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HomeMy WebLinkAbout0349 GREAT MARSH ROAD - Health 349 GREAT MARSH RD., CENTERVILLE A= 190 217 a 4 1 1 UPC 12534 No. 2-153LOR � HASTINGS, MN ._,...�:......u.ru:r.tea,...........,.v.. .-_..—._. -�..:.r.r.._,,,..,,4--.. _-.., _.�s..�...,n.�y.,..�Z.:....,.,.,.....n....._,�.....�..,_.�.,J.... �;;,;� Commonwealth of Massachusetts ;� - - ;� Title 5 Official Inspection Form � Subsurface Sewage Disposal,System ForrIl for Voluntary Assessments 349 GREAT MARSH RD Property Address QUAN TOBEY- PO BOX 94 OSTERVILLE MAiQ2655 Owner Owner's Name . information is / c x required for every CENTERVILLE VMA 02632 12/16/2020 page. City/Town ;State Zip Code Date of Inspections Inspection results must be submitted on thWform. Inspection forms may not be altered in an way. Please see completeness checklist at the end of the form. y i Important:out f A. ion forms p:When filling out f Inspector Informati on on the computer, i use only the tab Christopher Maki } key to move your Name of Inspector cursor-do not Cape Cod Septic Services t use the return . key. Company Name 350 Main St. Company Address z s W Yarmouth t R MA 02673 City/Town State Zip Code reran 508-775-2825 SI-14423 Telephone Number +` License Number i B. Certification f certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes t, 2. ❑ Conditionally Passes a' 3. ❑ Needs Further Evaluation by-the Local Approving Authority T 4. ❑ Fails phi -- - 12/18/2020 spector's Ign A I 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ti 41 Please note: 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. �P a5insp.doc rev.7/2 612 0 1 8 Title}5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form t I Subsurface Sewage Disposal System Form Y ,Not for Voluntary Assessments 349 GREAT MARSH RD Property Address I, QUAN TOBEY- PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is CE_NTERVILLE required For every __ )MA 02632 12/16/2020 page. City/Town 1-§tate Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5. nd all of 4 and 6, 1) 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: SYSTEM IS IN WORKING CONDITION 2) System Conditionally Passes: )I ❑ 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. (i Check the box for"yes", no or not determined (Y, N, ND)for the following statements. If"not determined," please explain. t 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 exfltration or tank failure is imminent. System will pass inspection if the existing tank is replaced witWa complying septic tank as approved by the Board of Health. ) t -1 *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. at . ❑ Y ❑ N ❑ ND (Explain below): f# 7t 1 �t i? f t5msp.doc•rev.7/26/2018 f' Title Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i �l Commonwealth of Massachusetts =-P Title 5 Official Ins ection Form Subsurface Sewage Disposal System Form "Not for Voluntary Assessments Y is 349 GREAT MARSH RD Property Address k QUAN TOBEY - PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is required for every CENTERVILLE _MA 02632 12/16/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) z Al 2) System Conditionally Passes (cont.): 1 ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or breakiout 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): ,l ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): 1! Elobstruction is removed J ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): -- It gv}! ❑ The system required pumping more than!, times a year due to broken or obstructed pipe(s). The system will pass inspection if(with appro aI of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): �1 ss Et S{ " !t 3) Further Evaluation is Required by the Boa d of Health: ,r ❑ 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. a. 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: E; i' :l t5insp doc•rev.7/26/2018 Title 5{Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 s' Commonwealth of Massachusetts J1x - Title 5 Official Inspection Form II'.I Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments �f, r 349 GREAT MARSH_RD (! Property Address QUAN TOBEY- PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is CENTERVILLE f required for every — _ VMA 02632 12/16/2020 page. City/Town -State Zip Code Date of Inspection C. Inspection Summary (cont.) n ❑ 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 b. 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 sail 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. j - El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 4 ❑ 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 otherfailure criteria are triggered. A copy of the analysis must be attached to this form. tI c. Other: ti �k ii 4) 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 t5insp.doc•rev.7/26/2018 Titlefi5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts `t Title 5 Official Inspection Form /5I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rem • 349 GREAT MARSH RD t Property Address E QUAN T_OBEY - PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is "t! required for every CENTERVILLE fiMA 02632 12/16/2020 page. City/Town State Zip Code . Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 %day flow Ck Ck ❑ ® 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 1 cesspool or privy is below high ground water elevation. t. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. A �t ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. k ❑ ® Any portion of a cesspool or privy is less than 1 00 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 col liform 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 2000 gpd- 10,000 gpd. ❑ ® 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. ,l 5) 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. 11 For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 40d'Ifeet of a surface drinking water supply 1f ❑ ❑ 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 5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r ' Commonwealth of Massachusetts P Title 5 Official Ins pection Form (Q / Subsurface Sewage Disposal System Form ;Not for Voluntary Assessments ^` .. 349 GREAT MARSH RD Property Address QUAN TOBEY - PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is CENTERVILLE t required for every 1MA _02632 12/16/2020 page. City/Town ;State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes".to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system omponents pumped out in the previous two weeks? t ® ❑ 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 prope"maintenance of subsurface sewage disposal systems? The size and location ofrthe Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. • t ® ❑ Determined in the field (ifany of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] i }r F ' R l5insp.doc•rev.7/26/2018 Title•5 Official Inspection Form:Subsurface Sewage Disposal System•page 6 of 18 e Commonwealth of Massachusetts " �* Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,4. 349 GREAT MARSH RD Property Address r, _QUAN TOBEY - PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name a= — information is + required for every CENTERVILLE __ _ _ IMA 02632 12/16/2020 page City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: I Number of bedrooms (design): 2 ? Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (fo'r example: 110 gpd x#of bedrooms): 220 Description: ' 4 iz �1 S , Number of current residents: VACANT Does residence have a garbage grinder? ' ❑ Yes ® No Does residence have a water treatment unit? � ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) "" ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): '19- GPD '18 - GPD Detail: t , Sump pump? ❑ Yes ® No Last date of occupancy: VACANT FOR 4 MONTHS 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form <,; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 349 GREAT MARSH RD Property Address d" Owner QUAN TOBEY- PO BOX 94 OSTERVILLE MA 02655 information is Owner's Name required for every CENTERVILLE _ .MA 02632 12/16/2020 page. City/Town ,St ate Zip Code Date of Inspection D. System Information (cont.) . 