Loading...
HomeMy WebLinkAbout0079 HALYARD WAY - Health g Halyard Way Center✓ille A= 194 -68 -.r i i 'AN v � 0 2C12534 i i Commonwealth of Massachusetts 1941 d�8 Title 5 Official Inspection Form Subsurface Sewage bisposal System Form-Not for Voluntary Assessments 79 Halyard-Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is Centervill MA 02668 06/26/2018 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form: Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, , use only the tab 1. Inspector: key to move your cursor-do not REID C. ELLIS use the return Name of Inspector key. .ELLIS BROTHERS CONSTRUCTION try Company Name 23 ENTERPRISE ROAD Company Address ream YARMOUTH PORT MA 02675 Cityrrown State Zip Code 508-362-6237 S121891 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the. information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage di osal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3 0 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Jr Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report tci1he appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6f16 Title 5 Official Inspection Fomr.Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owners Name information is required for every Centervill MA 02668 06/26/2018 page. Cityrrown State Zip Code . Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not fou any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, up n completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not dete fined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 yeai r,old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration o exfiltrabon or tank failure is imminent. System will pass inspection if the existing tank is replaced Nith a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection f it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is le than 20 years old is available. ❑ Y ❑ N ❑ ND(Exp in below): t5ins.doc-rev.W16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is required for every Centervill MA 02668 06/26/2018 page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) enystem ❑ Pump Chamber pumps/alarms not opera will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont): ❑ Observation of sewage backup or break ou 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 o Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or repla d ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approv of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Boar of Health: ❑ Conditions exist which require further evaluati n by the Board of Health in order to determine if the system is failing to protect public health, s fety or the environment. 1. System.will pass unless Board of Heap determines in accordance with 310 CMR 15.303(1)(b)that.the.system is not function ng 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 tle 5 official inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 t5ins.doc-rev.6/16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is Centervill MA 02668 06/26/2018 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board Health(and Public Water Supplier, if any) determines that the system is functio ing in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and so I absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tribi tary 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 SA S and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS a id 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 analy is, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the pr(sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other ailure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El or liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Ell Liquid depth in cesspool is less than 6°below invert or available volume is less than 'h day flow t5ins.doc.rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owners Name information is Centervill MA 02668 06/26/2018 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or ❑ obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the oard of Health to determine what will be necessary to correct the fail r E) Large Systems: To be considered a large syst m the system must serve a facility with a (� design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"o "no"to each of.the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Z ne II of a public water supply well If you have answered "yes"to any question in Sect n E the system is considered a significant threat, or answered"yes" in Section D above the large sy em has failed. The owner or operator of any large system considered a significant threat under Secti E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The stem owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts lugTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner owner's Name information is required for every Centervill MA 02668 06/26/2018 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No i ❑ Pumping information was provided by the owner,occupant, or Board of_Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components4wclu ding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins.doc•rev.6116 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 6 of 17 . h i Commonwealth of Massachusetts = Title 5 Official Inspection Form i. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is required for every Centervill MA 02668 06/26/2018 page. City/Town state Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes VNo information in this report.) Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: �� � •'��.