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Home My WebLink About0218 FIVE CORNERS ROAD - Health 218 FIVE CORNERS.RD.;;CENTERVILLE A = 168108 y Slnl-__JI J�,aEa /1///fiP.QIC UPC 12534 No.2 � HASTINGS. MN No. FEE �O CMMONW�AI.114 ®F MASSAC14USETTS Board of Health, °��''^Sb MA. APPLICATION FOP, DISPOSAL SYSKM CONSTRUCTION PERMIT Application for a Permit to Construct(. ) Repair( ) Upgrade(KAbandon( ) - 0 Complete System Rgndividual Components Location q,-- Cc,c-ner3 C+ Owner's Name L%j G 1 v So r ct; b4-Z C.0 Me Map/Parcel# I G? —1 0-`. Address Lot# 2, Telephone# Installer's Name V,A, `f ro-�a ,el C Designer's Name _e r, . Address P 0� 3 0,� -1 A _.Ce f-e�d; 11 e l� Address )2 W 1. Criss e Telephone# 5O H&a—7 t 7j,32 Telephone# 5Q<g—a.?7_53 1 474 LN Type of Building lzQ S^� � 1 Lot Size 3}��- sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building AIJ A- It No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) 330 gpd Calculated design flow 3 Design flow provided 3-47�� gpd Plan: Date 9 Z 1 , O g Number of sheets 2— Revision Date q Title PruettS&c� �one1-1 (21A Description of Soil(s) —k '3 a^13 Z Soil Evaluator Form No. Name of Soil Evaluator d— C dLi4V—Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS S-)KtA 4,nc,L ab O*L A S . The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agreestdAott wplace the tem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections NN t FEE a l 4EALTH Or MZ"1iSSACHUSETTS ^i Board(:Health,. MA i APPLICATIOT .. t N FOP DISPOSAL. SYSTEM CONSTRUCTION P�RMIT Application for a Permit to Construct( Repair( Upgrade(K Abandon'O •O Complete System aIndividual Components Location v^e: Cc,cxri e�s � , Can-}-, Owner's Name 50,-ct 1 q �s b r' jc ec a rc� A Map/Parcel# I G? I O Address 5q r^ti4 Lot# Z Telephone# Installer's Name Designer's Name r r � �t Icpwn �nC. Desi g ' ✓► Qer, nuh WcrrUS ('NC-. Address P Q� �U-A 1 Q 3 Ce I�r V, Address14 11 e N114 IZ'W, CroSS .{l c I�t`eS 4-c�� Telephone# 5-d C' �y U O.-'7 51S Q Z_� 7jZ-. Telephone# .�U$-t�7"7-53 1 0 Z4 Lf 1� Type of Buildings $i(�e't �'U ( Lot Size ��.$��3+fir- sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder ( ) Other:-Type of Building No. of persons Showers.( ),Cafeteria ( ) .,k- Other.Fixtures Design Flow (min.required) U gpd Calculated design flow 3 3 Design flow'provided � 7, S gpd Plan: Date 1 ��1 Q `l Number of sheets. Revision Date Title A n a �e��. .�+�� U'o�,c-,b - 2,1¢> 1:, r4r-~� ( C��n- r,�.lie Description of Soil(s) 3 cr-13 Z_ Sav�ol ,, -�-2 d 3�--t'3'� 5,0AY Soil Evaluator Form No. Name of Soil Evaluator 7 cam!" MC 4' 4Q.Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS a�0 cw,•�cH^ The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree ,to not t `lace the system in operation until a Certificate of Compliance has been issued by the Board-of Health. Signed Date Inspections f ��( (� FEE G V COMMONWEALTH.V'V'EALTH OF..MASSAl HUSETTS Board of Health, Gfn 5 t c b MA. CERTIFICATE OF COMPLIANCE Description of Work: P<Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed.( ),Repaired (_1,Upgraded ( ),Abandoned ( ) by:., F�r�rA� \cjSep N) at. -`c9 ly S has been installW m accordance with the p sion of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No Q dated . Approved Design Flow 0 (gpd) Installer_ 1 G ( AlA Iklo r� 4 Designer:Y„tr..ar= N body C Cd Inspector: j i< Date: /'Yf/ A The issuance of this permit shall not be construed as a guarantee that thIVsystem will function as designed. No. 9 - / 3 FEE COMMONWEALTIT Of. MASSACHUSETTS Board of Health, of v.5.4-ra b MA. DISPOSAL SYSTEM STEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( �) Repair( Upgrade( ) Abandon( ) an indi«dual sewage disposal system at F) j Q C-•near S lC�l ll It r d 1�� m as described in the application for Disposal System Construction Permit No� dated //0. 09 Provided: Construction shall be completed within three years of the dat6of-this pertni . All local conditions must be met. `Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date g/ Board of Health TOWN OF BARNSTABLE LOCATION i �i y'C. C3� -'��C SEWAGE # V—LAGE �' �'� ASSESSOR'S MAP& LOT lb INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) i\ (size) \o C� �• NO.OF BEDROOMS BUILDER OR OWNER fEltNtMDATE: rdMq 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 fe of aching facility) Feet Furnished by4CsC, �. a t� � 6c1 �� TOWN OF BARNSTABLE LOCATION 2 ru,e&wi i?d SEWAGE# ?fit /3 C VILLAGE (Ps�l t ASSESSOR'S MAP&PARCEL J&f3 1QF3 _ INSTALLER'S NAME&PHONE NO. A lir-dwt3 a: � SEPTIC TANK CAPACITY lCXlS�rnpcD LEACHING FACILITY.(type) 9joe), dSLTS (size) //. 3 K 25— NO:OF BEDROOMS 3 OWNER PERMIT DATE: COMPLIANCE DATE: / Separation Distance Between the: �� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 401C c,&13� 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 1-37 s-6 It 1 � vc.I VC--4c( z-1� C 3-Y3`G r 6-70 g4/vr—��°3'� 01/'23/2009 23:25 5084775313 ENGINEERING WORKS PAGE 01 Town of Barnstable Regulatory Seances Thomas F.Geller,Director a.., m Public Health Di"Slon Thomas MdCean,Direder r4ain Street,Hyannis,MA 0201 t Office: 508-862-4644 Fax: 50&790-630l I sler&De ner Cerdfl Flo»&Egan late* IL-5—/0 sewage Permit# Assessor's MlapWarcel De signer i t a�� [AC. Installlere Address; Add�so -� _ wart J M Ft azwl x'k !