2. 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 Water treatment unit present? El Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5' ystem? El Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): { 3. Pumping Records: 'f Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: y, ;5insp doc•rev '126!2018 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts I`'P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments 349 GREAT MARSH RD Property Address QUAN TOBEY- PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is CENTERVILLE required for every MA 02632 12/16/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool i ❑ Overflow cesspool 1 ❑ 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 beobtained 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): Approximate age of all components, date installed (if known) and source of information: 2013 PER PERMIT ON FILE AT BOH I� fl Were sewage odors detected when arriving at the site? ❑ Yes ® No 1 4' 5. Building Sewer.(locate on site plan): Depth below grade: 17" 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.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED ' F 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments 349 GREAT MARSH RD ;( Property Address u I QUAN TO_BE_Y - PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Namet information is required for every CENTERVILLE ,MA 02632 12/16/2020 page. City/Town 3 State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: ' 10" ' feet Material of construction: , ® concrete ❑ metal ❑'fiberglass ❑ polyethylene El other(explain) t / t 4 If tank is metal, list age: r years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes.❑ No ,f Dimensions: 1000 GALLONS i Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle { gyypp. 1 Scum thickness �, 211 Distance from top Of scum to top of outlet teeor baffle Distance from bottom of scum to bottom of outlet tee or baffle is How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITIONS PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 10'k•,BELOW GRADE L t5insp voc•rev 7r26/2018 Titles Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 1e Commonwealth of Massachusetts Title 5- •yr; Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ? � 349 GREAT MARSH RD Property Address QUAN TOBEY- PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name }, information is CENTERVILLE ! required for every MA 02632 12/16/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) V 7. Grease Trap (locate on site plan): 1. i£ Depth below grade: 1 feet Material of construction: ` - )I ❑ concrete ❑ metal fiberglass�i 9 El polyethylene ❑ other(explain): y. Dimensions:. r Scum thickness Distance from top of scum to top of outlet tee''or baffle t i Distance from bottom of scum to bottom of outlet tee or baffle )' Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: k t Material of construction: '. ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: ! gallons per day t5insp.doc•rev.7/2 612 0 1 8 Titlep5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of IS t -4 Commonwealth of Massachusetts } Title 5 Official Inspection Form 1s1� Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments 349 GREAT^MARSH RD Property Address QUAN TOBEY - PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is NTERVILLE E required for every _-C-_- --..-_—_ _ :_MA 02632 12/16/2020 page. City/Town ,State Zip Code Date of Inspection D. System Information (cont.) I 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No e Alarm level: i' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): a i Attach copy of current pumping contract(re)quired). Is copy attached? El Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): 1, EVEN 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.): .. DISTRIBUTION BOX LEVEL AND WATERTGGHT - T• F f f t5insp.00c•rev 7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 y'' Commonwealth of Massachusetts x ,IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `-_ 349 GREAT MARSH RD Property Address \ QUAN TOBEY - PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is CENT_E_RVILLE required for every MA _02632 _ 12/16/2020' page. City/Town ,State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): ;1 t Pumps in working order: t ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of�pump chamber,t,condition of.pumps and appurtenances, etc.): " If pumps or alarms are not in working order,`•system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan; excavation not required): 1 If SAS not located, explain why: �F -- IF it Type: Y i ❑ leaching pits number: ® leaching chambers number: ❑ leaching galleries number: Y leaching trenches number, length: ® leaching fields , number, dimensions: 20-ARC36 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: :51nsp.00c,rev 7r26r2018 Titl) official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts 10 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 349_GREAT MARSH RD Property Address QUAN TOBEY - PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is CENTERVILLE required for every _ MA 02632 12/16/2020 page. City/Town 'State Zip Code Date of Inspection D. System Information (cont.) js 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 20-ARC36 CHAMBERS WITH 4 ROWS OF 5 CHAMBERS FOUND IN OPERATING CONDITION DURING INSPECTION WITH NO EVIDENT FAILURE OR PONDING. 12. 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 �f Dimensions of cesspool ,t Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of,hydraulic failure, level of ponding, condition of vegetation, etc.): f 1 iSlnspdoc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts , ' Title 5 Official Insp etion Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments 349 GREAT MARSH RD Property Address QUAN TOBEY - PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name l information is RVILLE CENTE required for every _ .T— iMA 02632 12/16/2020 page. Cityl own State ZipCode . Date of Inspection D. System Information (cont.) 13. 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.): lk ,r w� l� y! 5 sl S • ;t ft v.e 6 r � k l5insp.d6c•rev 7/26I2018 Title 0 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts I Title 5 Official Inspection p tion Form v Subsurface Sewage Disposal System Form -,Not for Voluntary.Assessments 349 GREAT MARSH RD Property Address QUAN TOBEY - PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is CENTERVILLE"required for every MA 02632 12/16/2020 page. City/Town 'State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: if 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: '6 i ❑ hand-sketch in the area below ® drawing attached separately si �r F 3� �I <I a' {i r 2 L _ I i5insp ooc-rev 7i261201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,} Subsurface Sewage Disposal System Form -Not for Voluntary fY ,, ry Assessments t � 349 GREAT MARSH RD V� Property Address QUAN TOBEY- PO BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is CENTERVILLE required for every MA 02632 12/16/2020 page. Clty/Town "State Zip Code Date of Inspection D. System Information (cont.) A� 15. Site Exam: ;t ® Check Slope .e ® Surface water " ® Check cellar ® Shallow wells :4 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: 12/5/2012 q Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) 1: ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) .q ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: TEST HOLE DATA PER PLAN ON FILE AT BOH SHOWS NO WATER ENCOUNTERED AT 126". SYSTEM INSTALLED PER PLAN Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/201 B Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments to 349 GREAT MARSH RD Property Address QUAN TOBE_Y - PO_ BOX 94 OSTERVILLE MA 02655 Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/16/2020 page. City/Town State ZipCode, Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—,Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included :Smsp aoc•rev i 26 20t t3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 t �I . t 3 � svu v� 9 ®�� ��� Y I � uw�w.