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HomeMy WebLinkAbout0064 HARRISON ROAD - Health 64 Harris.oh Road Centerville P A = 229 077 e Omrford. NO. 1521/3 ORA ;i•.� 10% k c Commonwealth of Massachusetts9_ Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address ' Henson Owner Owner's Name / information is Centerville ✓ Ma 02632 9/5/2019 required for every ' page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information <54 M11(P on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co Company Address Centerville Ma 02632 , City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestltle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/5/2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 64 Harrison Rd Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 500 gallon precast leaching chambers. The system was found to be in proper working condition at the time of inspection. 2) 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): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'Av 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, -safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary.to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the.SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' .1' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) 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: current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 19 1 Subsurface Sewage Disposal System Form - Not for.Voluntary.Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(god) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No / Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: 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.): Joints in good condition, no leakage, vented through roof. I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. 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 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 211 Distance from top of scum to top of outlet tee.or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet, tank was not leaking and was structurally sound. Suggest installing risers and new covers to make access easier. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 011 y Comments (note if box is'level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. was video inspected and was found dry with a stain line only a few inches from bottom f .. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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: i ® hand-sketch in the area below ❑ drawing attached separately r31. !O SrC� IAA- ace %A . a Za lA3. ;A Q to . I 3 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 64 Harrison Road Property Address Henson Owner Owner's Name information is required for every Centerville Ma 02632 9/5/2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached I For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 A a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return key. Name of Inspector B & B Excavation,lnc. �p Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 Cityrrown State Zip Code 508-477-0653 S 113640 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 � tenanc&bf one sewage disposal systems. I am a DEP approved system inspector pursuant ection tff.340 Title 5(310 CMR 15.000). The system: �- r, P Q ® Passes ❑ Conditionally Passes ❑ ❑ Needs Further Evaluation by the Local Approving Authority 6/17/13 oll Inspector's Sig ature f Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Y W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 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 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® 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 CM 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Sver 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is Centerville MA 02632 6/14/13 required for 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): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 J i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 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 I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10, feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage. 