�,� on )2 A', ,vut0 in C was issued a permit to install a (date) (installer) septic systmn at ZI$ N� Co�y s � C�.n-� based on a design drawn 11)y (address) dated 1 2-1 U (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the ,.r distribution box and/or septic tank. I certify that the septic system referenced above was installed with major cbh urges (i.e. grater than 10' lateral relocation of the SAS or any vertical relocation of atly"mponeat of the septic system)but in accordance with State &Local Regulations. Plan ryavision or certified as-built by designer to follow. Y ��N OF AAgss All PETER T. s signature) CIVIL No-35109 p �. 6� I S-T �1. (Designers Signature) (Affix designer s Stamp1��) RNSTABLE t, Ng—T RE o 0- Ig, BO °rxas ®t a r C u #' 'rK1 I)BY THEBARNSIA�LE PUBLIC&E.DTI1 I-IVIlSIQ—N,T1 6n-QU. i t HMth/STfio1ksig=Cexdficadm Porte 3-26d34.doc .t i<j . ^ Commonwealth OfMassachusetts Title~�^~.�U�� ~k��~��~�� ~�^�� U�� v�� NQB��K�� Inspection K—��° xox Subsurface Sewage Disposal System Form Not for Vo/untsryAauesame Owner Owner's Name information is for �cv/red every page, City/Town ' State ZipCnda Date of|ns�e��n Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. ��6�7�V l��F�l2�f^��n Woen�moom ^ ~ General Information ' iomsonthe computer.use 1 | | on�m:�b�y �mo��ur cursor do not use the return N 2rne of Inspector xcy. �Z5'7 X a PV) Ci��mwn State Zip code Ll�—�--' n Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addreZ. I � information^^ reported~ b~'~~ is true,~ accurate and complete ~' of the time of -'~ ''—� was performed based on my training and experience in the proper function d maint sewage disposal systems. | anmaOEP approved system inspector pursuant toS 15&0of� Title 5 (310 CN mo ~``1R 15�OOO)� The � ' �� Passes U Co��Uypa�eu ��FaUy F-1 Needs Further Evaluation by the Local Approving Authority � Inspe or's Signature Date ' The system inspector shall submit a copy of this inspection report to the Appr,civiro ri'vutihoF;-;y /Bo—` of Health or DEP\within 30 days of completing this inspection. IF the system is e ahsre� ays�en or � � ^ has a design flow of1O.00Ogpdor greater, the inspector and the system ownersha|| a�bni� ��e report to the appropriate regional office oil the DEP. The original should be -'-othasys�arr �rre� 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 fulture under ` the same or different conditions of use. � sm� 0310 ��som�.�a��ro=ae�"�c � Commonwealth of Massachusetts Title 5 Official Inspection For* m I=� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ov;ner Owner�sarrle infcrnation is / /� / Qo�� of ��I required for (� ✓l�� /�_ every page. Cityrrown State Zip Code �a:- B. Certification (cons.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) ystem sses ind have not found any information which indicates that any of the failure criteria described n 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are icated below. Comments: 7System nditionally Passes: ne or more system components as described in the"Conditional Pass' section neec t0 be placed or repaired.The system, upon completion ofthe replacer llent orrep�aiF. as appro,;,ed by e Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is im.;inert. 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 Ce-ificate of Compliance indicating that the tank is less than 20 years old is avaiiable. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the to broken or obstructed pipe(s)or due to a broken, settled or uneven pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp•03iO3 Title 5 Offirz;Irsxcicr,=.,.n: iL - Commonwealth of Massachusetts al err Title 5 Official Inspection Fora r U�Y�< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Ow ers Name information is _ /_ A required for 4 V( � every pace. City/own State Zip Cc-He Date of I:^Sp_o`ic. B. Certification (coat.) B) System ditionally Passes (cont.): distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).-":e system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: G) F tf her Evaluation is Required by the Board of Health: I Conditions exist which require further evaluation by the Board of Heal-� in crder to deer, i-e 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 mannerwhich 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 r✓etland or a sai ,Mars~ 2. System will fail unless the Board of Health (and Public Water Supplier, i'' 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 (S.;S) and i 00 feet of a surface water supply or tributary to a surface water supc'v ❑ The system has a septic tank and SAS and the SAS is within ? %one supply. ❑ The system has a septic tank and SAS and the SAS is withi:l, 50 fee, supply well. :Sirsp•03108 Title 5 OtiCial Insoe_:io Sjc__ .� Commonwealth of Massachusetts � � Title 5 Official Inspection Form �z ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's N me information is �/( Qa6 �oZ �?/� required for (_ P-(/i 1 P h even;page. City/Town e i Sta<' Zip Code Date^f ,i n B. Certification (cons.) ;C) u r Evaluation is Required by the Board of Health (cont.): The system has a septic 'tank and SAS and the SAS is less than 100 feet but e0 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 labor21tary, for ce11,c;,,, 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 o ❑ Backup of sewage into facility or system component due to ovenc�C'ed cr clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the grou.d, or s pace',v ters due to an overloaded or clogged SAS or cesspoo! ❑ Static liquid level in the distribution box above c!.!e ;r!. ..0 iJ or clogged SAS or cesspool Liquid depth in cesspool is less than 6' below inveri or avai ae ❑ than 1/2 day flow Required pumping more than 4 times in the iasf year NOT c ❑ I^ / obstructed oipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is belovr hich cm Any portion of cesspool or privy is within 1,00 feet of a su,"ace ❑ tributary to a surface water supply. '5insp•03/08 T;ileSO-:=iali^sDeC.l- , __..c =__._,.