-lam r Sump pump? ❑ Yes Tr No Last date of occupancy: �' 6,,pa cy. Date Commercial/industrial Flow Conditions: -1 Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.fL, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 sys tem? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Tille 5 Official Inspection form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owners Name information is required for every Centervill MA 02668 06/26/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information. ��� Was&yystem pumped as part of the inspection? ❑ Yes No If yes, volume pumped: �-�" T gallons How was uanti pu d termined? Reason for pumping: '�� Type of System: , L�'of Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is required for every Centervill MA 02668 06/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors diected when/Cerriving at the site? ❑ Yes 15/No Building Sewer(locate on site plan): Depth below grade: feet Material of constructiV ❑cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: «�/ feet Comments(on condition of joints, venting, evidence of leakage, etc.): A& IgAk4 t1,49 A 02A) /J 6z�" Septic Tank(locate on site plan): Depth below grade: i��t �!�G .>feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene y El other(explain) �e" /�k-k �'7A If tank is me I, I age: ,r/� Zcer%tificate) ,+� Is age conf by a Certifi e f Complian (a ach a copy "esCr i✓5:c� Dimensions: S Sludge depth: t5ins.doc-rev.6/16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is required for every Centervill MA 02668 06/26/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) G/ 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 b b Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �y Q.S l�i�' �lj�l /'�iJ 01 `/✓j .i Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fi erglass ❑ polyethylene y El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee o baffle I Distance from bottom of scum to bottom of outlet t tee or baffle Date of last pumping: _ Date t5ins.doc•rev.6116 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is required for every Centervill MA 02668 06/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Z Comments(on pumping recommendations, ir4 and eutlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence f leakage, etc.): /v Tight or Holding Tank(tank must be pumpe at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑f berglass ❑ polyethylene ❑ other(explain): a Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switch 3s, etc.): "Attach copy of current pumping contract(req ired). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner owners Name information is required for every Centervill MA 02668 06/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on a plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of Ids carryover, any evidence of leakage into or out of box, etc.): J Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamb , condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is required for every Centervill MA 02668 06/26/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Gv� � � � Type: ❑ leaching pits number: leaching chambers number: CR ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r - � 7h;_ .gyp!/ t r_ Cesspools(cesspool must be pumped a art of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is I Centervill required for every MA 02668 06/26/2018 page. City/Town state Zip Code Date of Inspection D. System Information (cost.) Comments(note condition of soil, signs of hydrauli 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 hydra ilic failure, level of ponding, condition of vegetation, etc.): I t5ins.doc•rev.6/16 Trlle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owners Name information is required for every Centervill MA 02668 06/26/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate LA/ 7hand-sketch public water supply enters the building. Check one of the boxes below: in the area below ❑ drawing attached separately 23-1 30 y f 15ins.doc-rev.6116 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 15 of 17 0 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is Centervill AAA 02668 06/26/2018 required for every page. ;5ty/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope 1 �A t�� vzl ❑ Surface water ❑ Check cellar ❑ Shallow wells /111� // r Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain:. A*1'4 Val You must describe how you established the high ground water elevation: ��4 op 5 Before filing this Inspection Report, please see Report Completeness Checklist on next page. Tine 5 OfrmW hsPection Fomc Subswj6oe Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Halyard:Way, Centerville, MA Property Address Peter E Stovich Owner Owner's Name information is Centervill MA 02668 06/26/2018 required for every page. Cityrrown State Zip Code Date of Inspedion E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked [Inspection Summary D (System Failure Criteria Applicable to All Systems)completed WSystem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r� t5ins.doc•rev.6116 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 17 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services3 Company Namea 29 Atwater Dr Company Address ICA E. Falmouth MA 02536 Citylrown State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I'am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CM 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority All 10-18-11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the. report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I I ' I j I � t5ins•11/10 Title 5 Official