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HomeMy WebLinkAbout1107 FALMOUTH ROAD/RTE 28 - Health 1107 FALMOU H ROAD) Centerville A = 250 — 009 �I S M E A D Na Z-1NWR UPC 1204 w1mcLe m • W&In USA mumimim kf F I p w 0IF21 MmmsouKwummEmm I I ' Commonwealth of Massachusetts ECEMEEN Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 1107 Falmouth Rd Property Address Michael Sullivan Owner ' Owners Name information is required for every Centerville ✓ MA 02632 11-6-2017 r, page. City/Town State Zip Code Date of Inspection r Inspection results must be submitted on this form. Inspection forms may not be altered in-rany way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Darrell Stone use the return Name of Inspector key. Cape Cod Septic Inspection r� Company Name P.O. Box 1466 VIA— Company Address R Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: . ® Pas s ❑ Conditionally Pa _ ❑ Fails ❑ d F rther aluati ocal Approving Authority 11-8-2017 pecto ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 kolltdr r r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �Mr Syey`er 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M , 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 Cit !Town State Zip Code Date f Inspection page. Y p o B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow !Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ., 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location.of the Soil Absorption System (SAS) on the site has been determined based,on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 310 CMR 15.302 5 Pp p ) [ Ol D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments M , 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: 3 bedroom residential dwelling Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3A 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2010 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 13"+/- feet Material of construction: ❑ cast iron 40 PVC other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Apparent good condition Septic Tank (locate on site plan): Depth below grade: 7"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 5" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts a` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M , 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle 61' Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet Invert, evidence of leakage, etc.): Normal liquid level No sign of leakage Sch 40 outlet tee Recommended next maintenance pumping within 1.5 year Recommended maintenance pumping every 2-3 years Grease Trap(locate on site plan): De pth below grade. feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Grade to box 38" Cover 1" OK condition 1 outlet Normal liquid level No sign of leakage No scum No sign of failure Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2 H-20 (500 gallon) chambers with stone (25x12.83x2') Grade to chamber 38" Cover to grade Bottom 72" below grade 1" of staining water on the bottom of the leaching facility No sign of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately REAP- I I 3 —�_ D -� �I 3 2= k%T3 _ �' 3i- I4 `ts- 23 _ 5 6 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 jCommonwealth of Massachusetts ` Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary- g p y o tary Assessments 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) Site Exam: . ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked' date of designIan reviewed: 2010 p Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan on file ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Elevations from design plan Bottom of SAS ELV. 49.0 Bottom of test hole ELV. 44.0 NWE Separation >5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 1107 Falmouth Rd Property Address Michael Sullivan Owner Owner's Name information is required for every Centerville MA 02632 11-6-2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is required for every Centerville Ma 02632 May-24-2013. page City/Town State Zip Code. Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end.of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: V key move your our cursor-do not . Matthew Gilfoy use the return' key. Name of Inspector B & B Excavationjnc. _. _. � Company Name 14 Teaberry Lane Company Address Forestdale MA _: : 02644 City/Town State Zip Code 508-477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the.inspection. The inspection was performed based.on my training and experience,in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: .2 O ® Passes. ❑ Conditionally Passes ❑ .Falls , . ❑ Needs Further Evaluation by the Local Approving Authority Ma -24-2013 Inspector's Signature Date - The system inspector shall submit a.copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 re al office of the DEP. The original should be sent to the system owner Pregional 9 . . .