__._____ _ _ _ Commonwealth of Massachusetts Title 5 Official Inspection Form i�i Subsurface Sewage Disposal System Fo(rm Not for Voluntary Assessments Property Address Owner 0y(nerIs Nameinibi"i'"n2tion is required for 1.— � �`^ Ile— every page. City/Town State Zip Code Date of Ins;ec ion B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ Z?*"� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [�ny portion of a cesspool or privy is within 50 feet of a private water supply ❑ 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 /wand chain of custody must be attached to this form.] El , The system is a cesspool serving a facility with a design flow of 2000cpd u 000gpd. El 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:: tails. The system owner should contact the Board of Health to determine what l! be necessary to correct the failure. E) L ge 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 folle,,Jng, in ad'i-or. to t :e questions in Section D. Yes No ❑ ❑ tile system is within 400 feet of a surface drinking water supp`_: ❑ ❑ the system is within 200 feet of a tributary to a surface the system is located in a nitrogen sensitive area (Inge-i: ❑ Area — IWPA) or a mapped Zone II of a public water If you have answered "yes"to any question in Section E 'the syste,m� is c0,si0'er2 or answered "yes" in Section D above the large system has failed. The cv,!ner C,7 _- system considered a significant threat under Section E or failed under Section s :a': u.grace system in accordance with 310 CMR 15.304.The system owner should contact -=e regional office of the Department. ,5insp•03I08 Tile 50s:dal inso _...cn _.____= Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntaw Assessmer.=s /g E mer Fe- Co ', �L�, Property Address Owner 0 er's N me information is required for every page. City/Town State Zip Code Dare o-lnsoect n C. Checklist Check if the following have been done. You must indicate"yes" or "no"as to each; o,the oiicv:in,. Yes No ❑ umping information was provided by the owner, occupant, or Board of e-ait;n ❑ ere any of the system components pumped out in the Previous two weeks? ❑ Has the system received normal flows in the previous -,no week period? Have large volumes of water been introduced to the system recent'y or as pay o` ❑ this inspection? ❑ Were as built plans of the system obtained and examined? (If they were no 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? �EE-11 Were the septic tank manholes uncovered, opened, and 'he interior of the tank inspected for the condition of the baffles or tees, material of Co�strucio, , dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner (and occupants if different from o% ner) provided information on the proper maintenance of subsufiace sewage disppsal The size and location of the Soil Absorption System (SAS) on the site has een determined based on. ❑ fisting information. For example; a plan at the Board OF ❑ Determined in the field (if any of the failure criferia related tc =a- s_e approximation of distance is unacceota le) "' -b f3 iC ��:�� ic..;u2;5' s n5.•c ros - _ Tice 5 Off-ida!In=_ce:ie-:r_— � Commonwealth _ Massachusetts ' ~�^^^�� Official ��°=�~�� 0~0�� Title �� 0UU��H�~� Uux~°��~°��0~=" ° Form Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments `m�� '------'— --------' Property Address Owner Owner's in�nmanunis � ,evu;red for 'State-- Zi:)Code�� Dai-=�xmsp��n:c/ every page. ~^' ~`' D. System Information Residential Flow —� . Number Number ofbedroomo (actua|): ---------- � -------- � DESIGN flow based on310CMR15283 (for example: 11Ugpdx# of bedrooms }� --------�-- ---_{=�.--- Number of current reeidonta� ^ Does residence have a garbage grindar?� 71 Yos 7/- No Is laundry on a separate sewage system? [if yes separate inspection required] Li Yes '�o -- ~'�o Laundry system inspected? �� Yes �4 � � �j Yos N"o Seasonal use? � 2 ( d))� � VVabermeter readings, �available 8�� years �l~^ Ic Sump pump? Last date ofocooponcy: :asr Comm erciaVindustrio| Flow Conditions: Type ofEstablishment: Design flow (based on31UCMR15.203): Gallons per Jey(n�d) Basis of design flow /aeats/persons/sq.ff, etc.): No Grease trap present? Industrial vvaato holding tank present? � Non-sanitary waste discharged to the Title 5syotem? Yes Ni Water meter readings, if available: / Last date ofoccupancXuse: Ds� Other (describe): t5is,-03,'0 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner 0 vr1r�c7�ame information is ✓y� � J� QZ �,� � reeuired for State Zip Code Date of e :ion every page. City/Town In D. System Information (cost.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? 71 Yes i o If yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: Type of S em: Septic tank, distribution box, soil absorption system 1-1 Single cesspool ❑ Overflow cesspool I ❑ 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 ':a_est inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe).- Approximate age of all components, date installe (if known) and source of i;;ferm:a_ n Were sewage odors detected when arrivina at the site? "es t5irsp•03103 Title 5 o`idel _ --_ °.e Commonwealth of Massachusetts ^00-,; Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's N2 e // 77 nfcrmation is �� O� d /1 required for — -- evenV page. —ity/own State Zip Code D2'.e c in cc io D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: feet Material construction: cast iron �140 PPVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Materi�ofnstructjon'. concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑i ether (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) _1 Yes w0 ------------------------------------------------------------------------------------------ z Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle / Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? tsinso•03,108 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary ssessmen-s Property Address Owner Ow is Na/ne 1 information is �• //SO-- required for ��//�/��Ti►" e ry page. City/Town State Zp Code Cate of!rs ectic; D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integri%(, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site pl n): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑i polyethylene ❑ other (exo'ain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or bathe conditio ,, liquid levels as related to outlet invert, evidence of leakage, etc.): v Tight or Holding Tank (tank must be pumped at time of inspection) (ocate cn s:�e Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ ooi;etvlee I :"e: x 5r,SO•03/08 Titie 5 Cmc,21 Lacs_ioo AT Commonwealth of[Massachusetts Title 5 Official Inspection Form F. Subsurface Sewage Disposal System Form -Not for Voluntary Assessmsn`s Property Address Owner O er's N -ne ` information is m! /9- l.3 h' recuired for every page. City/Town State Zp Code Dale of!n..pec'�on D. System Information (cost. �J Tight or Holding Tank(coat.) l J/ Dimensions: — Capacity: gallons Design Flow: gallons per gay Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes !iI 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 ❑I '`o Distribution Box (if present must be opened) (locate on It e of n): Depth of liquid level above outlet invert - Comments (note if box is level and distribution to outlets equal, any evidence of solids carr:vc,;e.-, ainly evid� e of leakage into or out of box, etc. i� S S Pump Chamber(locate on site plan): s Pumps in working order: ve _ � � ` o Alarms in working order: ``-s -' ` _ 5 nsp•o?ms _ TIlI?5 O-I��2l Inc^uE C.._i_r_.-:J:___ ._�J=:•____=._'c '._—.-_ _ _ Commonwealth of Massachusetts Title 5 Official Inspection Form ,c l.) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments —� Property Address Owner Owner's Name �} l information is /�� C/�� h13V7 recuired for every page. Cityrown State Zip Code Date of Ins t cr, D. System information (cont.) 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: Type: leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimen ions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure: level of po cing; c'a sci`. c= vegetation, etc.): S��►c�c Yz fV?VP 1/4 4 er nso•0 03 Title 5 0` ._l Ins_ Fa._ : Commonwealth of Massachusetts = r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner OW I N e inforn-12tion is required for �—LL i, every pane. City/Town State Zip Code Date or inspe.t'ion D. System information (cost.) 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 ❑ Nc Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of'receta`?on. etc.): r, Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of pending, cer.di ier of pet_=t;o etc.): sin5o•cs;os - -- - - Commonwealth of Massachusetts ice..,=i Title 5 Official inspection Form 14W--, !- Subsurface Sewage Disposal System Form - Not for Voluntary _Assessmems Property Address Ov:ner Owner's Nam / information is /�1 �� /// /4P6 �f� reeuired for ( 777 f�f�//� // — S�—� even.,Dane. City/Town State Zip Code Date of in s ection/ D. System Information (cost.) Sketch Of Sewage Disposal System: Provide a sketch of the sewaae dis'rosai system includi .g: ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 fee:. Locate where pu lic water supply enters the building. 1 ' �I t5insp•mms r r. Commonwealth of Massachusetts nip? Title 5 Official Inspection Form U Subsurface Sewage Disposal System Form - Not for Voluntary, ss ems:- ,I: w��/ �/C� / /'�C� CO/✓aPrl' �� Property Address Owner Owner's Name rerec ^ation is ui 3d— cired for every page. City/Town State Zip Code Dare os in so c+on D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water Check cellar I ❑ Shallow wells / 7 / Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevatlen: ❑ 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: ❑ Checked with local excavators; installers - (attach documenaion) ❑ Accessed USGS database - explain: You must describe how you established the high ground water e!evatiori: Z C'l :5inse 03lD3 Title 5 Ofidal.;rse=_ction i f Citizen Web Request Page 1 of 1 dgy T311 �A. TABLE, r Citizen Request Management - Int ernal Use eo u>o� Request ID: 41429 Created: 10/15/2012 10:43:02 AM Status: Assigned To Staff Assigned To: Martin, Cynthia Health Office Anonymous: No Category: Chapter 108 Hazardous Materials E.C. Date: 10/29/2012 Created By: Wadlington, Ellen Citations: Health Office Time Worked: 0 Response Time: 0 Requestor Details: Request Location: 218 FIVE CORNERS ROAD Centerville, Ma 02632 Parcel Number: rMap: 168 Block: 108 Lot: 000 Request: Has been more than one year.There are automobiles being repaired and stored. Needs to know ordinance re. this. Unregistered cars reported to Police Dept. and pit bull reported