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Home My WebLink About0033 HARBOR HILLS ROAD - Health a 33 Harbor Hills Road Centerville P A = 247 049 I (;'i1/li o 5 UPC 12543 No. 53LOR_ WASTiN05 MN No. Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Disposal *pBtrm Construction permit Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 33 i:4ADiW2 E((LC.S 0 Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel .1T C`Vt 33 L&S -P.-D VILS-c Installer's Name,Address,and Tel.No. D�-4-Z�"8�Z`I Designer's Name,Address,and Tel.No.v 69-X13 CAPCk,t015 CFJU`r-Qep/tc_S�85 L(.(. TC- -t-tc- Co e_t Ne c�— Jj Type of Building:J 1 eJV4 6-,d g -3 -0 V&/ Dwelling No.of Bedrooms -3 Lot Size 1,500— sq.ft. Garbage Grinder( ) Other Type of Building Q1Z&(b(W-r1&_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided ,�� gpd Plan Date 10&* ,ac4 a 0 1(2 Number of sheets 1 Revision Date Title 33 HAkBai_ i4 tL. ,5 P-Coon Size of Septic Tank I! �p Type of S.A.S. CQ $ G Description of Soil 60 — � 26 40 1:5 AQ �J' CAA] Nature of Repairs or Alterations(Answer when applicable) (PS6- 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 Healt S" ed Date ®� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ��/6 D�aq _ Date Issued TOWN OF BARNSTABLE LOCATION J9 3 (4 AP tAQ'R T<<u-S SEWAGE# A01 f_o, - .�La4 VILLAGE(2e-& E—P-V1LQ= ASSESSOR'S MAP&PARCEL ;L47,[ it cl INSTALLER'S,NAME&PHONE NO.lam► i'16 �NTEA? SES�Ct. 477-018 1 SEPTIC TANK CAPACITY (Sp® 6LL.O t-lS LEACHING FACILITY:(type)(a) 500 GAL C (size) l;t NO.OF BEDROOMS OWNER-1ltworet F _� ��LLV WA4SI-( PERMIT DATE: 6-aRq-;k0f(0 COMPLIANCE DATE:A 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) 01A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �� Feet FURNISHED BY`APC— J 1 AE e AV5*e C�� Anl _ y®1 A-?,= 46' A► 3= 29.t A-4 x 33.4' e � A-s: 30.4e �# 33' &Aar A-6= 3o' 00 go- g.z: 13.Lt' 5 4 Q-L( -32,-4' 6-(.= Li s No. Entered in computer: THE COMMONWEALTH OFWASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN�017 BARNSTABLE, MASSACHUSETTS 2pplication for Vsposal,6pstrut Construction Permit Application for a Permit to Construct Repair(X) Upgrade Abandon El Complete System 0 individual Components Location Address or Lot No. 33 WAosop_ t4(LL-S ko Owner's Name,Address,and Tel.No. r(^* 15.4L&>4 W4LS&4 Assessor's Map/Parcel a4,7 /49 ,33 Rfto-p- 14 1 LLs -P-0 CZ��J�Vi(_!`-E. Installer's Name,Address,and Tel.No. 50'R-4_7'7—ZZ_?_1 Designer's Name,Address,and Tel.No.5-09—X73—03,17 CAPGwtN5 L(,C- _TC_ -=)C. I IS.3 Coca mGe_d_t4-( _ S;-r MALS4PElr C"4-jaw?4 MAJN+ E AAM Type of Building: fi Dwelling No.of Bedrooms Lot Size 1,500— sq.ft. Garbage Grinder Other Type of Building Q1e&(bW'r1AL_ No.of Persons Showers( ) Cafeteria( Other Fixtures Design Flow(min.required) .330 gpd Design flow provided gpd Plan. Date--TIU&* ;14, � Number of sheets Revision Date Title 33 HAP_00(_ (4 iL. ,!g P-,oAb e6u-tex-V(Lkc- Size of Septic Tank 11 150 0 — Type of S.A.S.(X) 64&mt C664ado!4Z Description of SoilCO/4 PS C- 4S�-)I S 4&b 157 pgxv tr Nature of Repairs or Alterations(Answer when applicable) &_-_MAA' r 1,500a&C&aA) :SdY_[L<_Tea!r, It WEV-2 H-010 P-eQ).( 70 (-A) 5-C42 C-�ACCOP H-Ay 41EXCkf(AA 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 ol Compliance has been issued by this Boara,'of Heal l,S g ned Date 01(a Application Approved Date 6 1,A // 6- Application Disapproved by Date for the following reasons Permit No. Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired Upgraded Abandoned( )by �_31QG(AJtad ek)Tj�W: W(E_5 4..0 at o a- I(-(-& PO C'VILLi5 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No_r)CL(LrOa Ll dated Installer CAP GW(be< GVr6(PQ6G_f LLC Designer 42 C EAJ&1X.)6j9GkkX RUC bedrooms 3 Approved design flow 3 3 —gpd The issuance of this permi shall not be construed as a guarantee that the system will nc n designed Date Inspector__0 P601 (A--\) 0 ler --------------------------------------------------------------------------------------------------I-------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS . Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair Upgrade Abandon System located at 33 144g&g Ple-cs and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must Pe completed within three years of the date of this pd mit. Date Approved b -------------- "■ U 7/21/2016 13 :57 5082730367 :4910 P. 001/001 Town of Barnstable Regulatory Services Richard V. Scali,Interim Director a►RNSTAet.e. _ MAC. Public Health Division riot • Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790.6304 Installer& Designer Certification Form Date: Sewage Permit#QW(o —A R Assessor's Map\Parcel 297 q j Designer: TG Evl!�i flef-ci±L Toc,, Installer: GaQ2Wic��c �nr��es(ses Address: 2b51 u'aflberrj �i+way Address: 153 Ca,vtme-r'cto� SFreel East Wareka.m , ostiete-, riA UZ(o`i - On !,—21--ROI(r, Cc eeWiae- was issued a permit to install a (date) (installer) septic system at HaeW r HIS s (dead based on a design drawn by (address) S G lrn5cn2uicl c� '7E:0L , dated Tune. 24, 26 I(v (designer) VI 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. Strip out (if required) was inspected and the soils were found satisfactory. F 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. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed ' e with the terms of the I\A approval letters (if applicable) 0 4' JOHN L ° CHURCHILL JR. In all s ig t No I �eo� 9q�F� is esigner's St re) (Affix Des- er amp Here) PLEASE RE T TO BARNSTABLE PUBLIC HEALT DI SION. CERTIFICATE OF COMPLIANCE, WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. zz THANK YOU. QAScptic\Designer Certification Form Rev 5-14-13.doc Town of Barnstable P# -7 6O Departitnent of Regulatory Services Public Health Division Date MA89. 200 Main Street,Hyannis MA 02601 . rFB AA1K A Z' f / W ,Date Scheduled Time cm Fee Pd._ z . IV Soil Suitability Assessment for Se; a' a o^vD� isposal �"I w Y �p Performed-By: /-Ill alb ) jr C S ) 2 S> T.�� Witnessed By: 'U w• [,n r LOCATION&.GENERAL INFORMATION, Location Address Owner's Name •-r(�• ,5A L' , 3� �AR�� tEt�S Reap• . Y Address 33 k�VO O Q- 64 f L L< Ci=itri a y 7�!