Loading...
HomeMy WebLinkAbout0240 FIVE CORNERS ROAD - Health 240 Five Corners Road Centerville P A 168 006 No. 4210 1/3 ORA Pendaf lexo Kok 10% 4 � ry �L\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S;�sAym Rxmr Kn for VoWntary Ass'ass,'ments W7 Property Address— ------ L1 Ow qer 5�7n—ers Name information is required for every A114 oa 6 ;52 L Ima City/Town &7,u Z4)Code Date of Ins 6ectiorV-- 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. Irn portant:When filling out forrns A- General Information on the computer, use only the tab 1. Inspebtor key to move your cursor-do not a �/ p /f v`� use the return key. Na n*e of Inspector Corrpany Na /f/V10 C, rne la Company Address elyf row nrS., 0 1r7 0 State f?Co 9'� Zip Code l Telephone tuberLicense 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 16.340 of Title[:(310�Cl 5.000). The system-.Passes ,, Conditionally Passes El Fails El Needs Further Evaluation by the Local Approving Authority a o �:� InspectoN Signature [We /I 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only ciescribes 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. t5rz-3(13 Me 5 Official Iris pection F am subsurface sewage Disposal s)bvm-Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage.Dis"l System Form -Not for Voluntary Assessments a, r4ej Nroperty Address Owner Cw information is ner's Name /� �3 required for every C2>�` 'Vl / i�4 (/o �„Z a,1 /-4 page. Cltyfrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always com plete 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 ex0ain. 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): i. fs,s-3n 3 Title 5 0ffidal Irepecticn F orm Subsurface Sewage Disposal System*Page 2 of 17 i Commonwealth of Massachusetts Tide 5 official Inspection Form Subsurface Sewage Disposal System Fo Not for Voluntary Assessments (V 1...0 Property Address ON ner O v ner's Name �. Information is required for every Z 3,) $ ao page. City/Town State Zip Code Date of Inspection B. Ceitficatuon (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Pates(coat.): ❑ 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(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 t5ns•3H 3 Tiae s official Inspecticn F ant Subsu face sevage Disposal System•Page 30f 17 Commonwealth of Massachusetts 19 Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � co�o.e�f �� r 2li Property Address Owner Ow ner's Name infomtiation is q required for every page. Citylrown State Zip Code Date of InspecUoff B. Certification (coat.) 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 f ❑ 5-� tatic 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 Y day I ow t5as•3M 3 Title 5 official Uspection F cmc Subsuface Sa"e Disposal S)Stem•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments R7operty Address Yo ON ner OH ner's Name infonretion is required for every �� ✓� /� Q�6 �� 8 �� �� page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) Yes No ElRequired pumping more than 4 times in the last year NOT due to clogged or / obstructed pipe(s). Number of times pumped: . ❑ I—J/ 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. ❑ ny 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 well. ❑ Any portion of a cesspool or privy is less than 100 fleet 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 nd chain of custody must be attached to this form.] ❑ e system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system Wis. 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. tare•3M 3 Title 5 0fficlal Irepecfion F orm subsuface sewage Disposal sum•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments V0 �y-e_ 60✓kq-ers Property Address information is ner's Name required for every Ce vi !i6Ile page. 5ty/Town State Zip Cade Date of Inspection C. Checklist Check if the following have been done. You must indicate`des"or"no"as to each of the following: Yes ❑ mping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ 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 (f 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): Number of bedrooms (actual): DESIGN.flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):PC- s C> 18ns•W 3 Tide 501ficial Inspection F onrc SubsWace Se wagelJisposal SysOem•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments YO F vic 6o rN��j o J Roperty Address / 1 c� av ner Ow rtWs Naf ie cr'e 4) 1 1 efformation is Q j 3 ) oZ0 required for every GQ� l/1 I � o� L/ page. Cityrrown State Zip Code Date of Inspection D. System Information Description: / / o G�, !