to Animal Control. -Request Work History: -Internal Note History: System entry on 10/15/2012 10:43:02 AM: Assigned to Martin,Cynthia http://issgl2/InternalWRS/WRequestPrint.aspx?ID=41429 10/16/2012 Citizen Web Request Page 1 of 1 aj BA�1`STA(9LL�„ f L619, Citizen Request Management Request ID: 36202 Created: 11/29/2011 8:56:04 AM Status: Assigned To Staff Assigned To: Martin, Cynthia Health Office Chapter 108 Anonymous: Yes Category:` Hazardous Materials General E.C. Date: 12/13/2011 Created By: Wadlington, Ellen Citations: Health Office Time Worked: 1.00 Response Time: 2.00 Request Location: 218 FIVE CORNERS ROAD Centerville, Ma 02632 Parcel Number: Map: 168 Block: 108 Lot: 000 Request: Cutting down trees,rearranging soil with a Bob Cat or crawler machine; may be operating an auto repair type business on property and need to check for hazmat storage. Request Work History: http://issgl2/intemalwrs/WRequestPrintPub.aspx?ID=36202 11/29/2011 Citizen Web Request Page 1 of 1 0 Citizen Request Management Request ID: 34208 Created: 3/21/2011 8:21:55 AM Status: Closed Assigned To: Martin, Cynthia ' Health Office Anonymous: Yes Category: Chapter 108 : Hazardous Materials E.C. Date: 4/26/2011 Created By: Wadlington, Ellen Citations: Health Office Time Worked: 3.00 Response Time: 19.00 Request Location: 218 FIVE CORNERS ROAD Centerville, Ma 02632 Parcel Number: Map: 168 Block: 108 Lot: 000 Request: Lots of big trucks piled up in back yard seems to be.working on these out of his back yard. This has been going on for about one year. Seems to be lots of hazardous materials being used in this operation. Request Work History: http://issgl2/intemalwrs/WRequestPrintPub.aspx?ID=34208 5/3/2011 ` a M At w'.f5+'- (i F qq N1 ' a��.- .. J 1' ytM1 A•. j' ,_..1 I•a r � � t '1• .F • .i " `T"2 TM'a. § :11. r 6 � � �� -� ,� �� i... ,�'� �•� .y � w «ate f.�...�.�`( t «;�..„ vE31 H. a r .,=� .y 'x' ,'' � �s.. ,,,�.. •1 •1 .tt4P � a� �` fi. �.�7, •wr. ��?. ; '"� •1• 'tr 1 l '+�t �t��, x•,�'• ��• ,1 > .q_ �, }�,f"tS � �s}`�'Ay��. . +ri •`war {y„ � � s f�•x .ti �� ,.,T,,� ..t� � � r •.may A JS^ ✓.` ' 2K. +a �,,•, �� y a. , �t14 • �� _«r"'"' .w I, Y r ,t F yc#r y. ''t.µ � '.. � q b \� �.� • i �`. c F ��:`.1' l� i�`.�,.r' .. t,�z ai '" ► ..+ryF =<ra .� � „+,. _,.,A• �' fit, Y':✓ .r tr .:1 1 l•'-? � Y:f"'' AA ` ,.�,t�° � •�- ; « `-`�' .. a': .:11:11 •�� A ,' - � if" 11_11 .+« '. 'f 13� ,�/ � ,1� k>, F �l ' .'�� 4 , -At ��` ', ,F;. f' 2� �� '�• :1 1•1 1 cki ,,� • Hic, ,y r} .; �..� j . .'� t �:�. :1 1:1 1 {.. ;�.�:��."�CT t\ �,. - 's�,;, ma's` �*,1; ., ._.✓ � sue' �art _ —_- _,4 i_ �� .�.�`- `f..:e�._...a- -_�• Y ��" _.. `_,—"t,.- - I".. , • • 11 11 ' 1 1 1 11• Map Page 1 of 1 1 Town of Barnstable Geographic Information System New sear Parcel ViewerIF�m.Custom Map Abutters Map Size ■ Zoom Out �„�In JPG Map: 168 Parcel: 108 Location: 218 FIVE CORNERS ROAD _ a Owner: PICKERING,BRIAN J c 2•-«ryr,x v�� y 188080003 �+ IBFDq 23702 $ ; , ,� .� ,myf% Location Information Map&Parcel 168108 Location 218 FIVE CORNERS ROA1 Acreage 0.36 acres 188088 1x88 - �'.r- 18800Bu Current OWn¢r x 82 x 2 18 40 a, yn�t ' s- Mailing Address PICKERING,BRIAN J 218 FIVE CORNERS ROAC CENTERVILLE,MA 02632 \F 1p448 ' �c+ Appraised Value(FY 2011) Extra Features $5,700 Out Buildings $0 WESTMIHSTER RD ,y�., .rf ILand $132,100 Buildings $114,900 188108 Total Appraised $252,700 �$ A 218 181088 '� .;,,. ,„ Assessed Value(FY 2O11) p201 Rc' - . Extra Features $5,700 Q Out Buildings $0 i I6alm Land $132,100 / p208 1 168008008 Buildings $114,900 x80 Total Assessed $252,700 leang Construction Detail 8198 Style Ranch 188008005 Model Residential q52 I88008007 Grade. Average p70 Stories 1 Story I�111 R 198 IOW08104 Exterior Wall Vertical Sidin dr42 Roof Structure Gable/Hip o Roof Cover Asph/F GIs/Cmp 188 wu3 186112 A32 �€ Interior Wall Drywall 9176 i 188008002 CAtI fE LEE A`( Interior Floor Carpet Neat Fuel Oil N24 188908012 108067011 p51 11008012 Heat Type Hot Water $NFTE AC Type None Number of 3 Bedrooms Set Scale 1"=g2 July 2009 Coastal I MAP DISCLAIMER Bedrooms Copyright 2005-2010 Town of Barnstable,MA All rights reserved.Send questions or comments to GIS BarnstableMA v1.2,4339[Production] http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=168108&mapparback=168... 11/28/2011 d. z' Town o'f Department of Regulat�c�ry Services � : Fubl Walth Division Hate ' 2001yIain Street liyinms Iv1A 02601 Q s Date Sched>tied Fee g Pd ...� ' une 1 — - r ►poi Suita ih A sessment or Sewa a Didcl ' .f Performed By. s�r._M Gt^�`�- Witnessed By. lac 4 ` Location Address f r v4t corvters Owner's Name LV C O � f i Ce.,.ae.✓7t-� Address'Z1S .V:: Vf- vq Assessor's Map/Parcel: Engineer's.Name NEW CONSTRUCTION REPAIIt Telephone# SG - ]3 7-L{ (B 'Land Use .122S t Cte 4-ew 1 Slopes(%) `s Surface Stones Distances from: Open Water Body 7 ZC1U ft Possible Wet Area 7'ZA'u ft Drinking Water Well ft Drainage Way N�✓� ft Property Line y}J= ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Z 1v 4 I � �.vt✓ CCXZnt E2> l3 �� Parent material(geologic) ��0�`a� �"�'""'�'"� . Depth to Bedrock 7 2- Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face--------.IA- Estimated Seasonal High Groundwater ► RAMATION FOR,SEA.WNT Method Used: Depth Observed standing in obs.hole: in, . Depth to boll mottles: in, Depth to weeping from side_of obs.hole: in. Groundwater Adjustment f< . Index Well# Reading Date: Index Well level r, Ate{.factor , ACJ,�.Groundwater Level NIMST Observation Hole# Time at 9" ' Co It U Depth of Perc 9 �0 2� e)t; o` qS Time at 6" Start Pre-soak Tim Time e - ' >3�� t me(9"-6") t-1hJ� .5 End Pre-soak 7Z- Rate lvtinJlnch G Z— Site Suitability Assessment: Site Passed , Site Failed: Additional Testing Needed(X/N) Original: 'Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 10W of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPITC-PERCFORM.DOC DEEP•O`ESERVA IIOAT 1- 10ME LOG -oje# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Ivlottlin g (Structure,Stones,.Boulders, — I IaJ12`f1 Z 4 I2-3�, SS l_S 3 8-13-L- C 1)EE 'OE8EIV 'I1'1C? : Ll7C 2. Depth from'.. Soil Horizon Soil Texture Soil Color Tlc�le# Soil Other Surface(m) (USDA) (Mansell) Mptthng (Structure, to Boulders. 