� y� dAPGwr� Ersus Assessor's Map/Parcel: ` Engineer's Name �GGI L)eEa(06r Z-6u NEW CONSTRUCTION REPAIR Telephone# 502 7-1 - g9-7-1 JPb-273-037 7 Land Use Slopes(96) 0- Surface Stones Distances from: Open Water Body Possible Wet Area ft Drinking Water Well 1 SO ft Dralhage Way )PIP ft Property Line ' d ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) See. dtotelpj PICLn i Parent material(geologic) OU V,01 A P� �� Depth to Bedrock Depth to Groundwater. Standing Water in Hole: > f-7 �•�• •r Weeping$ari Pit Face ' ' (Nit (J a l7=J•• Estimated Seasonal High Oroundwater DETERMINATION FOR SEASONAL-HIGH WATER TABLE Method Used: DI,(1Ck Obs .N ea 0<1 4 Depth Observed standing in obs.hole: In, Depth to Sall mottles: 9 In. Depth to weeping from side of obs.bolo: In, Groundwater Adjustment A— tY. Index Well-# Rending Date: Index Well level =_,r„ Adj,factor„ � AtU,Groundwater Level „v PERCOLATION TEST bate 6-1tD-1 co Time if-OOa Observation Hole# Tlme at 9" Depth of Pere- �O• Time at 6" — i Start Pre-soak Time @ ` G►+n _ Tlma(9"-6") End Pre-soak I li i"1 Rate Miu./Inch Site Suitability Assessment: Sita Passed 1 $_ Site Failed: Additional Testing Needed(Y/N) /{/ Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted withln 100' of wetland,you must first notify the, Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICNPERCFORM.DOC i DEEP•OBSERVATION HOLE LOG Hole#-�� Depth from Soil Horizon Soil Texture Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. 0118istency.%'Drivel) amy cp�hcl Or _ 99 C, «_ co ,oatSe,ScYJ ).S T 6lr. — 15-)0% Gravel t-Co tiles , DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon _ Soil Texture Soil Color Soil -Other Surface(in.) ` + (USDA) (Munsell) a ' -Moitling ` (Structure,Stones,Boulders. onsistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistency.S(]ravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Snll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Slopes;Boulders. Consistency. 6ravgl)- Flood Insurance Rate Man: Above 500 year flood boundary No— Yes V Within 500 year boundary No I Yes-, Within 100 year flood boundary No.j Yes Death of Naturally Occurring Pervious Materlai Does at least four feet of naturally occurring per us material exist in all areas observed throughout the area proposed for the soil absorption system? 2S If not,what is the depth of naturally occurring pervious material's Certification cy I certify that on _7_ r (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 training,expertise a xperience described in�10 CNM 15.017. -Z Y-� Date d C� • Signature • Q:1S•BPTiCVBRCFORM.DOC Hazardous Materials Inventory Sheet Checklist Date ysical Street Address-Check database to ensure it exists tom- — Working Phone Number <--Actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials) L-- Storage Information -location of storage, how long is storage for? If none, note that. 4---Disposal Information -where and who? If none, note that. Applicant Signature - understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -provide a vehicle washing policy and plain it - note that it was given Attach the Business.Certificate with your sign off and comments "The inventory form should explain what the business consists of and the procedures fhav nnn rininn Alnfnc YOU WISH TO OPEN A BUSINESS? For Your Information: Busines6 certificates (cost40.00 for 4 ears). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to opera e.J You must first obtain the necessary signatures on this forni at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st. FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. s H DATE: G /n l Fill in please: APPLICANT'S YOUR NAME/S: �•.OV�n to ?,' BUSINESS YOUR HOME ADDRESS: 33 HAu2�306- �� CrJnJ i�fZt11LL S �/� TELEPHONE # Home Telephone Number � 1 I 1 r NAME OF CORPORATION:. '... .� SS NAME OF NE , / . FJlru ECBUSW BUSINESS E Ll ✓ INESS. IS THIS A HOME OCCUPATION,? ADDRESS OF BUSINESS33 M)R!�ci/� I BLS N �2✓I�L M/� MgppgRCEL NUMBS V. [Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St_ - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COQhe, ER'S CE This individn info m d fan pe mit requir ments that pertain to this type of businesPUST COMPLY WITH HOME OCCUPATION RULES AND REOWL.ATIONS FAILURE TO rize i natu ** COMPLY MAY gESUI.._T IN FINES, O ENT ! CT 2. BOAR ' OF OEALTH l CY2 This individual h e nformlad er it quireme hat pertain to this type of business. Authorized Si6Kature** COMMENTS: MUST w®MPLY VVITH ALL r-9 Z _ RDuUS MATERIAL S REGIJ1n.— 3. CONSUMER AFFAIRWILICEINING AUTHORITY) This individual hirm d o the licensing require entathat pertain to this type of business. v Authd ' ed i nature** COMMENTS: 7 �� Date: $ 106 120 r3 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: E L13- fb o cr/1 S s BUSINESS LOCATION: 3 a, NIL 5 62-J) P_Qr),uz 6 2yr L c s INVENTORY MAILING ADDRESS: TOTAL AMOUNT- TELEPHONE NUMBER: 50S } it $ I CONTACT PERSON: /02(2i L Lopgr.S EMERGENCY CONTACT TELEPHONE NUMBER: I MSDS ON SITE? TYPE OF BUSINESS: PA i N rl AJ& INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts(Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals(Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals(Developer) i lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initia� I Commonwealth of Massachusetts Oho W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' '' M 39 Harbor Hills Road Property Address i•a;; David and June Birdsall :a Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 page. City/Town State Zip Code Date of Inspection f;w Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information �-- on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return key. Name of Inspector B&B Excavation C Company Name 374 Route 130 Company Address RAM Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-15-17 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is ill t Cenerve Ma 02632 9-15-17 required for every � page. City/Town 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 ® 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 was in working order at time of inspection. No design plans, records or asbuilts were available at Board of Health for property. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 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 'h day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 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 m Q pp , 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 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? ®NA ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): No design Number of bedrooms (Actual) 2 plans DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2016-34,000gallons 2015-60,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: 3 months agoDate Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 L15ins-3/113Water meter readings, if available: Title 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 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner-date of last pump is unknown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 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: Unknown due to lack of records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑'other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1250gallons Sludge depth: 4 t5ins•3/13 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 39 Harbor Hills Road M Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 page. City/Town 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 32 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured 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 was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 page. CityTTown 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: NA 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM0 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs 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.): NA * 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: Ltlms 3/13 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 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: Infiltrators ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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•3/13 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 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 page. 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 ❑ drawing attached separately Driveway Al- 18' A2-24' A3-33' 131-25«5" 82-18' 133-30' B F_ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is required for every Centerville Ma 02632 9-15-17 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: No GW @ 144" 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: A perk test was on file for#33 Harbor Hills ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: The abutting property (#33 Harbor Hills) at the same elevation, had a perk test on file showing no ground water at 144" on 6-16-16. This shows the bottom of SAS at#39 is above high ground water elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 39 Harbor Hills Road Property Address David and June Birdsall Owner Owner's Name information is Centerville Ma 02632 9-15-17 required for every _ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may-not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information I on the computer, use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. Company Name 14 Teaberry Lane Company Address Sandwich MA 02563 Cityrrown State Zip Code 508-477-0653 S14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: u.E r , Passes El Conditionally Passes ❑ Fails cc ❑ Needs Further Evaluation by the Local Approving Authority 00, Ca i 3/12/12 de CD �` Inspector's Signature Date T es, stem inspector shall submit a co of this inspection report to the Approving Authority Board �. Y P PY P P PP 9 Y o � 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. �t V j I t5ins• 1 �E 09/08 Title 5 Official Inspection, or Subsurface Sewage Disposal System•Page 1 of 17 L__ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 ❑ ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Harbor Hills Rd. 'M Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 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•09/08 Title 5 Official Inspection Form:Subsurface •Sewage Disposal System Page 5 of 17 P Y 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ .Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: July 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is Centerville Ma 02632 3/12/12 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 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: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan) Depth below grade: 16"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5.8x5.8x10.6 Sludge depth: no sludge t5ins•09/08 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 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. City/Town 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good shape tees present no sign of back up 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a g P Y ry ,M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet'invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in working order.No sign of carryover or leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appeared to be in good shape no sign of staining or hydraulic failure.Leaching was dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 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 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): (Sins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form `s Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments �M 52 Harbor Hills Rd. .Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. 