/t,ti 41 C_,Ltj K l✓ bu 4t017 o voo ll017 64r-VW g'�; w �' Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes u -<o Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? Yes ❑ No G LA Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: t5rs,3M3 Tille5official InspecfionForra SubsufaceSevq;eDisposal System-Page 7of17. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �- `f o Five C©,,-Pievz Ptoperty Address ON ner Cw ner's Name information is required for every Cep, / ? yl ( 9 U��J� -9 .2o " page. Ckyf row n State Zip code Date of Ins ton D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ' 4 J Olvw,-- Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: galbns How was quantity pumped determined? ReZforpug: Typtic 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/Altemative 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 UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other (descri be): t5rs•3h3 nae 50Eficid I speetion Form Subsufam Sewage Disposal System•Page 8of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments TO F/vt Co -0-e Property Address Onr ner Qy ner's Nartte information is requ�ed for every Ce��"V y6 t�o�6�� e ao g page. City/Town State Zip Code Date of Ospection D. System Information (cont.) Approximate age f all components, date installed (if/Cnown) and source of information: CAI 9 `/����'19 . 9 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;40 ❑ cast iron PVC ❑ 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 Materia 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 X fo Dimensions: Sludge depth: t5ns-3M3 Title50fficiai lnspeclionForm SubsWace Sewage Disposal System-Page 9of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forge m Not for Voluntary Assessments - Vic? Five- Cod,,- ✓-ee,f Property Address av ner ON ner's Name information rs Ce v►��/1 I i - - D�6� � 0� 0 required for every page. Cityfrown State Zip Code Date of In pection D. System Information (cont.) Septic Tank(coat.) 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 Fo-le- a ylC6 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): bt W► r N �O 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 pns•3H 3 Title 5official Inspection F cm SubsWace SevMe Disposal Syslam•Page to d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage 'Disposal System Form -Not for Voluntary Assessments ) Property Address 12 0 r V•.� QN Ref Owner's Narita information is e /' 1_ requQed for every C,•2 K�/y � page. �'/OW n State Zip Code We of Inspection D. System information (corit.) 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 Bolding 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 worldng 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 t55rs•3M3 TM5Official ImpBrbanFam SuWwface Sewage Disposal System-Page 11 d 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form e Not for Voluntary Assessments a �(2_ F ve- Property Address Owner ON ner's Name information is required for every ��I'7 t; e ✓� X�0// page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (f present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): �� so It Cs X/t) 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: t5ns•313 Title 5oftiaal Inspection Form Subsuface Sewage Dispasat System•Page 12 cf 17 1_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessmentslug g 10 Fi v Property Address Ory ner l2 V' information is ON ner'S Name required for every A'� n page. Cdy/Town