HomeMy WebLinkAbout0012 EVELYN CIRCLE - Health 12 Evelyn Circle
Centerville P
A = 062 002
S//// J�RECYCIEOC
Oyu
UPC 10259
No. H1630R � M
HASTINOS MN
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppYicaction for Migooal 6pztem Cow5truction 30ermit
Application for a Permit to Construct( ) Repair(kf Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No.�a ��C 7n �r ec E Owner's Name,Address,and Tel.No.
CF�/TFI[�vr// tAJq/Tefe A ACC-2
Assessor'sMap/Parcel $�/Q(j�005, arvdlJ,eVine/
°
E'itC/l�Lr
Installer's Name ddress,aqd Tel.No. �v Designer' Name,Address and Tel.No. 3V�-36 4
�= ,,am, 1^0-0 r- 17C ere o2 kA
r:L5A Cc�t o _s-31>
Type of Building:
Dwelling No.of Bedrooms Lot Size 3l ]as( sq.ft. Garbage Grinder (AYQ
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) d gpd Design flow provided gpd
Plan Date 1—M-0 8 Number of sheets o? Revision Date
Title
Size of Septic Tank //000 �� lS�ua%x( Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(A wer when applicable) ci e e -& 01CCGS f�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
<Compliance has been issued by thi oard of Healt .
Signed , Date 6 Ja �f7
Application Approved by ` Date Z��
Application Disapproved by: Date
for the following reasons
L
Permit No. ��� Date Issued
"' ---'...r..,-��.r-+�.,t..,:'.�.�vr-..-..`✓-.,.�•..�.,.... ,r",.r,,,.,R..x�...,,- :,;::<-�.ra- .-'LL'ww.n...,,..;.w...:u=,-u,.s-....».-..,. ,.. .r T�4.,-,-. -... .,.- ..
� rfr Fee
_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplication for Mi.5pogal *pgtem Cottgtruction Permit
Application for a Permit to Construct( ) Repair(y) Upgrade-( ) Abandon( ❑Complete System ❑Individual Components
Location Address or Lot Nol /-(ie�T :cam('/,F Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel �j /GG�l 0 Z Cvc/1.r rle,/
Installer's Name,-Address,a d Tel.No. �L Designers Name,Address and Tel.No. � �^ 6 a
���ic_cCZ��-� Icy, � t_�3u 55� ����tz� ��
c r
PU. r..St1i1Crrt
Type of Building:
Dwelling No.of Bedrooms Lot Size_ ,s' S^ sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
}" Other Fixtures , 6
� r F _ s
Design Flow(min.required) Q gpd Design flow provided �j gpd
�
Plan Date Number of sheets o, Revision Date
Title
Size of Septic Tank OOO H( �-xt 1%/ f Type of S.A.S. 606,4 n-me ores(_- f{',;�G
Description of Soil [� ot
Af
u
Nature of
(! Repairs or Alterations((Answer whenapplic ble) rr l/ uj"I /
Uys/-)/ C/ � Y
t
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the.afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this oard of Heal h.
t ,
Signed Date 470/.
Application Approved by Date y��
Application Disapproved by: Date
for the following reasons
Permit No. a Od r Date Issued
————————-——————=—— — _
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
` Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sew_age.Disposal System Constructed ( ) Repaired / ) Upgraded ( )
Abandoned( )by
at F-, i_,,� C c�d t t ((C has been constructed in accordance
^ d
with the provisions of itle 5 and the for Disposal System Construction Permit^No.o. ��f ��i- dated L( j`'t'
Installer I C (C`Ca ( � ETC( Designer— pr('
#bedrooms 3 Approved design'flow gP
J EJ d
The issuance of this permit shall not be vo�n/sttruedyaas a guarantee that the system will-fun ction a esigned.