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 ❑ drawing attached separately dear N 35` E A A3= 2y' A 4 = 3i ' ® o A I = 25` �z = 3i O C� 63= I ' .Q4 _ ` 5 = 52 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. CityrFown 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: >12feet 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: Hand Augered hole Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Harbor Hills Rd. M Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. City(rown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Lt5ins /08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �r RECEIVED 4, ECOJECH JUL 0 9 2003 Environmental T�w�AITM p PTABLE www.eco-tech.us THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 33 Harbor Hills Road tf V mmis C-&MtXf,.V k 1,l Owner's Name: Timothy&Johanne Healy M P 2 Owner's Address: 33 Harbor Hills Road Hyannis,M FA 02601 Date of Inspection: July 8, 2003 4,7 Name of Inspector: (Please Print) David D. Couchanowr,R.S. Company Name: Eco-Tech Enviromnental Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: (508)364-0894 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature 11M� Q-S Date: lv�/ 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 NOTES AND COMMENTS Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****This report only describes conditions at the time of inspection and wider 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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 33 Harbor Hills Road Hyannis Owner: Timothy&Johanne Healy Date of Inspection: July 8, 2003 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B] System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no, or not determined(Y,N,or ND). in the_for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not),is structurally unsound,exhibits substantial infiltration or exfiltration, or tank failure is mmriinent. 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. ND explain: Observation of sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced. ND explain The system required pumping more than four 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 obstruction is removed ND explain 2 Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 33 Harbor Hills Road Hyannis Owner: Timothy&Johann Healy Date of Inspection: July 8, 2003 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 and 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 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 detennine distance "This system passes if the well water analysis, performed by a DEP certified laboratory, 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3)OTHER 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 33 Harbor Hills Road Hyannis Owner: Timothv&Johamne Healy Date of Inspection: July 8, 2003 D) System Failure Criteria applicable to all systems: You must indicate either"yes" or"no" to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge 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. X Liquid depth in cesspool is less than 6"below invert or available volwne is less than 1/2 day flow. X Required pumping more than 4 tunes 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 groundwater elevation. X 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 X Any portion of a cesspool or privy is witlun 50 feet of a private water supply well 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 by a DEP certified laboratory, 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form) No (Yes/No)The system fails. I have deternined 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 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) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 33 Harbor Hills Road Hyannis Owner: Timothy&Johanne Healy Date of Inspection: July 8, 2003 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant or Board of Health. X Were any of the system components pumped out in the last two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available as N/A) X _ Was the facility or dwelling inspected for signs of sewage back-up? X _ Was the site inspected for signs of breakout? X _ Were all system components,excluding the SAS. located on site? X _ Were the septic tank manholes uncovered, opened, and the interior of the septic tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum.? X _ Was the facility owner(and occupants, if different from owner) provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: X _ Existing information. For example,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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 33 Harbor Hills Road Hyannis Owner: Timothy&Johanne Healy Date of Inspection: July 8, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan on file at Health Dept. Number of current residents 4 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required) Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings, if available(last two year's usage(gpd): 82 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sgft/etc.): 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/use- .-OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS Source of information: System not pumped in recent past(Owner) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined'? Reason for pumping: TYPE OF SYSTEM: X 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/Alternate technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy PP of the DEP approval Other(describe) APPROXIMATE AGE of all components,date installed(if known)and source of information: Age: 5+years Certificate of Compliance issued 4/27/98 (BOH permit#98-255) Were sewage odors detected when arriving at the site: (yes or no) no 6 Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Harbor Hills Road Hyannis Owner: Timothy&Jobanne Healy Date of Inspection: July 8, 2003 BUILDING SEWER_(Locate on site plan) Depth below grade: 3.5 ft Material of construction: X cast iron _40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting, evidence of leakage, etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK: X (locate on site plan) Depth below grade: 36 inches Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 11.5 ft.x 5 ft x 5 ft(1500 gallon) Sludge depth: 8 in Distance from top of sludge to bottom of outlet tee or baffle: 26 in Scum thickness: 8 in Distance from top of scum to top of outlet tee or baffle: 6 in Distance from bottom of scum to bottom of outlet tee or baffle: 10 in How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations, ittlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): Pumping is recommended at this time,and maintenance pumping is recommended every 2 years Liquid level at outlet invert.Tank and tees appear structurally sound and fitnctiotung as intended No evidence of leakage in or out GREASE TRAP: none (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: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Harbor Hills Road Hyannis Owner: Timothy&Johatme Healy Date of Inspection: July 8, 2003 TIGHT OR HOLDING TANK: none (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/day Alarm present(yes or no):_ Alarm level:_ Alarm in working order(yes or no): Date of last pumping: Comments:(condition of inlet tee, condition of alarn and float switches, etc.) DISTRIBUTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: at outlet invert Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.) D-box appears structurally sound with no evidence of leakage in or out.Effluent level at outlet invert. No solids in tank. PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: . 