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HomeMy WebLinkAbout0161 FOX HILL ROAD - Health 161 FOX HILL RD. CENTERVILLE A = 190 141 0 No. 4210 1/3 ORA n m al z 10010@ ;1 .� =� �� -� ;1 .� ,� .i 4� O �� .'` �] .� 0 ;y Commonwealth of Massachusetts Title 5 Official Inspection Form 71 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .r wM ,- 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address +' ` James W. and June P. McGonigle - Owner Owner's Name information is A- required t✓ MA 02632 March 17 2018 r• required for every page. City/Town State Zip Code Date of Inspection 1,0 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information # /01 �� filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr use the return Name of Inspector key. Eco-Tech Rapid Response VIR� Company Name 155 George Ryder Road South Company Address Chatham MA 02633-1621 City/Town State Zip Code 508 364-0894 1328 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 �VIOF* ❑ Conditionally Passes ❑ Fails FDA ID �ti ❑ Needs F r Ev uatio a Local Approving Authority a OUGHANOWR N (44 a)I — 0.1328 °A March 17, 2018 Inspector's Signat Fqf�NgpE Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 koqyA VS 1 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or-the;septic;tan,k(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltrafioh or,tankfail�ure is imminent. System will pass ,f \! "Yrs,a ♦ I', inspection if the existing tank is replaced with a:jcomplying.septic,tank as approved by the Board of Health. f ro� *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,ava lable. ❑ Y ❑ N ❑ ND (Explain below): teat r t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 20009pd- 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins.doc•rev.6/16 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 �M 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Ye's ® No Water meter readings, if available last 2 ears usage d 158 gpd 9 ( Y 9 (gpd)): Detail: 2017: 43,000 gallons 2016: 72,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: 2 weeks ago Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , M 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. CitylTown 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: owner's agent 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 Elp ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 16+ years. Certificate of Compliance for a new system was issued 9/21/2001 (Permit#2001-573 at Health Department). 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: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling. 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: 10.5' x 5' x 6-1500 gallon Sludge depth: 6 inches t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments ;M 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is Centerville MA 02632 March 17, 2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 inches Scum thickness 1 inches Distance from top of scum to top of outlet tee or baffle 9 inches Distance from bottom of scum to bottom of outlet tee or baffle 14 inches How were dimensions determined? design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Maintenance pumping is recommended within 2 years and every 2-4 years thereafter with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): q Depth of liquid level above outlet invert at outlet invert p 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.): No adverse conditions observed. PumpChamber locate on site plan): ( P ) Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Cover was opened and drywell was empty and clean at interface. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 ' Commonwealth of Massachusetts 9,22 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17 2018 —page--- C-ityrrown --State -Zip-Code— --Date-of-Inspection-- D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the.building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately LEACHING SEPTIC 1�F® AT GALLERY � TECH.US j Ec®e 3 THIS SKETCH IS BEST COLOR VIEWED FORMAT IN L O CA TIOEV -OF SEPTIC COMPONENTS -DISTANCES IN DECIMAL FEET 2I DISTRIBUTION BOX A B 1 23 39 1500 GALLON B SEPTIC TANK 2 33 32.5 3 51 36 A I EMS TING DWELLING NOT TO o r F SCALE '� y Q 3 W W J ccO UJ 7J •• L _ 508 364-0894 FOX MILL ROAD t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGoni9 le Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 page. Cityfrown 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: 25+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed. 8/23/2001 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be over 5 feet above high groundwater. Town of Barnstable GIS Department records indicate that the property is over 25 feet above bog. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 161 Fox Hill Road Assessor's Map: 190 Parcel: 141 Property Address James W. and June P. McGonigle Owner Owner's Name information is required for every Centerville MA 02632 March 17, 2018 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 GEOHYDROLOGICAL PROFILE — NOT TO SCALE 1 rt 1� It 11 P /I 1`1 111 111 'I III 1111,11 1 1 1 =Mir PRECAST hE DRYWELL BOTTOM OF LEACHING PER DESIGN PLAN 'LEACHING IS ABOVE HIGH ,J GROUNDWATER w N GROUNDWATER ELEVATION PER GIS MAPS t5ins.cloc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. Cityrrown 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, use only the tab 1. Inspector: Ili//1 key to move your cursor-do not Ricky L. Wright i use the return Name of Inspector key. B & B Excavation, Inc. 4:1 Company Name 14 Teaberry Lane Company Address Sandwich MA 02563 City/Town State Zip Code 508-477-0653 S14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails I ❑ Needs Further Evaluation by the Local Approving Authority 6/2/11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. � I t5ins•09/08 Title 5 Official Inspection Form: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 °M 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. City/Town t State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 4 ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or,exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) t 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 groundwater elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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—11NPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. CityrTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M a' 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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)): n/a Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: March 2011Date Commercial/Industrial Flow Conditions:. Type of Establishment: Design flow(based on 310 CMR 15.203): , Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 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: B & B Excavation Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? site glass on truck Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: tank is original leaching upgraded in 2000 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: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 18"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: 5.2x5.2x8.6 Sludge depth: 6" t5ins•09/08 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 °M 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be,in good shape concrete baffels present no sign of back up Grease Trap (locate on site plan): Depth below grade: k feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. Cityrrown 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.): ' s Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appeared to be in good shape.No sign of back-up or carryover. Pump Chamber(locate on site plan): , Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields ; number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appeared to be in good shape no sign of staining or hydraulic failure.Leaching was dry at time of inspection. 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville ;MA 02630 6/2/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately F r AI - z.ot � h � I = 13 ' i C2 28 ` C3 = 29 '6 ; �J3 = 59 ' t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar i ® Shallow wells Estimated depth to high ground water: i feet 2 Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date/2000 ❑ 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: i You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments nM 130 Fox Glove Road Property Address Ann Stone Owner Owner's Name information is required for every Centerville MA 02630 6/2/11 page. City(rown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE L. � LOCATION ��C/ /`�,c. /�/��- VILLAGE SEWAGE ��� .