Inspe-'on Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water . supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any'portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name - information is Centerville MA 02632 10-18-11 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [f yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 9-2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i i Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 16" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 Title 5 Official Ins ectian Form:Subsurface Sewage Disposal p g System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms In working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers `` number: 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good condition with and empty at inspection with stain line at 8"from bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions.of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i O G A0 yor •J� J�`/ , V, Q, , t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Halyard Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 10-18-11 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r e No.cD OJS C_6 a Fe 1 0 0 /es TdiE COMMONWEALTH OF MASSACMSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Zigpoga16pgtem Con6truction�Vertnit , Application for a Permit to Construct( . )Repair( X)Upgrade( )Abandon( ) El Complete System- O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 7� ayard Way, Centerville Madeline Shrank 194/68 Assessor's ap yarc I 79 Halyard Way, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco—Tech PO Box 1089, Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(10) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new heavy duty leach system to plans of Eco—Tech, ETE-2066. Date last inspected: - Agreement: The undersigned agrees to ensure the construction and mai a ance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Env' onmen 1 ode and not to place the system in operation until a Certifi- cate of Compliance has been issue by thisleard ealth. S' ned Date a Application Approved Date x Application Disapproved for the following reasons Permit No. c�GZ7 'S t�— �� Date Issued —� Ile 1-4 NcC9 60, t �0� - Fee100a00 d THE,EGMMONWEALTH'OF MASSACHUSETTS Entered in computer: 'PUBLIC HEALTH DIVISION TOWN OF BARNSTAB°LES MASSACHUSETTS w Zipplication for Migpogal *pgtem CCongtructton Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 7Q ualyard ']a. Centerv�ll� Madeline Shrank . Assessor's Map/Parcel 7 a 1Installer's N. Address,and Tel:No: i 06igne,'s Name;Ad.dress and Tel:No Wm E Robinson •sr Septic' Eco=lech PO Box 1089, Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage GrinderT�o ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations Answer when applicable) Install a. new heavy duty leach P ( P ) system to plans of Eco-*Tech, ETE-20 6. ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and mainte• ance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the En�P'ronmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this -gard lealth. S' ned Date Application Approved Date Application Disapproved for the following reasons 3 iPermit No. e� S c�--� Date Issued ZZ------------ THE COMMONWEALTH OF MASSACHUSETTS r Shrank BARNSTABLE,,MASSACHUSETTS ,r Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( ) Abandoned( )by Wm E Robinson Sr Septic Service at 79 Halyard Way, Centerville has been constructed/A•n acc rdance with the provisions o tle 5 and the for Disposal System Construction Permit No. $dated 6/1-'11-5 Installer Desi ner _ CcC'x The issuance of this pe t hall not be construed as a guaran e`' that the sys e 1 u, ction as designed. Date (n �-�'� t 1 Inspector- - -�----- _ >. - .. No. Fe$100.00 Shrank THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 0i5pogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) i System located at 79 Halyard Way, Centerville I and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty,to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust be completed within three years of the date of this e t Date:_- - Li Approved b ��- Town of Barnstable °F1HE Regulatory Services Thomas F. Geiler, Director • BARNSTABLE, MASS. Public Health Division 1b39 �0 AlE0N1Pi� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: ����� b Designer: Eco-Tech Installer• Wm E Robinson Sr Septic Address: 43 Triangle Circle Address: PO Box 1089 Sandwich Centerville On Wm E Robinson Sr Sept4as issued a permit to install a (date) (installer) septic system at 79 Halyard Way, Centerville based on a design drawn by (address) Eco-Tech dated 06-10-05 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. 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. 11A OF DADVID (Ins a er's Signature) CIUGHANOWR w o. 1093 � o NI TA TAR IAN !tn (Desi er's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. i i Q:Health/Septic/Designer Certification Form r 9/16/03 Notice: This Form Is To Be Used For the.Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, ��V1 d C•Lghgw ow ,hereby certify that the engineered plan signed by me dated G ' O S , concerning the property located at 9 {• q yg Fd W 4LI meets all of the. following criteria: • This failed system is connected to a residential dwelling only. There are.no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed - • There are no variances requested or needed. .. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 7 B) G.W. Elevation +adjustment for high G.W. = 3 U DIFFERENCE BETWEEN A and B SIGNED . 