State Z' Code Date of Ins tid n � Pec D. System Information (cont.) Type' Soy ❑ leaching pits number ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): // o�► �� K r Vlr �T� hl� 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 t9m•313 Tide5Official InspecfionForm Sulmaface SewageDisposel System-Page 13 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form _Not for Voluntary Assessments r � �� zq Property Address�� CO✓'//1,2rs K Ow ner :01,ver's Nam InformatInformationfotion es requiredforevery 2A-VIe odJC �page. Town State Zip Code :e:of:l:n: ection ®e 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.): Mrs-3113 Title5Official Inspection Form Subsuface Sewage Disposal System,Page 14af 17 Commonwealth of Massachusetts Ti tle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a '/C-) C epj Property Address C Ow ner O t ✓-e- information is CW ner's Name required for every C2�►�t" l & 3� C'ZO page. Ca1y/town State Zip Code Date of I specti ah D. system Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two pe 5menent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where pu water supply enters the building. Check one of the boxes below. hand-sketch in the area below ❑ drawing attached separately iEK z T --,. - C31 POOL 33 _ . . _. 3 - 36- fens-3M3 Title 50ffiaal Inspection Farrtc Subsuface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn -Not for Voluntary Assessments Q / , � Co�O��f Property Address z)- Yo —- �e fj o l t� Owner Owner's Name - information is required for every Z v1 page. Cityfrown State Zip Code Date of Inspection D. System Informabon (corn.) Site Exam ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. feet Please i ate all methods used to determine the high ground water elevation: Obtained from system design plans on record O" o if checked, date of design plan reviewed: Date ❑ bserved site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: pie &n ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You mu describe how you established the high groun ter elevation: �1� C.SC e r G 1 e3 � � mac. /"ram SO�I C ki d S Se C6r 4L ✓ -e✓/ J9(A h�r r 4✓NJ �le Ae-, /A o Y"I V v l G Y', .firS-1 A S 4Y' 044 r Before filing this Inspection Report, please see Report Completeness Checklist on next page. 155ns•3f13 Title5Of ial Ins pecton F arm SubsWace SeviageDisposal S)ftm•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address 60 Ow ner ✓`� infom�on is ON ng's Marne G requiedforevey — page. dy-f own State Zip Code Date of Inspection E. nCO-letenessmp Checklist Ion Summary: A, B, C, D, or E checked i� inspection mary D(System Failure Criteria Applicable to All Systems)completed SY Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I5a6.= 'rme5omcia trspec&nF—SubsWaw Seae9eOisposal SpIBM•Page 17 d 17 NOTES: 1. ALL PIPE TO BE 4"DIA.SCH 40 PVC. ` 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION —'Z(e_' BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. I. 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE 6. INSTALL GAS BAFFLE IN OUTLET TEE. t'LAYER of sn• ONe oven 3/4••1 1/21 WA3HeD STONE ALL AROUND j TOP OF FOUND. @ EL. Zoe o / to, u• / �] z o0 I SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN GENERAL NOTES FOR 1. of ALL UTILITIES,ABOVEOR TO BE PONSIBLE FOR THE AND UNDERGROUND,LOCATION TO ANY EXCAVATION OR CONSTRUCTION. A./�--/. /� �/�.Z'• 4P 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR 15.00:TITLE V. 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE �7"� � DETERMINATION. / 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED- [DATE: Z-V' , zS//Cw SCALE: h�5 1"7"a.0 S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY i ------- — -- REQUIRED INSPECTIONS. I ' I I I - WELLER & ASSOCIATES 1645 FALMOUTH ROAD CENTERVILLE, MA. 02632 TEL: (508) 775-0735 FAX: (508) 775-0754 a .�.