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 Sludge depth: no sludge t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts , - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is Centerville MA 02632 6/14/13 required for 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts s W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is Centerville MA 02632 6/14/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in good condition. No signs of carry over or back-up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching is dry and appears to be in good working condition. No sign of 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 t5mn •1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 3 Commonwealth of Massachusetts Tine 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64-Harrison`Road Property Address ,Nat ie Jones, Trustee Owner Owners:Name information is required.forevery Centerville MA 02632 6/14/13 page. city/Town State Zip Code Date of Inspection D. 'System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below :El drawing-attached separately ►32- � �, A W DE She o ® 3 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name Information Is Centerville MA 02632 6/14/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: no gw @ 124" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 8/23/99 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: plan on file @ BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • < Commonwealth of Massachusetts Title 5 Official Inspection Form Raw- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Harrison Road Property Address Natalie Jones, Trustee Owner Owner's Name information is required for every Centerville MA 02632 6/14/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED SEP 1 8 2002 TITLE 5 T�WARNSTABLE HEOALTBH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION . Property Address: 64 Harrison Road Centerville, MA 02632 Owner's Name: Kenneth Pace Owner's Address: Same Date of Inspection: August 21, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 229 Osterville, MA 02655-0049 Parcel: 077 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs ru her Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: August 23, 2002 The system inspector shall subm copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 e Page 2 of 11 z OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 64 Harrison Road Centerville, MA Owner: Kenneth Pace Date of Inspection: August 21, 2002 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. 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: 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: 2 Page 3 of I l c:. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 64 Harrison Road Centerville, MA Owner: Kenneth Pace Date of Inspection: August 21, 2002 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 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 64 Harrison Road Centerville, AM Owner: Kenneth Pace Date of Inspection: August 21, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backupof sewage into facility or stem component due to overloaded or clogged SAS or cesspool g h' Y P gg ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ✓ 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.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 64 Harrison Road Centerville, MA Owner: Kenneth Pace Date of Inspection: August 21, 2002 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: Yes No ✓ 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)]. 5 Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 64 Harrison Road Centerville, MA Owner: Kenneth Pace Date of Inspection: August 21, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 220 Number of current residents: I Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: None on file-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ 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: July 27199-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Harrison Road Centerville, MA Owner: Kenneth Pace Date of Inspection: August 21, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Approx. 25" Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 15" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500,gal. Sludge depth: /" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs ofleakaze. The tank was H-20 GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Harrison Road Centerville, MA Owner: Kenneth Pace Date of Inspection: August 21, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc,): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. There were no signs of solids. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 r Page 9 of 11 .1. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Harrison Road Centerville, MA Owner: Kenneth Pace Date of Inspection: August 21, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: ✓ leaching galleries,number: 2-500 gal. chambers- 12'x 25'(per design plans) 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.): 1 dug down in the stone beside the chambers and the stone was clean There were no signs of failure The bottom to grade was approximately 5. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): I 9 V Page 10 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Harrison Road Centerville, MA Owner: Kenneth Pace Date of Inspection: August 21, 2002 Map: 229 Parcel: 077 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. A I- al cv Q A3- D-9 FO 0 3 10 v Page I 1 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Harrison Road Centerville, MA Owner: Kenneth Pace Date of Inspection: August 21, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to round water feet P g , Please indicate (check) all methods used to determine the high ground water elevation: ✓ Obtained from system design plans on record- If checked, date of design plan reviewed: 7199 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: The bottom of the leach field to grade was approximately 5. Per the design plans no water was found at 124"when the system was installed. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 TOWN OFpBA1RNSTABLE LOCt':TION Arr/'i s m FC� SEWAGE # �� -'v ILLAGE 'QZ^4—erv�66— ASSESSOR'S MAP & LOT IIYSTALLER'S NAME&PHONE NO. 1 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) C1 5'010 SAI. Ci IAA-�tO(size) /01 x oZ�, NO. OF BEDROOMS BUILDER OR OWNER ke*-,, PERMITDATE: 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 leachif'g facility)—Y, �O� Feet Furnished by�.:�22 �t�tt� J , At Co A9, ace A3- JO (33_ to i 3 Sullivan Engineering Inc. 7 Parker Road Box 659 Osterville MA 02655 Peter Sullivan P.E . Mass. Registration No. 29733 508-428-3344 fax 508-428-3115 August 19, 1999 Town of Barnstable Board of Health 367 Main Street Hyannis, MA 02601 RE: 64 Harrison Road, Centerville, MA Dear Board of Health, On July 26, 1999, in conjunction with Jerry Dunning, Town of Barnstable Health Agent, I conducted an on site inspection of the septic system installation at 64 Harrison Road in Centerville. I found the system to be in substantial compliance with the variances granted by the Board of Health. Very truly yours, (:�i Lo Peter Sullivan PE Sullivan Engineering Inc. Members of American Society of Civil Engineers, Boston Society of Civil Engineers Town of Barnstable Department of Health, Safety, and Environmental Services BARNSTABM 1 39. 1� Public Health Division �FDa P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A McKean,RS,CHO FAX: 508-790-6304 Director of Public Health March 5, 1999 Peter Sullivan , P.E. Sullivan Engineering Inc. 7 Parker Rd., Osterville, MA, 02655 RE: 64 Harrison Rd., Centerville Dear Mr. Sullivan, You are granted variances on behalf of your client, Margo Culley,_to install a replacement on-site sewage disposal system at 64 Harrison Road, Centerville, MA. The following variances are granted: • 310 CNIR 15.211 To install a soil absorption system two feet away from the side property line and three feet away from the front property line, in lieu of the required minimum separation distance of ten feet. • Part VIH, Section 10.00 To install a soil absorption system 65 feet away from a wetland in lieu of the required minimum separation distance of 100 feet. The variances are granted with the following conditions: 1. The septic system shall be installed in strict accordance with the submitted plans dated January 12, 1999. 2. The designing engineer shall revise the plan to show the proper soil profile colors in accordance with the State Environmental Code, Title V. KS -q/suliv.hrs 3. The designing engineer shall supervise the construction of the septic system and shall certify in writing to the Board of Health that the system was installed in strict accordance with the submitted plans, dated January 12, 1999. 4. The existing cesspool(s) shall be removed or abandoned properly in accordance with the State Environmental Code, Title V. These variances were granted because the existing is malfunctioning and must be replaced. The proposed septic system meets the State Environmental Code to the maximum feasible compliance criteria contained therein. Sincerely yours, Susan Rask .S. Chairman of the Board of Health. KS-q/suliv.hrs TOWN OF BARNSTABLE �✓ _ - t SEWAGE #G U it A /;?Q �- ��/ 7 �'L LOCA'i`ION / .