�. . Y and copies sent to the buyer, if applicable, and the approving authority.::: ****.This report only describes conditions at the time.of inspection and under the conditions of use at that time-This inspection does not address how.the system.will perform in the future under the same or different conditions.of use. .. _. 13 t5ins•11110 Tifle 5 Official Insp'IVEewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every y- page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N FIND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every Y- page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every Y- page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every Y- page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 NIS Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments G7M 1107 Falmouth Rd.Property Address _. Alice Setler Owner Owner's Name .. i is required for every Centerville Ma 02632 Ma - 24-2013 page. Cityrrowri - State Zip Code. Date of inspection C. Checklist ...::Check if the following.have been done. You must indicate"yes" or"no as to each:of the following: Yes No ® Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the.system components:pumped out in the previous two weeks? JZ 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 ® El available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 El Was the site inspected for signs of break out? ® "❑ Were all system components, excluding the SAS, located on site?. . ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ❑ ® information on the proper maintenance of subsurface sewage disposal.systems?. The size and_location of the Soil Absorption System (SAS) on the,site has. been determined based on: - - - ® ❑ Existing information. For example, a plan at the Board of Health.. ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System.Information Residential Flow Conditions: 3 3 Number of bedrooms (design): Number of bedrooms (actual)- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): .. 349 i l5ins•11/10. - Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is required for every Centerville Ma 02632 May-24-2013 page. City/Town State Zip Code Date of Inspection D. System Information Description: Tank, d-box, and 2- 500gallon chambers Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: 2011-41 GPD 2012-210 GPD Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every y- page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every y- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: new leaching 2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order no sign of leakage or blockage. Septic Tank(locate on site plan): 7" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: 1000 gal Sludge depth: 2" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every y- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 5" 9 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? scour 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.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every Y- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Upon inspection Tees are present and tank does not need to be pumped at this time. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 r Commonwealth of Massachusetts N w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every y- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every y- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500gallon ❑ 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.): At time of inspection leaching appears to be in working condition. No sign of hydraulic failure. Water level 1'10' below invert Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every y- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 ._ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every y- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one ofthe boxes below: 0 hand-sketch in the area below ❑ drawing attached separately 4�e�= ko_7 A 6 Al 36 13 z' Z 3S' 6Z 3f' f�3- 03- t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every y- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >10, feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 8-31-10 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan at B.O.H dated 8-31-10 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1107 Falmouth Rd. Property Address Alice Setler Owner Owner's Name information is Centerville Ma 02632 Ma 24-2013 required for every Y- page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed groundwater high System Information— Estimated depth to ® Y p 9 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliLatlon for Misposal 6pstPrn Construction 3permit Application for a Permit to Construct( ) Repair(J>grade( ) Abandon( ) El Complete System El Individual Components Location Address or Lot No. V I 0-t 'R+t_ O�vner',s Name,Address,and Tel.No. 9 t14 -4$-7- C t 23 GP1r�ery l - -1►Le p r0 y Assessor's Map/Parcel (P Len-5 WITp(,V 1 Installer's Name Address,and Tel.No. Sop 4'77 .d(63 Designer's N e,Address,am fel.No. 0 2-L+ 4� 3 w+8 XC VA. �vr1 -DarnUitp� �� 1 near t KA Type of Building: Dwelling No.of Bedrooms IJ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 8 j z7110 Number of sheets Revision Date / Title --fi+1r_ 5 S 1+e�1[k (` Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b his Board of Health. .. a d 0 Date $ G 1 Application Approved by Date Application Disapproved by Date for the following reasons n Permit No. 6�0 Date issued y Fee No. L ' THE COIN ONWEALTH OF MASSACHUSETTS Entered in computer: ?UBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes v Zipplicatlon for Disposal *pstem �C-on'strUctlon Permit ` d .Application for a Permit to Constructs(--),!,-Repair(i) U ,g rade( ) Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 1 1 0-j Owner's Name,Address,and Tel.No. �1 14 - Cr?nI � r,� I �C� `�'� � 1dC Ctr1�y Assessor's Ma /Parcel f (� p (n. V-P,i 1 (; I G ( t Installer's Name,Address,and Tel.No. 5CA 117 Designer's Name,Address,and Tel.No. 5L) --3L-,2- Li 6'4 1 6 G � C (1 VCL i c',rl ( r I H P'.f r'l f / l k Type of Building: 6 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ( gpd Design flow provided o gpd Plan Date b l ; 7 ID Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Ig ed Date ' 3YC� Application Approved by / Date I; v _ Application Disapproved by Date for the following reasons Permit No. '� Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by } �/� ! at `` (�� k;(�►) �' � C� has been const cted in accor Dance_ " with the provisions of Title 5 and the for Disposal System Construction Permit No dated Installer v w r �-g / Designer -p CC n['j . #bedrooms Approved design flow 3 3 b gpd The issuance of this permit sh Il no be construed as a guarantee that the syste will fun as de 'gned. Date yd Inspector ------------------------------------'-—----------------------------- ------------ -------------------=_------- ---------- No. � � Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( v) Upgrade( ) Abandon( ) System located at 2-k r 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:ConstructiojAnust be 6mpleted within three years of the date of this permit. Date 1,11-'2 Approved by IV • 1 v FROM :down cape engineering inc FAX NO. .:15083629880 Sep. 07 2010 11:56AM Pl NIE Choman F. Geiler,Director KA, RA'A.WaE. :L659 6' Thomas M'Keftn., D-Lrecto-r 200 Mqiu Street,Hyannis,MIA,02,601 0 f ric, 508-869-4044 Fax: i0fl,,790-6304 tmitalkp- .q,.Dcsi"eT (Certification Form D a d e- 17A Sewage Per-laftil Asseslsor'9 sipTarce, Designer: 6L,)V\ Cape F-XcaL); P�. AdIdirCHN: Add ress- OV", On was issil M a Permit to lustali a (date) (installer) septic,sy'C.ftel'a at.. based ou a design drawn by (address) Q. igper) daied T ueTtll'y-that the septic system. refercticed. above was instahed SllJ)3l-Mfi,911y a.000Tding to tJ,).e design, which may iw"I��&.' millor applow'd Changes such as latc.-.ralrelocation of the distribuh'.on box and/or soptle tank. i certify that the sel7fic syqtein referenced above was installed Y04b. m;ljoi. cl(anges (to, greater than 10' lateral relocatiou.of thc SAS or any vertical relocation of atly component of the septic systom) bW ixt ncoulance with State & Local Re.gi.ilatloiis. Plan revision or certified Y ul ied as-built b dosigaor to follow. D NILLA, JAL.A JTLstafler's Sicilake) CIVIL No,46502 0��6 (' VL VP NAI. (1)eslgiler'3 "),j.P- lab V� (Affix Designer's SVIUIP Here) PLr4,ASE Kj3i'r'('ftlN .f" 0 BARTISTABLE PTJ13LJC—Fr.FA.L-'.l.'.H. D.I.N.1,990N. C'ERTMCAjE,_..Sq;� NCYl' fif, ISS'17,T) Ufqlfl., )t;OT'U TXII.Fj' MIA. AND A8-Yf(JU,T C'A'9D ARE RECEIVED.BY''I"I)li',.'OA:RN,9TABLE PTJBL.IC TTEALTH DMSTON. THA.NK YOU. Q I lealth/sepfic/Drsiguc."r C"C-,TfiTj.E;"I.i0Tl Form 3-26-04.doc TO 0 BARNSTABLE LOCATION 110'7 L-,, z 08 SEWAGE# c70/0 VILLAGE Ccn4c.rui) )c ASSESSOR'S MAP&PARCEL 050 - 00 9 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /000 9a ) LEACHING FACILITY-(type),S�a I Champ �Z 1(size) 13 x 2 S X 7- NO.OF BEDROOMS 3 OWNER A I i cc. Fa rJa PERMIT DATE: 3 - 3o- /o COMPLIANCE DATE: 9-0-/O Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within_200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY A)- 30 .B) -39' AZ -35 132 '31 A3.39�/z B3 '3i Ay - yyllz R�a� i3y -3q , / B � O , Town of Barnstable IRE Departaneaat of Regulatory Services ✓f y nnRnsrnal.e : Public Health D➢�'YSflOIl71 Date MASS. ' 200 Main Street,Hyannis MA 02601 x6y 4. ti� ApFU�,l p Date Scheduled �O < V Time / 0 U Fee Pd. Soil Suitability A1.ssessnientfor Sewage Disposal Pcrfonned By: N��� /'► 0, ,h LA PE-6-9 St Witnessed By: ]LOICATI N & GENERAL I[NFORIVIIATION Location Address //O 7 40 1-1 o"(1'- Owner's Name Address Assessor's Map/Parcel: Engineer's Name J ULnI r4y e NEW CONSTRUCTION REPAIR Telephoneit Land Use _�l V.