED IMMEDIATELY BY HEALTH AGENT OR HEALTH INSPECTOR. ^' � 310 CMR 15.221(7) — COMPONENT ' �` 42�— DEPTH TO FINISH GRADE. 36 in F 00 j E'�E �qb ft MAX REQUIRED — VARIANCE TO 48 in OF COVER REQUESTED. ago UT§L0T§Es 310 CMR 15.2110) — SOIL ABSORPTION SYSTEM TO CELLAR WALL. WATER LINE REQUIRED VARIANCE TO 11 20 tft MIN ✓ OAS LINE GAS GA TE O G �� of Dss9� �\�� OF MgSs9` SEPARATION REQUESTED. Q o DAVID you, o�'' DAVID yes SEWAGE DISPOSAL OVERHEAD WIRE off O 40 � Q � D. �`, � D. � � - - UTILITY PLAN COUGHANOWR N 0 COUGHANOWR '% J SYSTEM PLAN POLE DRAIN® ® No. 1093 No. 461 TO SERVE EXISTING DWELLING SCALE: 1 in = 20 f t �FG$T s qP ovE� AMANDA AND. 0 20 40 sy R ���� wP� MARK BOARDLEY • . ' ' _ , OWNERISI OF RECORD • • O 10 20 80 ENSIGN ROAD PRINT ON 11 x 17 in ` y 'CENTERVILLE, MA •' THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM 155 Geo R der Rd S PAPER FOR PROPER SCALE DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING y PROPERTY ADDRESS PLACEMENT OF ADDITIONS. SHEDS, FENCES OR SWIMMING POOLS, OWl Chothom" MA 02633 SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. DOVIdcouOHotm011.Com DATE: APRIL 6, 2021 508 364-0894 PG. 1/2 �oe>< ETE-4547 necoe SOIL TEST LOG / DESIGN CALCULATIOO NS 00000o C��1fLL�0oNN ��G�'T�C� T�nNIG� SSOOpLL A SOORPTOON SOIL EVALUATOR: DAVID D. COUGHANOWR, ASE #461 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD EXISTING UNIT — DIMENSIONS & DETAIL SYSTEM CONSTRUCTION DETAIL WITNESSED BY: DAVID STANTON. HEALTH DEPT. SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS TANK TO BE PUMPED DRY AT TIME OF INSTALLATION USE SHOREY PRECAST 500 GALLON LEACHING DRYWELL NO GROUNDWATER ENCOUNTERED / AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL TEST PIT PERC AT 5a in - 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE.` DRYWELL 24.0 ft ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOUND STRUCTURAL CONDITION. IF NOT. INSTALL UNIT NEW 1500 GALLON SEPTIC TANK. REPLACE WITH A NEW INCHES HORIZON TEXTURE (MUNSELU MOTTLES (D 1500 GALLON TANK cw 43.90 0-10 Ap SANDY LOAM 10 YR 3/3 NONE FRIABLE DISTRIBUTION BOX. INSTALL UNIT DEPICTED BELOW. I in IF CRACKED, ROTTED c� +, 41.40 10-30 Bw LOAMY SAND 10 YR 4/6 NONE LOOSE SOIL ABSORBTION SYSTEM: TAPER 4 OR OTHERWISE w w ` COMPROMISED. ao u) THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE :, N 30-128 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 111 O. w 33.23 SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES ��' �°, ��• c 04 PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. o M NO GROUNDWATER ENCOUNTERED op aow TEST PIT 2 - 2 MIN/INCH IN C SOILS THE 24 ft x 12.5 ft x 2 ft LEACHING GALLERY ' o{ I NOT I I "' ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DEPICTED BELOW CAN LEACH: V - ° � v STONE : TO 3.5 ft 8.5 ft 8.5 ft 3.5 ft INCHES HORIZON TEXTURE (MUNSELU MOTTLES " 4= y= 43.20 BOTTOM AREA = (24 x 12.5) = 300 sq. ft. SCALE 0-12 Ap SANDY LOAM 10 YR 3/3 NONE FRIABLE SIDEWALL AREA = (24+24+12.5+12.5)x2 =146 sq. ft. I �° 40.53 12-32 Bw LOAMY SAND 10 YR 4/6 NONE LOOSE TOTAL AREA = 446 sq. ft. �0 ` 32-129 C MEDIUM SAND 10 YR 5/4 NONE LOOSE FLOW CAPACITY = 0.74 x 446 = 330.04 of/do 8 t� 500 GALLON DRYWELL 32.45 9 ft-6 in A DIMENSIONS & DETAIL INSTALL ONE INSPECTION INSTALL A 24 ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED RISER TO WITHIN THREE BELOW. FLOW CAPACITY = 330.04 gal/dog WHICH EXCEEDS INLET OUTLET INCHES& OTE FINAL LOCA(ZONGRADE THE 330 goI/doy REQUIRED FOR A THREE BEDROOM DESIGN. COVER COVER ON AS-BUILT -INSTALLER TO OBTAIN DISPOSAL WORKS "` � �°` ` PERMIT BEFORE STARTING WORK. no USE SHOREY 3 IN DROP a""" I -INSTALLER _ L)§STUFT§BVTQOIIV �0/N DB-3 H2O -► AlFLOW LINE36 ALL COMPONENTS INSTALLED SHALL MEET FROM - in THE MINIMUM REQUIREMENTS OF DIMENSIONS PIPES EXITING D-BOX TO RUN LEVEL 10 in 14 TOD AND DETAIL FOR 2 FEET.BEFORE PITCHING DOWN BUILDINGMASSACHUSETTS TITLE 5 'SEPTIC 'D-BOXCODE (310 CMR 15). 48 in TO VERIFY LOCATIONS OF ALL L LIOUID GASUNDERGROUND UTILITIES BEFORE "L 1 f�12 InG LEVEL BAFFLE ` /02 in EXCAVATING FOR SYSTEM. -ECO _ CROSS SECTION VIEW in-TECH RAPID RESPONSE RECOMMENDS E THE INSTALLATION OF LOW FLOW "`' � FROM INSTALL AN APPROVED GEOTEXTILE-\ b STONE BASE IF NEW FIXTURES & APPLIANCES. AND PERIODIC n1 TANK �' u, �, 1 To FABRIC OVER STONE PUMPING OF THE SEPTIC TANK. o ,� G 5A5 SEPARATION BETWEEN INLET & OUTLET -SEPTIC TANK NOT DESIGNED TO WITHSTAND ��Orf 9ob�4P TEES NO LESS THAN LIQUID DEPTH { r SVEHICULAR LOADING. DO NOT PARK OR "" �� b in STONE BASE CROSS SECTION VIEW �9 f= � 24 in e "r » DRIVE VEHICLES OVER SEPTIC TANK. 28 ••` 3�� p - 314 in TO 2j ;n 2 CROSS SECTION VIEW in Y#'i l/2 )n GRAVEL a DEPTH IVE© I-1/2 In GRAVEL, 46 in 58 in 46 in IF L O W O 150 in _ . TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO 4 in BE SCH. 40 PVC VENT AND TO PITCH AT 1/8 in/ft MIN = 44.39 +— 6 in OF FINAL GRADE PIPE ELii i i + / + 43-44 nno R,no NA 4 H SE 20 qp_ MAX RATED USE H-20 40.50 UNITS EXISTING 1000 GALLON — p00000000°oo° PRECAST o00 0 0°0�0 ��p��� �Q�� 39.85 39.55 DRYWELL oo�0000Q000 oOpOo DODO° O °pp°0 O°0°DO� 00�oQooO Oo�O EXISTING REFER TO DETAIL BOX 6 In SOO L A° o �OG�3pT00N + 3 9.72 STONE +� BASE 39.50 SYSTEM -REFER TO EXISTING b in STONE BASE IF NEW 7 f� 4 ft DETAIL BOX 37,50 NO GROUNDWATER V in BELOW MOTTLING OBSERVED _ 32.45 SEWAGE DISPOSAL SYSTEM PLAN1180 ENSIGN ROAD CENTERVILLE, WIJAPRIL 6. 2021 ETE-4547 PG 2/2