's'sten o t -3 � -►3 z s 2-s Y ply P=C4 RVA TION H4LE:.�t�� Depth from : Soil Horizon Soil Texture Soil Color Soil _ pt ... Surface(in):;:. . (USDA) (Munsell) Mottling (Structure,St6nes,13'tilders Gravel) IDEMOUSERVATION DOLE:LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Murrell) Mottling (Structure,Stones,Boulders• Flood Insurance Rate Maw Above SOO yem flood;boundary No Yes Within S00year boundary No� Yes Within 100 year floodboandary No .-Yes Death of 1Yaturally Occurrine`Pervious:Materlal, Does at least fo>ar feet of naturally occurring pervious tnaferial,oxist m ali areas observed throughout the area proposed for the soil absorption system? If not,what: the.depth of:naturally occurring pervious material? Celi'ti:ffeatton I crtlfy that on �� {date)I have passed the soil evaluatar.examination arrraved4y4kte Department of Enviro ental Prot6cfionL and that,the above analysis was performed by:me consistent with the-required` ng,expertise and.>experience descnbed'in 310:CNIR 15.017 Siilttiie Date d' f Q:ISEPTIG1k'ERrCFORIvt DOC 2 _ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIONS r ONE WINTER STREET, BOSTON MA 02108 (617) 292-550, m 6� WILLIAM F. WELD TRUDY COXE Governor t v Secretary ARGEO PAUL CELLUCCI DAVID B/ STRUHS Commissioner Lt. Governor o— / .. C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION QRM W �v C� PART A CERTIFICATION Address of Owner: �-�-� .c� Property Address: A t- Q Date of Inspection: e?�(Ackca (If different) -j 0 Name of Inspector: M t c�,,rLt� .1eL �c�S� I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CbDt 15.000) Company Name: Mailing Address: -p f—i, r Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails L�� Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design now of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMAi IARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defned in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI 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. Indicate yes, no, or not determined (Y. N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rerised 04/3/97) Page I of 10 ' t • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: Owner: Date of Inspection: BI SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distributio/tboxise to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspeh approval of the Board of Health). Describe observations broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to brok n or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): , broken pipe(s) are replaced obstruction is removed 1 CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 1 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health. safety and the environment. / i r 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DE'1;ERtiILNES THAT THE SYSTEM IS NOT FUNCTION NG IN' A MANNER Wh7CH �i7LL PROTECT THE PUBLIC HEAI:TH AND SAFETY A\D THE ENVIRO\1fE\-I: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering'/vegetated wetland or a salt marsh. 2) SYSTEM NNILL FAIL UNLESS THE BOARD OF HEALTH (A,NB PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERINUNES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PLBLIC HEALTH A.N'D SAFETY AIND THE ENVIRON'IENT: The system has a septic tank and soil abs Lion system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water su/da _ The system has a septic tank arption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank arption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank arption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a welysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that fthe presence of ammonia nitrogen and nitrate nitrogen is equal to or lessthan 5 ppm. Method used to determine dist (approximation not valid). 3) OTHER (revised 44/25/97) Page 2 of 10 r s � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DI SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as efined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to dete ine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surf re waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due o an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or avail le volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT/de to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool r privy is below the high groundwater elevation. v r tributary to a surface water supply. ' a•'/ane et of a surface w•ate, Supply o cesspool or privy is within PP. _ Any purt�on of a cessp p y . Any portion of a cesspool or privy is wi I of a public well.Any portion of a cesspool or privy is wit of a private water supply well. Any portion of a cesspool or privy is les feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If theeen analyzed to be acceptable, attach