�.+uw...i...� a wax P .f �• - M i° t No. ` Fee T E COMMONWEALTH OF MASSACHUSETTS Entered in computer: O Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 9pplitation for bisposal 6pstrm ConstCUttlon 30Prmit _ Application for a Permit to Construct( ) Repair(t6Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 'Y 9 Gr IfOwner's Name,Address,and Tel.No. Vogl& Assessor's Map/Parcel / O � 3 Yr G-,e-f-Vlw r1'4 .rf 4 o "63•z Installer's Name,Adds, n .N�o.w�r�0 F J-0 O� Designer's Name,Address,and Tel.No. fo.�" �r � /� 0�6YP Icf1v elveerl� fret lcefi Type of Building: ©d-j ?6 Dwelling No.of Bedrooms Lot Size ��� �� sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ® gpd Design flow provided gpd Plan Date /mil o �f�2 Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. C 3 6C Description of Soil amr- Nature of Repairs or Alterations(Answer when applicable)Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Z ed Date Application Approved by Date Application Disapproved by ffl- Date for the following reasons Permit No. Date Issued A —0 4 Fee No. ` ' �� s ` Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLE, MASSACHUSETTS A �IIIYIcatlon for MispoSal Epstein Construction permit Application for a Permit to Construct( ) Repair(;(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4/9 Q qW/J1 ors' 4. 'Owner'N ®�dress,and Tel.No. � N Assessor's Map/Parcel 0 y Gil r/bI f r rj �ol Installer's Name,Address,and Tel.No.fu/;s v S-y-o OJ'• Designer's Name,Address,and Tel.No. w eoX o�p t / i2�o Type of Building: p r ©d J 3 6 Dwelling No.of Bedrooms Lot Size �Z,2,j ®O o sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures r w i Design Flow(min.required) 3 gpd Design flow provided gpd Plan Date o Number of sheets / Revision Date Title Size of Septic Tank /p o(J i,�d Type of S.A.S. r� 111 a) /�L/z c Description of Soil (-D /j r J at/1 .✓� i Nature of Repairs or Alterations(Answer when applicable) ,.:,r P d-// -e A0- oX j Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in - accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ed Date 0Z i Application Approved by /r/ �/ Q ' ` Date / Application Disapproved by Date for the following reasons i v 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 =0 a at r'r'1V_,qL� MA X-,)�. �f1 j�\l'Qhas been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. " fluted (9 / -� Installer Designer CS #bedrooms Approved design flow 733d and The issuance of this permit shall not be construed as a guarantee that the system wil JeI6-_: d,esigned. Date 1 Inspect - ---------- -------------------------- ------ -- -- -----------------_---------- -----------------—---------------- No. ''�73 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposar 6pstem Construction 3permlt Permission is hereby granted to Con (st �ruct( ) Repai�( ) Upgrade( ) AbandonL System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with i Title 5 and the following local provisions or special conditions. f Provided:Construction nyust be completed within three years of the date of this permit.` L Date Approved by I Town ®f Barnstable Regulatory Services 4a Thomas F.Geiler,Director wxxsraBr� = Public Health Division a9.ida`� Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax:f 508-790-6304 Date: X 1 1 3 Sewage Permit/3 0 L1 3 Assessor's Map/Parcel, jr,j o 1)�J Installer&Designer Certification Form - 711— Designer: G-s1,j Enri`t:'1�2 �J1C, Ioso-aller: � �� �� ay/f Address: i3 c/C xo 3c Address: f©"W er-1 df j am,-h ck_e- : E1,1 A 3 On was issued a permit to install a (date) (installer) septic system at 349 Gear har0 ; , R^. based on a design drawn by (address) dated (designer) 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.el greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required) and the soils were found satisfactory. � �N OF kqt LIN J. PIN (Installer's S' afore) " C0. PiLt 1 8 (Designers Signablre.) (Affix Desib__ r _ ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF CC W-LI &NCE NMLL NOT BE JSS[TED UN TY-L BOTH THIS FORT M AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU gAoffice fonnMesignerwrtification formdm TOWN OF BAR�INST/ABLE LOCATION ,� l�/''�/�� /�r.�G� SEWAGE# CJQ/ 3 C�C.�- ��yi ��P ASSESSOR'S MAP&PARCEL VILLAGE � INSTALLER'S NAME&PHONE NO. 4r f,,, Z. QTeZi O, SEPTIC TANK CAPACITY 1, O 0 LEACHING FACILITY:(type) /� '�'4� ' (size) NO.OF BEDROOMS OWNER p PERMIT DATE: COMPLIANCE DATE: - Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY - ✓erg J ---=°`` TOWN OF BARNSTABLE LOCATION �` `� �� SEWAGE# VILLAGE VWA ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LC OO 90!!�- LEACHING FACIL=: (type) (size) lb NO.OF BEDROOMS _ BUILDER OR OWNER 'C.00kZZ- -PERMffDATE: + COMPLIANCE DATE: Separation Distance Between the: 9 Maximum Adjusted Groundwater Table to the �O Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist ' within 300 fe t of leaching facility) � , Feet y Furnished by 'l. Y 1 4 ® O Town of Barnstable Barnstable Regulatory Services Department efi"aC hy nA LE,i MASS. 01 public Health Division m MASS. Te t6�q 0 200 Main Street Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3524 6802 October 3, 2012 Mr.. John Nicholson 349 Great Marsh Road Centerville, MA 02632 The septic system located at 349 Great Marsh Road, Centerville, MA was last inspected on 9/14/2012 by Mark White, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Septic system is in hydraulic failure You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thom a c ean, R.S. Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\TOB ltr I I Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 349 GREAT MARSH RD Property Address i Owner JOHN NICHOLSON j information is Owner's Name i required for every page. CENTERVILLE MA 02632 SEP I EMBER 14,2012 City/Town State Zip Code Date of Inspection i 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. I Important:When A. General Information filling out forms on the computer, use only-the tab 1. Inspector: key to move your cursor-do not MARK L WHITE i use the return Name of Inspector key. j NEIGHBORHOOD WASTE WATER ICI Company Name 350 RT 28 Company Address WEST YARMOUTH MA ( ` City/Town State j 02673 Zip Code 508-775-2820 S113381 ! Telephone Number License Number j i i 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 t-`-A r,t sews a disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of ._..c n: 9 p Y pp y p �.�Title 5 (310 CMR 15.000).The system: El Passes Conditionally Passes Fails El Needs Further.Evaluation by the Local Approving Authority .