Date s�-���® C� Inspector
———————————
a ----- . —
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
Migpogar *pgtem Coon5truction Permit
Permission is hereby granted to Construct lepair (lam ) Upgrade ( ) Abandon
System located at a E, e. (-r 61
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction us be completed within three years of the date of this .it -- t'
Date Approved by ; ?
✓�GFit�
5
TOWN OF BARNSTABLE Y/{
LOC A711710N I oZ �v e�N (,1 ICI,. SEWAGE #oZ 08-
VILGE � /--6 x ? r ASSESSOR'S MAP & LOT/8 2 "'0
L A l 02
INSTALLER'S NAME&PHONE NO. +U �A�g���T'p 6-4"9a8"tea
SEPTIC TANK CAPACITY 1po0 G/}�_. FJUS l � g
LEACHING FACILITY: (type) r006 A-CWAMb-Q✓M (size) /3 3CoZs
NO.OF BEDROOMS 3
BUILDER OR OWNER Gt/ /7F2 61440 rF/2
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
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(,.','/' BUILDING SKETCH - -
Borro.Wer WalterA. Gardner et ux HeNo. SA194 ----------------.-
Property Address 1 2 Evel yn Ci rcle State MA ZipCode 02632 -----
County Barnstable ---
Lender
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I I . Form P46 -- 'TOTAL 2000*appraisal software by a la mode,inc. -- 1-800-ALAMODE
I .
-
Town of Barnstable Barnstable
o M-ftaieaC tt
Regulatory Services Department
+ BARNSnABM
A Public Health Division
A 200 Main Street, Hyannis MA 02601 2Q07
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
April 1, 2008
Walter&Mary Gardner
12 Evelyn Circle
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 12 Evelyn Circle, Centerville MA was last inspected on
March 12, 2008,by James M. Ford, a certified septic inspector for the State of.
Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged SAS:
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER O HE BOARD OF HEALTH
limas McKean R.S. CHO
Agent of the Board of Health
CERTIFIED MAIL# 7006 2150 0002 1038 7091
Q:\SEPTIC\Letters Septic Inspection Failures\12 Evelyn Circle.doc
�. C.OMMONWEALTH'OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 12 Evelyn Circle
Centerville, MA 02632
Owner's Name:. Walter&Mary Gardener
Owner's Address:
Date of Inspection:, March 12. 2008 � =' '
Name of Inspector: (P.lea§e`Print) James M Ford
-- �.
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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.(31.0 CMR 15.000): The system:.
Passes
Conditionally Passes
Needs Further Evaluatiom by the Local Approving Authority
Y Fa'
Inspector's Signature: Date: March 18, 2008
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 inspectioni lf,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
DER 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 describesat 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:
Title 5'Inspection Form 6/15/2000 page 1
Page 2 of 7 I t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 Evelyn Circle
Centerville, MA
Owner: Walter&Mary Gardener
Date of Inspection: March 18, 2008
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR'15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass".section.need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
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:
2
Page 3 of'11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 Evelyn Circle
Centerville, MA
Owner: . Walter&Mary Gardener
Date of Inspection: March 18, 2008
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 aseptic 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 Evelyn Circle
Centerville, MA
Owner: Walter&Mary Gardener
Date of Inspection: March 18, 2008
D. System Failure Criteria applicable to all systems:
You must indicate either".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
✓ 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 onprivy is below high groundwater.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 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.]"
Yes (Yes/No):The system fails. Lhave 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 System: s
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.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.
4
Page 5 of•11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 12 Evelyn Circle
Centerville, MA
Owner: Walter&Mary Gardener
Date of Inspection: March 18, 2008
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 breakout?
✓ _ 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
✓ _ 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(3)(b)).
5
9 Page 6 of 11
OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 12 Evelyn Circle
Centerville, MA
Owner: Walter&Mary Gardener
Date of Inspection: -March 18. 2008
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: 2
Does residence have a garbage grinder(yes.or no): Yes
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected.(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): spd
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
Source of information: Pumped on 2128108 for maintenance
Was system pumped as part of the inspection(yes or 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)
Tight Tank Attach a copy of the DEP approval .