33 Harbor Hills Road Hyannis Owner: Timothy&Johanne Healy Date of Inspection: Jul),S, 2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan;excavation not required) If SAS not located,explain why: Type: _leaching pits,number_ _leaching chambers,number X leaching galleries,number 1 _leaching trenches, number, length _leaching fields,number,dimensions _overflow cesspool,numberin_ novative/altemate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure, level of ponding, dump soil,condition of vegetation,etc.) Soils above leaching allery appeared unsaturated. No evidence of surface ponding,breakout lush vegetation or other evidence of hydraulic failure was observed. CESSPOOLS: none (cesspool must be pumped at time 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 or no): Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: none (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Harbor Hills Road Hyannis Owner: Timothy&Johann Healy Date of Inspection: July 8, 2003 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100'(Locate where public water supply enters the building) LOCATIONS A B ACHING 1 39.5 ft 19 ft D-BOX ® LEGALLERY 2 47 ft 17 f t SEPTIC z o o, 3 49.5 f t 24 ft TANK 1-1 A B EXISTING DWELLING # 33 W z J W H 3I HARBOR HILLS ROAD NOT TO SCALE 10 i Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Harbor Hills Road Hyannis Owner: Timothy&Joh nne Healy Date of Inspection: July 8, 2003 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 30+ feet Please indicate(check) all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: _ Checked local excavators,installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Town of Barnstable GIS Department records indicate that the groundwater table lies over 30 feet below the surface of the lot. 11 TOWN OF BARNSTABLE rLOCATION � � f �� 5 SEWAGE # VILLAGE _ ASSESSOR'S MAP & LOT 11-� ..� INSTALLER'S NAME&PHONE NO. N1 Q—(-64Pe—S'YJ n( C SEPTIC TANK CAPACITY 1 dOJC,1' LEACHING FACILITY: (type) cc. \I�la (size) 2y,Vc L NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE:_�'1-1-Of COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist_ on site of 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 L its R No. t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zippfication for &!6 Zpgrade( *pgtem �Conmruction Permit Application for a Permit to Construct( )Repair( )Abandon( ) E]Complete System ❑Individual Components Location Address or Lot No.�j 3 o'--t-1/ Qm� Owner's Name,Address and Tel.No. V t (>j I l Assessor's Map/Parcel DL" .rO t ` 5(n n D01 Installer's Name,Address,and Tel.No. "V l Designer's Name,Address and Tel.No. Type of Building: 22 Dwelling No.of Bedrooms J Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow '330 gallons per day. Calculated daily flow -3 qC1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank I s- � �:1 Type of S.A.S. � `n.CA act �T�- ��•`�`� Description of Soil Nature of Repairs or Alterations(Answer when applicable) -\S7 OD a Y- k-�V r,dJ L1`SSA L,Ti C--L"K o YZ S I A- A [V t I 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 Environment 1 Code and not to place the system in operation until a Certifi- cate of Compliance has been ' his B Signed Date Application Approved by Date '— Application Disapproved for the following reasons Permit No. Date Issued � 17 No. Fee _900 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4 Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zlpplicatton for Mt' f 6p5tem Cori$truction Verrntt Application for a Pernut to Construct( )Repair( Upgrade( )Abandon( ) ❑Colhplete System i❑Individual Components Location Address or Lot No.3 3 v ( ` 5 Owner's Name,Address and Tel.No. i Assessor's Map/Parcel - G 11(� t Installer's Name,Address and Tel.No. Designer's Name,Address and Tel.No. 2 ft1�1c��. Type of Building: 2 Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures r Design Flow 33 gallons per day. Calculated daily flow C{ gallons. Plan Date Number of sheets Revision Date Title i Size of Septic Tank ' S 5,T, Type of S.A.S. Co�cI LTvc•TQJ Description of Soil I/w� S�q V\J Nature of Repairs or Alterations(Answer when applicable) l-� L a 1 QtF 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 Environment l Code an'd not to place,the system in operation until a Certifi- cate of Compliance has bee is B el-Idea. # [, 1. Signed Date Application Approved by Date fflr Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS • � ` Certfftcate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(P_r � Abandoned( )by k at 3 3 v C,%.%,r A S OYT has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction ermit No. O dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date W Inspector Qt ' No. ---------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS wtoozal 6p5tem Construction Verna Permission is hereby granted to Construct( )Repair( )Upgrade�Abandon( ) System located at b �b .\Y,t and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this t. Date: �".