��1J T"1�-+-+ — Slopes(%) Surface Stones Distances from: Open Water Body N ft Possible Wet.Area>i0.1 fL Drinking Water Well I` a� It Drainage Way too ft Property Line Ft Oilier ft 5 ICE TCH: (StreeL came,dimensions of lot,exact locations of test holes&pere tests,locate wedands'fn proxfiluty to holes) a_ .J op-Y % 4n 9 Parent material(geologic)_ d1A V y Depth to QC.b'ock. 1 v` Depth to Groundwater: Standing Water in II01e: t4 Weeping i'rom Pit Film? PI LA- Estimated Seasonal High Groundwater D]CTE IMNATION FOR SEASONAL 110E WATER TABLE Method Used: Depth Observed standing in obs.hole: In. Depth to soli mutdox; r III, Depth to weeping from side of obs.hole: In. Groundwater Adf uslment„e _ _ Fl. Index Well# Reading Date: Index Well IeYvI m Adl•fattot, A41.01' Ontlwater L evel Observation Hale tF Time lit 9" _ _ / Depth of Pcrc Time at 6' ,--•- Start Pre-soak Time @ _ Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed SiL.G',Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted witinn 100' of wetland,you must first Uotify tile. Barnstable Consefvataorl Divtsfoai Fat least one (1) WeCl4 prior to beginaaapag. QASEPTIC\PERCFORM.DOC HOLELOG Dcpth from Soil linrizon Soil Texture )Bole# Surface(in.) Soil Color Soil• Other (USDA). (Munsell) Mottling (Structure,Stones;Boulders, Ir1 Con istene ,%(ravel_)___ i DER U-USE RVATIONROLI'a LOG Depth from Soil Horizon Ir0.1e# I-- Surface(in.) Soil Texture Soil Color (USDA) Soil Other (Munsell) Mottling (Structure,Stones,Boulders. Q •�` It Consis enc %Gravel --------------- DEED OBSERVATION HOLD LOG Depth from Soil Horizon # Surface(in.) Soil Texture Soil Color Soil (USDA) (Munsv)l Other Mottling (Structure,Stones,Boulders. Consistenmffp—OmveI DE E P OBSERVATION HOLE LOG Depth from Soil Horizon Hole# Surface(in) Soil Texture Soil Color Soil (USDA) ,• Other (Munseu) Motliing (Structure,Stones;Boulders, Consistency.%Oray� ei�10 -,�T_ Rgod Insurance Rate Maw Above 500 year flood boundary No_ Yes z Within 500 year boundary NoI Yes. Within 100yearfloodboundary No Yes . Depj o, LXt>Igu>rsallp Oceutrrdn�Peiryious Materfa6 Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervi us material? y CeHificntion I certifyat on A✓3V' that (date)I have passed the soil evaluator examination approved by the Department of Environmental.Protection and that the above analy.-is was performed by me consistent with the required training, expertise and experience described in CIO CMR 15.017. Signature Datb Q:1S.EETIC\PBRCFORM.DOC } tom. 't7 s i 1 1 1 cif i - �� - ram' � ,.�'�CIS�'i►�� �a � )T7U sue. 1 92� ------------- , 5 s �- F-LoD i �• �d i '�` i 1 r^ { 1 ';4.1 - M e- 1 4- LNt9 {i APPRO G + S r O NOTE CHAN( lAw ' •�� -""ti,..r, t� .."ram'✓+-.,,,,. -+,,'-.f."+..1.c TOWN 0 BAR Building Impecticn D No.__.lL57117,�_ I Fmc.3.0....Q.Q........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Diopwial Work.6 Tonotrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair OCX)I an Individual Sewage Disposal System at: 1107 Route 28 Centerville , -•-•----•---••••-•-•----•-•••••-------------------•---•-•-••-••---....._....-•---•----•----_------ Mass Location-Address or Lot No. Ge o- ge act --••---------------------------------------------------- owner Address ,Wa -------J_-P•_Maaomb-er•---Jr--.............................................. --------------------------..----------•----•---------- Installer Address Type of Building Size Lot............................Sq. feet �-, DwellingX-- No. of Bedrooms---------.1--------------------------------Expansion Attic ( ) Garbage Grinder (N aOther—Type of Building ----NIA---------------- No. of persons---------.-.---------------- Showers ( ) — Cafeteria ( ) d Other fixtures WDesign Flow_...:,-, 5.5 =---------------------------gallons per person per day. Total daily flow--------440---------------------_.......gallons. WSeptic Tanks--Liquid capacity..1.5C10gallons Length---------------- Width...-.---.------. Diameter---------------. Depth................ x Disposal Trench—No- -------------------- Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..--------- -----. Depth below inlet.................... Total leaching area. ..._._._--_.._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------------------------------------------------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit......-.------------ Depth to ground water..................... GL. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ 9 ............. ......................................................................................--•--•-•--------•-••...-•• -------------•---. 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------- --------•---••-••---. USand...&---- rave-1---------•---------------------------------------------------------------------------------- W x --•••-----•---------------- ------------------------------------------------•-------------------------------------------------------------------------------------------------------------------•_------ U Nature of Repairs or Alterations—Answer when applicable.-Qmi.t----ces-S.p.Q-Q1......1.--1--5.QQ...gallon.............. -------.tank-- 1,d i-str-ihutian---b.ox....._4...3.3-0---Re-charge-r.s----=----------------------------------------------------................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has e iss ed by th boar of health. Signed .. - ----- -- -----.------ lr� -- �:....... 1..0.�.5.%.9.5......... Application Approved BY - ..- Dace Application Disapproved for the following reasons: ..... -......................_.......----------------------------....------------...........------------------------------------ - -- ------------------ -------------------------------------------- ---------- � Dace Permit No- ------------ ---------- Issued ............ la.a �...-.. .:�...... ....... ...1 ? /� ..... Dace :.�7 ' I THE COMMONWEALTH OF MASSACHUSETTS G- BOARD OF HEALTH - TOWN OF BARNSTABLE Applirtttion for Uhip ittl 3Vorkii Tonstrnrtion 11amit Application is hereby made for a Permit to Construct ( ) or Repair K;{]Y, an Individual Sewage Disposal System at: 1107: Route 28 Centerville,Mass --------------------------------------------------------•--•-•------------._................---•- /� Location-:Address or Lot No. Ln ------------------•-----•- ..--.-----.-.-.-----.--.-- W Owner Address M Installer Address U Type of.Building Size Lot.................... q S feet t-, Dwellingv No. of Bedrooms----------/Y---------------------------_--Expansion Attic ( ) Garbage Grinder (N)� 04 Other—Type of Building --------------- No. of persons---------------------------- Showers Cafeteria a ( ) � Other fixtures ................ ......... . ------------------------------------ ------ ------....................................................... Design Flow.....4.405............................. allons er erson er da Total dail flow_.___-__ �p___..__.._....._____,....__ W gg P P P Y Y �__,... gallons. WSeptic Tank!-Liquid capacity___ OCl allons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench— No- -------------------- Width.................... Total Length.................... Total leaching area.........._---------sq. ft. Seepage Pit No................. ... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ { Test Pit No. i----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.......-:__-_-_-___---_ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_.----_.----__-_---._--. 0 04 ......----•--•---•------------------------••--•--------•-•------....--•-•-•----------...------............................................. Description of Soil................................................................................................................................................ .............................................................. ................... ------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable._ Alit---.O.eS$-UQAl.--_-1• 1- 00.--F_ 10n.............. .......tank--- ...3-30... -- -------- -------- -------- -------- -------- --••--•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has . e,iss ed by th boa of health. ly< Signed .. . . /.'.-_..... ........... -A----------_------------------- ..10/119-5-----:...... F 1' >�te q Application Approved By ----------Z�� �„ � ........... /...v `..6_ `f�.,3�'' Date Application.Disapproved for the following reasons: --------------------------------------. ---------------------------------------------------------- ................ ......._............. ....... . ............ ..-...------------- -------.....------------------------------------------------------------- - ------..-------- .tom Date :. Permit No. ............ � 1 7.. .... Issued ....... ID_-... ... ---�--------- Date I r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�ertifira e of CZomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ((X ) by ...J•p.GIs-camber Jr-- --------- -- ------- ------------- - r ....................... .._..... .. ---------------------------------------- Installe - at ---1107 Route 28 Centerville,Mass. - - --------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ... s L`..... dated . - �6y THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ... , ....:0 ----------------- Inspector , _r� 7 " t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C TOWN OF BARNSTABLE 30...00 No.C�� -_-� J I"� FEE ........ .......... �io�roottl or�� �on�trtion prnti� Permission is hereby granted---Js_ .a. to Construct ( ) or RepairX(XX) an Individual Sewage Disposal System at No....1_a.10.7 Rowte.-2-g... Pxlt_exv .lore., i r ------------------------------------------------------------------------------ ............ Street as shown on the application for Disposal Works Construction Permit No,),t7, ,�._y: bated-----1/0^_C r���i ............................ --------------------------- ------------------------------- ` Board of Health DATE 0 � Imo" ,`�--------------------------- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS T 41r �r3;o Y CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, Joseph P. Macomber Jr, hereby certify that the application for disposal works construction permit signed by me dated 10/5/9 5 , concerning the property located at 1 107 Route 28 Hyannis ,Mass . meets all of the following criteria: • There are no wetlands within,300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is :4 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED DATE: 10 f 5/25 LIC D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. - v.. Commonwealth of Massachusetts _■ 100012607 Asbestos Notification Form ANF-001 Decal Number L _ . iAP PARCEL LOT Important:When filling out A. Asbestos Abatement Description forms on the computer,use 1. a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied only the tab key residence of four units or less? ;L!Yes :�] No to move your cursor-do not b. Provide blanket decal number if applicable:use the return Blanket Decal Number key. 2. Facility Location: 11 a7 t' �GEORGE FARDY 1 FALMOUTH RD. a.Name of Facility /�.Street Address BARNSTABLE I MA �02601 c.City/Town d.State e.Zip Code f.Telephone Number INSTRUCTIONS 3. Worksite Location: EXTERIOR 1.All sections of this i L I form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room completed in order to comply with 4. Is the facility occupied? 2]Yes No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the division of Occupational :NEW ENGLAND SURFACE MAINTENANCE ! 1850 WASHINGTON STREET Safety(DOS) A Name b.Address notification •WEYMOUTH 02189 '781337211T requirements of 4$3 i 1 CMR 6.12- - c.City/Town d.Zip Code e.Telephone Number AC000196'' f.DOS License Number g. Contract Type: ❑ Written G Verbal h.Facili Contact Person i.Contact Person's Title -• JOHN S BUTTS JR !ASO40209 6' a.Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS Certification Number iN/A I !N/A 7' a.Name of Project Monitor b.Project Monitor DOS Certification Number N/A jN/A i 8. a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number 9. 01/06/2005 101/11/2005 a.Project Start Date(mm/ddlyyyy) b.End Date(mm/dd/yyyy) �o `8-4 �N c.Work hours Mon-Fri. d.Work hours Sat-Sun. �0 10. a.What type of project is this? —�-0 ,= Demolition iri Renovation i -- Repair Q Other, please specify: b.Describe 11. a. Check abatement procedures: �o Glove bag Encapsulation —o i Enclosure ._ ❑ Disposal only - 9�_LL Cleanup Other, specify: ... 7_ Full.containment "...__. ... ___._..__-.-_____ .. ..._. ... b."Describe--_.__ - .._ _ __._ �l —�Q 12. Is the job being conducted: � Indoors , ,Outdoors?_ e anf001ap.doo`�10/02 �" '` Asbestos Notification-Form.Page 1 of 3 ■ Commonwealth of Massachusetts ■ 100012607 Asbestos Notification Form ANF-001 Decal Number iL A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or encapsulated: 10 ; 11000 a.Total pipes or ducts(linear ft) 0. 1 otal other surfaces square c.Boiler,breaching,duct,tank i — I d.Insulating cement surface coatings Lin.ft. Sq.ft. Lin.ft. Sq.ft. e.Corrugated or layered paper j ; ; f.Trowel/Sprayer coatings pipe insulation Lin.ft. Sq.ft. Lin.ft. Sq.ft. g.Spray-on fireproofing h.Transite board,wall board Lin.ft. Sq.ft. Lin.ft. Sq.ft. i.Cloths,woven fabrics i j.Other,please specify: F_ 11000 Lin.ft Sg.ft. Lin ft Sg ft k.Thermal,solid core pipe (SHINGLES insulation Lin.ft. Sq.ft. I.Specify 14. Describe the decontamination system(s)to be used: AS REQUIRED ' 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): ;:AS REQUIRED i 16. For Emergency.Asbestos Operations, the DEP and DOS.officials who evaluated the emergency: I i a.Name of DEP Official b.Title ( I c.Date(mm/dd/yyyy)of Authorization d.DEP Waiver# e.Name of DOS Official f.DOS Official Title I I f N g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver# 0 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? [!Yes E"] No B. Facility Description N _—0 1. Current or prior use of facility: 'RESIDENCE �o 