Other(describe):
Approximate age of all.components,date installed(if known)and source of information:
unavailable
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Evelyn Circle
Centerville, MA
Owner: Walter&Mary Gardener
Date of Inspection: March 18, 2008
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron _40 PVC other(explain):
Distance from private water supply.well or suction fine:
Comments(on condition of,joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 15"
Material of construction: ✓ concrete _metal _fiberglass, _polyethylene
other(explain)
I.f tank is metal list age: Is age confirmed by.a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth:. -
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: -
Distance from top,of scum to top of outlet tee or baffle: -
Distance from bottom of scum to bottom of outlet tee or baffle: -
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc:):
Cement tees were present. The liquid level was even with outlet invert
GREASE TRAP: None (locate on site plan):
Depth below grade:
Material of construction: concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee.or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition;structural integrity,liquid level
as related to outlet invert,.evidence of leakage,etc.);
Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Evelyn Circle
Centerville. MA
Owner: Walter&Mary Gardener
Date of Inspection: March 18, 2008
TIGHT or HOLDING TANK: None (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
Alann 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 site plan)
Depth of liquid level above outlet invert: Above
Comments(note if box is level and distribution to outlets equalh any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-bot was not dug up it was under water from the leach pit backinkup.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alanns in working order(yes or no)
Continents(note condition of pump chamber,condition of pumps and appurtenances;etc.):
8
Page 9 of*11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12 Evelyn Circle
Centerville, MA
Owner: Walter&Mary Gardener
Date of Inspection: March 1.8.2008
SOIL ABSORPTION SYSTEM(SAS):, ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6x61000 gal.
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.):
The leach pit was full. The liquid level was up into the riser. The leach pit was in failure.
CESSPOOLS: None (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: None (locate on site plan) .
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,.signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:. 12 Evelyn Circle
Centerville, MA
Owner: Walter.&Marty Gardener.
Date of Inspection: . March 18, 2008:
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.
n -
Ai .
A Q
as ra a Cl
3
10
Page I of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
SYSTEM INFORMATION(continued) .
Property Address: 12 Evelyn Circle
Centerville, MA
Owner: Walter&Mary Gardener
Date of Inspection: March 18, 2008
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25.+/, 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:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground:water elevation:
Using Barnstable topographic and water contours maps, the maps were showin-a00roximately 25'+/-to Around water at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected as of the date of inspection and failed. This report is not a warranty or guarantee that the system will function properly
in.the future. There have been no warranties or guarantees,either expressed, written or implied,relating to the septic
system, the inspection, this report andlor any components of the septic system which have not been located and inspected.'
11
oFtHEr�
Town of Barnstable
Regulatory Services
enxrsrABM ; Thomas F. Geiler,Director
9�A 1639. ��� Public Health Division
rfD N1A'�A ,
Thomas McKean,Director
200.Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
I .
gown of BArnstable P#
• � Department of.Regulatory Services
L% : Public Health Division Date
0.79. tee$ 200 Main Street,Hyannis MA 02601
AlfD MRl�' i � � •
Date Scheduled Time I Fee Pd.
Soil Suitability Assessment for Sewa a Disposal
Performed By ��'„�'�'I '"t' /'11�it' Witnessed By: r .
LOCATION & GENERAL INFORMATION
Location Address Owner's Name
q� ,, rAr.
