HomeMy WebLinkAbout0007 HARRISON ROAD - Health 7 Harrison Road
Centerville
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
rr 7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name 3
information is Centerville Ma. 02632 4-3-15
required for -
every page. City/Town State Zip Code Date of Inspection
�i
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
I
Important:
When filling out A. General Information
,
forms on the
computer, use 1. Inspector: C�
only the tab key
to move your Matthew F. Gilfo
cursor-do not use the return Name of Inspector
key. B&B Excavation
Company Name
VQ 14 Teaberry Lane
Company Address
Sandwich Ma. 02644
Citylrown State Zip Code
(508)477-0653 S113640
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
CkAd
4-3-15
Inspector's Sign ure 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.
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. CitylTown 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•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
7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. Citylrown 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 obstructedpipe(s). The
❑ Y q P P 9 Y
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
7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every 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
r I provided r failure cri ri r triggered. A f the anal sis must
too less than 5 m ro ded that no other criteria areco 0
PP , PPY Y
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 '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
i
Commonwealth of Massachusetts
Title -5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. Citylrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. Cityfrown 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): 352
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.'' 7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (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 (9P ))�
Detail:
2014- 111,000 (304gpd) 2013-295,000 (808gpd)
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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•3113 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
'r 7 Harrison Road
Property Address
Tim Perry
Owner Owners Name
information is
required for Centerville Ma. 02632
4-3-15
every page. City/Town State Zip Code Date of Inspection
D. system Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
I
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•3/13
Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
upTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every 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:
2011
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good working order no sign of leakage.
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gal.
Sludge depth:
4"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Harrison Road
Property Address
Tim Perry
Owner Owners Name
information is
required for Centerville Ma. 02632 4-3-15
every page. Citylrown 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
3"
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
14"
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.):
At time of inspection septic tank appeared to be in working order,Tees present no sign of back-
u .Li uid level equal with outlet invert.
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene
El 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
N. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.�° 7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Box if resent must be opened) locate on site plan):
Distributiono ( p )
( P P )
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 in working order no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
AM Title 5 Official Inspection Form
wwwf
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 gallon
El leaching galleries number:
9
❑ 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 appears to be in working order with no sign of hydraulic failure. Water
level 1'6" below invert at time of inspection. Old system is still hooked up but capped off.
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
7 Harrison Road
Property Address
Tim Perry
Owner Owners Name
information is
required for Centerville Ma. 02632 4-3-15
every page. Cltylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch of Sewage Disposal System: Provide a`view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks: Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
0 .drawing attached separately
All-
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A - 5ST
a
o ® o
A
! A
E
I
t5mn •3113
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
yc 7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. Citylrown 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 120
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: 11-21-02 Old septic plan
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)
x❑ Accessed USGS database explain:
You must describe how you established the high ground water elevation:
Plan on file
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
.h . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Harrison Road
Property Address
Tim Perry
Owner Owner's Name
information is required for Centerville Ma. 02632 4-3-15
every page. Citylrown 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
Town of Barnstable Barnstable
�p SHf
P` y A®-ftmic Cite
Regulatory Services Department I 1
BARNSTABLE,
MASS. Public Health Division
�A i6gq. 2007
rfb MAt a 200 Main Street, Hyannis MA 02601 .
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7006 0810 0000 3524 5546-
December 5, 2011
Carlos Santos
% BANK OF AMERICA,NA
Box 5170
Simi Valley, CA 93065
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 7 Harrison Road ,Centerville, MA was last inspected on
11/15/2011, by Michael T. Bisienere, a certified septic inspector for the State.of
Massachusetts.
The inspection of the septic system showed that the system"Fails" under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
0 Backup of sewage
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system with the deadline period will result in future
enforcement action.
PER ORDER OF THE BO OF HEALTH
s cKean, R.S, �—
Agent of the Board of Health
Q:\SEPTIMLetters Septic Inspection Failures\Town of Barnstable.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owner's Name
information is Centerville MA 02632 11/15/2011
required for
State Zip Code Date of Inspection
every page. City/Town
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: A. General Information
When filling out
forms the
computer,
r,use 1. Inspector:
only the tab key
to move your Michael T. Bisienere v
cursor-do not Name of Inspector,
use the return
key. A&K Septic Systems Plus
Company Name
- A 565 Carriage Shop Rd
Company Address
East Falmouth MA 02536
�n Cityrrown State Zip Code
508 540-6706 S13938
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
11/15/2011
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_regio.nal_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•09108 Title 5 Official Inspection Form:Subsurfa4S.. posal Syslem•Page 1 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owner's Name
information is required for Centerville MA 02632 11/15/2011
every 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
( ) 9
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 Farm: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 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owner's Name
information is
required for Centerville MA 02632 11/15/2011
every page. CityrFown 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G M 7 Harrison Road _
Property Address
Bank of America/Santos, Carlos
Owner Owner's Name
information is required for Centerville MA 02632 11/15/2011
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
t5ins•09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owner's Name
information is required for Centerville MA 02632 11/15/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
ElRequired 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°wM 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owners Name
information is required for Centerville MA 02632 11/15/2011
every page. Cityrrown 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): Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�, ,•''y 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owners Name
information is required for Centerville MA 02632 11/15/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
System consists of 1500 Gallon Septic Tank, D-box and SAS
Number of current residents: 5
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 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-09108 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
w 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owners Name
information is required for Centerville MA 02632 11/15/2011
every page. CityfTown 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:
galloris
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-OWN Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owner's Name
information is required for Centerville MA 02632 11/15/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 14"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
A sewer ejection pump is located in the basement.