���``�'' c a_ o? MARK v, WHITECP '" No.S13381 :u, SEPTEMBER 14, 2012 A 0- 10 Inspector's Signa Date P The system inspector shall submit a.copy of this inspection report to theApproving i oard 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 20 I I i Commonwealth of Massachusetts ' i Title 5 Official Inspection Form ^' a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 349 GREAT MARSH RD j Property Address Owner JOHN NICHOLSON information is Owner's Name required for every CENTERVILLE MA 02632 SEPTEMBER 14 2012 page. Cityrrown State Zip Code Date of Inspection t B. Certification (cont.) i Inspection Summary: Check A,B,C,D or E/always complete all of Sec ion 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. l Comments: ' i I I i 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(whett er 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. E *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'. e ❑ Y ❑ N ❑ ND (Explain below): j i I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 20 I i ( Commonwealth of Massachusetts �P Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 349 GREAT MARSH RD j Property Address j { Owner JOHN NICHOLSON information is Owner's Name required for every i - page. CENTERVILLE MA 02632 SEPTEMBER 14,2012 Citylrown State Zip Code Date of Inspection I I I j l i i i B. Certification (cont.) i B) System Conditionally Passes (cost.): ❑ Observation of sewage backup or break out or high static waterllevel 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): i ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): I ❑ obstruction is removed ❑ Y ❑ N j ❑ ND (Explain below): I ❑ distribution box is leveled or replaced ❑ Y ❑ N i ❑ ND (Explain below): I i t i ❑ 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): i ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N j ❑ ND (Explain below): I .. i i j i i t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 20 - I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 349 GREAT MARSH RD i Property Address Owner JOHN NICHOLSON information is Owner's Name required for every CENTERVI LLE MA 02632 SEPTEMBER 14,2012 page. Cityrrown State Zip Code Date of Inspection C) Further Evaluation is Required by the Board of Health: i ❑ 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 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 i distance: j **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. { I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 20 I i i i Commonwealth of Massachusetts Title 5 Official Inspection Form ^' a Subsurface Sewage Disposal System Form Not for VoluntaryAssessment s t 349 GREAT MARSH RD Property Address i Owner JOHN NICHOLSON I` information is Owner's Name required for every CENTERVILLE MA 02632 SEPTEMBER 14 2012 page. City/Town State Zip Code Date of Inspection 3. Other: i I i I I 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 ElDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool; ❑ ❑x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool . ElLiquid depth in cesspool is less than 6" below invelrt or available volume is less than Y day flow j B. Certification (cont.) Yes No i El ❑x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑x Any portion of the SAS, cesspool or privy is below:high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑x Any portion of a cesspool or privy is within a Zone:1 of a public well. I 0 ❑x Any portion of a cesspool or privy is within 50 feet of a private water supply well. i i I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 20 i i i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 349 GREAT MARSH RD Property Address Owner JOHN NICHOLSON information is Owner's Name required for every page. CENTERVILLE MA 02632 SEP I EMBER 14,2012 Cityrrown State Zip Code Date of Inspection ❑ ❑x 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑x ❑ 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. i i 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. i 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 I ❑ ❑ 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 11 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. C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: I Yes No i ❑x ❑' Pumping information was provided by the owner, occupant, or Board of Health ❑ x❑ Were any of the system components pumped out ini the previous two weeks? ❑ ❑x Has the system received normal flows in the previous two week period? i I t5ins•11/10 Title 5 Official Inspection Form:Subs u i rface Sewage Disposal System•Page 6 of 20 I I i I - • i Commonwealth of Massachusetts > Title 5 Official Inspection Form ' a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 349 GREAT MARSH RD Property Address i Owner JOHN NICHOLSON information is Owner's Name required for every page. CENTERVILLE MA 02632 SEPTEMBER 14,2012 Cityrrown State Zip Code Date of Inspection ❑ ❑x Have large volumes of water been introduced to the system recently or as part of this inspection? i ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A)N/A f ❑x ❑ Was the facility or dwelling inspected for signs of sewage backup? ❑x ❑ Was the site inspected for signs of break out? I ❑ Were all system components, excluding the SAS, located on site? I ❑x ❑ Were the septic tank manholes uncovered, opened j 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: ❑x ❑ Existing information. For example, a plan at the Board of Health. ❑x ❑ 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)] j i D. System Information j Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 2 i DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): i - j D. System Information i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 20 i i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 349 GREAT MARSH RD Property Address I Owner JOHN NICHOLSON information is Owner's Name required for every page. CENTERVILLE MA 02632 SEPTEMBER 14,2012 Cityrrown State Zip Code Date of Inspection Description: I I i Number of current residents: 0 II� j i f E Does residence have a garbage grinder? } 0 Yes ❑ No M Yes ❑ Is laundry on a separate sewage system? [if yes separate inspection required] No t Laundry system inspected? ❑ Yes ❑ No Seasonal use? 0 Yes ❑ No I Water meter readings, if available (last 2 years usage(gpd)): 2011-99,000 2010-32,000 I i i t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 20 I i f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i Y 349 GREAT MARSH RD Property Address Owner JOHN NICHOLSON information is Owner's Name required for every page. CENTERVILLE MA 02632 SEPTEMBER 14,2012 Cityrrown State Zip Code Date of Inspection Sump pump? ❑ Yes ❑x No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: I Design flow(based on 310 CMR 15.203): Gallons per day(gpd) I ! Basis of design flow(seats/persons/sq.ft., etc.): .Grease trap present? j ❑ Yes ❑ No L ❑ Yes ❑ Industrial waste holding tank present? No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: i D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): j i General Information Pumping Records: B.O.H. 8/9/02 A.B. CANCO Source of information: — - Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped:. gallons t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 20 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 349 GREAT MARSH RD Property Address i Owner JOHN NICHOLSON information is Owner's Name required for every CENTERVILLE MA 02632 SEPTEMBER 14 2012 page. CitylTown State Zip Code Date of Inspection i. i How was quantity pumped determined? I I Reason for pumping: J Type of System: ❑x Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool i ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract i ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: PERMIT DATED 1/20/99 Were sewage odors detected when arriving at the site? ❑ Yes M No Building Sewer(locate on site plan): Depth below grade: 15 INCHES feet i i Material of construction: ❑cast iron ❑x 40 PVC ❑other(explain): t5ins•11/10 Title 5 Official Inspection Form:Subsu i rface Sewage Disposal System•Page 10 of 20 i f Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 349 GREAT MARSH RD Property Address I Owner JOHN NICHOLSON information is Owner's Name required for every i page. CENTERVILLE MA 02632 SEP I EMBER 14,2012 Cityrrown State Zip Code Date of Inspection Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): INSPECTED MAIN LINE WITH SEWER CAMERA, LINE IS CLEAR AND TEES ARE IN PLACE. JOINTS ARE ALL GOOD I i i Septic Tank(locate on site plan): Depth below grade 7 INCHES feet Material of construction: X concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 GALLON TANK IN FAIR SHAPE i I I I I I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certifcate) ❑ Yes ❑ No Dimensions: 1 Sludge depth: 81NC141ES i I i D. System Information (cont.) i i t5ins•11/10 Title 5 Official Inspection Form:Subs Irface Sewage Disposal System•Page 11 of 20 Commonwealth of Massachusetts qj Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i �Y 349 GREAT MARSH RD j Property Address Owner JOHN NICHOLSON information is Owner's Name required for every CENTERVILLE MA 02632 SEPTEMBER 14 2012 page. Cityrrown State Zip Code Date of Inspection I Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 12 INCHES I Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle I i How were dimensions determined? SLUDGE JUDGE AND TAPE i Comments(on pumping recommendations, inlet and outlet tee or baffle;condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.) i INLET& OUTLET BAFFLES IN PLACE, NO SIGNS OF LEAKAGE P - i i j i I Grease Trap (locate on site plan): Depth below grader , feet I Material of construction: i ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: — Scum thickness Distance from top of scum to top of outlet tee or baffle 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 349 GREAT MARSH RD Property Address Owner JOHN NICHOLSON information is Owner's Name required for every CENTERVILLE MA 02632 page. $EPTEMBER 14,2012 Cityrrown State Zip Code Date of Inspection Distance from bottom of scum to bottom of outlet tee or baffle I Date of last pumping: Date D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle icondition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i i 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: i Capacity: gallons I 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.): i 1 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 20 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 349 GREAT MARSH RD Property Address Owner JOHN NICHOLSON information is Owner's Name required for every page. CENTERVILLE MA 02632 SEPTEMBER 14,2012 Citylrown State Zip Code Date of Inspection i . i i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NO DISTRIBUTION BOX I 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.): i i Pump Chamber(locate on site plan): f Pumps in working order: ❑ Yes ❑ No i Alarms in working order: P Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 349 GREAT MARSH RD Property Address Owner JOHN NICHOLSON information is Owner's Name required for every CENTERVILLE MA 02632 SEPTEMBER 14 2012 page. City/Town State Zip Code Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: D. System Information (cont.) Type I x❑ leaching pits number: 1 6X6 I i ❑ leaching chambers number:3 ! i ❑ leaching galleries number: I ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 20 Commonwealth of Massachusetts Title 5 Official inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 349 GREAT MARSH RD Property Address Owner JOHN NICHOLSON information is Owner's Name required for every i page. CENTERVILLE MA 02632 SEPTEMBER 14,2012 City/Town State Zip Code Date of Inspection 4 ❑ overflow cesspool number: ❑ innovative/alternative system I Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) LEACH PIT LEVEL IS 6 INCHES BELOW INVERT AND SHOWS HEAVY STAINING ABOVE THE INLET LINE WITH SOME SOLID CARRY OVER . i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration _ I Depth-top of liquid to inlet invert I I i Depth of solids layer — Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater,inflow 0 Yes ❑ No D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): SIGNS OF HYDRAULIC FAILURE WITH HIGH STAINING AND SOLID CARRY OVER. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 20 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 349 GREAT MARSH RD Property Address i Owner JOHN NICHOLSON information is Owner's Name required for every page. CENTERVILLE MA 02632 SEPTEMBER 14,2012 City/Town State Zip Code Date of Inspection 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.): i I i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 349 GREAT MARSH RD Property Address Owner JOHN NICHOLSON information is Owner's Name required for every page. CENTERVILLE MA 02632 SEPTEMBER 14,2012 Cityrrown 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 0 drawing attached separately j a i 'I i - o 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 20 i Commonwealth of Massachusetts Title 5 Official Inspection Form R' a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 349 GREAT MARSH RD Property Address Owner JOHN NICHOLSON information is Owner's Name required for every page. CENTERVILLE MA 02632 SEPTEMBER 14,2012 Cityrrown State Zip Code Date of Inspection I D. System Information (cont.) j Site Exam: ❑R Check Slope Surface water ❑X Check cellar Shallow wells Estimated depth to high ground water:. f et i Please indicate all methods used to determine the high ground water elevation: i i I ❑ Obtained from system design plans on record i If checked, date of.design plan reviewed: Date x❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑x Checked with local Board of Health-explain: prior reports listed at 30+feet ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 19 of 20 i i I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 349 GREAT MARSH RD Property Address i Owner JOHN NICHOLSON information is Owner's Name required for every page. CENTERVILLE MA 02632 SEPTEMBER 14,2012 page. City/Town State Zip Code Date of Inspection You must describe how you established the high ground water elevation: i performed an auger hole to 14 feet 5 inches with no groundwater encountered l Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist j ❑x 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 a Sketch of Sewage Disposal System either drawn on page 15 or,attached in separate file I j t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 20 of 20 i . ! I V V' 1 olzC a 6, / . t7 ' �1 _t � • . of� Town of Barnstable P# 3 Departitnent of Regulatory Services i Public Health Division J� ,� Date 206 Main Street,Hyannis MA 02601 Date Scheduled / ��h,-,),, Time Fee Pd. Soil Suitability Assessmentfor S e disposal Performed By: Witnessed By: LOCATION&GENERAL INFORMATION Location Address L1 ('1 6 r-e A ,�/� A 2s i A l Owner's Name p r l • _l 'l y �- V' � 1� t`s�' 6V iC.hOI Le e\ r v I l Address f L 12.�f�l"11 P-C Assessor's Map/Parcel: i p Z 1 -1 Engineer's Name _ L i rJ✓J)A �t� _5 NEW CONSTRUCTION REPAIR Telephone# 0 Z 1`f -�3 K Land Use ef+�c. Slopes(%) 0 - 10°% Surface Stones Distances from: Open Water Body 7 100 ft Possible Wet Area N� ft Drinking Water Well 1A ft Drainage Way I��A ft Property Line _ 4- ,r�__ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) I w • J q c><ts�1N� 2 BDVA"A v.