Assessor's Map/P reel: `$7 r 6c; /0 0� ( Engineer's Name � � M r
I Cn ,
NEW CONSIRU00N REPAIR X Telephone# st) L 21
Land Use 8�14? hA-11 Slopes M '0—E Surface Stones N
Distances from: Open Water Body ? ft Possible Wet Area ft Drinking Water_Welt 7-ft
i
thainage Way ft Property Line l�ft . Other ft
SKETCH:(street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
,S E t0"1-+1J. i
i
• i
Parent material(geologic) ad OV 454 I Depth to Bedrock N1,
Depth to Groundwater. dnding Water in Hole:'
N A I Weeping tlom Pit Face Nh'
Estimated Seasonal illigh Groundwater N/� I
OTE! TION FOR SEASONAL IIIGII WATER TAELE
Method Used:
Depth obperved standing in obs.hole: in. Depth to sail ttlolt!^s: in•
Depth toiweeping from side of obs.hole: I in, Groundwater AdJuetment
Index Welt#____�� Reading Date Index Well level Ac -Actor,�,,...a A�.Groundwater Larvel,,e
PERCOLATION TEST Date 1 g 'Flute•
Observation Time at 9"
Hole#
�(�rr
Depth of Perc Time at 6"
Time(9"-6") — — --------
Start Pre-soak Time,@
End Pre-soak f 9
Bate Min./Inch
Site Suitability Assessment: Site Passed Site Failed;' Additional Testing Needed(Y/N)
Original:.Public Health Division Observation Hole Data To Be Completed on Back--- -- 4
***If percolaibn testis to be conducted within 100' of wetland,you must first notify the
Barnstable C4#servation Division at least one(1)eveck prior to beginning.
DEEP OBSERVATION:HOLE LOG Hole# I
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
onsis enc %Gravel
!0 Y4 3/z
`j 10 YQ SA-
7
DEEP OBSERVATION HOLE LOG Hole# ,
Depth from Soil Horizon Soil Texture Soil Color Soil' ' _ Other
Surface(in.).' (LSDA) (Mansell) Mottling (Structure,Stones,Boulders.
C nsis enc %Gravel)
D'I— �o'�, s l'�1 •�
t SArInY �o l b 2.31v ,
7u'I o ' 0YLS1
2.SY 7/
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil' Other n
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Cons i to c o ravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) ( DA) (Munsell) Mottling (Structure,Stones,Boulders.
consistency.
Flood Insurance Rate Man:
Above 500 year flood boundary No_ Yes X
_ Within 500 year boundary No X Yes
Within l00 year flood boundary No X Yes.
Depth of Naturally Occurring Pervious Material ;
Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the
area proposed for the soil absorption system? �5
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on 101 q01 _(date)I have passed the soil evaluator.examination approved by the
Department of Environmental Protection and that the above analysis`was performed by me consistent with
the required training,expertise and experience,described in 3.10 CNR 15.017...
C:J Signature ( Date
Q:\SEPTIC\PERCFORM.DOC
TOWN OF BARN STABLE
LOCATION C-tl-e CiT, SEWAGE #5�0" 1/0y
VILLAGE ASSESSOR'S MAP 6z LOT )6z�Z
J
INSTALLER'S NAME & PHONE NO. ,'c,,L'p.� Coos/ Co
SEPTIC TANK CAPACITY Sly®(?
LEACHING FACILITY:(type) P cps/ (size)
NO. OF BEDROOMS PRIVATE WELL O �B--LIC.WATER
BUILDER OR OWNER r o e
DATE PERMIT ISSUED: /6 /9 - �10
DATE COMPLIANCE ISSUED: /®
VARIANCE GRANTED: Yes No
4 r !
36
a �-
TOWN OFBARNSTABLE
t&-IkTION FV J n C 1 FLU SEWAGE#
VI LLAGE UAniry,16- ASSESSOR'S MAP&PARCEL 7 060? -(2
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY I OW
LEACHING FACILITY:(type) PT (size) (n/b
NO.OF BEDROOMS 31I-
OWNER GAr",,-
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY -J Fbr2 3 l- Qk
fA ,
� I
aa33� I
3y3 �-1
COMMONVA'EALTH OF MASSACHUSETTS
x = EXECUTIVE OFFICE OF ENVIRONMENTAL AXFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION.FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION,
/77
Property Address:. l n
taco z RECEIVED
Owner's Name: _
Owner's Address:
JAN 11 2001
Date of Inspection:
TOWN OF BARNSTABLE
Name of Ltspector: (please print / Tp / J HEALTH DEPT.