cop)• of well water analysis for coliform bacteria, volatile organic compmonia nitrogen and nitrate nitrogen. EI LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of t e following: The following criteria apply to large system in addition to the criteria above: The system serves a facility with a design/flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 fee of a surface drinking water supply I the system is within 200 11/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) j The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. r i 1/ (revised 04/25/97) Page 3 of 10 c , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ��}F�VCCGLN2�S Owner: VION Date of Inspection: S t kclC" Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. Non system components e of the s have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. \( _ The site was inspected for signs of breakout. All system components. excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees. na[erial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: a l cb Q4\zf"Z`LC' Owner: 1W Q 0 Date of inspection: k, FLOW CONDITIONS RESIDENTIAL: Design flow: p.d./bedroom for S.A.S. Number of bedrooms: 03 Number of current residents: C� Garbage grinder (yes or no): 'u Laundry connected to system (yes or no): Seasonal use (yes or no): N Water meter readings. if available (last two (2) year usage (gpd):1tJ Sump Pump (yes or no): Last date of occupancy: '5Q;-NW'X 2. JS 14S . CO M1MI[ERCIAL/INDUSTRIAL: Type of establishment. Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL III-FOP-NLaTION PUNIPLtiG RECORDS and source of information: System pumped as part of inspection: (yes or no) I`J� If yes, volume pumped: gallons 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) I/A Technology etc. Copy of up to date contract? Other R- APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) �v (revised 04/25197) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 0 CC 4.N��. Owner: K�? Date of Inspection: .a,�t,�ci BUILDING SEWER: N� (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints. venting, evidence of leakage, etc.) SEPTIC TANK; j (locate on site plan) u Depth below grade: �Z Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: I L-QO q fT I - Sludge depth: 'L t' ct Distance from top of sludi:e to bottom of outlet tee or baffle: 3 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: 1'A 4 How dimensions were determined: 1I�?�.,�y ,�2 • Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation too tle: invert, structural intN ri evidence of leakaee. etc.) `G -s & fie,- T Il l 1 C l `tv GREASE TRAP: P( (locate on site plan) Depth below grade: Material of,construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity. evidence of leakage, etc.) (revised 04125197) P2ge 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �O V P Date of Inspection: ��1 S C TIGHT OR HOLDING TANK: 'tl1 (Tank must be pumped prior to, or at time. of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order _ Yes: _ No Date of previous pumping: Comments: (condition of inlet tee.condition of alarm and float switches. etc.) )ISTRIBLTIOti BOX:�Q,S (locate on site plan) Depth of liquid level above outlet invert: .C�lw� O:+tZ2 ZNti`$�L Comments: (note if level and distribution is equal, evidence �o-f�soli s carr),over, (evidence of leakage into or out of box, etc.) Lk IA QS\LiI kIrl"' 41 Cw PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (rerued 04/=S/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IIYFORMATION (continued) Property Address: 9L1 b'V X J.0 Cc.u�C� Owner: ,�P Date of Inspection:tion:calk.�q SOIL ABSORPTION SYSTEM (SAS):_' (locate on site plan, if possible: excavation nut required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: e X W leaching chambers, number:_ leaching galleries, number: leaching trenches. number.length: leaching fields. number, dimensions: overflow cesspool. number: Alternative system: Name of Technology: Comments: (note condition of soil. signs ofhydraulic failure, level of ponding, conditipn of ge jn, etc.) t AArx CESSPOOLS: D (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: 1I yv (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.) (revised 04125/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ( 0 Fl t/'� C otN.?IGS Owner: to P P Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) thr �3 L17' (revised 04125197) Pagc 9 of 10 I _ a h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIM PART C SYSTEM INFORMATION (continued) �-± PropertyAddress: a��j V�. �C;r2ill2�—S F) Owner: Y"a Q Date of Inspection:,s�` Depth to Groundwater tLZ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) (Ne (revised 04125/97) P2ge 10 of 10 �l o° --99 --EXISTING CONTOUR �� c°,,,befl Mir x 100.98 EXISTING SPOT GRADE Rd 97 PROPOSED CONTOUR for Rd W EXISTING WATER SERVICE QHW-OVERHEAD WIRES h�0 Route 28 TEST PIT QG n � Westminster Rd BENCHMARK' 4)1 V �a LEGEND f ey v c m E'e LOCUS Ben ch m ark Set LOCUS NOT O SCALE AP TOP OF SONO TUBE x 101.20 '11702\ EL.=100.00 (Assumed) x 101.06 S 46 01'50" W \ CB/dh CB/dh 114.96' 2� /x 104.02 LOT - - - - - - -N �\ \J0 15,563f S.F. \ Map 168 11.3' Parcel 108 i .ram-0 VENT 1 'NI I I ALL LINES V.TP-1 'o i U EXISTING LEACH PIT -I TO BE PUMPED, FILLED WITH I Ia1 I I SAND AND ABANDONED 44' 1 I in 1 EXISTING SEPTIC TANK TOP OF TANK, EL.=96.67f Z INV(OUT), EL.=95.32f �0 , 1 Af + o W W I N CN x .16 / o 0 100.00 I 5` Ln a = DECK i I 103.54 90' 99.89 x / 1 97.15 x 11.42 W, , 51 96 ,ExisnNG . _ _ - --HOUSE TOF=-/104.55± o.,(b ! // Q x 102. x 104. 