� �1fa VILLAGE �sr�l / ASSESSOR'S MAP & LOT 6 - INSTALLER'S NAME&PHONE NO. e ; fd ' SEPTIC TANK CAPACITY LEACHING FACII,ITY: (type) �/ 1 ° (size) r'Z e1' _ NO.OF BEDROOMS o�-- BUILDER OR OWNER C C� PERMITDATE: '01"/9-7 COMPLIANCE DATE: L-2i'''S' 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 S �c 'I :. No. pet�_ Fee THE COMMONWEALTH F MA CHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN ARNSTABLES MASSACHUSETTS Rpplication for Migool proem Construction Permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 64 7AAp q 1>01�j �N V E, Owner's Name,Address and Tel.No. Lc-ry rE2�/ �-�G- q6 MA"C} L 0 Assessor's Map/Parcel 2Z�/7.7 3w ��� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. gZE� A d- 1 1��2 U L t V A,,Q 77E-� Type of Building: Dwelling No.of Bedrooms 3 Lot Size 93 GO sq.ft. Garbage Grinder 40) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Y10 gallons per day. Calculated daily flow _ gallons. Plan Date:L1 t? mil.Jam) Number of sheets Revision Date 'Z 24 99 Title � R � 5' EP i1 G �YSvt� Size of Septic Tank i Type of S.A.S. 1 Z x Z.' Description of Soil D-A `+ f 2 A L Z A ", C 0�- Q A C_ 'Z l_FnaSe t5 Cc7tS�s . .ginS©�tilc �G �SLCS Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of e E ironment ode and not to place the system in operation until a Certifi- cate of Compliance has been issupd by o 54 f gealth. Signed Date Application Approved by Date, �•' Application Disapproved for the following reasons Permit No. 39e Yr Date Issued - 'r No. L Fee THE COMMONWEALTH/OF MA $ACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN ARNSTABLES MASSACHUSETTS ZIpprication for Digooal pgtem Construction Permit Application for a.Permit to Construct( )Repair(>Q Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. G 4�Akh e v_y SOsJ A V i, Owner's Name,Address and Tel.No. Geti T-eev tAAkLGO Gu�trt�( Assessor's Map/Parcel ZZ aJ/7'7 3 L�' T L MA Installer's Name,Address,and Tel.No.0 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 'J Lot Size 9 3 C-0 sq.ft. Garbage Grinder(1l0) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures f ' r' Design Flow 330 gallons per day. Calculated daily flow 2 gallons. Plan Date 1 19�� Number of sheets 1 Revision Date 2 Z4 9 Title �fi�R�E,� ^J EP i l G S yVI 0,?6 Q.4J Size of Septic Tank I`5� Type of S.A.S. 1 Z A Z.`5 w Description-of Soil Q'A 4 Z-A �� C-Z 7-q -&13) l2q C, Nature of Repairs or Alterations(Answer when applicable) 'a 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 e E tronmenta ode and not to place the system in operation until a Certifi- i Cate of Compliance has been issu by t oaz of Health. Signed t- Date Application Approved by Date Application Disapproved for the following reasons Permit No. Y 91- Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 4 Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned 4 )by at c"q 15C) CE ill has been constructed in accordance- with the provisions of Title 5 and the for Disposal System Construction Permit No. s dated .V- : ~ Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date �`�-�p Inspectors o --------------------------------------- No. / / Fee THE COMMONWEALTH OF MASSACHUSETTS t, PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Diopozai *potent Construction Permit Permission is hereby granted`to Construct( )Re air(x)Upgrade( )Abandon( ) System located at (g (-t�k��h S(�1� 90",O C. --_ tsTF_e�� 1 ( C, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. -' Provided:Construction must be completed within three years of the date of this permit. Date: :Z_ Approved by �4', / TOWN OF B'ARNSTABLE LOCATION _l�� �f�A r, 1.)a SEWAGE # 4� VILLAGE ASSESSOR'S MAP & LOT,21 4- Lzz INSTALLER'S NAME&PHONE NO. 4 SEPTIC TANK CAPACITY 1 s:<d-<J d , LEACHING FACILITY: (type) �, 1 0 — l- �= (size) NO. OF BEDROOMS �-- BUILDER OR OWNER PERMITDATE: —/%-2 9 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 C,7 '1 W t �' r DATE s FZZ: = s MNffAets, $ � 6 9 . Town of Barnstable REC. BYJ�� q e �r Board of Health 367 Main Street,Hyannis MA.02601 Q9 A r Office: 90.6265 Susan O.Rask,R.S. S 1gg p FAX: 0-630)._ Sumner A.Kaufman,Murphy, D. VARIANCE REQUEST FORM LO Z 1 t 20,�o CF��e-d 1 t_(-E Property Addres . }�ot6z.l2lSol•.k Assessor's Map and Parcel Number: 22 9 Z -T7 Size of Lot: 0. en A L 93rdp s t= •. aiOD�u1SlON OFLAr...4O s Wetlands Within 300 Ft. Yes K Subdivision Name: 1�04 T. i► l-4r. soti. No qa ro A Pz.\1. 