� Approved y . � 1019197 1 e Used For the Repair Of Failed NOTICE: This Form Is To B Septic e stems Only. P SY CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPO SAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) i C i 1 j hereby certify that the application for disposal works I l signedby me dated _a concerning the construction permit meets all of the property located at ✓bQy T following criteria: � proposed leaching fhcility � l/e There are no wetlands located within 100 feet of the Thereas no prlvete wells within 150 feet of the proposed septic"m ; I There is no increase in flow and/or change in use proposed j �/ Thero ere no"firm"Mwlad or needed. landso bottom of the pro If the teaching fhclilty will be located within 250 feet of any wet inch the leaching facility will no be located less then (14)feet above the maximum adjustedOW ' groouunndwater table'elevetift pieltse eomplete the follewieg: t f A)Top of a�md Elevation(according to the Engineering Division 0.1.3.map) aronndweta Table Elevation(accord to Health Division well Map) g)observed DATE: 31t31�fED LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER I 1 lot plan, { (AttaeA a ricNeA Plan state d a!► +•Alse Ihbe lleenred Installer Penn" eerttAed p this plan should be submitted). o. � 1 l} � Adldi Iblht ; �,-- l a v h �- �: - - TOWN OF BARNSTABLE ,LOCATION 33r� 1t�1\s SEWAGE # S.S `<VIILAGE N��....M s Ili i r'1 ASSESSOR'S MAP&LOT 14 7•toly IIVS?ALLER'S NAME&PHONE N0' . . I�1t L7-C1�� .SEPTIC TANK CAPACITY l� 0- . .S.GI't TA^ — .LEACHING FACILITY: (type) _dry�1►� 1 (size)� O-IC �2�r NO,OF BEDROOMS _ n BUILDER OR OWNER S Oo ri `PERMTTDATE: —17. ft COMPLIANCE DATE:_ _ 1 7 . CJP... : SOaration Distance Between the: -Maximum Adjusted Groundwater Table to.the Bottom of Leaching Facility Feet Pgvate 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 ,Cv�•d 0 o Q ', I-TnI '� . TOWN OF BARNSTABLE LOCATION ,L h1 SEWAGE # VILLAGE�t ASSESSOR'S MAP & LOT AVZ-6 INSTALLER'S NAME & PHONE NO. '��/-2 Y2 X r SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Al 11 (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER I.= BUILDER OR OWNER tS--- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Li oL Y� No.. -. �-- Fxs..... ..." THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH APPnOVED TOWN OF BARNSTABLE BafnstableC`'�ts`�`VaClonOepanme6lt v -2 Appliration for Dirpmml Hlurlw Tontitrg%amt oet® Application is hereby made for a Permit to Construct ( ) or Repair (✓ 'an Individual Sewage Disposal System at: � 33 -f-�n� �� H( Its C : .......................................•......•........•......... ............................... .................................................................................................. -Address or Lot No. re VOL/, !rite-� � �G—�/� - ,v �' r ......................_. --------•--•--••••--•-•---••--• . ------------.e Z.C.fZ.C._... . .. .................... W O�sncr Address Installer Address Q Type of Building Size Lot............................Sq. feet ,V. Dwelling— No. of Bedrooms--------3----------------------------___Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons------------------------.--- Showers ( ) — Cafeteria ( ) a' Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length-.-------------- Width................ Diameter---.............. Depth................ x Disposal Trench-- No. ............... Width-------------------- -Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...........--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------------------------•-••-••-••••••-•-•••••-•-•----•-•--•••••--------------------------------•-•.....•........---•......... .................... 0 Description of Soil-•------------------------------------------•-------------------------------------------------------------•-------...........-•--------••----••••••..................... V ....----•-•••-•••.....----•••-••-•--•-•••--•---•-••••-----•-••-••---••••--•---•---•••-••••---•-----•--•-••-•---•-••--•-••••••---•••••••••-•••--------•-.....-••-•-•.........................•••••....... •------------•-------------------------------------------------------------------------------------- ---------------•--------------------------....----•-------------------------------------.......... 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 TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance been ' s by e board of health. Signed ---------. .. .................. Dare Application Approved By ............C� a..-.. ..-...Pf. - ----....--------............. Dare Application Disapproved for the following reasons: .......................................... .. .................................................. .............................. ............................................................... . ..................... ................................ ... -- ...................................................... ......... . .................... Date Permit No. ----/..qq;)�-------.5.. .`............................. Issued ......................................................... Date ?j3 TOWN OFF BARNSTABLE LOCATION le� AD SEWAGF-i: VILLAGE. ) ASSESSOR'S MAP & LOT �/ 6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /-� -�' 11�C LEACHING FACILnT: (type) % /�Y/ .0�>"�/O!S (size) NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: 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 o leac in cility) Feet Furnished by � +" -�. �� ,� � \ /cue, ��// ,� ` � \ � i/ -� � � 33 �--�1c��' �__fs� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY, That the Indite dual Sewage Disposal Sygpm constructed or Repaired by ...................--------- ........... ....... ------- -----------------------------------------.............................................. at .................. ......"—'��'x ......... --------- --- --- --- ...1—te. �. .... .....................------.................................................. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .......... dated --------..............-.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �' - )..1) , � .................... Inspector -........... DATE .........------- r.................. ---------- ------------- --------------------....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No...... TOWN OF BARNSTABLE FEEJ-d.... DisVosal Workii Tomitrurtion .......................................................................... Permission is hereby granted......... to Construct or Repair ( � an Individual Sewage Disposal System atNo.......... - .................................................................. ------- 2,1 -------- -N .Street 5�� /' /7 as shown on the application for Disposal Works Construction Permit No.4---------D-- Dated.._._. ....................... N17R�� Board of Health .. ......................