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gallon ST
Sludge depth:
1"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner owner's Name
information is
required for Centerville MA 02632 11/15/2011
every 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
39"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
11"
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.):
System is in Hydraulic Failure
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 Forth: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
M 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner owner's Name
information is required for Centerville MA 02632 11/15/2011
every page. CitylTown 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 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
µM 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owner's Name
information is required for Centerville MA 02632 11/15/2011
every page. CitylTown 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
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 Hydraulic failure
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-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owner's Name
information is required for Centerville MA 02632 11/15/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number:
TWO-500 gal.
❑ 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.):
System- Hydraulic Failure
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owner's Name
information is required for Centerville MA 02632 11/15/2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owners Name
information is
required for Centerville MA 02632 11/15/2011
every page. Cltyfrown 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
------ ..._--- - - ---- —_ - -- - --.. -----._...- ---- - -- --- ---- -----._...----- ---- ---- --------- ----------- - -- -
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 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner Owner's Name
information is
required for Centerville MA 02632 11/15/2011
every page. Cltylrown 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: Undetermined failed system
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/o6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 7 Harrison Road
Property Address
Bank of America/Santos, Carlos
Owner information is Owner's Name
required for Centerville MA 02632 11/15/2011
every page. Cltylrown 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-09108
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
4v ssessing As-Built Cards Page 1 of 1
'TOWN OF STABLE h
LOCATION Qrr� SEWAGEM�CJL,t�'�Jj
VU LAGE ASSESSOR'S MAP. LOT
INSTALLER'S NAM&PH NE NO.
SEPTIC ANK CAPA�rnr849 0
LEACHING FACII_IIY:( 4
NO.OFBEDROOMS
BUILDER OR OWNER
j PERMITDATE.: ! f'O 0.2 COMPLIANCE DATE- �3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility et
j .Private Water Supply Well and beaching 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
i within 300 feet of leaching facility) Feet
Furnished by
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TOWN OF BARNSTABLE
I LOCATIONJryc. �G'/ SEWA11%19\
VILLAGE o ASSESSO/R'S NI�� 2ARCELQ
NAME&PHONE NO. Cr ��/``��
SEPTIC TANK CAPACITY �"oo as
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: -0(/P-y) n,G rt vl,c.
;BUSINESS LOCATION: +, ;: �� rr�r¢y c, o )
° MAILINGADDRESS: Mail To:
a TELEPHONE NUMBER: J(4 '� Z a ! - b i O Board of Health
� -� it
Town of Barnstable
CONTACT.P,ERSON t
P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601
TYPEOFBUSINESS: r ,d nn I C7
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered.YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS: Q - 14.e'e(J0 h 've ,��. r �� 6 z
TELEPHONE:, b � 13 a
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic.or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
'✓ Antifreeze(for gasoline or coolant sy stems) 19 Drain cleaners
a
NEW USED 0 Cesspool cleaners
Automatic transmission fluid 0 Disinfectants
' E.r-iaine..an.dyrad ator.flushes_ , __.��. _. , , . _ - ? Road_Sali_.(
i
Hydraulic fluid (including brake fluid) 0 Refrigerants
? Motor oils Pesticides
NEW USED insecticides herbicides rodenticides
Gasoline, Jet Fuel Photochemicals (Fixers)
.0 Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
0 Degreasers for driveways & garages Wood preservatives (creosote)
C? Battery acid (electrolyte) _ Swimming pool chlorine
10 Rustproofers Lye or caustic soda
0 Car wash detergents `C? Jewelry cleaners
Car waxes and polishes0 Leather dyes
Asphalt & roofing tar 0 Fertilizers
0 Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
E NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers,
Any other products with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
Floor & furniture strippers hydrochloric acid, other acids)
l Metal polishes
rl� Laundry soil & stain removers o Other products not listed which you feel
(including bleach) maybe toxic.or hazardous (please Fist):
Spot removers & cleaning fluids
Q (dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
IT T
TOWN OF BARNSTABLE
LOCATION '7 iL ici lio", :� SEWAGE# 30 t 1 - y 3-1
VILLAGE CtA)Ver t J I p ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.mr A ?if['ha3n) �AX
SEPTIC TANK CAPACITY i SC27 hX ni►N�
LEACHING FACILITY:(type) SZ�0gccJJC!,j O -gyp (size)
NO.OF BEDROOMS 3
OWNER
PERMIT DATE: � J��l /I COMPLIANCE'DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to.the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If;any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leachin facility) Feet
FURNISHED BY ""_
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Neu)
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No. t / Fee t/ Dd
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitatlon for Disposal 6pstem Construttion permit
Application for a Permit to Construct( ) Repair(11 pgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. / Owne4r,'s Name,Address,and Tel.No.