291 9 S Business Name: M/A APPLICANT Name: W A O-Co G ULLE-( NameJ�ErEIZ Address: 32. W C-�S �T Vj C its i~ ��- Address: `{O rig . ru A o�=5 0�379 Phone: L 9-78- 5AA - 2020 Phone:tft- AZ9 FAX: K�lA - FAX: 506- A7,0 VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more span needed) (t� Ti xt-6 S : S 6-r PbP.QC. r-9.t S o,rar_ M ax t- �1B c_E COwI t ,5 Ac 1L9 ��t a e ?rio oeQrl L�,ru s 0.41�t�.. �5' t2EQuEbt�D Clfecklist(to be completed by office staff-person receiving variance request application) ✓ Four(4)copies of plan submitted(including septic system plans and/or restaurant floor plans) Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variances only) Variance request application fee collected(fro ree for fireguard modification renewals,grove tmp variance renewals[same owner/leasee only],outside dining variance renewals[same ownerAcnee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Ralph A.Murphy,M.D. Q:/WP/VARIREQ r Sullivan Engineering Inc. 1�+ 7 Parker Road Box 659 Osterville MA 02655 Peter Sullivan P.E . Mass. Registration No. 29733 428-3344 fax 428-3115 e-mail:PSullPE@aol.com ABUTTER NOTIFICATION LETTER RE: Board of Health To Whom It May Concern, As a direct abutter to a proposed project, please be advised that a Board of Health Meeting will be held to discuss this project. The specific information is as follows: Applicant Margaret Culley for Marea Sefton Project Location 64 Harrison Road Centerville, MA 02632 Map 229 Parcel 77 Project Description Proposed upgrade of existing septic system to maximum feasible compliance. Applicant's Agent Peter Sullivan PE Sullivan Engineering Inc. 7 Parker Road Osterville, MA 02655 Public Hearing Barnstable Town Hall, Hyannis Date: Feb 23, 1999 Please call on the day of the hearing to get specific information on which room the meeting is to take place in and,at what time (meetings are held in the evening). Thank you. Sullivan Engineering Inc. 9 9 ' Box 659 Ostery i I l e MA 02655 Abutter Notification List of Direct Abutters to 64 Harrison Road, Centerville, MA Map 229 Parcel 77 Map Parcel Owner 229 76 Michael J. Murphy P O Box 132 Hyannisport, MA 02672 229 78 Ellen O. Lindgren 72 Harrison Road Centerville, MA 02632 2229 79 Peter A. & Susan I. Hern Anne H. Scanlon 40 Liberty Pole Road Hingham, MA 02043 229 80 Susie Chase Clarie Dewilde 61 Harrison Road Centerville, MA 02632 229 84 Jose & Carmelia Dasilva 1325 Falmouth Road Centerville, MA 02632 pi� — CO.�2%1ONWEALTH OF MASSACHUSETTS _ to EXECUTIVE OFFICE OF EINVIROINMETNTAL AFFAIRS t{- DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE tCINTER STREET. BOSTON KA 02105 (617) 292-550u TRUDY CORE Secre;ar% ARGEO PAUL CELLUCCI DAVID B. STRI:HS Governor Cornmissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Mar ie Property Address: 64 Harrison Rd.. NameofOwner Margo Culley/ Sefton Center }`61 MA AddressofOw : `�2 West St . , Wendell, MA Date of Inspection: /� ner Name of Inspector:(Please Print)Wm. E . Robinson Sr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) c«npanyNan,e: Wm. E . Robinson eptic Service MalingAddress: PO Box 1089, Centerville , MA Telephone Number: �8 (� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails 'Inspector's Signature: 6. .�� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS A�� 0 visa 0 0 1999 1 � y revised 9/2/98 Pagel of11 i� ✓r.^ied on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a •, PART A CERTIFICATION (continued). 'roperty Address:64 Harrison Rd.. , Centerville a--: Mar go go Culley�g Date of Inspection: INSPECTION SUMMARY: Check A, A C, o/ D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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 re aired. The system, u P P Y on P completion of the replacement or repair, as approved by the Board of Health, will pass. Indicat yes, no, or not determined.(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed y revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icorrtinued) Property Address: 64 Harrison Rd.. , Centerville , MA Owner: Margo Culley Date of Inspection: �—(;/n` 0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND,SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER I revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Pr Address: 64 Harrison Rd.. Centerville �Y r Owner: Margo Culle Date of Inspection: D. SYSTEM FAILS: / You m st indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described iri 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes o _ j Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. I 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Ye 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. a • revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prop"Address: 64 Harrison Rd.. , Centerville owner: Margo C ulle Date of Inspection: — �— Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks an&the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. Ll _ The system does not receive non-sanitary or industrial waste flow. Id/ _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. Ls _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / 115.302(3)(b)I The facility owner (and occupants,if different from owner) were provided with information on the proper maintanaurik-0f Subsurface Disposal Systems. revised 9/2/98 page 5oril SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 64 Harrison Rd.. , Centerville Owner: Margo Culle Date of Ins pection: �,� FLOW CONDITIONS RESIDENTIAL: Design flow: F 0 g.p.d./bedroom. Number of bedrooms(design):_�2— Number of bedrooms (actual): Total DESIGN flow f� Number of current residents: t� Garbage grinder(yes or no): A,0 Laundry(separate system) (yes or no);40 If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):.44- 0 Water meter readings,if available(last two year's usage(gpd): 1998 4, 000 gal. Sump Pump(yes or no):Al 0 1887 18, 000 gal. Last date of occupancy: C MERCIALfINDUSTRIAL: Type of establishment: Des i n flow: gpd 1 Based on 15.203) Basis of design flow Grea a trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or nol_ Wetei meter readings, if available: Last date of occupancy: O (Describe) Las date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)—le If yes, volume pumped: -e> gallons Reason for um in /�, P P 9 � ITYPISTEM vvy 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: '2- � t Sewage odors detected when arriving at the site: (yes or no) � 0 //V— 9,._ / revised 9/2/96 Page 6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) IroroopertyAddress: 64 Harrison Rd. , Centerville, MA Owner: Margo Culle Date of Inspection: BU DING SEWER: ILoc to on site plan) Dept below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Dist nce from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth:_ t` Distance from top of sludge to bottom of outlet tee or baffle: 1 Scum thickness: d 1 1 Distance from top of scum to top of outlet tee or baffle: S' _ -- Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and outlet ees or baffle, depth'9I liquid I vel in relation to outlet i vert, structural integrity, evidence of leakage, etc.) f-Q A r� C ` Ca ._ GREASE TRAP: (locate on site plan) Depth`�elow grade:_ Materi I of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum/thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) I OL revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .1ropertyAddress: 64 Harrison Rd.. , Centerville Owner: Margo�JCulley Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locat\on site plan) Depth b low grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (conditi i on of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: I (note if level and distribution is equal, evidence of solids carr ,ovgr, evidence of leakage into or out of box, etc.) - PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comm nts: (note c ndition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of1.1 I _. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 64 Harrison Rd.. , Cemterville , MA Owner: Margo Culley Date of Inspection: - 7— SOIL ABSORPTION SYSTEM(SAS):_V (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: leaching galleries, number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Altemative system: Name of Technology: Comments: i (note conditi n of soil, signs of hydraulic failure, level of onding, damp soil, condition of vegetation, etc.) a CESSPOOLS:_ (locate on site plan) i Number and configuration: V11 L Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Co merits: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY•:_ (locatel on site plan) Materials of construction:' Dimensions: Depth of solids: Comments: (noW) ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) '►opertyAddress: 64 Harrison Rd.. , Centerville Jwrw: Margo Culley Jate of Inspection: :�02 Q SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public.water supply comes into house) 1—i L1v i �. Kok L11( O D (5 '5- revised 9/2/98 Page10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rop"Address:64 Harrison Rd.. , Centerville owner: Margo Culley Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells x Estimated Depth to Groundwater F Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record l//Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) l revised 9/2/98 Page 11of11 / rest P V T to S-T 1-1 O t.