�,// ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACTiy LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER O OWNE /f PERMTTDATE:_ COMPLIANCE DATE: Separation Distance Between the: T-0= Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of-leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by /�j` Feet F r ,i�r 14/ ' 1 47. 1 li .y TOWN OF BARNSTABLE LOCATION ��� Fix l�// /f�� SEWAGE #AO/-f 7; VILLAGE CC�77`/�di ASSESSOR'S MAP & LOT 196-IW INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY 4` , LEACHING FACILITY: (type);5C-0 t �/�ie�� �� (size) ",,.f NO.OF BEDROOMS 3 BUILDER O OWNE /\ e L<29414 41 PERMITDATE: /P/d> COMPLIANCE DATE: L� 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 byL f � IQr9 f 1 i } No. `"�'.'�• Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t� Yes PUI§LIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Z(ppriration for �Btgpool *pztem Construction Permit Application for a Permit to Construct( )Repair( V�Upgrade( )Abandon( ) 0 /Complete System j9dividual Components Location Address or Lot No. r� ,(,�f J�r Owner's Name,Address and Te)e.No. Assessor's M;p,(Pazcel Installer's Name,Addre s,and Tel.No. Designer's Name,Address and Tel No Type of Building: Z Dwelling No.of Bedrooms Lot Size Is ® �sq. ft. Garbage Grinder(✓�e Other Type of Building �$_ l Wn<. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow lue gallons. Plan Date Numbe o sheets Revision Date Title 0 Size of Septic Tank Type of S.A.S. ` , ®Dr,191G .(/ J` 8;3 " Z Description of Soil � X�� 3' Nature of Repairs or Alterations(Answer when applicable) ! z7 I-ewm/ 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 bee ' ued by t is Bo f a Sign n Date Application Approved by Date Application Disapproved or the following re& j, Permit No. Date Issued ../ -No. .. ._:.- Fee b- . THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Yes 2pprication for Diopw6ar *potent Construction Permit Application for a Permit to Construct( )Repair( Vf Upgrade( )Abandon( ) L",Complete System tdividual Components Location Address or Lot No./dl�©/f�'`iAW Owner's Name,Address and Te.No. yycGa�� � Assessor's M,p4parcel Installer's Name,Addre s,and Tel o. Designer's. ame,Address and Tel.No. 7���9��9 Type of Building: D Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(/W Other Type of Building e3Jj- ewc4o. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow I-UP gallons. Plan Date / Number,, sheets Revision Date e Title )2 J— ,51 /"1CT/7 D Size of Septic Tank /J—aa Type of S.A.S. `Si:v-4� G nw,6 Description of Soil /r ✓�� I . S ?_c 'A- Z' Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: r 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 is ued byt4isBo Bar f Sign r 7j Date Application Approved by _ Date / Application Disapproved for the following reas 06 r-- Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTEEY,that th On-site Se, age Disposal System Constructed( )Repaired ( ✓)Upgraded( � ) Abandoned( )by ,U ��?l l/� at 0 haste en constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No �� ated2 1n4T Installer Designer The issuance of this Permit sliall not be construed as a guarantee that th rsystom will function,,as dest'gned. Date / �1 10 ( Inspector�-,o < O . `4- C(,,Z� ----^� ————---————---— — No. Fee 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS -Mioozar *pgtem Conotruction Permit Permission is hereby grante to_Construct�j ) epai (✓ )Upgr de( )Abandon( ) �rv�Il,Z�(System located at /X/ �/� Z'�9 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 must be com feted w Ore years of the date of t 's rmi Date: Approved by ' ) J 1 FILE Nc.462 08/21 '01 AN 10:32 ID:BOP,TOLOTTI CONSTRUCTION FAY:508 428 9399 PAGE 1 srzs10 t NOTICE; This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL.EVALUATION EXEMPTION. FORM 1, A et4i✓ 4. ®y A,i—^ , hereby certify that the engineered plan signed by me dated of , concerning the property located at (o l T-o Y- �h L4, CEa-t ' ets all of"the following criteria: e This failed systern is connected to a residential dwelling only. There are no commercial or businehs uses associated with the dwelling. • The soil is classified as CLASS i and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed, • The bottom of the