Company Name: ,
Mailing Address:
(/J'
Telephone Number:,
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 DE.P
approved system inspector pursuant to Section 15.340 of Title 5(•310 CNIR 15.000). The system:
/Passes
Conditionally Passes
Needs.Further Evaluation by the Local Approving.Authority.
ails
Inspector's.Signature: Date: l v
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 approvirtg
authority.
Notes and.Commerits
****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.
Title 5 Inspection Form 6/15/2000 page I
` _Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: /
Date of Inspection: / o`4 Q/
Inspection Summary: Check A,B,C,D�or T/ALWAYS complete all of Section D
I
A. System Passes:
I have not found any information which indicates that any of the failure criteria describe_d 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 dt 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 year's old is available.
ND explain:
Observation.of sewage backup or breakout orhigh static water level in the distribution box due to broken or
obstructed pipe(s)or.due to abroken;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:'
2
Page 3 of 1.1
OFFICIAL INSPECTION FORM :NOT FOR VOLUNTARY°ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM
PART A
CERTIFICATION(continued) F;
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 ut order to determine if the system
is failing to protect public health, safety or the enviromnent.
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 pullic 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 t►te 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 aseptic 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:
3
Page 4 of I 1
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_FORM
PART A
CERTIFICATION(continued)
Property Address:,
Owners Q
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to'each of the following for all inspections:
Yes N9�
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
lclogged SAS or cesspool
q/ Static liquid level in the distribution box above outlet invert due to an overloaded.of clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow
V
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.
T 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 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 muist be attached to this form.]
(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 II of!a public water supply well
If you have answered"yes"to any questi0n.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 3 10 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1.1
OrI+ICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURF ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CIIECKLI,ST
Property Address: /D? I, y e-
/�
Owner:, a
Date of Inspection: �.
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?
'AR_ 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 oil 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?
d _ 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 Systwa(SAS)on the site has been determined based on:
Yes no
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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTIONIF4 0RM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SVSTEM INSPECTION FORM
PART C
SVSTEM INFORMATION
Property Address: G _
Owner:
Date of inspection: 1(ja(o_1 O) .
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):�� . Number of bedrooms(actilal):
DESIGN flow based'on`310 CMR 15.203 (for example: 11:0 gpd x#of bedrooms): t
Number of current residents:
Does residence.have.a garbage grinder(yes or no):-00
Is laundry on a separate sewage`system (yes or no):DD,[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):o ..
Water meter readings, if available(last 2 years usage(gnd)):
Sump pump(yes or no): :/10
Last date of occupancy:_tA UVWY1
COMMERCIAL/INDUSTRIAL.
Type of establishment:.
'Design flow(based on 310 CMR.15.203): gpd "
I3asis.of design.flow('seats%persons/sgft,'ete,): .
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 yq
Source of information:. ,)
Was system.pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping: .
TY�')✓ OF SYSTEM
1/Septic tank,distribution box,soilabtsorption 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:
Were sewage odors•detected when arriving at the site(yes or no):AV
6. '
Page 7 of 11
OFFICIAL INSPECTION FORM NOT FOR. VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM
PART C
SYSTEM:INFORMATION(continued)
Property Address: .
P ,� .to
Owner:J/aL
Date of.Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 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: !/ (locate on site plan)
Depth below grade:
Material of construction: / 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: X C e,
Sludge depth: IJ
Distance from top of sl to bottom of outlet tee or baffle: 34
Scum thickness: t( Z /l l
Distance from top of scum to top.of outlet tee or baffle.:
Distance from bottom of scum to bottonj.of outlet tee or baffle'
How were dimensions determined: I a k. 1u0my-)
Comments(on pumping recommendations inlet and outlet tee or baffle condition`,structural integrity, liquid levels
as related to outlet inve t,ev' ence 12
age,etc.