2. Is the facility owner-occupied residential with 4 units or less? n Yes Of No ;SAME 1 3. a.Facility Owner Name b.Address o o c.City/Town d.Tip Code e.Telephone Number(area code and extension) 4. i i a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address i ; �Q c.City/Town d.Zip Code e.Telephone Number(area code and extension) ■ anf001ap.doc•10/02 Asbestos Notification Form•Pa qe,2 of 3,■ Commonwealth of Massachusetts 100012607Li j Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont.) 5. a.Name of General Contractor b.Address i I c.City/Town d.Zip Code e.Telephone Number(area code and extension) f.Contractor's Worker's Comp.Insurer g.Policy Number h.Exp.Date(mm/dd/yyyy) 6. What is the size of this facility? ' I a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): NESM LLP j Note:Transfer a.Name of Transporter b.Address Stations must 1 comply with the c.City/Town d.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 ;WASTE MANAGEMENT a.Name of Transporter b.Address c.City/Town d.Zip Code e.Telephone Number 3. I j: a.Refuse Transfer Station and Owner b.Address c.City/Town d.Zip Code e.Telephone Number 4. ;TURNKEY LANDFILL(WASTE MGT NH) a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name 17 ROCHESTER NECK ROAD jROCHESTER c.Final Disposal Site Address d.City/Town INH !03839 e.State f.Zip Code g.Telephone Number —o D. Certification �N The undersigned hereby states,under the ;KEN FURTNEY penalties of perjury,that he/she has read the a.Name b.Authorized Signature o Commonwealth of Massachusetts regulations �12/2412004 for the Removal,Containment or c.Positionfritle d.Date mm/dd/ Nv) Encapsulation of Asbestos,453 CMR 6.00 and I- 310 CMR 7.15,and that the information i contained in this notification is true and correct e.Telephone Number f.Representing to the best of his/her knowledge and belief. o q.Address i �tL i h.City/Town i.Zip Code Z anf001ap.doc•10/02 Asbestos Notification Form•Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. City(rown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: I I key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. kCompany Name 14 Teaberry Lane Company Address r Forestdale MA 02644 _ Cityrrown State Zip Code 508-477-0653 S14595 _ Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and`maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant'to Section 15.34016f Title 5(310 CMR 15.000). The system: <- ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority _ 1 7/19/10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l f� l l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage i posal System•Page 1 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i . l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? site glass on truck Reason for pumping: customer request Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20 feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ® Yes ❑ No Dimensions: 55"X 65"X 102" Sludge depth: 1' t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1' Distance from top of scum to top of outlet tee or baffle equal with 4" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? scour 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.): At time of inspection septic tank appeared to be structurally sound -water staining above outlet invert which is a sign of hydraulic failure Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1107 Falmouth Road Property Address Alice Fardy - Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 1" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box deteriorated -water backed up into pipe and staining above invert-signs of solids carryover Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 ❑ 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.): At time of inspection leaching appeared to be in hydraulic failure due to signs in the d-box Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately _ � C I A I � c� y 0 'U dZ ( . Al � 30 ' - AZ= 3,5 c� A3 = 27� AH = 19 "B 1 = 32 B 2 = 31 ' I 133 = 35 ' Bq = 27 ' [ t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 r Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: f 12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: reviewed plan on file for 942 West main Street(abutting property) ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1107 Falmouth Road Property Address Alice Fardy Owner Owner's Name information is required for every Centerville MA 02632 7/19/10 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION ZZ l 7 4- a L SEWAGE #!,5—/72;� VILLAGE n 3 �v'�t'y''—"42ASSESSOR'S MAP&LOT , INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /S o v LEACHING FACILITY: (type) 41 12Y (size) NO.OF BEDROOMS BAR OR OWNER z PERMIT DATE: l <" % 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 i /lo.