✓ a a s.i✓+/ u v v SOIL EVALUATOR: WITNESS: - PERC RATE:C z ,r�iiy/ii✓c� � GoAreS 1 e-, S, Zy � i J V SC-cc 1� �o wATE,e E'n/cau�JT�2� j / a DESIGN DATA DAILY FLOW: (`/) DRMS.x 110 GPD=, GPD 1 GPD x 200%= 88 o GPD SEPTIC TANK: y USE:/moo o GALLON PRECAST SEPTIC TANK LEACHING FACILITY: oo USE:(Z),5 S'`Z . -- S � CAPACITY: SIDEWALL �V �e d,2 yt/. •Co BOTTOM: /3 TOTAL:- yS9. DANIEI E. �yG � BRAMAN c!� CIVIL y All Oi p 'I (.2 No.32686 (ip ��p .ref y+ � �'`yE,:"•ffi:���.( , n r r C � 6 / o� a J J Ut J N / A� p� 41 / o �� f: ovP" r to oo / I" `Q TOWN OF BA.RNSTA.BLE LOCATION -Yo !SSE QA.)aAs- kill SEWAGE # 2 9 VILLAGE_ r<ni-rgoe ASSESSOR'S MAP &LOT v INSTALLER'S NAME&PHONE NO. �� ',Q, r 1JL�.�U% !:?7 /Vol SEPTIC TANK CAPACITY LEACHING FACILITY: (type) i.•ser os.#L ,Dk vtyz (size) /.3 "x 33.5 x �' NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: Y—9— g y 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 9E F 1S a1 g -7,,d ZI/0 �a '14 �o Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Five Corners Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 page. CityrFown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I ' use only the tab 1. Inspector: 0 key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M. Jones Title V Septic Inspection r� Company Name 74 Beldan Ln. Company Address Centerville Ma. 02632 CitylTown State Zip Code 774-2484850 smjonestitle5@gmail.com SI4522 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: ® Passes ❑ Conditionally Passes ❑ Fails -wr C) ❑ Needs Further Evaluation by the Local Approving Authority ; .-. a F5 9/22/2011 - Inspector's Signature Date g i The system inspector shall submit a copy of this inspection report to the Approving Authority([Trd of Health or DEP)within 30 days of completing this inspection. If the system is a sharedrsystem 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•11/10 Tifie 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 240 Five Corners Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 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-11/10 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 y< 240 Five Corners Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 page. Cityfrown 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 Y2 day flow t5ins-11/10 Title 5 Official Inspection Forth: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 240 Five Corners Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 page. Cityrrown 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts ffim Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Five Corners Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 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): 4 Number of bedrooms(actual); 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 459.9 gpd provided t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Five Corners Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 page. City/Town State Zip Code Date of Inspection D. System Information Description: 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 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date CommerciaUlndustrial 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 lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Five Corners Rd. Property Address Tracy Field - Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 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: 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 <C\, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 240 Five Comers Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system repaired 5/10/2000 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 1 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 gallons Sludge depth: 5" t5ins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 Five Comers Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 3.5' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years as maintenance. Inlet and outlet tees intact and in good condition, water level was at bottom of outlet invert, tank was not leaking and was structurally sound. 