*------".... ..... --------------------------------------DATE.-------- ------ ............ .... ......... .................. FORM 38306 HOBBS&WARREN.INC..PUBLISHERS ��+ri;:.✓'b"^'V-.t.r•v�..-.yw•r-. L.-._,�.n...n� ......�_ �.-.�....�..s..r.--,...v..-..��.._,^:.:v,... .:� _..Y.ti,.� .._. .. __•. ..,- , ,.. ,. - - ...-v �Y «., ,. �t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE /a Appliration for Diaipwiul Wur1w Cfanstrnrttnn Thrmit Application is hereby made for a Permit to Construct ( ) or Repair (t/S an Individual Sewage Disposal System at 33 ` f792S o2. l �S -------------------------------------------------------------------•-------------.......------.... -•----......•--•---••----••---....----------------------------------------........................ Location- ddress `. ' r --... 14 Owner rA-ds WcR Address ..............................• � Installer Address Type of Building Size Lot............................Sq. feet ., Dwelling— No. of Bedrooms-------- -------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------•....--------..........--•-----•--.....------------......-----....--------- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Gd Septic Tank—Liquid capacity............gallons Length---------------- Width..._------------ Diameter---._._._....... Depth................ Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------.-.. _-_-.- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0.4 Percolation Test Results Performed by........ -------------------••-•---•------------•---------•-•------....... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GZ.t Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ •--••--••••....................•--•----•--••----•-••----•---••-------••-------------------................................................................... ODescription of Soil........................................................................................................................................................................ w UNature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been •ss ed by the board of health. Signed ............ .... ... -��................................................. ........................................ Date Application Approved By ............... ..... ...� ..._.. /................................................... ....... ...1.. .._..� .-... '..' Date Application Disapproved for the following reasons: ........................................................................................................................................ .............................................................. .. . . ....................... ...... ..... . ... .................................................. '........................................ Dare PermitNo. ..... ........�� ..l.�............................ Issued ..................................................... Date T.O.F. EL.= 45.1'f FINISH GRADE OVER D-BOX= 45.37' PROP. VENT WITH CHARCOAL FILTER TO ABOVE GRADE FINISH GRADE OVER CHAMBERS= 44.8' - 45.83' GENERAL NOTES PROVIDE EXTENSION RISER REMOVABLE WATER-TIGHT COVER OVER SLOPE @ 2% MIN. OVER SYSTEM 3/4"TO 1-1/2" DOUBLE WASHED WITH COVER OVER INLET& RISER TO WITHIN 6" OF FINISHED GRADE STONE TO CROWN OF PIPE 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE OUTLET TO WITHIN 6"OF F.G. 4" SCHEDULE 40 PVC INSPECTION PORT WITH ACCESS METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL @ FND. EL.= 45.0'± F.G. OVER TANK EL.= 45j.4'f [5" DIA. OUTLET(S) MIN SLOPE 1% (SEE NOTE 21) 2" OF 1/8"TO 1/2" DOUBLE WASHED CODE AND ANY APPLICABLE LOCAL RULES. - BOX TO F.G. STONE OR GEOTEXTILE FILTER FABRIC f � ti s 2 2 ANY CH ENGINEERSTOTHIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE EXISTING 4'° PROPOSED 4" 4' MAX. TOP OF SAS = 40.83' PLACE RISERS ON ALL SEE NOTE 22 5 MAX. CHAMBERS WITH SCH. 40 PVC 40.00' SEE NOTE 22 , INLET PIPES TO 6"OF 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL ��SEWER PIPE BREAKOUT EL = 40.50 SYSTEM UNLESS OTHERWISE NOTED. �- � � �� SEWER PIPE � FINISHED GRADE--"." 6 3" 3" DROP MAX 3" 9" ---- . L=31'f 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN - - 2" DROP MIN MIN SLOPE i r_ PROVIDE WATERTIGHT _ _ 13" 4" PVC IN FROM JOINTS (TYP.) ELEVATION =40.50' FOR A DISTANCE OF 15 AROUND THE PERIMETER OF THE SAS. UNLESS A 14" 4i,�,d $ SEPTIC TANK 4" PVC OUT TO o � � � � � � � � � � � � O � � � 0 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF CONTRACTOR TO PROVIDE - -- O LEACHING FACILITY o0 0 0 THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. SPECIFIED DROP BETWEEN Too 00 0 5. SLOPE ALL SOLID PIPE AT 1.0/° MINIMUM. INLET AND OUTLET CONTRACTOR CONTRACTOR SHALL 12 6" oo a a 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. SHALL VERIFY SIZE 48' VERIFY CONDITION OF � OUTLET TEE 40.37 MIN. 40.20 2 00 � 0 � 0 � 0 0� 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK AND CONDITION OF EXISTING TEES GAS BAFFLE 6" CRUSHED STONE °° o 0 00 EXISTING SEPTIC i AND REPLACE AS .� ' + OVER MECHANICALLY t Qo . F-I r^I F� (-_I � � �� e o F I-� r_ F-{ f l o FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS TANK NECESSARY COMPACTED BASE - i i I I NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH AND DESIGN ENGINEER. 3 4.0 8.5' (TYP) 4.0' 4.0' 4.0' n OUTLET DISTRIBUTION BOX 4.83' 8, ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF 45.00, TO BE INSTALLED ON A LEVEL STABLE 25.p' (TYP.) - - -- - - - ESTABLISHED ON A CORNER OF BULK HEAD, AS SHOWN ON THE PLAN. BASE. FIRST TWO FEET OF OUTLET , GROUND WATER ELEV.- � 33.00' PIPES TO BE LAID LEVEL. 38.00 -12.83' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION ` EXISTING 1,500 GALLON CONCRETE SEPTIC TANK 2 - 500 H-20 GALLON CHAMBERS 5 MIN. l,A „-IsVItJL�I . i*vv V iL_W u THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT `CONTRACTOR TO VERIFY EXISTING CROSS SECTION VIEW TYPICAL CHAMBER PROFILE 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES ELEVATION PRIOR TO ANY WORK& 0 r- I I`"°' I �r4N r_lr,�ki1" II H-20 DISTRIPI ITlf`N 'PDX nETAIL H-20 CH A 11 ,4 1r7M ')ETAILS TO THE DESIGN ENGINEER. NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE 10 ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. NOTES: _ TEST PIT DATA 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING • `'"=-1• • ' 'I'' ' . • ' 'r"' r REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM ' 1` •' ' ''s� " '`�`' `' PERC NO 15076 l APPROPRIATE AUTHORITY. 