-E L=L,1 oo Q::. Pt 7 Sty o ,� r. ,.• pwe/'�� O TO P5O1 t- sY R 2./2 :a • 40'� .� ;. .0 IBROWN AM IN SAND F 10YR 5/3 t, ''�..':��. 'u u� o •,':�° 11 C3 CpARSP- AND SOME C06pL/0 S -o `•GS • so -�u "was G� �- Il Il/ l/11/l l l /l / I / l/ l/ I/l�l/► I!�I1 / //I/II/I/ II I Il / II I I I Il: 62•r \ S °� 12 „ F- /y '•,� e _;n,< :o'n 4 Ao SOME c0113SSSoYR � eeehw 84.4 '00" E 0 e51 %112--a-wq NO GROUK •q 107. "11TI IF-55 13v a.Aut l tNw t. i ' .t.,•� at • • Fl ��D • •'" •I pp,•11 fL4,, '•' � - ! ••r 1'1.• Fa aJii� 0 / R 841 g' LOCUS PLAN_ , � - o^ m 108 1 Scale:1 -2000 h of Assessors Map 229 I I l 4 II / I I °' l I 1 1 It / / I / / / it #I / 1 / / I I Parcel 77 w I . 11 1 � 1 I ' I 1.9' 1 /! I I I I III I I I N 0 i NOTES DESIGN DATA I.Water SuDPIY FT Lot is Municipal Water. q Y- Bedroom/j n With no Garbage Grinder C= 2 Location of Utilities Shown on This Plan Are Approx. Daily Flow I10 x3=330 GPD / ProieeadsThe Cont actot 72 Hours rSholor to AMake Theny tReqion�ired 1e Use 1500 Gallon Septic Tank Plastic 0 �( C I f � " v 1 'Notification to Dig Safe(I-800-322-4844 SepticTonk1330 GPpDx200%c660 GPD 461 I Storage Q 1 g AREA S / L -- _J O / 3,The Contractor is Required to Secure Appropriate LEACHING O 1 Permits From Town Agencies For Construction ' 330 GPD/0.74=446 SF Required Defined byThis Plan. Sidewall=2(12+25')2 a 148 S.F. redto Within l2"ofa= 4. Install Risers as Re ui Bottom Ar 12'x25 F. = 300 S. Finished Grade. LEACHING 448 S.F.S Total Provided / / / / / / / Q) I I I I I I O =,'1 .moo I , ► LEACHING CHAMBERDESI6N 1 1 5.All Structures Buried Four Feet or More or Subject' All Pipes to be Schedule 40. Use 1 to Vehicular Traffic lobe H-20 Loading. 2-500 Gal.Leaching Chambers Ina co I 6 Septic System to be Installed in Accordance With 12'x 25' Washed Stone Field as Shown 310 C M R 15.00 Latest Revision And The Town of Barnstable Board of Health Regulations I / It / / O / / / / I• ) / O C 0 C / Rfm�9®� T. All Piping to beSch.40 PVC. 18 IIIIII 1 ' Ill /l l li ll y 000 j1 Finish Grade f 64 17.2'l W o # 1 e � Filter Dwelling O to Fabric Compacted Fi ll # CCCRAWL sP/ OWL in - N N o j Pea Stone I I IIIIIIIII I � I� ;I I 1 I I I I I I I � l l / I o (�� i N Chambe9 - 3/4" 11/h2ed I I IIII I III I I I I I I I I I I I I I I I I I / Stone I I IIIIIIIII I Ij I l j l l I I I I I I I I I I I I NOTE ° ; I 12'-oN IIIIII I I I I I I I I I ;I I I I I I I I I I l I > Lu 1 Existing Septic System to be Pumped i I I I I I I I I I a Filled With Clean Material. _ / , CROSS SECTION OF CHAMBER ..NOT TO SCALE I I IIII IIII IIIIIII I I I I I I I I I I I I I I I I 2o.s.�\ d- I I I I I I I I I I I I III III I I 1 1 I I I I I I I FG.100.0 FG. 100.0 I I 1 1 I I I I I I I I I 0 0 n ri 98.0 97.0 I I 1 1 I I I I j 978 1500 Gallon 976 Top EL 98.0 f I I I 1 1 1 1 1 I ONO N l l I (nW I 11 1 1 1 1 1 h I I I I. J OJ / Septic Tank 97.4 Bot.El.95.0 I l h l l l t o 111 � Ijl l IIII I I I I I I 1 1 1.: l 972 I I I I I I I I I I I ! o,% 9g Beddi 16 Per T ng as 53� IIII I I I I III �� I I I I I I I I III I .� 111. ___ o o �- ►� I III IIII I I I I IIiI �i I I IIII IIII ,r Post & all Fence -__. C _- — o� lo' I I.' IOe 5 to' 121 Bottom of Test Hole El.89.7 I No Ground Water cB/DH I I I I I I I i t III S 85 37 45 W — _ - - �I Fnd I I I 1 11 1 I I I I I I I I I I I I;' BRB I DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM IIII IIII I I i I (; I I I I I I I I I I I I I 11: I Fnd �, Not to Scale IIIIIIIIIIIII 1 1 i1 Ii l l IIII 1 \ \ \ \ \ \ / VARIANCES REQUESTED: W�` N o �tA�%1kOFP` , 1. Title 5 (310CMR15.211) Minimum Set � Dr ,.. PETER PLAN VIEW 9$ back Distances Front and Side Property t�� BicRAno ��~ SULLtVVll Scale: I = 10 a LHEURFUX Ill29 33 Une Set back to Leach Field: 10 feet CIVIL i required; 3 foot and 2 foot requesteda•34312 0 ". / 2. Town of Barnstable 100 Foot 00000 Sty K, Regulation to Top of Inland Bank; 65 feet �- 'Q � � � _ 1 �• :y requested REv1SIO1V 2124/d9 BOARD of taffATH COMM1sf1Ts / �Revision: Title: PREPARED BY- � PREPARED FOR: Notes PROPOSED SEPTIC SYSTEM ZrI Cb UPGRADE PO Engineering, Inc. uapeSury MARGO CULLEY Cb PO Box 659 . PO Box 718 Ostervllle, MA 02655 Hyannis MA 02601-0718 32 WEST STREET 64 HARRISON ROAD (508)428-M" (508)428-3115 lax (508)790-'7902 (508)7D0-711 fax W E N D E LL MASS 0 C E N T E RV I L L E , MASS PsuurE.na•aarn aopeeurv�capecsdn.t t i0 0 '5) ao 20 140 Field: RRL RJM Draft: Date: Scale: Cl Review: January 12, 1999 1 "=10' Proj. # Drawing # C360g1 98140