�\ ,?`-- 3fo , -- ----------- AU SYSTE SHALL SYSTEM PROFILE MARKED WITHCMAGNETICTTAPE ORBE NOTES (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS APPROX. NGVD Wequaquet ACCESS COVERS TO WITHIN 6" OF FIN. GRADE WATERTIGHT C.I. COVERS TO GRADE Lake 2" PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING \ FILTER FABRIC OVER STONE a r MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. f 3. O MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED .OVER SYSTEM 54.8 � 4. DESIGN LOADING FOR ALL PROPOSED PRECAST PRECAST H-io j BLOCKS OR UNITS TO BE AASHO H-200 RISERS (TYP.) PRECAST RISERS o 2'0 4"OSCH40 PVC MORTAR ALL H-10 PIPES LEVEL 1ST 2' 4' COMPONENTS 5. PIPE JOINTS TO BE MADE WATERTIGHT. (TYP.) INV' 1. 4' SIDES ENDS ", 52 0 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE �� oe s Lo s 14" 10" EXISTING o 0 0 0 0 0 0 0 TEE SEPTIC TANK** TEE 51 .8'f* ° ° ° °rE=: 0M O (�O='1O� 0 310 CMR 15.000 (TITLE 5.) Ph MIN. 6" SUMP 0000000�a aomoma�'o0 0 0 0 0 0 0 0 0 0 > o 0 0 o° ° ° ° aaoa000c7o �oaoaaaa�oo BASEMENT SLAB ELEV. GAS BAFFLE .' ° ° ° ° ° MIN. 12" INT. DIM. Ci ' o° ����0�0� a���aa����a °o°o°o°o 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND o 0 0„o o_ o 0 0 0 O C7 C7 C� .C7 0 o 0 0 0 o o ° 54.9' ° ° ° ° ° ° ° ° NOT TO BE USED FOR LOT LINE STAKING OR ANY 51 .3' S1.13' 00000000 00000000 49.0 4 LIQ. LEVEL (ACME OR EQUAL) - OTHER PURPOSE. 2 �9fj L H-20 50G° GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. = Shoo/ 3/4"-1-1/2' DOUBLE WASHED STONE 4' MIN'. (2) UNITS REQUIRED ALL AROUND PRECAST STRUCTURES 9. COMPONENTS NOT TO BE BACKFILLED OR 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.8' CONCEALED WITHOUT INSPECTION BY BOARD OF COMPACTION. (15.221 [21) o HEALTH AND PERMISSION OBTAINED FROM BOARD ( 5 % SLOPE) ( 1 % SLOPE) OF HEALTH. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP FOUNDATION EXIST. SEPTIC TANK 10' D' BOX 15' LEACHING CALLING DIGSAFE (1-888-344-7233) AND FACILITY 44.0' BOTTOM TH-1 VERIFYING THE LOCATION OF ALL UNDERGROUND & NOT TO SCALE NO GROUNDWATER FOUND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF *THE INSTALLER STALL AND nLL SHALL Y THEWER OUTLETS AND ELLEVATIONs "INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT WORK. ASSESSORS MAP '250 PARCEL 009 UTILIPRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE WITH 1500 GALLON H-10 SEPTIC TANK IF NOT SUITABLE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND SAND. 99- EXISTING CONTOUR SYSTEM DESIGN. X 99.1 EXIST. SPOT ELEV. 99 PROPOSED CONTOUR GARBAGE DISPOSER IS NOT ALLOWED [98.4] PROPOSED SPOT EL. 0.89 DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD TH 1 60.81 - TEST HOLE L�1 N USE A 330 GPD DESIGN FLOW x 1 60.62 2 SLOPE OF GROUND SEPTIC TANK: 330 GPD (2) = 660� 15' 17 A= 9. x \60.16 �► **RE-USE EXISTING 1000 GAL. SEPTIC TANK UTILITY POLE ZS R�uTE 3'9 FIRE HYDRANT -' C6 9. I FACHING: 8. NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING A_112 • .47 SIDES: 2 (25 + 12.83) 2 (.74) 112.GPD R-33g1 .39 31 ��s8s��x 59.20 BOTTOM 25 x 12.83 .74 = 237 GPD TEST HOLE LOGS EXISTING TOTAL: 472 S.F. 349 GPD LOT AREA x 5 1 DWELLING ��� Se 9,338 f SF 8 63 -tea 5 go sz 6 \\ 4 = USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) ENGINEER: ARNE H. OJALA, PE, SE \ -� S >l5 .32 \ .41 WITH 4 STONE ALL AROUND WITNESS: DAVID STANTON, IRS 5� x 56.81 PAVED 4.8 � �/ x 3.95 DRIVE DATE: AUGUST 19, 2010 51 55.72 \ 5 7.8 2 O PERC. RATE _ < 2 MIN/INCH CHAIN LINK FENCED 56 55 DECK 54. DRAINAGE AREA '� 5 pPRpy ` \ S, 5 x 53.29 �� 54 W WATER\ CLASS I SOILS P# < 2 MIN/INCH S�s ° W \ \\ S S x 53.50 x 53.71 3 4 19 S6 \7.09 , MA 47.99APPROVED DATE BOARD OF HEALTH ELEV. ELEV. S xx 3. j 7.oo o5`5\2 62 4 x 0 1 (L�P 11.72 � 3.74 x 55�1 5 \�56.55 p" 1 54.0' p" 2 54.5' x 3.9 - 5 - - S.8 x 53yN TH ,o .94 TITLE 5 SITE PLAN FILL FILL 55 OF �- \\55.18 x 55.40 x 55.64 x 55.81 07.36 1107 ROUTE 28 36" 51.0' 36" 51 .5' CENTERVILLE SLEEVE WATERLINE WHERE WITHIN 10' OF SEPTIC SYSTEM COMPONENT;; PREPARED FOR BENCH MARK - HYDRANT ON B&B EXCAVATION/ C C TAG BOLT #512 ELEV. = 57.4 PERC CMS W/ CMS W/ PROP. VENT WITH CHARCOAL FILTER AND A L I C E F A R D 1 BUGSCREEN (FINAL PLACEMENT BY CONTRACTOR GRAVEL GRAVEL ° AUGUST WITH HOMEOWNER CONSULTATION) _ REV. 8/3 /103(MOVE SAS) 1 OYR 6/6 1 OYR 6/6 �zH of M. ���JN of M,18. Assy''i o� DANIEL �y off 508-362-4541 oy .r � fax 508-362-9880 DANIELA. A. �n I d o OJALA OJALA � owncope.com-© CIVIL 65 p No.4o98a down cope engineering inc. No.�6a �0F �� , 120 120 n w t ss I 44.0 44.5 T �� �� �� q p s �a civil engineers Scale: 1"= 20' ro A�' ., . ° :° f^-� land surveyors NO GROUNDWATER ENCOUNTERED ='' e v.: 939 Main Street ( R to 6A) p 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 0- 1 /�/U 10-178.DWG (SBO)