Assessor's Map/Parcel ;?20( ®q ✓� /
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
�O -4f A �jfacw✓ 5zo_N
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 14600 sq.ft. Garbage Grinder( )
Other Type of Building ��,�9� No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 13?,0 gpd Design flow provided 3 S7'2 gpd
Plan Date ///j . Number of sheets Revision Date
Title o
Size of Septic Tank /f�jNS Type of S.A.S.��(y��
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Sys �/wrw �j. •s as Reseseye Arec,�
t✓9 1^%.A1,111 heIn , AMCdc n6f A a. J .c 0
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed � Date
Application Approved by Date
pp 1c o Disapproved by Date
for the following reasons
Permit No. 0 Date Issued C 2 Z—I
a_ �
No. =W�l — Fee OU �----
�� THE COMMONWEALTH OFIMASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS j
2pplicatlon for Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair(grade Abandon( )s ❑Complete System ❑Individual Components
i
Location Address or Lot No. 7 J.I�, ✓r g u•o lrrN�r�w� Ovine �s Name,
p, Address,and Tel.No.
; v
Assessor's Map/Parcel a2e( •.(� '� '� �' ,,;
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
.moo ��5 A �j/vu�✓ -TNe- Ste-
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size ,//7G sq.ft. Garbage Grinder( )
Other Type of Building ,,,,. No.ofPersons Showers( ) Cafeteria( )
Other Fixtures
i
Design Flow(min.required) 3$n gpd Design flow provided 3 5`2 gpd
Plan Date //121 hyl— Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. rr)e2 1 )Ac,, , -_�
Description of Soil
Nature of Repairs
or Alterations(Answer when applicable)�ye_,&,//A&W 5 A ,5 A3 Res t/ve d(ioc.4�t
61
7 —a o C ty,ex
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed B <z- Date r
t Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. t I Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(4o< Upgraded( )
Abandoned( )by �� j� �.i / T
at? �,Sri f piJ ��r,,i/-t rde 1/ram has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated jj�_ 1-9 I )1}
`z 3
Installer. � zwt iry r�N Designer
#bedrooms Approved design flow :10 gpd
The issuance of this permit shall not be construed as a guarantee that the system whl funclio 'as designed.
Date �} �'� Inspector
----------------------------------------------------------------------------------------------------------------------------------------
No. OC1 O/(— ��� Fee /
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
3Disposal *pstem Construction i3ermit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at �7 Ad
!( V1,11
-t
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to cCdply with PL✓
Title 5 and the following local provisions or special conditions. '151-k5
Provided:/Construction must be completed within three years of the date of this permit.
�
Date / 7= � ��� Approved by i� M
I
Town of Barnstable
Regulatory Services
Thomas.F. Geiler,Director
Public 'Jealth Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: :1,1 Sewage Permit# o Assessor's Map/Parcel
Installer&Designer Certification Form
Designer: W a f li s, InS . Installer: llnal,5 A Bred Q TIC
Address: )z W. C.rb S s :e 1e1 iz4. Address: I
rw 3-4 e, t{ . M A— 6 Z,6 C0Qkf_r\A L_ M� 3�--
On 12 22- / � ,s & 'Breczti was issued a permit to install a
(date' (installer)
septic system at 7 Harr,'s > based on a design drawn by
(address
dated
(designer)
V I certifY that the stem referenced above was installed substantially according to
septic
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.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. Stripout(if required) was ' cted and the soils
were found satisfactory. t1 OFM,gss
� qc
ER
- d McENTEE
ler s lgnature) CIVIL
.0 9 No:35109�
STS
(Designer's Signature) (Affix Design- re)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice fommsWesignercertification form.doc
I,
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
N
Inspection results must be submitted on this form or on the official Title 5 Ins 'on form dpted
6115/2000.Inspection forms may not be altered in any way. f
A. Certification d S �
Important: _
When filling out 1. Property Information: . :0
forms on the
computer,use 7 Harrison Road
only the tab key Property Addressto '
not or-do ur Marcio Coelho CDP"
curs
use the return Owners Name
key. 27 Shammas Lane
Owner's Address
Marstons Mills MA 02648
Cityrrown State Zip Code
Date of Inspection: 10/21/2005
Date
2. Inspector.
Sean B. Skehill
Name of Inspector
Tomily Corp.