9 x 102.77 101.29 y 96 \ 97.44 x stone ret. wolf 03 575.Oa N 46 2 " E -100-7 edge of povement + GENERAL NOTES: 9 '9 �'6 96 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL FIVE CORNERS ROAD BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: 310 CMR 15.405(1)(b): 1) A 1' variance to the 3' maximum cover requirement, for no greater than 4' of cover. S.A.S. shall be vented and H-20 Rated. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. MgSs90 i 4, ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN o PETER T. ENGINEER BEFORE CONSTRUCTION CONTINUES. McENTEE 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. o CIVIL ' 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF N . 35109 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF S��E� HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. FSS ��G�CY OWNER OF RECORD 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. FABRI, LUCIO & SORAIA 8. THERE ARE NO PRIVATE WELLS WITHIN 150' OF THE PROPOSED S.A.S. DECASTRO SILVA 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS f J ZI I 218 FIVE CORNERS ROAD AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE CENTERVILLE, MA 02632 DIRECTED BY THE APPROVING AUTHORITIES. ' 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE PROPOSED SEPTIC SYSTEM UPGRADE PLAN THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING I CONSTRUCTION. 218 FIVE CORNERS ROAD, CENTERVILLE, MA 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS j IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND Prepared for: D. A. Brown, Inc., P.O. BOX 145, Centerville, MA 02632 REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC SYSTEM Engineering by: SCALE DRAWN JOB. NO. Engineering Works, Inc. 1"=20' P.T.M. 101-09 COMPONENTS NOT SHOWN ON THE PLAN. 13, THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. (508) 477-5313 1/21/09 P.T.M. 1 of 2 i e NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL:95.23 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL INSPECTION PORT OVER END UNIT T.O.F. OUTLET AND SET TO 6' OF FINISH GRADE SET TO 6" OF GRADE CHARCOAL EXISTING F.G. EL: 99.2(MAX.) VENT F.G. EL.=97.5f �F.G. EL: 97.5t MAINTAIN 2% GRADE (MIN.) OVER S.A.S. jA L = 19' L = 8'(MAX) INSPECTION 0 S=1% (MIN.) +� S=1% (MIN.) PORT 4"SCH40 PVC 4"SCH40 PVC 6" 10" s 11.3" TO I ° INVERT EXISTING 48" uoUID L LEVEL ADD GAS BAFFLE INV.=95.12 PROPOSED INV.=94.95 r 4 ROWS W/4 UNITS AT 6.252/UNIT = 25.0' INV.=95.32t D-BOX INV.=94.84 EXISTING 4 OUTLETS (MIN.) SOIL ABSORPTION SYSTEM (PROFILE)EXISTING SEPTIC TANK ESTABLISH VEGETATIVE COVER BACKFlLL WITH"ftEAN NATIVE OR PERC SAND TO TOP OF CHAMBERS NOTES: BREAKOUT EL.=TOP L. 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP ELEV.=95.23 INVERTS, PRIOR TO INSTALLATION. INV. ELEV.=94.84 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE BOTTOM ELEV.=93.90 III®ual nm®u ON A MECHANICALLY COMPACTED SIX INCH CRUSHED 2.83' STONE BASE, AS SPECIFIED IN 310 CMR 15"221(2). 5' MIN. ABOVE BOTTOM OF EFFECTIVE WID W EXCAVATION OR G T.P. . . TH=11.3' 3) INSTALL INLET & OUTLET TEES AS REQUIRED. EXISTING SUITABLE 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE NO G.W., EL=86.5 = MATERIAL AS MANUFACTURED BY TUF-TITE, LABEL OR EQUAL. 4 ROWS OF 16" (H-20) ADS BIODIFFUSER UNITS WITH NO. SEPARATION BETWEEN EACH ROW & NO STONE SEPTIC SYSTEM PROFILE TYPICAL SECTION N.TS. N.T.S. SOIL LOG ' 21" 6-4" POLYSEAL OUTLETS DATE: JANUARY 20, 2009,(REF#12,451) 2 2" 1-4" POLYSEAL INLETS SOIL EVALUATOR: PETER Mc ENTEE PE CSE WITNESS: DONNA MIORANDI R.S. i O -HEALTH_AGENT-+-- LLELEV. TP- 1 DEPTH ELEV. TP-2 Y DEPTH N to o ,n 97.6 A 0 97.5 A SANDY LOAM SANDY LOAM 96.6 B 10YR 4/2 12" 96.6 B 10YR 4/2 11„ fV Top View Section LOAMY SAND LOAMY SAND D-BOX 10YR'5/8 10YR, 5/8 94.4 38" 94.5 ;R» C 38.1 C PERC - -75" 50" MED. SAND MED. SAND 2,5Y 6/4 2.5Y 6/4 86.6 132" 86.5 132" _I h � 76" PERC RATE <2 MIN/IN. ("C" HORIZON) PROFILE NO GROUNDWATER ENCOUNTERED 16" 34"-� SECTION END CAP DESIGN CRITERIA 16"" HIGH CAPACITY (H-20) BIODIFFUSER UNIT NUMBER OF BEDROOMS: 3 BEDROOMS MODEL 16" HICAP SOIL TEXTURAL CLASS: CLASS I LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT DESIGN PERCOLATION RATE: <2 MIN/IN EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY DAILY FLOW: 330 G.P.D. SIDE WALL HEIGHT 11.2" DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. DESIGN FLOW: 330 G.P.D. OVERALL HEIGHT 16" GARBAGE GRINDER: NO OVERALL WIDTH 34" 4640 TRUEMAN BLVD LEACHING AREA REQUIRED: (330) = 445.9 S"F, 13.6 CF mum,HILLIARD, OHIO 43026 .74 CAPACITY EXISTING SEPTIC TANK: 1000 GALLON CAPACITY (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC. ' PROPOSED 0-BOX:: 1 INLET, 4 OUTLET (MINIMUM), H-,o RATED PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 4 ROWS OF 4 - 16" (H-20) ADS BIODIFFUSER UNITS 218 FIVE CORNERS ROAD, CENTERVILLE, MA W/ NO STONE FOR AN S.A.S. WITH DIMENSIONS 1 1.3' x 25.0' Prepared for: D. A. Brown, Inc., P.O, Box 145, Centerville, MA 02632 (HIGH CAPACITY INFILTRATORS MAY BE SUBSTITUTED) SIDEWALL AREA: NOT APPLICABLE Engineering by: SCALE DRAWN JOB. N0. BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.7 SF/LF OF BIODIFFUSER) Engineering Works, Inc. NTS P.T.M. 101-09 16 UNITS x 6,26 LF x 4.7 SF/LF = 470.0 SF 12 West Crossfield Road, Forestdole, MA 02644 DATE -CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 x 470.0 = 347.8 GPD (508) 477-5313 1/21/09 P.T.M. 2 of 2 u ,