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 yt 240 Five Corners Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 page. Citylrown 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•11/10 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 240 Five Corners Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 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 off 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.): Water level in d-box was even with bottom of both outlets, no signs of past hydraulic overloading, no solids carryover. Box was structurally sound with no rot. 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 240 Five Comers Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s.was video inspected from d-box and found to have approx. l'of standing water with no sign of past hydraulic overloading. 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 °yt 240 Five Comers Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-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 ' 240 Five Corners Rd. Property Address Tracy Field Owner Owner's(dame information is required for every Centerville Ma 02632 W2/2011 page. City/Town State tip 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 �-► (3 t3- 3 A-2 6'3 )3 � 3w Z�o oI ; 8-3 YY 5AS, A,y 5L 13..E �' t5ins•11110 Us 6 Official hspechon Forth: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 "t 240 Five Corners Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 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: 2/9/1999 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: Design plan on file at Town of Barnstable Board of Health dated 2/9/1999 indicates that no groundwater was encountered at 120"and system is designed to have 5'of seperation between bottom of s.a.s. and adjusted high water elevation. 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 Commonwealth of Massachusetts YJTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Five Corners Rd. Property Address Tracy Field Owner Owner's Name information is required for every Centerville Ma 02632 9/22/2011 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 I t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTTABLE LOCATION ��O Rye— C6!/1f, R�. SEWAGE # V9.LAGE � ��� ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. - a Il SS 1 J SEPTIC TANK CAPACITY 5'X I EACHING FACILITY: (type) 3 SOD 4 (size) i 3 33.sx a NO. OF BEDROOMS WILDER OR OWNER T^'t pol„ e/S PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) / Feet Furnished bye n Sp C GI i an S C' d r(2 r a , O O A 45 w 3 43 31 3 G � yy s .,.i TOWN OF BARNSTABLE LOCATION 2 Y8 E.11E Qa,2,,ES- del- —SEWAGE # - 19 r / ?Z VII.LAGE rFa1T����:L/� ASSESSOR'S MAP &LOT INSTALLER'S NAME&.PHONE NO.;- �������� 997—e yyy SEPTIC TANK CAPACITY /S e n G s7- - LEACHING FACILITY: (type)•a- c,4L bt ywr1L:r (size) /.t �,r 3.35 x Z� '• NO. OF BEDROOMS - BiiLDER OR OWNER PERMTr DATE:•- y_9.-- q COMPLIANCE DATE: 0 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 a within 300 feef.of leaching facility) Feet Furnished by - i �y-ro Q fr Z p c L 404 z- rq 2 - 33 No. Fee �O THE COMMONWEALTH OF MA SAC".1 SETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Mizpogal *p5tem Construction Vertu Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) �omplete System El Individual Components Location Address or Lot No. Zy b vE C�,� R o/1 Owner's Name,Address and Tel.No. GGki Av,&uE +Itic VAA3- B, PoWG✓-5- Assessor's Map/Parcel 2y o FWCE co Awfi;,#s e,,4 4 Inssttaller's Name,Address,and Tel.No. o yYY Designer's Nam�e�,Adpdres andeTel.No. �,rzl q,J C• 1�1 S S1%✓� u7 {'rS-ro 64f 9'7 To, AJ �ROoK R.0.4 C �i�jy,,44 6,4W l 6 W EsT A o Type of Building: Dwelling No.of Bedrooms Lh Lot Size sq.ft. Garbage Grinder(ale) Other Type of Building Wova rMaaG- No.of Persons "i'W o Showers( ) Cafeteria(oo) Other Fixtures Design Flow y No gallons per day. Calculated daily flow ys'9. 