Company Name
P.O. Box 959
Company Address
North Falmouth MA 02556
Cityrrown State Zap Code
608-563-5877
Telephone Number
Cert'fication 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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Need �u�rthe/rZvjaaon by the Local Approving Authority
10/21/2005
In or 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.
t5insp2.doc•112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
_ — I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cunt.)
7 Harrison Lane
Property Address
Centerville MA 02632
Cityfrown State Zip Code
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Residence has finished basement with no additional bedrooms. Owner stated,5 residents reside
here. Permit for basement was issued by Town of Barnstable.
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, 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 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.
ND Explain:
t5insp2.doc•112004 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
UVNot for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
7 Harrison Road
Property Address
Centerville MA 02632
Cityrrown state Zip Code
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
B) System Conditionally Passes(cunt.):
❑ 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
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
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 CHAR
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
Lt5insp2.doc•1 U2004 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cunt.)
7 Harrison Road
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Marcio Coelho 10/21/2005
Owners Name Date of Inspection
Board of Health(cont):
C Further Evaluation is Required b the oa )
)
eq Y (
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 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.
t5insp2.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
J
saw
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certificabon (cont.)
7 Harrison Road
Property Address
Centerville MA 02632
cityrrown . state ZipCode
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
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%day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the 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 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.]
Yes No
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 31.0 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.
t5insp2.doc•11/2004 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 5 of 16
Commonwealth of Massachusetts . �.
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cunt.)
7 Harrison Road
Property Address
Centerville MA 02632
Citylrown State rip Code
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
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.
t5insp2.doc•112004 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
7 Harrison Lane
Property Address
Centerville MA 02632
cityrrown State Zip Code
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
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(3)(b)j
t5ins 2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Disposal P nspedw Sewage �sPosa System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
7 Harrison Lane
Property Address
Centerville MA 02632
City/Town State Zip Code
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
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): 330gpd
Number of current residents:
5
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 667gpd+
9 ( y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CM N/A
R 15.203): N/AGallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
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: N/A
Last date of occupancy/use: N/A
Date
Other(describe):
t5insp2.doc•11/2004 Title 5 official Inspection Form:Subsurface Sewage Disposal System
Page 8of16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt.)
7 Harrison Lane
Property Address
Centerville MA 02632
Citylrown State Zip Code
Marcio Coelho 10/21/2005
Owners Name Date of Inspection
General Information
Pumping Records:
Source of information: Owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: 1500 gal. done 6/17/2005 by E.F Winslow
gallons
How was quantity pumped determined? receipt provided by owner
Reason for pumping: Regular Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components,date installed(if known)and source of information:
2.5 yrs.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp2.doc.11/2004 Title 5 Offx:ial Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not.for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt.)
7 Harrison Road
Property Address
Centerville MA 02632
Citylrown State Zip Code
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage,etc.):
All in good condition
Septic Tank(locate on site plan):
Depth below grade: 12"feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list N/A
age' years
Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ® No
certificate)
Dimensions: 1500 gal.tank
Sludge depth:
5"
Distance from top of sludge to bottom of outlet tee or baffle
26"
2„
Scum thickness
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Stick Measurement
t5insp2.doc.112004 Tide 5 Oftal Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt.)
7 Harrison Lane
Property Address
Centerville MA 02632
cityrrown. State Zip Code
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump every 2 years with current use
Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: NIADate
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: N/A
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
t5inW.doc•1 U2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt.)
7 Harrison Lane
Property Address
Centerville MA 02632
Cityrrown state Zip Code
Marcia,Coelho 10/21/2005
Owners Name Date of Inspection
Tight or Holding Tank(cont.)
Dimensions: NIA
Capacity: N/A
p ty' gallons
Design Flow:
N/A
gallons per day
Alarm present: ❑ Yes ® No
Alarm level: N/A Alarm in working order: ❑ Yes❑ No
Date.of last pumping: N/A
Date
Comments(condition of alarm and float switches,etc.):
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
W
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 could not be located on site. No as built plan available.
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp2.doc.11/2OD4 Title 5 Oftal Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 .Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt.)
7 Harrison Lane
Property Address
Centerville MA 02632
City/Town State zip code
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
As built plan not availabe. System is young and appears to be functioning well.
Type:
® leaching pits number. 1 @ 1000gal.??
❑ leaching chambers number: N/A
❑ leaching galleries number: N/A
❑ leaching trenches number, length: N/A
❑ leaching fields number, dimensions:
N/A
❑ overflow cesspool number: N/A
❑ innovative/altemative system
Type/name of technology: N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
Grading is good, no indications of failures of any nature
t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt:)
7 Harrison Lane
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer WA
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction WA
Indication of groundwater inflow ❑ Yes ® No
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: N/A
Dimensions WA
Depth of solids N/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5insp2.doc•112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
q Subsurface Sewage Disposal System Form
4 r•
C. System Information (cont.)
7 Harrison Lane
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Marcio Coelho 10/21/2005
Owner's Name Date of Inspection
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 feet.