� t" M Parent material(geologic) y I ALtc�� oj�kdm h -7 d-00 i Depth t0 Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face �A . Estimated Seasonal High Groundwater N`1 IA DETERNIINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In. Depth to loll mottles: In. Depth to weeping from side of obs,hole: in, Groundwater Adjustment Index Well# Reading Date: Index Well level Adj,factor.,.,,..,,, Adj.Groundwater Level, Observation PERCOLATION' TEST Date ,. Thne Hole# Time at 9" _ Depth of Pere Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./Inch ` Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***I£percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:IS EPTICIPERCFORM.DOC a� DEEP-OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture .Sdil Color Soil- Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,,Boulders. o i ten y,96'Ciravell 16 q-al -SL 16 413 LS to s1� erc q� ILIA Ct CScAelci DEEP OBSERVATION HOLE LOG Hole# �— Depth from Soil,Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. on is en %Gravel) to 3)A �-Zy (SL 10 ')-y' - qq, �. LS to-u Cl°I-11 C,. C Stied I b "k DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Oravell DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Sol] Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, • Cositn . y Flood Insurance Rate Man: Above 500 year flood boundary No—/ Yes Within 500 year boundary No '; Yes Within 100 year flood boundary No.." Yes Depth of Naturally Occurring Pervious Material` Does at least four feet of naturally occurring perviou ma'terial exist in all areas observed throughout the area proposed for the soil absorption system? e-8 If not,what is the depth of naturally occurring pervious material? Certification I certify that on &V Ao 2 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required train ,expertise and experience described in�10 CMR 15.017. Signature Datb Q:15.EPTICVERCF0RM.D0C � L �I r -f • " _ -== COIN-IM011\WE ALTH OF MASSACHli SETTS I j EkECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS -- FFDEPARTMENT OF ENVIRONMENTAL PROTECTION ONE R`I\TER STREET, BOSTON "&k 02108 (617) 292.5500 8 ° TRUD COTE <`�p "•���►`^ Sec etan• ARGEO PAUL CELLUCCI <7 HAD B. 5 UHS Governor 19 Conum±s inner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR 0°0 .I999 r- PART ALtT_ ` CERTIFICATION Property Address: 3L 7 �,—�(>�,� �vL V�GI. Name of Owner V\wn, 0.Ze,AV Address of Owner: 5 Ri vy� Date of Inspection: k\-L,o Name of Inspector:(Please Pnm �+)/ f •(ir 2 c> Jl F EL�O I am a DEP approved system inspector pursuant to Section 15.(340 of Title 5(310 CMR 15.000) Company Name: Ads_ ._ _F_k L^"r r,Id F - Mailing Address:-?d2 ?,V -. h:4 e E- I'f At Telephone Number: !�t 31 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: A. Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: ulf-Itz, Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 iWill, Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: e 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 the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER f 1 r' f, 1 I G revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: e D. SYSTEM FAILS: J You must indicate either "Yes" or "No" to each of the following: ! I have determined that one or more of the following failure conditions exist as described in210 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine hat will be necessary to correct the failure. Yes No 'i Backup of sewage into facility-or system component due to an overloaded or.clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due;to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I.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 1`00 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well,has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds', ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet/of a surface drinking water supply r the system is within 200 fekt 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) l The owner or operator of any such i syste, shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further infolmation. i� revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3y5 C��ec�1 N�P�'ll S h, Owner: 'CL.,7—t �k> Date of Inspection: e Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X _ As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. >( _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] r - _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintenaar.6-of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , tom," SYSTEM INFORMATION 'roper[y Address: tomA \ �I (KZ:% Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:--110 g.p.d./bedroom. Number of bedrooms (design)iC.yL Number of bedrooms (actual):QZ Total DESIGN flow Number of current residents: Garbage grinder(yes or no):__J Laundry(separate system) (yes or no): 0; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no): N Water meter readings, if available (last two year's usage (gpd): N Sump Pump (yes or no):�J Last date of occupancy: �� COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: W r •—j System pumped as part of inspection: (yes'or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM _ Septic tank soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: �.'-j C Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6ofII . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirwed) *roperty Address:3�� L1 � vW +►LS�!`. Owner:Clz,, Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:—" Material of construction:_cast iron 440 PVC_other (explain) Distance from private water supply well or suction line lo - Diameter it Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_,A (locate on site plan) L �1 Depth below grade:�Z Material of construction: {concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: \ _ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: k i Distance from bottom of scum to bottom of outlet tee or baffle:•' How dimensions were determined: ;omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, s urp ural int, rity, ev' ence leakage, etc.) \ �N N 1 GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal _Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirwed) 'roperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to'or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal _Fiberglass_Polyethylene—other(explain) Dimensions: Capacity: gallons f Design flow: gallons/day Alarm present /J Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) i � I DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: - (note if level and distribution is equal, evidence of solids carryov r, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,-condition of umps and appurtenances, etc.) revised 9 /98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION (continued) `roperty Address: Owner: GrZcavl Date of Inspection: %Vzok la f j SOIL ABSORPTION SYSTEM(S S): (locate on site plan, if possible; excavitidA not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: +. twA leaching chambers, num er:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of pond Lj in damp s il, condi " n vegetation, tc.) �_ 13 A G CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:' (locate/on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 ♦ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q aa SYSTEM INFORMATION (continued) 'roperty Address: r LOA- lia� Jwrwr: �-\ZtAu tT Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: / include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) k 3" _ CL2.GLi/L L l ti c lt'K'i C,- ( revised 9/2/98 Page 10of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION (continued) roperty Address: Owner: Cq�76-e�,Av \ Date of Inspection: i i�t4� NRCS Report name__) A I Soil Type_ Typical depth to groundwater USGS Date website visited ou(1' Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope N Surface water t-.> Check Cellar Shallow wells (J Estimated Depth to Groundwater� t Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) CO to 3 �y revised 9/2/98 Page 11of11 371 No......................... Fsa.....`�.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _..._.......OF..................................... ..........- -- ...-....................----- Appliration -for M_qp al Works Towi#rurtion Vrrnift Application is hereby made for a Permit to Construct ( ) or Repair ( )' an Individual Sewage Disposal System at: ... .................-.....-............................................ ...................•• ---------- / Location-A4dress or Lot N W .... wner Address Installer Address QType of Building Size Lot........................... Sq. feet Dwelling—No. of Bedrooms-------------------2.r.........---------Expansion Attic ( ) Garbage Grinder ( ) f pa, Other—Type of Building _..