1.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF THE :�' +, •PI E �( '��-" `' .,' .,-'•_. « • sue t. I PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST PIT DATA _ lie •• ' .. � INSPECTOR: David W. Stanton R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL BOARD OF HEALTH !� , ;I• 1e� (• '� EVALUATOR. Michael Pimentel, EIT, CSE UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT, DRIVES, OR IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. f �J, , , )� / • W • • TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING. „ ;;; •.. •• * . _ • C.S.E. APPROVAL DATE: Oct. 1999 2. ENTIRE PROPERTY IS LOCATED WITHIN THE ESTUARINE WATERSHED Y. '''r' r `/' i •' `= ♦ + 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. RS ED ONLY. l �-. June 16, 2016 ,►�. + 1�« , ? � �,>' -z�` DATE: TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM SUBSOIL AND UNSUITABLE �N • / ` * , �, MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. �� •• . C3 ELEV TOP= 45.00' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, ELEV WATER= < 33.00' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). LOCUS . - 1`• ' '� t k� 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN r "�� PERC RATE _ <2 min./inch nV AP 247 MAP 247 •, SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. n /� LOT 50 5 ' ' ; r •�•', = ` ' j" DEPTH OF PERC = 32" - 50" �. LOT 61 • - / f�`,« ,' ';�=.1'•.. �y+ ,r -- 16. PROPOSED PROJECT IS LOCATED WITHIN: a PROPOSED 4" PVC VENT PIPE; , • • .(1�;!;;:y ti' Ir r • I EXACT LOCATION PER OWNER + ,,; �•. •: � :r}y+ ' ' �� TEXTURAL CLASS: 1 ASSESSOR'S MAP 247 LOT 49 a PROPOSED 2-500 GALLON I f ,.� '�' • ` ,f� " OWNER OF RECORD: TIMOTHY J. & SALLY E. WALSH H-20 LEACHING CHAMBERS WITH AGGREGATE (2 ,--PROPOSED H-20 t d i;� .:/,;�? ♦ , 0,. 45.00' ADDRESS: 33 HARBOR HILLS ROAD •: Fill 1 DISTRIBUTION BOX i '� - 1 3 44.75' CENTERVILLE, MA. 02632 r PROPOSED 45.0' -�' N74-p2, , • � ' INSPECTION PORT `\ 1) lOp p p, fit/ 1♦•i J . (. •.`�_�� • . I! FEMA FLOOD ZONE X �.�►�� •1/ B Loamy Sand COMMUNITY PANEL# 25001CO564J ♦ - � •• �• •• • r ��• 10Yr 5/8 TP 2 ' `/' •` 17. DEED REFERENCE: DEED BOOK 17380, PAGE 242 O /' • y •I ��. • . ` " '� • 32" 43.33' o c / j +. i �••+8 •18 �, �;1. 18. PLAN REFERENCE: PLAN BOOK 103, PAGE 127 _. y , - N c� QAK \ !J S �L��• --- • `«r 50 0.8.3 •'1 ;:��• •' 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY / s I �• 'mot • � • «� • FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY / Q �HC-2 .'!. rj 1, r ! ' •• •��* . a Coarse Sand EXISTING HIGH CAPACITY CHAMBERS i ft/ 2::• 11 . . FOR USES F T ' j `' e1' Al `�1:•+�'�` C 2.5Y 6/6 LITY J •% r !1 �.or IT.'+! !i II •• .l• 15-20% Gravel & S O HIS PLAN OTHER THAN ITS INTENDED PURPOSE. (PORTION TO BE REMOVED& �, -,.1 1 ,i.!! ; . . • ,. REPLACED WI TH CLEAN COARSE SAND ' �I BRICK Cobbles 21. A 4" PERFORATED SCH. 40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A . PER 310 CMR 15.255(3) AS SHOD""''• - 1. (3 �___ .. - .. ._ PATIO DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3" OF FINISH GRADE. A REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS. '2.8�� LOCUS PLAN 4) 2241+ ' 22. IN ACCORDANCE WITH 310 CMR 15.401 - 15.405, THE FOLLOWING LOCAL UPGRADE SCALE: 1" = 1000' APPROVALS ARE REQUESTED FROM 310 CMR 15.221 (7): ' 144" 33.00' (1.) A 2.0'WAIVER (3.00' - 5.00') FOR THE MAXIMUM COVER OVER THE LEACHING SYSTEM. No Mottling, Standing or Weeping Observed (2.) A 1.0'WAIVER (3.00' -4.00') FOR THE MAXIMUM COVER OVER THE DISTRIBUTION BOX. 9 9 P 9 SHED / � { __ ______..---__._.___ _ __- _ __ ._. MAP 247 LOT61 rr� EXISTING DESIGN DATA r TEST PIT DATA 3-BEDROOM ) MAP 247 PERC NO. 15076 / jj HC-1 DWELLING INSPECTOR: David W. Stanton, R.S. x50.0' EXISTING SPOT GRADE f?; f LOT 49 NUMBER OF BEDROOMS (DESIGN) 3 ro 15" OAK - TOF=45.1'± 7,500 S.F.± Q DESIGN FLOW 110 GAUDAY/BEDROOM I EVALUATOR: Michael Pimentel, EIT, CSE - 50 EXISTING CONTOUR BH O C.S.E. APPROVAL DATE: Oct. 1999 20",OAK \ o TOTAL DESIGN FLOW 330 GAUDAY 50 PROPOSED CONTOUR cr ry _ j DATE: June 16, 2016 o ; �O DESIGN FLOW x 200 % = 660 GAUDAY TEST PIT#' 2 50 PROPOSED SPOT GRADE co Z 4 USE EXISTING 1,500 GALLON SEPTIC TANK ELEV TOP = 45.00' EXISTING GAS LINE ELEV WATER = < 33.00' EXISTING OVERHEAD WIRES �< PERC RATE _ m IV� '� Q INSTALL 2 - 500 GALLON H-20 CHAMBERS EXISTING WATER LINE \ w ' DEPTH OF PERC = r \ ' w/ AGGREGATE EXISTING 1,500 GALLON SEPTIC TANK TEXTURAL CLASS. 1 SIDEWALL CAPACITY (LENGTH + WIDTH) (2 SIDES) (2' HIGH) (0.74 GPD/S.F.) = GAUDAY l - ■ r ■ TEST PIT LOCATION STONE DRIVEWAY � (25.0' + 12.83') (2 ) ( 2' ) ( 0.74 GPD/S.F.) = 112.0 GAL/DAY Benchmark �•� W '` 0" 45.00' Corner Bulk Head �'�.. \ ' FIII PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE Elev. = 45.00' ��,,, N74. BOTTOM CAPACITY Approx. M.S.L. �'�•�2 20 t I ' 3" 44.75' ® PROPOSED H-20 DISTRIBUTION BOX /p tz (LENGTH x WIDTH) (0.74 GPD/S.F.) = GAL/DAY MAP 247 O p0, w''1� I ,- _4-3 (25.0' x 12.83') (0.74 GPD/S.F-) = 237.4 GAL/DAY B Loamy Sand PROPOSED 500 GALLON H-20 LEACHING CHAMBER LOT 4$ � 10Yr 5/8 TOTALS: 32" 43.33' 2 TOTAL NUMBER OF CHAMBERS 2 REV. DATE BY APP'D. DESCRIPTION TOTAL LEACHING AREA 472.2 SQ.FT. TOTAL LEACHING CAPACITY 349.4 GAL./DAY PROPOSED SEPTIC SYSTEM UPGRADE PREPARED FOR: O Coarse Sand C 2.5Y 6/6 CAPEWIDE ENTERPRISES J4?Oar 15-20% Gravel& Cobbles LOCATED AT 33 HARBOR HILLS ROAD CENTERVILLE, MA 02632 SWING-TIES 144" 33.00' SCALE: 1 INCH = 10 FT. DATE: JUNE 24, 2016 0 5 10 20 40 FEET DESCRIPTION H -1 HC-2 No Mottling, Standing or Weeping Observed j OFF{,, CORNER OF STONE (1) 42.4' 24.5' � RESERVED FOR BOARD OF HEALTH USE Ago '�( PREPARED BY: JC ENGINEERING INC. CORNER OF STONE (2) 49.1' 37.2' 2854 CRANBERRY HIGHWAY I CORNER OF STONE (3) 33.1' SITE PLAN EAST WAREHAM, MA 02538 's ` 508.273.0377 ss, / CORNER OF STONE (4) 22.1' 31.8' j SCALE: 1" = 10' _ >Jjt Drawn By SJI Designed By:MCP Checked By: JLC JOB No. 3523