Locate where public water supply enters the building.
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t5insp2.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
7 Harrison Lane
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Marcia,Coelho 10/21/2005
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water.
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: N/A
Data
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Reviewed 9
design plans in general area submitted to BOH
P
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Review of Design plan soil logs in general area
t5insp2.doc•I M004 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
t
Town of Barnstable . P# elo, 377-------
°``►�r0"rti
Department of Regulatory Services
aA MASSHMO Public Health Division Date �
M,►as.
�Al fo1 f•�0� 200 Main Street,Hyannis MA 02601
Date Scheduled Time Fee Pd.
Soil Suitability Assessment for Sewage Disposal
Witnessed By: 'f Gr✓I�U
Performed By: -
M.-ME
jr4i'':'jyi�i.1 i."' ` 7.....L... y..ir.: : 1 t". 1 i. Vi � :.I i ...i: 1 Ii♦Y i 1 6:
L`��"iyr.t �
!I'u�iry( Li'ai. •'�P, .i 'I �L...
l. aiuti ,uP �4 I aa:. n . Owner's Name` t
Location Address .7 I1tiff 50 V' rd j�vre,� .5L� X L-
'f Address a
C e r7z-e, -V.- d Z
Assessor's Map/Parcel: ;a l-UY 3 Engineer's Name
NEW CONSTRUCTION REPAIR Telephone#
Land UseI le P_ S�CJ e h �i / Slopes(°/,) � Surface Stones
Distances from: Open Water Body �� Possible Wet Area
ft Drinking Water Well �ft
Drainage Way ft Property Line
d f ft Other �- ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes)
lz. T
2 � '
lz��
-x�
A/ 4aT
U r / U �
0
� lV�D I �,
v c�
D E C 6 2002 g -
TOWN OF BARNSTABLE
HEALTH DEPT.
Parent material(geologic) 4=A PZ-VET Depth to Bedrock
Imo/♦4 weeping from Pit Face
Depth to Groundwater: Standing Water in Hole: P
Estimated Seasonal High Groundwater — {{ ra{
r 10,
'
ME
1 Sam
�lnz�' Iti!k MAN
? k
Nilf�ni'i�! nu �. � a��zr ��,�
Method Used: in. Depth to soil mottles: 1D
Depth Observed standing in obs.hole: in. Groundwater Adjustment ft.
--I Depth to wAJA6eeping from side of obs.hole: Ad' factor Adj.Groundwater Level_
Index Well# Reading Date: Index Well level_ - j.
t r I; 7. 9
ry, y g
01.i.;,°y•(n. ° �r �.AL''aSIk' pTry' '1 y7 •`
Observation 2„ Time at 9"
Hole#
Q 4?6—4,,,e Time at 6"
Depth of Pere
Start Pre-soak Time
® G�� /SM i 7 Time(9"-6')
End Pre-soak
Rate MinAnch Z M
✓ Site Failed: Additional Testing Needed(Y"
Site Suitability Assessment: Site Passed —
Original: Public Health Division Observation Hole Data To Be Completed on Back
..:::: .Sl�rv.?d:{r.: •.vl;ll .r .a ,,..I.I:k� ..:ry'•�yl-r :.�4}: :: ,r :I� j; `; :'ti �'". ,'1 ;ji,,.,'�,�..T GI� j0.
.� NE'I"�i• " � e
a is a r�
„j f a. ,. � ��x 1 y'��
�lCR r __ a .: L1 I L S :.:..
Depth from Soil IIorizon Soil Texture Soil Color oil Other
Surface(in.) (USDA) '(Munsell) Mottling Structure,Stones,Boulders.
Consistency,%Gravel
,. c. v o,.z y , j✓2 ,�/�
ti �
�c�'r •c,-, sy
C&nrs�.So•, �eayR i�
ZLI! CZ y`l'6fe/ V
I., .0
I t
tI€,`kJ�fi. ��y•'�.i;� �'p' ,,,{�u - ,'j. �� y i ,. .... ., ..�
alta�u'bb > -.�I $011
Depth from Soil Horizon Soil Texture Soil Color
Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consistency.%Gravel
..
40
w
,.... .,.',; I l�s�.
l - Y
4, J.'...:. 1 "�
Soil Other �61I�k IA �d
i R 2hXh. 4e'�4R
Depth from Soil Horizon Soil Texture Soil Color
Surface(in.) (USDA), •.�, .. (Munsell) Mottling Structure,Stones,Boulders.
Consistency,%Gravel
{ .� Ir,,�: I jr ,
R1fi II lit'� hu �' j �, ! ''t� 't'� �h I nII..jT.. 5�•w�ll'Ili
,. }:; ., .I ��II �� III•' S.b...I
�dJ llil'a i'7!'°4:tF 'vU411S��.1 ,. � 'i j , , '• Iw Rr 7614..
a dnnl dy H , 1 t , a..MINOR" '�. "a..` Soil Other
Depth from Soil Horizon Soil Texture Soil Color
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consistency,%Gravel
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No_ Yes
Within 100 year flood boundary No_ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in:all areas
.area throughout the
area proposed for the soil absorption system? Xe
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on /-f�O`J `I' (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 and experience described in 310 CMR 15.017.