40
GREASE TRAP: ✓ (locate on.site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene_other
(explain): — — —
Dimensions:
Scum thickness:
Distance from top of scum to top 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.):
7
Page 8 of I l
OFFICIAL JNSPECTION,TORM-NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION-(continied)
Property Address: �C2
Owner:.
Date of Iiispection: it
TIGHT or HOLDING TANK: 06 (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: V .
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:.. (if present must be opened)(]ocate'on site.plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakabe into or out of box, tc.):
PUMP CHAMBER: 41 (locate onsite 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.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ls � _
Owner: J 1�
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):`"` (locate on site plan,excavation not required)
If SAS not located explain why:
Type j
✓ leaching.pits, number:
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.):
o
U/ 7
or k4
CESSPOOLS: jqQ (cesspool must be pumped as part of inspect ion)(]ocate 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.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM=NOT FOR yOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
'FART C
SYSTEM INFORMATION(continued)
�1
Property Address:. JV-
Own er
Date of Inspection: 11"ILaloo d
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.
-
�
Pi,
10
Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: fJ Al
yr .
Owner:
Date of Inspection: I U
SITE EXAM.
Slope
Surface water
Check cellar.
Shallow wells
`'�/
Estimated depth to ground water .l 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:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked.with local Board of Health-exp.lain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: `
r
11
Permit Number: Date:
sA', Completed by:-.
kS�yM HIGH GROUND-WATER.LEVEL COMPUTATION:
EV
Rlsr Site Location: fi �
i=:skis;; Lot No.
Owner: '
�Q Address:
:. Contractor Address
=F Notes:
,• STEP 1 Measure depth to water table
to nearest 1/10 ft. 111,711
............... Date
C
c - - month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropnate index well....................................................
OWater-level range zone .................... J
STEP 3 Using monthly.report "Current
Water Resources Conditions"
determine current depth to
water level for index well ......
month/year.
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (S.T EP 3),
and water-level zone (STEP 2B) y
determine water-level adjustment ....................................................;.....................................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) .......::................:.
igure 13.-Repro ucible computation igi m.
1
' r
o�
'own of Ba-almstable
Regulatory Semites
Thomas F.Geiler,Director
artist.
9.
Public Health Division
Thomas McKean,Director
- - -- 200 Main Street,Hyannis,MA 02601
Office: 508-862-
Fars: 508-790-6304
Installer& Designer Certification Form
Date: A 3 ,008 Sewage Permit'#oL28-IOQ Assessor's Map\Parcel /8 06dlooa
Designer: '2 9 aee,<l J,�- Al /�S, Installer: 1']Ff"'e/ /q,Ce,- ram
r D Q8/Address: Yvx Address:
On y-a a-Og 31ievCE/�acCJ�i/ems was issued a per_nit to install a
(date) (installers)
septic system at A 2 Eec% G�r, - (e_,Oe 1-1 based on a design drawn by
(address).
Per;W.��y�iP 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_ or the
distribution box andlor septic tank.
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.
5 H OF A2gs`r1
DA PEN cyc
(Installer's Signature) U ME
. 1140
� c
TIE /
(Designer's Signature) (_affix Design ere)
PLEASE RETURN TO B STABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS EORIM AND AS-BUILT CARD ARE
RECEIVED BY THE BAKNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:HealtWeptic'Designer Certification Form 3-26.04doc
LEGEND RIVERS RD o��J9 FERNBRpO�
enterville�
PROPOSED CONTOUR o
% o� W Historic
98 PROPOSED SPOT GRADE c>Q a > mugel O
o —— 98 —— EXISTING CONTOURCHURL„ y
w r
o ��., e3>-�/l, t — ` + 96.52 EXISTING SPOT GRADE �JG ppN NERD l�
LA
'' j�,., r �entervllle 9 �G
v i /' , \ 3 r W— EXISTING WATER SERVICE F9
E$
;' / I �..1 z2 �/ R TEST PIT S1TE a� pR�HARD lY
ro
Or �� b \ \ ISLAND �Qp T fR
/y i g, iI I RD
i�
eAR�sT�'eA,c�92 ,Sq r
/S i i —HORSES
\ ` LOCUS MAP N.T.S.