7 gallons. Plan Date 4— 44�Number of sheets Revision Date Title Size of Septic Tank /.to a Type of S.A.S. 3 PREcas•r Soo c Z Qe. wa Description of Soil 0 ro E% 19 S`L /o Ed 561 6�P0 Z f gag sir L�ems: /o yltj sad /zo= r Nature of Repairs or Alterations(Answer when applicable) :•Q-A) A. _ S�b c ' So E S' �AsZ 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 Certifi- cate of Compliance has been issued by this Board of Health. Signed Date y— P—9 9 Application Approved by Date " Application Disapproved for the following reasons Permit No. 7Z— Date Issued 3 n No. Fee So - Ir THE COMMONWEALTH OF M ACHUSETTS� .j Entered Q PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS •r"Yes 01pprication for Migogar 6pgtem Congtruction Permit ` Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) (OComplete System ❑Individual Components +� _ Location Address or Lot No. Zt•/0 F 1✓ir C a t'NE4V R o,a Owner's Name,Address and Tel.No. ¢� CCKJ1-9/IJiVJC p 4kI ,14Ar E, P0i.JG,2,s'/ Assessor's Map/Parcel /�8 / A�CEL 6 Z�/o F ivt_Co/t w&As lec,4 e Installer's Name,Address,and Tel.No. 9/ r-0,/yof Designer's Name,Address and Tel.No. Ai Aj C. k s-sZj:,j P4 S/Sp Ct } s 9�3-o—"i �Rcok RoAc /6Ys FiQLtcfocily Ror)r1 Wr=_-7" y,41tuoJl CEw E u c.-263Z Type of Building: ~ 'Dwelling No.of Bedrooms 1 ' Lot Size sq. ft. Garbage Grinder(rJ®) _. Other Type of Building won6 tRAw+C No. of Persons "7ryj0 Showers( ) Cafeteria(ao) Other Fixtures Design Flow gallons per day. Calculated daily flow ys 7, 9 gallons. Plan Date /— 2,7'—77 Number of sheets Revision Date Title 1 ' Size of Septic Tank /Soo Type of S.A.S. 3 PkEcA rr Sop G,4',A,f jw�l�s 'Description of Soil n ro 6'1::� lQ 5'y�" /o Y/t Z/2 E '-ro z Y n SE' L. /20 Nature of Repairs or Alterations(Answer when applicable) ,t,a<u, s4!�4rnc sYsr Pail 4Q. ct L Svo Gs D o 3 - S-00 G.4L# &tWEL[ 1 s a✓�v 4�! 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 Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date 'Y r 9'77 Application Disapproved 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 1- A� C. i SSG✓JG at 2 Y0 t�,65- ro..4XF.tIr— has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer R 'a,,J Designer Wgf. EAilm) , f \ r/}. rThe issuance of this permitsbal not e cbnstrued as a guarantee that the system will,,function as:designi i a 9Date '`> >l� 1 Inspector ��� 1./� � D �l��� ,tCl!�.� 1 �+ ----------------------------------Fee S-10• 00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mwigpogar *pgtem �Congtruction Permit Permission is hereby granted to Construct( )Repair( ti)Upgrade( )Abandon( ) System located at ZNo Fi,,e Cc c'YtJ s A ri C'�N ttr-hoi 6 - and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mmstt be completed within three years of the date of this permit. Date: by TEST HOLE LOG DATE:-.4vcr,, /e, 1199a SOIL EVALUATOR:&P. /t��}ScuJ c ser WITNESS:._-/, D u v PERC RATE:--d-.7-Z psis//ii✓c.�/ 0,43 / �o0 119 5,G. �,,z Z Z ✓G31a e, SEE ,P�i/c.,e,SE s-•o� S�l�c 0 aDESIGN DATA DAILY FLOW: (510'�)PDRM&z 110 GPD=ff�o GPD \ SEPTIC TANK: Wd-GPD z 200%= 88 o GPD V USE:/So o GALLON PRECAST SEPTIC TANK LEACHING FACILITY: USE:(3).Si<a Soo I w�e,!'vf 1 � CAPACITY: ` � SIDEWALL•. 3�f Z x d, ` BOTTOM:--/3�t TOTAL: y$9,� DANIEL E. BRAMAN C. CIVIL SN M cd No 32}68k nwo NOTES: r r 1. ALL PIPE TO BE 4"DIA.SCII 40 PVC. s 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION t ,,Z BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. S. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEE 2•LAYER OF 34'FEASTONE OVER 314*-1 1/2'WAMED STONE ALL AROUND TOP OF FOUND. SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN GENERAL NOTES FOR I. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR TO ANY EXCAVATION OR CONSTRUCTION. 2. SEPTIC SYSTEM TO BE INSTALLED 1N COMPLIANCE WITH PREPARED FOR 310 CMR 1&00:TITLE V. QT,�/C/H' �OW 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION. / l` 4. ALL DISTURBED AREAS TO LOANED AND SEEDED. DATE: /.- i,/, ZS SCALE: S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY --'---- — -- REQUIRED INSPECTIONS 1 FTEL: WELLER & ASSOCIATES FALMOUTH ROAD CENTERVILLE, MA. 02632 (508)775-0735 FAX: (508)775-0754 I ' APPROVED BY: � o 3� \ o ��o boo \ N • N TEST HOLE LOG DATE: Avg• /e, /994B SOIL EVALUATOR:� WITNESS:.