Signature
�J�- Date
r No. Zoo Z"��� ` . � Fee /00�.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Migpogat 6pelem Con.5truction Permit
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) Ll Complete System ❑Individual Components
Location Address or Lot No. ':7 t4a fJ-,S o wN a Owner's Name,Address and Tel.No.
Assessor's
a
WVi keg_, Z IP`MR vz63 ,i c a ��s 913.21
el
Installer's Name,Addre s,and Tel.No. Designer's N e,Address and Tel1l_No.
a -T: 3 e�e I a c$ �a a"S-4-. C•2. ST► a V-'t- P. t .
p.0,R-X 6ag, Rres4lCe_, 01A 6__08_Y3 33r C-0-t- We ler�a6 0
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder WO)
Other Type of Building NO.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33 a gallons per day. Calculated daily flow gallons.
Plan Date - 1 0 D.- Number of sheets Revision Date
Title S40 w 0�-2 S` a� /v 2 S'v �- S 2 �- �?o S�
Size of Septic Tank ype of S.A.S. y S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the cons tion and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 e Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue y bard f Health.
Signed Date "'A d 2—
Application Approved by Date / 2 p 2
Application Disapproved for the following reasons
Permit No. ',57'70 Date Issued O
No.n l/LJ 2 5 /o c _ c ii„ ^Yev /,00 '
THE COMMONWEALTH OF MASSACHUSETTS Entered"in computer:
P Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS,
01ppYtcatton for Mt.5pozal *pstem Congtructton ,,permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Z Complete System ❑Individual Components
Location Address or Lot No. -7 Pa nl Owner's Name,Address and Tel.No.
Assessor's el ���-�►'u� lt_t�� WIf� ,�]632 p tC� �Cff.KS { ` C
��/Pasc � �'
Installer's Name,Addre s,and Tel.No. Designer's Name,Address and Tel.No.
T eve a c �a Cv�S`E.T CT a, S k�,_,t
p. .3.k 6D_9 Fo�5A cl,G. IAA ��&-�'3 33 r 4:6e r (;d�'e-, 4Zr ,•.
Type of Building: i
Dwelling No.of Bedrooms c: Lot Size �i sq.ft. Garbage Grinder W11)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 gallons per day. Calculated daily flow gallons.
Plan Date I I a I `��- Number of sheets I Revision Date
Title 16", P, /)/•oPOP9 S In c- I)tS�oS
Size of Septic Tank r, b 0-" rrccQ. ype of S.A.S. y S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
-Date last inspected:
Agreement:
The undersigned agrees to ensure the constxCiction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5p•f e Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued'by s and of Health.
Signed Date I'Z d 2__
Application Approved by Date / 2 U-2-
Application Disapproved for the following reasons
Permit No. 2��Z `,a'70 � Date Issued D
——————————————L———————————————————————--
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
at 7 f44 k t S611 C FAIT ER V/L LE has been constructel iq accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2G 6 7_-S&dated 1216110 2-
Installer Designer
The issuance of °'s permit shall of be construed as a guarantee that the systemi3il ate ti coon asdesigned.
Date y / 6 3 Inspector Yv
---------------------------------------
No. 2 t0 2—520 Fee /6 6
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwtzpozal p5tem Congtruction Vermtt
Permission is hereby granted to Construct(✓Repair( )Upgrade( Abandon
System located at W�(�'�1 SQ N �
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:Constru do must be completed within three years of the date of this pe
Date:_ �i Approved by —
TOWN OF BARNST
LOCATION Har-11SCOPonSEWAGE # /VhhG.r�TV
VILLAGE ASSESSOR'S MAP & LOT2L
INSTALLER'S NAME&PH NE N0. V Ib5l ,6-
sEPTIc508 � 33 �£�g9onn�h�
OO
LEACHING FACILITY:�( pe)
tk size)��v
NO. OF BEDROOMS
BUDDER OR OWNER (—"C,1,,=d Hows
PERMITDATE: JL * 6 * 02 COMPLIANCE DATE:' ' ( � 0—�)
Separation Distance Between the:
_ Y
_Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Fumished by
E - 31'
ZA _
B " 2-1'6�
C- ZI I E A
'D --,34`
P 3 to
C 8 �
2
'R.E AR J:2OWJ
TOWN OF BARNST LE
LOCATION a�r� Orel SEWAGE #:20M r6�
VILLAGE ASSESSOR'S MAP I LOT
INSTALLER'S NAME&PH NE NO. V I
SEPTIC CAPACITY
F�q9
- - 4 --
LEACHING FACILITY:
NO. OF BEDROOMS
BUILDER OR OWNER How
PERMITDATE: 1G 02 COMPLIANCE DATE:'
I
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
E = 31' i
-44 �O
B PT
C _ 29 , E
,D `34
3jo , o
-7c a 1
E AfL
l:rZ
E
1 :
Vi
- — --- 4B'-O" — V LLI
r 4'-5°_— ---- 7'-0r 14 6 7-0. _
ff~��. - AND. Z,46 AND. 2432 AND. 2432 .,_ ' AND. 2446cc 11D
.