�o
n1ER UnE'
o \ ', \ ` \ - GENERAL NOTES:
Existi(NotenlpLeochpit �� I \ 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER.
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
O T i LOCAL RULES AND REGULATIONS.
^ /�� / / 3' 2 I 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
a DESIGN ENGINEER.
y\ 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
/ I' FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
i !srRR+c� ENGINEER BEFORE CONSTRUCTION CONTINUES.
5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
\ �►/, �rH,� ��/ / /� / 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.(-M e E KE LOLAM)
Qa _/��` !0 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
°' <a 3~ ! TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
s j 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE
\
NOTE: , F ! THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
( !A 5 FOOT REMOVAL 70 TOP OF "C" LAYER MAY BE REOUIP.ED `3j6.0g--� CONSTRUCTION. m BUT IT IS BELIEVED THAT FILL LEVEL FOUND IN TESTNOLES fj -i ! 10. EXISTING LEACHING PIT TO BE PUMPED, CRUSHED AND REMOVED.
I NOT REPRESENTATIVE OF SO4S IN DRIVEWAY, REPLACE WITH CLEAN, MEDIUM SAND.
\ \ It Ii 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION
12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY
AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY
j 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING.
It 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING.
i 115. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPECIFIED)
OF MASsq
r DARR
I, E
V " No. 1140 "' #
ci E ° PROPOSED SEPTIC SYSTEM UPGRADE PLAN
SANITWa� 12 EVELYN CIRCLE, CENTERVILLE, MA
MAP.• 187 Prepared for: Walter Gardner
SURVEY REFERENCE: LOT.-0621002 Engineering by: Surveying by: SCALE DRAWN JOB. NO.
PLAN OF LAND BY BARTER & NYE, INC. E DEED BOOK-20565 DARRENM.MEYER,R.S. Eco—Tech Environmental 1"=30" DMM
DATED: F LAND R 4, AXTE DEED PAGE.•309 EAST SANDWICH,MA 02537 (508) 364-0894 DATE CHECKED SHEET NO.
508-362-2922 04/17/08 DMM 1 of 2
I
ELEV. TOP COVER TO GRADE WITH STEEL FRAME
FOUNDATION "NOTE: ALL COVERS TO BE MARKED WITH MAGNETIC TAPE
(Existing)
I FINISH GRADE=43.0
44.40 F.G.EL: 43.0
F.G.EL: 43.0 F.G. EL: 43.0
MAINTAIN 2% MIN SLOPE OVER LEACHING AREA COVER OVER LEACHING = 3.0 FT.
COVERS TO WITHIN 6 OF GRADE
2" OF 3/8" DOUBLE 3/4" - 1-1/2" DOUBLE
�. WASHED STONE WASHED STONE
6" . ~ 4" SCH 40 PVC 4 4" SCH 40 PVC
®®®®• 0 ®®®®
10"I @ S= 1% MIN. e' ) ®®®®®®®®0E3
(MIN.) 14„ (MIN.) @ S= 1% (MIN. ®®®®®®®®®®®
TEE'S ARE TO BE 2 EFF. DEPTH E3E3 3E3E3 �l®®®®®
.: 4" SCH 40 PVC INV.40.64
•�'71 INV.40.69
INV.40.44 4' 2 X 8.5' 4'
EXISTING OUTLET GAS : PROPOSED DB-3
BAFFLE EFFECTIVE LENGTH = 25'
�•. .. •.: . •• H 10 DISTRIBUTION BOX
i1 INV., 40.94 EXISTING 1 ,000 GALLON SEPTIC TANK INV. ELEV.= 39.5
GAS BAFFLE TO BE INSTALLED ON NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING BREAKOUT
OUTLET TEE AS MANUFACTURED BY PIPE INVERTS PRIOR TO CONSTRUCTION ELEV.= 40.0
2) D-BOX SHALL BE SET LEVEL AND TRUE TO TOP CONC. ELEV.= 40.5
TUF-TITE, ZABEL, OR EQUAL GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.= 39.5 •®®� o ®®
INCH CRUSHED STONE BASE, AS SPECIFIED IN ®®®®®®® .