0 �� DATE: ,1 e NOTICE 4 Based upon the above information,a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc TOWN OF.EARNSTABL.E LOCATION 7 r �7� / c2 re SEWAGE VII:LACsE �.Ile ASSESSOR'S M I.®T IN TA,L,PR'S NAME&PHONE NO. i t SEPTIC TANK CAPACITY �l OCR !1 I.EAczvGACILIT7r: tt ) a G�s ,'(size) ?�NO.OF'EE®ROOMS-3 13UILDER OR OWNER. .�. PERMIT®ATE: C( WU1LIANCE DATE: Separation Distance Between the: I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist i on site or Wltldn 200 feet of leaching facility) Peal Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of aebing,facility) � � ..-.- ._,_----,:sec � Furnished by D 430 �r o F FI-� IyG`• �.c, 3`f`6eo A 0- av- -D- you F< _ TOWN OF BARNSTABLE LOCATION. �� , t✓eit _ SEWAGE # VILLAGE Cee1�e,...11e ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEP17C TANK CAPACITl' —.Fc>oo G- — LEACHING FACIL=: (type) &-Sbo tLrAd&Ift Nbo (size) C9q)(i✓9.-X o? NO.OF BEDROOMS BUILDER OR OWNER S�Me. IC PERMIT DATE: `r(0,5- COMPLIANCE DATE:k f o Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ® / Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist .within 300 feet of leaching facility) Feet �o b t Furnished by Q S F � A a I �r REFERENCE 98 CONTOURS SERVICE ROAD . — PLAN E . .PLAN BOOK 379 PAGE 70 100 EXISTING - - - - - - N SACS ROAD ��- l02 .' - •70 z ASSESSOR'S MAP: 194 104 MINIMAL GRADING PROPOSED 3 Locus LOT. 68 N3 iN . _ _-CIO ' / HAL YARD CENTERVILLE. -MA P� .22 � \ �i 0�e Z�A \ � LOCUS MAP WA Y I NOT TO SCALE G� �0 24 f t x 12.5 ft x 2 f t LEACHING GALLERY P� - USE.H-20 UA9TS / �Z A I� QlL iCS BENCH. MARK �pE�T Io-o �\4 TOP OF GAS GATE b ELEVATION - 104.13 o /0 T �— O� �;�S\ BARNSTABLE GIS DATUM d�}ZaZ G) O� \ �� . '� o� 240 r NOFMgss9ti GAS LINE .. DAVID COUGH D. GAS \ DRIVEWAY L OT I �3 GA TE PAVED No. 1093 A EA = 5 2 sOIST +- � NIT FLOW PROFILE — - _ — 106 104 102 100 98 96 106 287.95 rl 108 I08 RAISE COVERS TO WITHIN Ir PIPE PLAN TOP OF FOUNDATION 6 in OF FINAL GRADE j LEGEND EL - 108.67 {- ONE INSPECTION RISER FOR $t SCALE. ' In - 20 1 t LEACHING GALLERY EXISTING ' 1000 GALLON D -BOX 2' LAYER OF 1/8- SEPTIC TANK H-20 1/2' STONE 3' DROP SEWAGE DISPOSAL SYSTEM PLAN 20 FLOW LINE H-20 D-BOX o -TO SERVE EXISTING DWELLING 10- - 4' H-20 TEST PIT ® MADELEINE SHRANK 4F GASH PRECAST 314•-I1/4- 79 HALYARD WAY CENTERVILLE, MA BAFFLE DRYWELL STONE 105.10+- BOTTOM OF EXISTING 6 O LEACHINGSYSTEMO ECO-TECH ENVIRONMENTAL STONE 104,90 OSORPTION LEACH PIT EXISTING BASE EXIBTN° 43 TRIANGLE CIRCLE SANDWICH MA 0256 ;-r ros.o� Io4.8o GALLERY UTILITY POLE -8 006TING EXISTING l'' 5.00 r, • 508 364-0894 (END VIEW) 102!8o ETE-2066 DUNE 10. 2005 1000 GALLON lie E�STPKi SEPTIC TANK 1 r, a3 3.5 !, 12.s r, TREE THS PLAN IS TO BE CONSIDERED A DRAFT PLAN UNLESS,IT'. (i 0 -NUMBER REFERS TO DIAMETER ESTIMATED 38.10 IN INCHES. LETTER DENOTES TYPE BEARS THE STAMP AND SIGNATURE OF THE DESIGN ENGINEER SEASONAL HIGH r O-OAK M-MAPLE P-PINE ORIGINAL PLANS INTENDED FOR SUBMITTAL TO TH_.BOARD. GR OF,HEALTH WILL BE SIGNED N BLUE.AND STAMPED IN'RED. O.JNDWATER SOIL TEST LO.G . . DESIGN CALCULATIONS - , DATE OF TEST: JUNE 4. 2005 SOIL EVALUATOR: DAVID D. COUGHANOWR, RS DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD WITNESS REQUIREMENT WAIVED NO VARIANCES SOUGHT NO OUMATEATER IAL: EPROGLACIALDOUTWASH SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS TEST PIT I PARENT ELEVATION - 107.50 •- PERC AT 50 in : 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL CONDITION. IF NOT, INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 3 OUTLET D-BOX. (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 107.50 0-9 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH 9-30 B LOAMY SAND 10 YR 4/6 NONE FRIABLE A 6 O t - ( 24 x 12.5 ) - 300 of 105.00 30-138 C MEDIUM SAND 10 YR 6/3 NONE FRIABLE A t o t - 446 of 24 12.5 + 12.5 ) x 2 - 146 of 96•00 Vt 0.74 x 446 - 330.04 GPD USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED GROUNDWATER ADJUSTMENT EXISTING GROUNDWATER LEVEL BASED ON TOWN OF BARBSTABLE GIS DEPARTMENT RECORDS. INDICATED GW 35.00 LEACHING GALLERY 500 GALLON DRYWELL INDEX WELL AIW-247 DIMENSIONS MD DETAL ZONE C CONSTRUCTION DETAIL c H-20 E"r ' , READING DATE APRIL. 2005 UVST`ALr_roNE'1NSPECr10N READING 22.3 YWELL UNIT STONE RISER TO•WITHIN S/Xt` ADJUSTMENT 2.1 8•-fi'x 4'-10'x 2•-9' .+ .JNCHE OF FINAL.GRADE ADJUSTED GW 38.1 2 ft EFF• DEPTH -AND INPICATE LOCATION T 24.0 Pt ON As=s(nc-r IvLAN NOTES S o 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN U! QD 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. N v chi �c�op C OC�00 In o �Op�pOO��Op ��QD 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS �O o [� 000 OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) M ��oa�'p000p 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES � 3.5' 8.5' 8.5" 3.5' G)� BEFORE EXCAVATING FOR SYSTEM, , 24.0 f r 5) EXISTING LEACH PIT TO BE PUMPED AND REMOVED. REPLACE CONTAMINATED SOILS NOT 2 WITH CLEAN MEDIUM SAND PER TITLE 5. 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0- BEFORE PITCHING DOWN 8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES , AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK 9) SEPTIC TANK IS NOT DESIGNED TO_ WITHSTAND VEHICULAR LOADING. DO NOT SEWAGE DISPOSAL SYSTEM PLAN PARK OR DRIVE VEHICLES OVER SEPTIC TANK. 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. —TO SERVE EXISTING DWELLING 11) SEPTIC TANKS SHALL BE INSTALLED LEVELL' AND TRUE TO GRADE ON A LEVEL MADELEINE SHRANK STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING 79 HALYARD WAY CENTERVILLE. MA 12) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. ECO-TECH ENVIRONMENTAL 43 TRIANGLE CIRCLE SANDWICH MA 02563 ETE-2066 I JUNE 10. 2005 1 12'/2