12 8 ` 6Q — "2,-4" T,-6, -
-- __'
30 14-2'1/2° AND. 244 .� U
BAT1-1 _
BATH
6
BEDROOM 24
LOSET
1 24 24 MASTER °
BEDROOM .
PALL 2¢
,
N
AND. 244
I
WALK-IN
` - CLOSET . .. AC ESS �y
4' KNEE WALL
LINE OF CEILING CLIP ABOVE - -
o�OPEN TO
--BELOW AC
c 4' KNEE WALL _
77
.: - ...
z
14 O
.. ... -=------ p
N
C�
O
SECOND .:" .LOOK PLAN ' SHEET
.- SCALE: 1/4" = 1'-C° .
A4
,2k
JOB: 0206
DRAWN. BY: KW
DATE: 4/25/O2
'o
QO ) 4W - -
12'-4° 11'-20
uj
DECKtu
O
n
.. .: D. 2432 AND 2432
9
6Q SLIDER LITE ate-
2$
- W
KITCHEN- 00 `" Ia AUNDRY V
BULK HEAD 23'-20 3'-41 3'-6" 3'-11 14'-0°
I-FLD '
AND. 2446-2 m ISLAND .
o BREAKFAST 6EF: o 2k
24 .. _ AND. 2446
. 2A 1 �` S 2. FIRE N
`9 & m RATED GARAGE
(3) 9 I/4° LVL'" ABOVE FLUSH DN I CONCRETE SLAB
4'-pu v PITCH TO DOOR N
LOS Cr
1
s
(VAULTED CEILINGBEDROOM ... -A 1
CV ). /
BI=FLD—
_ �] m LIVINGFAMILY
.7'x9' O.H. DOOR
U
-6 2'-4" 12'-6' is p
3Q <
AND. 2446 AND. 2446 AND 2446 AND.2446 .�
Cc
�0/ Z
A' 0°. 51-10" 7'-2" 7'-2r 5' Ipr 41-00 71 0r T-O° ..0
4.
.. 48 O
r)
c.
. - .
F(RST 'FL'OOR PLAN
SCALE: 114" _ 1'-0" S SHEET
I
AS
11
G JOB. 0206
DRAWN BY. KW
DATE. 1/24/02
I
SOIL TES 3 7 7
P K q L /^j z OAa DATE OF SOIL TEST J/ lj o Z .
TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLAR 4•PVC VENT PIPE SOIL TEST DONE BY �" + +��'. !'�.
ELEV. = S�/00 10 FT. MINIMUM
10 FT. MINIMUM FROM SLAB OR CRAW!- SPACE PADaW nAT DMK WITNESSED BY -.��_ v 7'39�V 1'70iv .Q a I
CJEANSAND Gar, OBSERVATION HOLE 1 ELEV.-���
� m4 OBSERVATION HOLE 2 ELEV:- ��'•'Z
COVERS IOA►/AND SEE D FILTER IS PERCOLATION RATE 42 MIN./INCH AT 2 6#40 INCHES PERCOLATION RATE 'CP MIN./INCH AT A- INCHES
4" SCHEDULE 40 PVC PIPE y LAY'.r].OF DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH HORIZ TEXTURE COLOR MO TT. OTHER
PI TCH 1/8" PER FT. ` ur WA TO lir TWICE
jo O rr�•••bl r a ft. O �',,•t3/t
ELEV.•,•4 7,,r Max ELll V- r..✓ A A. •+.�/ 1 oyna � 9 / A A' •o&'*y O r A0
4` CAST IRON PIPE -2% ,/�,�„�' 9 /9 rJt•1 4 3 o
(OR EQUAL) MINIMUM 6,
PITCH 1/4" vcR FT. YM M -�-- ND rQ �� / d"�. ii �+ � ii ,0e, i�
s •48 s/L F� •rz. Z
F1 Iry >r r S ,i
FLOW LINE �¢
ELEV. _ .(v00 10` -4 �� .ads �Z el.W2.75 cam oJG �OyiC
-'T MIN. ,��2.5- 2 O' o • o O C� O d O G . y 5�17 / Ale
1 ELEV. _ LEVEL r • d, O O co O O d o 0 0 cake✓./! /0 /'� • C SI d
ELEV. _ _�S,SO GAS ELEV. 6"SUMP El EEVV =s14.84 d cm CO d CO d o
BAFFLE - ---DISTRIBUTION - / ° o o C= o o m o °I° F1.Ey ��/•7J' x N �i•.is✓e�
LIQUID OUTLETLEJ 2 J / 2d �V. �vc/ /ZO
• p�v S00 dlAI.DIRYWELLS(OR EQUAL)WMMMEDI •
a FEET 14 INCHES DEPTH TEE (TO BE PLACED ON FIRM BASE) TO BE WATER TESTED ' A ELEV. _ __ •
4 FEET 14 INCHES IF MORE THAN ONE OUTLET 13 X PS it 2 TR04CH FORMATION � � A D WATER ENCOUNTERED AT �2 � •, '�f L G i✓O WATER ENCOUNTERED AT ����,ELEV. • 3 L Z
7 FEET 29 INCHES 1500 GALLON (TO BE PLACED ON FIRM BASE) ,SQjj, ABSORPTION h 4f 'u �4