310 CMR 15.221(2) ®®®®®®®
3) REPLACE EXISTING 1,000 GALLON SEPTIC ®®®®®®®
BOTTOM EL
TANK WITH 1500 GALLON SEPTIC TANK .= 37.5 4' ®®5 FT. 4'
IF FAILED, DAMAGED, OR UNDERSIZED.
4) INSTALL INLET & OUTLET TEES AS REQUIRED ,
SEPARATION 5.60 FT. EFFECTIVE WIDTH = 13
SEPTIC SYSTEM PROFILE BOTTOM OF TESTHOLE EL: 31 .90 SOIL ABSORPTION SYSTEM (SECTION)
(500 GALLON LEACH CHAMBER (H-20) LOADING)
N.T.S.
SOIL LOGS DESIGN CRITERIA
NUMBER OF BEDROOMS: 3 BEDROOM
DATE: APRIL 11, 2008 SOIL TEXTURAL CLASS: CLASS I
SOIL EVALUATOR: DARREN MEYER, R.S., CSE DESIGN PERCOLATION RATE: <2 MIN/IN
WITNESS: DONNA MIORANDI DAILY FLOW: 110 G.P.D.
HEALTH AGENT DESIGN FLOW: 330 G.P.D.
SEPTIC TANK (VOL. REQUIRED): 330 gpd x 2 = 660 gpd (USE EXIST. 1,000G SEPTIC TANK)
Elev. TH-1 Depth Elev. TH-2 Depth i GARBAGE GRINDER: NO (not designed for garbage grinder)
42.90 0" 43.10 0"
LEACHING AREA REQUIRED: 330 gpd/0.74 = 445.94 S.F.
FILL FILL
USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS (H-20 LOADING)
39.32 A 43" 39.77 A 40" ,
WITH 4 FT. ON ALL SIDES: 25 L x 13 W x 2 D
SANDY LOAM SANDY LOAM 10YR 3/2 10YR 3/2 BOTTOM AREA: 25 X 13 = 325 SF
38.74 a 50" 38.85 B 51" SIDE AREA: (25 + 13) X 2 X 2 = 152 SF
rTM LOAMY SAND LOAMY SAND TOTAL SQUARE FEET PROVIDED = 477 vs. 445.94 REQ'D
10YR 5/8 10YR 5/8 DESIGN FLOW PROVIDED: 0.74(477 S.F.) = 352.98 G.P.D. vs. req'd 330 GPO
36.74 74" 36.94 74" �* OF
C1 MqS
Ci D A4 N Ms9�y PROPOSED SEPTIC SYSTEM UPGRADE PLAN
MED. SANDE 'PERC 0 35.74 MED. SAND
�--� 12 EVELYN CIRCLE CENTERVILLE, MA
2.5Y 7/4 2.5Y 7/4 �
0_ 11 Prepared for: Walter Gardner
O Engineering by: Surveying by: SCALE DRAWN JOB. NO.
31.90 132" 32.10 132" 1E � DARRENM.MEYER,R.S. N.T.S.
6co-Tech 6nviroamental DMM
PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) SANITAR�a PO BOX981 (508) 364-0894
,�q EASTSANDWICH,MA 02537 DATE CHECKED SHEET NO.
NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED 'GZ•r7iS 50&362.2922 04/17/08 DMM 2 Of 2