- O PERC RATE: C".Z wis//ir✓c�,/ G � C:oA2S G, s' � ✓� NOT4= _ �N zinc sA� i DESIGN DATA W DAILY FLOW:( ))3DRMS.z 110 GPD 41 GPD V \ SEPTIC TANK: T d GPD z 200%= 88 o GPD USE:/So o GALLON PRECAST SEPTIC TANK 0 LEACHING FACILITY: I USE: X Rs ;c Z CAPACITY: SIDEWALL 93�Z x di2yr/5, BOTTOM: /3 X 33,5 x D,21=3ZZ,3: ��jj TOTAL:: O� DA IEL E. �y BRAMAN -.:y;., O CIVIL Vjlo OFM�R_ v No 32686t y Mt ' NOTES: 1 1. ALL PIPE TO BE 4"DIA.SCH 40 PVC. 2. PIPE BOX.TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION t .ZCe 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2'LAYER OF 318'PEASTONE OVER 314'-1 1/2'WASMD STONE ALL AROUND TOP OF FOUND. / /& oo /(�.-yo SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN GENERAL NOTES FOR I. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR FDATE: V, 5 TO ANY EXCAVATION OR CONSTRUCTION. A,�' /�� ��'� � 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR 1&00:TITLE V. �� 3. THIS DETERMMIIN ION 15 NOT TO BE USED FOR PROPERTY LINE IAQ-V, ZS//'W SCALE:fay Ao672e-0 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY ---- — -- REQUIRED INSPECTIONS. WELLER & ASSOCIATES FFT1645FALMOUTH ROAD CENTERVILLE, MA. 02632 EL: (508)775-0735 FAX: (508)775-0754 APPROVED BY: n \L. oar 011 of �Z.;l 5� ---------- LINE I DIRE ��]DMTANCE I Li S 43*02'30" W 11.13, 1 LQUUb L2 S 5744'40" E N4 W 'n se 10 11*0 LOCATIbN MAP COTUIT QUADRANGLE SCALE-. 1:25,000 ASSESSORS MAP 116'PARCEL 2 ZONES- AQUIFER PROTEC116N OVERLAY DISTRICT ZONING DISTRICT' RC CB/DH 17ND MINIMUMS rtlL 9.73' AREA = 43,560 S. F. FRONTAGE = 20' 0 WIDTH 100' FRONT SETBACK 20' I< SIDE SETBACK 10, 10 L4j 'REAR SETBACK 10' AK VV ^A + A FLOOD ZONES- A13 (EL 11 & 12) CB/DH FND FIRM COMMUNITY PANEL EL 8.66' 41 No. 250601 0016 D & 0018 D REVISED*. JULY 2, 1992 CB/D RID 4 EL 8.6 4' AS SHOWN ON THIS PLAN 41- 0 SEE NOTE RE ORIENTATION/PLACEMENT S T 0 N E Z 0 N E A 1 3 -k V E W Y lei JAC- DATUM FOR THIS PLAN IS NGVD 10 .40# (EL il) PROPOSED 58' LQ 4"0 SEWER LINE ff C.1 0 ir POLE 7/12 0 z 14! 4& 0 0 N t A 1 31 P A R C E L A R E A 0 4v 0 + (OL 12) PLAN BOOK 96 PAGE 25 0 14' 16,100 Square Feet 1), 0 0.37 Acres 0 9 0 0 C7 00911111141 CARW 7 4-) PROPOSED GUEST COTTAGE 2 BEDROOM 4v ri 410 '0 PA606S6 -k 2 BEDROOM 0 COTTAGE t 0(" D t s i a m o A Y A jCB H FND EXISTING GARAGE FLOOO EL .28 EL 10.2' EXISTING SINGLE FAMILY bWtWNO te GARAGE 3 BEDROOMS TOTAL 4v P P'OSED SINGLE FAMI UE'ST 6OT' tAGt RO LY & G' COTTAGE 4v 1 BEDROOM DWELLING 4- 2 8MR66M TING PROPOSED 58' EXISTING 3 BEDROOM sEp-nc SYSTEM T EL - 8.3' 10, 4*0 SEWER LINE, 7 FLOW DIFPUSORS AND DISTRIBUTION BOX PLOTTED MOM INSTALLERS SEW4..� PERMIT #86804 SEP11C 4 <V SEPTIC TANK LOCATION FROM FIELD TIES 12-01-098 TANK COMPLIANCE ISSUED SEPTEMBER 11, 1986 #86-804 POLE #7/12 4D AL OP,0060666, SiM-- b64kk&fibk' NOT TO SCALE Olt, op t I T E L A N AT Z 0 N E A 1 3 Z 0 N E A 1 3 88 BROGE STREET (EL 11) (EL 12) OSTERMLLE, MASS*. FLOOD LINES DIGITIZED USING FIELD/TOWN GIS SHEET LOCATION OF EXISTING BUILDINGS ON LOCUS AS ORIENTATION; TOWN GIS SHEETS F60 ALLIGNED WITH FIRM COMMUNITY PANELS USING ROADS AND WATER LINES. ql eTl OLAt AOR k6l AHAM 4i N 0 T E S HYDRANT sckt: (f,i lo Dt k 16, 1006 wv WATER VALVE 130TER At NYto INC.-: IRRIGATION SPRINKLER HEAD I CERTIFY THAT THE EXISTING STRUCTURES SHOWN Yl 812 MAIN, STRELT HEREON ARE LOCATED RELATIVE TO THE MONUMENTS 13 OSTERVILLE, MASS., 0266t POST AND RAIL FENCE a SHOWN ON THIS PLAN. THESE STRUCTURES ARE (508)-428-9131 LOCATED WITHIN A SPECIAL FLOOD HAZARD ZONE. PICKET FENCE x RETAINING WALL DATE: GARAGE FLOOR SLAB ELEVATION FLOOR C, S UTILITY POLE/NUMBER -Oj 13AXTER & NYE, INC. STEPHEN ac A. 2� CONCRETE COVER (S) ALLYN rn AL 0— 2, 1 IC3 DRAINAGE COVER 0 01 GIs v OVERHEAD ELECTRIC WIRES E E N L 66h go it LOCATION OF SEPTIC COMPONENTS SHOWN ON THIS r-LAN IS APPROXIMATE AND BASED ON INSTALLER TIES FROM SEWAGE PERMIT No. 86-804 (SEPTEMBER 11, 1986) AND JUNE 6. 1995. 0 DWG iw, 4wwl elma w, ----------