zoo
SYSTEM (SAS)DOUBLE WASHED STONE
IxDUS LEGEND: DESIGN CALCULATIONS
FREE OF FINES k SILT ADJUST EXISTING SPOT ELEVATION 00„0 NUMBER OF BEDROOMS '3
EXISTING CONTOUR ----DO---- GARBAGE DISPOSAL UNIT Nc
USt3S PROBABLE WATER TAB] ELEV.- FINAL SPOT ELEVATION TOTAL ESTIMATED FLOW
SEWAGE DISPOSAL SYSTEM PROFILE FINAL CONTOUR 330 GAL./DAY
NOT TO SCALE 08.S&RVEDWA.'ff3tTAlsLE( � / )EL6V
Banum��sT wu F1.6V•- SOIL TEST LOCATION REQUIRED SEPTIC TANK CAPACITY t35 GAL.
UTILITY POLE -0- ACTUAL SIZE OF SEPTIC TANK / , o GAL.
TOWN WATER —W --- SOIL CLASSIFICATION =
CATCH BASIN `"'I DESIGN PERCOLATION RATE
GAS LINE EFFLUENT LOADING RATE , , 0.74 GAL./DAY/S.F.
CLEAN OUT C .. LEACHING AREA / 3;tZf •►- 74 A 7 SO. FT.
CESSPOOL C.P. Q LEACHING CAPACITY (AREA X RATE) -AM GAL/D�kY
RESERVE LEACHING CAPACITY , GAL./DAY
/ / TH ROAD NOTES:
�� L M O v 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P.
O TE Q TITLE 5 AND THE TOWN RULES .AND REGULATIONS FOR THE SUBSURFACE
R / U DISPOSAL OF SEWAGE.
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
WITHIN 6" OF FINISHED GRADE.
' 3. ALL COMPONENTS OF T iE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN
10 FT. OF DRIVES ORPARKING AREAS. H-20 LOADING SHALL BE
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS.
4. 'ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL
r0 `` BE MORTARED IN PLACE.
5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
g��-6etK£ Pit 1�'r DEEDED OR ZONING REGULATIONS. OWNER /:APPUCANT IS TO
_ _ OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
6, UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR
IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS
PRIOR TO COMMENCING WORK ON SITE.
7. CONTRACTOR IS TO VERIFY GRADES_ AND ELEVATIONS AS WELL AS
SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. ANY VARIATION
ite 5 /t IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER
�m� s,A.s• , ` IMMEDIATELY. C
8. PARCEL IS IN FLOOD ZONE _.___�
9. LOT IS SHOWN ON ASSESSORS MAP AS PARCEL .
10. ALL UNSUITABLE MATERIAL SHALL BE REMOVED FROM UNDER. AND
FOR A MINIMUM OF 5 FEET FROM AROUND THE SOIL ABSORPTION SYSTEM,
AND BE REPLACED WITH SAND AS .SPECIFIED IN 310 CMR 15.255: (3)
(I.E. TITLE 5) IF ENCOUNTERED BELOW S.A.S. PIPE INVERT.
WMAX
• .: i . ' w6mii.KA) H OF
'�,+
bRAI
Z3 GA/L . \ - _,�. : c SHORT i w`I" •
rw- _ , f 4 . . APPROVED,_ _ - _ t CIVIL 1lED BOARD OF HEALTH
No. 274
' ra ti: qF
Zj vV
4' `t- _ S1`� DATE A '
Z3 GENT
w,l� Qv�44 c?as
r� ►�; 'ROPOS D SEP'TIIO DESIGN
[ A x Ar FOR
SUNRISE REALTY TRUST
LOT 13 --- '• \ / s? \�,
77,600f S.F. ZO LOC. i ON 13
BAPIMABI4. -MASS•,
N�'�'�,s s.✓ ry ANIS,,-MASS. .
Ait
T
235 GREAT WESTERN "LOAD
,,,,,,� '�/ 338-8311. S H 026GU
4 3 -• oATE ��/r�/.el,z • sCA1� � �� _ 20' . ,
( REVISED
LOCATION 'MAP " REVISED SHEET OF.