---_------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------------------------- WDesign Flow..................... --------------gallons per person per day. Total daily flow...........2_a_6..................... 9 Septic Tank—Liquid capacity/07.ZLgallons Length---------------- Width---------------- Diameter---............. Depth.._.._----_.- xDisposal Trench—No-_--___-- Width.. ............... Total Length--_------_----_--- Total leaching area--------------:-----sq. ft. Seepage Pit No/.. ...... iamete Depth belo inlet.................... Total leaching area.......________.sq. ft. z Other Distribution box ( ) Dosing tank ( ) ® 00C401 C/o — .2 g a 2 ,` Percolation Test Results Performed by-------------------------------------------------------------------------- Date--=-•---------------------------------- ,� Test Pit No. L-__-_-___._--minutes per inch Depth of Test Pit____________________ Depth to ground water..........--..-.--.----. rX, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ 9 p a ---- -- -----�--•--- ----------- -- ------ C -=,.c�.� Descrt ttonPf Soil _. . �. '� -------- - - x ---Vs---------m---7-------Ai'�---�- `----------�--'--•t_a4` _ .Id-..---------••---•-•-•---------------- W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- ......... U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------- ------------------------•-----------•-•--.------•-----------.-.---------.--.-.-----..------- ------------------------- -------_--------------------------------------------•-------.----- Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee 'ss d*the oard of health. igne ...If...`-�` 7.� Date Application Approved By----- --- = •. • .. .••� _` t�l ' ate-- --- Application Disapproved for the following reasons---------------- -----•-•--- ..... ---••-•------------•-.......----•----••------------•--••-...----••..... ------------------------•--••---••-----------------------------••--.......---•-----•••••-••••...•••--••------.......----••----------.......................---------------_------..--•------------•.---- Date 1. PermitNo.......................................................... Issued. ? .................. Date _---------.--- ----__.____- �_ -------------------------------� (B-) - No......... •------- FE$.....<......................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... ... ..... .........OF.. ..............I............. ... ........................ Appliration -for Di.gVoott1 Works Cnonw#rnrtion Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: , / / Location•A dress l�^'oo or Lot )V U 2ULtc/ W Address f.( ,f� ......................•----•--•---•---..... Installer Address UType of Building Size Lot-_-------------------------Sq. feet .R Dwelling—No. of Bedrooms._----------------Z-------------------.-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.---.-..--.-------.-.-.----- Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------------- W Design Flow--------------------- ..----........gallons per person per day. Total daily flow---------?. -6----------------------gallons. P4 Septic Tank—Liquid capacity/Q-1b.gallons Length................ Width................ Diameter-----_-_.--.- Depth._...-.-----_-- xDisposal Trench—No.------- _- x Width--`_�:= -.-_--. Total Length.................... Total leaching area--------------------sq. ft. 3 Seepage Pit No'--07-M------- Diamete _----------------- Depth belo}�' inlet------------------:. Total leaching area..-...._.--_.----sq. ft. Z Other Distribution box ( ) Dosing tank ( ) .2 OC�_ C/,O, — ,� ?- 7 j— �' Percolation Test Results Performed bY.......................................................................... Date----------------.-..----------------.... Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.---.-------..---------- f� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water--.---------------...._. ------ � /.............�`--•------ x Description.of S .... �!/_i._ .� - ._ U ----------1'/----------- --------- r ---------/-X--------� W --------- --------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable.----------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee Jlss>je dy the board of health. �Signi ...0_1` . . t... �r" ------------------- -------------------------------- Date / } Date Application Approved B Date .G�: 7_`. ......-.- �. Application Disapproved for the following reasons:.......................................... -----------•-------•---------••••-••--....-•--- -----•-------- - ---- --------------- Date Permit No......................................................... Issued•.. `.-. - -7Q. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O-E HEALTH s�7...........OF........ '? '' '"s......................................... Qwrttfirat a of T"amplianre THI • IS'TO CE IF Vat the Individual Sewage Disposal System constructed ( �or Repaired ( ) ---------- ------------------ le------------------...------------------------------------------•------ a at. _......... . _ ... .. ..... - ........... has been installed in acc rdance with the provisions of . rticle XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit N .t---- a.l.................. dated.... -..1�'- .7. ................ THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTR AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � � . DATE............ -•-------------------------------------------------------------- Inspector------- --------------------------- � THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH 7s � OF... -------- ---------------------------•---•--- No. t % ..... . . ---------------•- FEE/0 -------•------- Dispoli brkii jng tion rrrntit Permission is ereby granted------. to Constr`ct` ( ) or Repair ( )Zavivid S�eyv e Disposal System yli' at No y .. = d /G1���- ------i-�t�s�-----------/'�1't ...................................... y Street • as shown on the application for Disposal Works Construction -Permit N :.;.:- Dated--�.'_f........................... f --..._ Board of Health DATE............................................ ................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS I GRE f IWA L� 2 ! CE>`Tir=Y T1-iAT T4c FQut�l f) .-C'tc*K s H O W 4 4)14 THIS f'l A,4 ty L0. 07I A7 r ID ON THE GRou�-lt3 AS SHOWN HERE04 � AND COMPLY5 WITH 7HE ZONING 1-,0\W S OF Ty E- '1 OWN, 0 f- {6 A R M S t",NZL E . Ul fzEGtsTE� I> 1- "�taJ Slt�'.w'e 1G2 A' T. 17 ' , f 5 o± OV C4' � mg i I , a` ' L O P�___ R� t J t O r. =• r`1 zt SGA L IN 40 rT BAXT c k N Y E- l Ki c . 1 KEG1S4'E_RED LAN 5t,RVEYGRS� TOP OF FOUNDATION 24"diameter concrete covers CENTERV I LLE, EL=50.2 raised to within E'offinrsh tads MA x� (or as noted) g /nspectron Port and cap with magn Wequaquetetic t\ Lake marking tape to within 3'of grade Open Great Mar \ sh Road 40'Pubtfc Way __- - Existing EL=46.2+ EL=48.5� EL=4&.3(maxJ LOCUS Y ..: ���� ��\j j/�� c4 Bath S 84°40'10°E o° Bedroom 20.G5' Great Marsh Road Bedroom 47.3 W -0 Errstrng 46.5-* Second Floor 0 m 45.3+ 3 - w Existing 46./+ Living ExiStm `' O 45.Bi 45.17 - 45.00 44.90 F 0 9� �B g ,r - � Eristrny N cV - 0 � Gas Baffle 44.00 Kit N 87°324 1"E a q Dmmg G5.00V 9 Longest RunJ TWENTY(20)A,95 ARC36HC 6 0,¢ Bath N 80°4E'2 g3` CZoute 28 -4 } - 59' 9' (36/6B©2)LEACH CfIAMBER5 IN BE© Existing DB !7 COIVF/GURAROM WTII FOUR(4)ROWS �m EXISTING /000 GALLON (H-20 Rated) OF FIVE(5)CHAMBERS First Floor �� ` Existing `� Dwelling SITE LOCUS fPT /-� /K �/ / n /�j/ /�/� p 'R p FLOOD PLAN "' `-/ ` �(� TANK V' ` D-15o/� LEf�f..i/ I (..il !A/F/ 25f EL=3&.D�Bottom of Test Ho% to- ``` NOT TO SCALE NOT TO SCALE FLO V V I RO FI LE �o I .) Assessor's Map 190 Parcel 2 17 ��^^��°'� p` '�^ 0- Shed Q 2.) Deed Book 201 G5 Page 202 l�lJ N TI\V l�T�O N NOTES NOT TO SCALE z � 3.) Plan Book 2G8 Page 20 \ 69 4.) Th15 property is in a Zone 11 of a Public 1.)ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE,TITLE 5 (3 10 CMR 15.000): ��2�`� Water Supply STANDARD REQUIREMENTS FOR THE SITING, CONSTRUCTION, INSPECTION, UPGRADE,AND TWENTY(20)ADS ARC3GHC(3G I GBD2)LEACH 60 5.) Flood Zone: C EXPAN51ON OF ON-51TE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOR THE TRANSPORT CHAMBERS IN BED CONFIGURATION IN FOUR(4) AND DISPOSAL OF 5EPTAGE, AND THE LOCAL BOARD OF HEALTH REGULATIONS. ROWS OF FIVE(5) UNITS EACH LEGEND 2.) ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE 15 POTENTIAL FOR 25' KEY MAP 1 Af VEHICLES OR HEAVY EQUIPMENT TO PA55 OVER IT SHALL BE DESIGNED TO WITHSTAND AN H-20 5.0' 5.0' 5.0' + 5.0' + 5.0` 2.= EXISTING SPOT GRADE LOADING. IF UNDER AN IMPERVIOUS SURFACE, SYSTEM SHALL BE VENTED TO THE ATMOSPHERE. ma SCALE: I" = 100, 24x5 PROPOSED SPOT GRADE 3.)TO MINIMIZE UNEVEN SETTLING, SEPTIC TANKS SHALL BE INSTALLED ON A STABLE - ---- �i EXISTING CONTOUR MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE. �a r T 24- PROPOSED CONTOUR 4 J COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK,THE DISTRIBUTION BOX,AND N W WATER SERVICE LINE THE SO{L ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN G"OF FINAL GRADE. LEACHING D--BOX 0 OVERHEAD UTILITY LINES FIELDS,TRENCHES, AND OTHER SOIL ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL a "' INSTALLER TO VERIFY THE LOCATION OF ALL U UNDERGROUND UTILITY LINES HAVE AT VERTICALLY TO E BOTTOM OFi�E SORIL ABSORPTION OF PERFORATED 4"PVC PIPE PLACEDw "� � � a� ON SYSTEM WITH A CAP,TIED WITH MAGNETIC a _• m _ � �, UNDERGROUND AND OVERHEAD UTILITIES -G- TOM SERVICE LINE MARKING TAPE,ACCE55115LE TO WITHIN 3"of FINAL GRADE. PRIOR TO THE START OF ANY EXCAVATION �ti EDGE OF CLEARING ACTIVITIES AND RELOCATE AS NECESSARY P FENCE /nspect�on Port(See Nate#4) Tp 5.)PIPING SHALL CONSIST OF 4"SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A (SEE NOTE #1 5) (a TEST HOLE LOCATION MINIMUM CONTINUOUS GRADE OF NOT LE55 THAN 2%FROM THE BUILDING TO THE SEPTIC TANK, ST SEPTIC TANK PLAN VIEW (TYP.) AND NOT LESS THAN I%OTtiERW,SE: �" -' DB DCST�i13.�JTCON BOX _.; ° v- G.) DISTRIBUTION LINES FOR THE SOIL ABSORPTION SYSTEM 5HALI BE 4"DIAMETER SCHEDULE 40 SCALE: I" = 10' SAS 501L ABSORPTION SYSTEM PVC(OR EQUIVALENT)LAID AT 0.005 FT/FT. UNLESS OTHERWISE NOTED. LINES SHALL BE CAPPED 48 LOT 3 AT END'OR AS NOTED. w ,. _ Area=22,800 S.F.-� t 7.) LINES FROM THE D15TPIDUTION.BOX TO BE LEVEL FOR THE FIRST TWO(2) FEET BEFORE H 49.8 t CERTIFY THAT t AM CURRENTLY APPROVED BY THE PITCHING TO THE SOIL ADSORPTION SYSTEM. DISTRIBUTION BOX SHALL BE WATER TESTED Q. DEPARTMENT OF ENVIRONM.:' 'AL PROTECTION PURSUANT TO ASSURE EVEN DISTRIBUTION. \ f R� 1 /� 4G -��0 aj 310 CMR 15,017 TO CONDUCT SOIL EVALUATIONS AND THAT V/�T�M D�S{G 1 V �ALC V Lf1� O N�.- \ cp a y THE 501L ANALYSIS HAS BEEN PERFORMED BY ME CON515TENT 8.)GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES \ a \0 rr WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE IN ORDER TO PROVIDE A WATERTIGHT SEAL 49.0 DESCRIBED IN 3 10 CMR 15.017. 1 FURTHER CERTIFY THAT THE SEWAGE DESIGN FLOW REQUIRED.-2 BEDROOM DWELLING ` 1 RESULTS OF MY SOIL EVALUATION AS INDICATED ON THE 9.) HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE //O GPD/BEDROOM=220 GPD(330 GPD MIN DE51GAo REQUIRED) 9 49.0 1 ., "O ATTACHED `SOIL EVALUATION FORM, ARE ACCURATE AND IN DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. SEWAGEDES/GNFLOWPROV1,9t9- TWENTY(20)ADS UNITS fNBED 6 \. 0 ACCORDANCE WITH 3 10 CMR 15.100 THROUGH 1 5.107 CONFIGURAT/ON IN FOUR(4)ROWS OFFIV,-(5)UNITS EACfL 4�. / 10.) IN ACCORDANCE WITH 3 10 CMR 15.22 1,ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING TAPE. 2` t/t-C(330/0.74)/(4.8 FT/FT)/S.O LF]_ /9 AD5 UNITS ` ?- � .P't REQU/RED(20 PROU/DED) W f O ,° () 1 1.)THERE ARE NO KNOWN WELLS WITHIN 100'OF THE PROPOSED 501L ABSORPTION SYSTEM. / a., . �� © e��`�dat`o� �6 355 GPD PROflIDED>330 GPD REOU/RED _ v 4G 1 ce ' a o�Fob 2- i 5H m Linda J. Pinto, Certified Soil Evaluator 12.)FROM THE DATE OF THE INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL RECEIPT OF °" \°P��5 CO VqN pF THE CERTIFICATE OF COMPLIANCE,THE PERIMETER SHALL BE STAKED AND FLAGGED TO PREVENT SEPTIC TANK CAPACITYREQUfRED: 330 GPDX2DO% =660 GPD REQU/RFD ° c4 MAS USE OF THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. O _ 4ao BENCHMARK S4C .SEPTIC TANK CAPACITYPROVIDED: EXIST/NG /OOO GALLON SEPTIC TANK z ,. Tqp Corner Concrete �0 LINDA y�N 13.) THE DESIGNER WILL NOT BE RE5PON51BLE FOR THE SYSTEM AS DESIGNED UNLE55 t��t 48.2 EL=50.00(Assumed Datum) PINTO � CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE A GAKBAGED/SPO5AL/S NOT PERM/TTED WITI-1 TfifS DESIGN FLOW Enclosed C DESIGNER. a Porch - 45.2 S 14.)THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF THE 4 F�GLSTF- BOARD OF HEALTH AND THE DESIGNER. THE DESIGNER SHALL CERTIFY IN WRITING THAT THE " S /� ENG SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS OF THE PERMIT '� -1 49 Existing Septic Tank to be S NAL �{ l F C, 11 AND THE APPROVED PLANS. 48 HOURS ADVANCE NOTICE 15 REQUESTED. TEST HOLE O LE LOG✓ � , 48.5 Mote02I) Survey Work by., Utilized(see 15.) LOCATION OF UTILITIES IS APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FOR " Test Hole#I (EL=48.5-*) � rn-s � `Y ` � ,,A� A & M' Land Services DETERMINING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO /f �Q. _ f 618 Route 28, Suite 3 COMMENCEMENT OF ANY WORK.THIS INCLUDES, BUT 15 NOT LIMITED TO, REQUESTS TO DIG5AFE, ANY PRIVATE UTILITY COMPANIES,AND THE LOCAL WATER DEPARTMENT. Depth Layer Soil Class Soil Color Comments � WESt Yarmouth, H4 02673 Existing Leach Prt to be Pb. (508) 737-1777 Email.• anmlend®eomcast net 0"-9" A Medium Sandy Loam I OYR 3/2 1 i fj Abandoned(see Note#22) I G.)CONTRACTOR SHALL VERIFY THAT ALL WA5TELINES ARE CONNECTED BY WATER TESTING ' /f 9'-2 I" B Fine Sandy Loam 10YR 4/3 WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. Shed 21"-9G" C I Fine Loamy Sand I OYR 5/G Friable Prepared for: 9G"-1 2G' C2 Coarse Sand I OYR GIG Perc @ 58" 17.)CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANY SEPTIC SYSTEM COMPONENTS. Mashpee Wampanoag Tribal Housing Department I Q 48A 7GG Falmouth Rd., Mashpee, MA 02G49 t 18.) INSTRUMENT SURVEY CONDUCTED FOR PROPOSED WORK ONLY. 51TE PLAN SHALL NOT BE Test Hole#2 (EL=48.5±) USED FOR STAKING, OR ANY OTHER PURPOSES. 24.0' I o'mrn Prop©sed Sewage Disposal System 19.)THIS PLAN DOES NOT CERTIFY, GUARANTEE OR WARRANTY COMPLIANCE WITH DEEDED OR Depth Layer Soil Class Soil Color Comments 349 Great Marsh Rd- Centerville, MA ZONING BYLAWS, SPECIFICALLY, BUT NOT LIMITED TO,SIDELINE SETBACKS AND BUILDING HEIGHT 0"8" A Medium Sandy Loam I OYR 3/2 J RESTRICTIONS. OWNER IS RESPONSIBLE FOR OBTAINING SUCH A DETERMINATION FROM THE 8"-24" B fine Sandy Loam I OYR 4/3 APPROPRIATE AUTHORITY. Prepared by: 24"-99" C I Fine Loamy Sand 10YR SIG Friable � � 2'I 99"-1 20' C2 Coarse Sand I OYR GIG 20.) IF SOILS DIFFER FROM THOSE SHOWN IN THE SOILS LOGS, DESIGN ENGINEER 15 TO INSPECT 48 5 THE SOILS PRIOR TO PROCEEDING WITH INSTALLATION. CSN 1,,,� 2 1.) EXISTING 1000 GALLON SEPTIC TANK TO BE UTILIZED. PVC TEES TO BE INSTALLED ON INLET DATE OF TESTING: 12110112 P#13809 �r� . AND OUTLET PIPES IF NECESSARY,AND A GAS BAFFLE INSTALLED IN THE OUTLET TEE. 501L EVALUATOR: LINDA J. PINTO, P.E., C5N ENGINEERING SATE PLAN ,��(' Engineering BOARD OF HEALTH AGENT: DON DESMARAIS, BARN5TABLE HEALTH DEPARTMENT 22.) EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN SAND AND PERCOLATION RATE: LE55 THAN 5 MIN/INCH IN"C"LAYER ABANDONED IN PLACE. AREA TO BE COMPACTED TO MINIMIZE SETTLING. Q �Q 4© 6O P.O.Box2030 Phone:(508)299-3250 NO GROUNDWATER ENCOUNTERED SCALE: I" = 20' Teaticket,MA 02536 Fax:(508)548-5478 23.) INSPECTION NOTE: PRIOR TO FINAL INSPECTION BY THE ENGINEER, SYSTEM NEEDS TO BE SCALE 1"=20' COMPLETE INCLUDING BUILDUP FOR COVERS. C:\C5N\Great Marsh\Great Mar5h-5D5 Pian.dwg Date: 12/05/12 Scale:As Shown By:LJP Check:{VITA Project No.C5NO292 4