proposed leaching facility will not be located less than foutteen (14)feet above the maximum adjusted groundwater table elevation. LAdjust the groundwater table using the hrimptor method when applicable] Please complete the following: A) Top of Gmund Surface Elevation (using GIS information) B) G.W. Elevation + adjustment for high U.W. DIFFERENCE BETWEEN A and B '2 SIGI�i l? DATE: 2Z NOTICE 8.i:>ed upon the above information, u repair permit will he issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered peptic system plans._,__ _ y;hcall:h Folder:percczmp � �a SOWN 0 HNSTAB `' t flea LOCATION 14//� aLc 1f7��/ ��'� SEWAGE VILLAGE 6, AS;$ESSOR'S MAP'& LOTr,19a 1'11 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /SaQ e�L LEACEING FACILITY: (type) j-,a L �/,�a��. � (size) I2,S� =2f bl ' 1 . NO. OF BEDROOMS 3 BUIL)SER OF( PERMIT DATE: q/071dy COMPLIANCE_DATE: Vat O 4%eparation Distance Between the. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet` Private Water.Supp Welland Leaching Facility (If any wells exist' on site or within 200 feet of leaching facility) Feet g g tyty ( y wetlands exist Edge of Wetland and Leaching Facility If:an r within 300 feet of leaching facili Feet Furnished by #�G - a SYSTEM PROFILE TOP FNDN, AT EL. 49.7' - ACCESS COVER TO WITHIN 6' OF FIN. GRADE <Nor TO SCALE) ACCESS COVER (WATERTIGHT) TO / 48 MUNIMUM .75' OF COVER OVER PRECAST WITHIN 6' OF FIN, GRADE 2% SLOPE REQUIRED OVER SYSTEM 46.0' � � o 2' DOUBLE WASHED PEASTONE - I. TL RUN PIPE LEVEL v� FOR FIRST 3' MAX. �p _f1 PROPOSED . - 43.83' �0 4 GALLON SEPTIC � 45.25 I 45.0' ITE ,___, -- TANK (H- 10 > . GAS �43.14' O C=� O O CJ © O C34W . "'- i BAFFLE 43.31' �" 0 43.p' (� f-] O O O O O O C� �� MIN C Ot� O O OOOO SLOPE) �__6' CRUSHED STONE OR MECH Him 2 COMPACTION, (15.22I C2l> �oBS O O O O O O O O L..) _ 0 41. 4' 1 LOCUS DEPTH' OF FLOW = 4 ( 12. r SLOPE) ( % SLOPE) 3/4' TO 1 1/2' DOUBLE WASHED STONE, �( TES:. SIZES! z INLET DEPTH = 10" OUTLET DEPTH = LOCATION MAP NTS 14 FOUNDATION- 10' SEPTIC TANK 14' D' BOX 16' LEACHING,, 5, ASSESSORS MAP 190 PARCEL 141 FACILITY PROVIDE GRAVITY FLOW AT MIN. 2% PITCH TO PROPOSED SEPTIC TANK FROM EXIST. INVERT + 42,6 CONTRACTOR TO CONFIRM SUITABLE SOILS AND NO WATER FOR MINIMUM 5' BELOW LEACHING 36.0' FACILITY AT TIME OF INSTALLATION. L=41,15' INVERT OF LEACHING FACILITY _ R=25.00' - MUST BE IN SUITABLE SOILS. BENCH MARK - CTR. OF C.BASiN '` 44.2 ELEVATION = 41.5' ' 1.6 \ �� 1.5 / O 45.1 + 45.4 LOT 25 \� ^� 15,098t SQ. FT. �S \ N❑ E S F, 0.35t ACRES SC 'TIC DESIGN. (GARBAGE DISPOSER tS NOT ALLOWED > 1, DATUM IS APPRpXIMATED�FROM QQUAD 47,3 \,� DESIGN FLOW: 3_ BEDROOMS ( 110 GPD) = 330 GPD 2. MUNICIPAL ,WATER .-W . '3. MINIMUM PTPF PITCH T9 BE 1/8 PER F'(lOT. L + >,t� \ _ 660 4. DE�:SI .-N'� LQADIilIi:i I- i-I r i-L i `a;t_�,:, a i �i i a' _:.., s. SI RTIC TANK. 330 GPD ( 2 > / + 'I .E, 5, PIPE JOINTS TQ BE MADE WATERTIGHT. I -/412 \ U 'E A- 1500 GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 4 .a Ike \� LI-ACHING ENVIRONMENTAL CODE TITLE V. 48,9 2(30 + 9.83) 2 (.74) = 118 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT 4B`B 1 9 74 TO BE USED FOR ANY OTHER PURPOSE. 4+: 30 x 9.$3 A GAR. - � ,. (SLAB) BOTTOM: (' ) Z18 8. PIPE' FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. 49.1 f + 49.6 Lw48.31' T' TAL: 454 S.F. 336 GpD 9. COMPONENTS NOT TO BE BACKFII_LED OR CONCEALED WITHOUT ENC. R=32.30' I INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED U`�E (2) 500 GAL. LEACHING CHAMBERS WITH 4 PORCH q �.., FROM BOARD OF HEALTH. SLAB) '� i� 493 STONE AT ENDS, 5' BETWEEN THE 2 UNITS AND 2.5' AT 10, PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING 'SEPTIC SYSTEM 4 D,p SIDES 49,5 49,7 � LEGEND EXIST, DWELL. 49.5 TITLE ST�'.E' PLAN 47.8 TOP FNDN. a \W / 100.0 PROPOSED SPOT ELEVATION OF 49.7 161 F X HI ROAD + aR.6 49.4 100x0 EXISTING SPAT ELEVATION IN THE TOWN OF: CP 49.0 PROPOSED CONTOUR ( CENTERVILLE ) B A R N S TA B LE 49.8 100 EXISTING CONTOUR PREPARED FOR: BORTOLOTTI 49,4 / CONSTRUCTION/McGONICLE (�9� / 20 0 2,0 4.0 60 S / BOARD OF WEALTH MA " AUGUST 20, 2001 / APPROVED DATE SCALE: 1 - 20' DATE: I SQ.3fa8^368 ,Q.4 x S3362-980 GAOwn cope engir?ecring, inc, v�►Of �,. .. ARNE H. ��, c ARNE s CIVIL ENGINEERS OJALA o,a CIVIL LAND SURVEYORS No. 3o 1 <> Nt 0 1-- 06 939 main st. ormouth, mo 02675 ors ' r r ____._ _ _