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Home My WebLink About0020 HAVILAND WAY - Health 20 Haviland Way Centerville P A = 143 240 *PwK~ i aEsse/te 1521/3 ORA 10010 P2 �I � ^ ~ u�^ Commonwealth of Massachusetts /r` l COPY � ~ � D 0 �� N�� ~��~�~~��N N��*��N�� Nr�1�| , ! -�� N N N ��N�� yN0Q��0��N Nmm��m��mw Form Subsurface Sewage Disposal System Form'Not for Voluntary Assessments � .� 20 nd WayRicharqProperty Address k �Owner ownor,Name~ � information is CenbmmiUo �^ MA 36 7 2017 �^ m�ui�mm,wm� ~ --__---__ __---' nooa� ou�Town State Zip Code ua�u,`nvn°=" �_. �. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end mV the form. |mpodant:mmen A. ��0 U��m�K��^�� nmmmmmmnno ' ' General - vo the computer, use only the tab 1 Inspector: key m move your cursor'ovnot Patrick TSullivan use the return -----'--------'----'--- Name mInspector wuv. Ready �� ha E d �� Company Name - uA pO Box 8O Company Address Fovnstda|e �A 02644 u��z��zo ------'------------------��c/tyrrmwn a�aStateZip Code 508-888-6055 S112843 Telephone Number License Number B. Certification ' | certify dh�g\ have personally inspected the sewage disposal system at this address and that the information—� reported below is true, accurate and completecompleteaa of the time of the inspection. The inspection was pendtonne d based on my training and experience in the proper function and maintenance ofon site nawage disposal systems. Imnn m DEP approved system inspector pursuant tpSection 15.340mf Title S(310 CYNR 15.000).The system: Passes �l Conditionally Passes [J Fails Needs Further Evaluation by the Local Approving Authority December7 2017 /n,nwov,u=y"°`"= ~~~ 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 DER The original should be sent hu the system owner and copies sent 0othe � � buyar, if andtheoppmvingau�hohty . . . � °°^"This report only describes conditions a*the time mf 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. o Official Inspection Form:n��rface Sewage Disposal System'Page`m1/ �~^ A C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Haviland Way Property Address Richard Ogonowsky Owner Owner's Name information is Centerville MA 02636 December 7, 2017 required for every -------- --- page. City/Town — _ State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A), System Passes: ® 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): Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 2 of 17 t5ins.doc•rev.6116 4 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Haviland Way Property Address Richard OgonoyA� — Owner Owner's Name information is required for every Centerville MA 02636 December 7, 2017 ------ -- --- page. Cityrrown _ _ -----State Zip Code — Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a br ken, 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): i ❑ distribution box is leveled orreplaced ❑ 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): I C) Further Evaluation is Required by the Bo�rd 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.doc•rev.6116 - 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 20 Haviland Way Property Address Richard Ogonowsky Owner Owner's Name information is Centerville MA 02636 December 7, 2017 required for every --- -- page. Citylrown _--_-- 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 tfIe 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:,, i This system passes if the well wader analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent end the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less _ than '/�day flow_ _ t5ins.doc•rev.6116 `' Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Haviland Property Address Richard Ogonowsky_—____ _ Owner Owner's Name information is Centerville MA 02636 December 7, 2017 required for every --------- - -- page. City(rown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of.the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15,303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is wjt'hin 200 feet of a tributary to a surface drinking water supply t 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 an "yes"to Oy question in Section E the system is considered a significant threat, or answered"yes" in Section p 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. l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 . a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 Haviland WaY_.-..------_--.- — -- - -- Property Address Richard Ogonowsky Owner Owner's Name information is required for every Centerville MA 02636 December 7, 2017 --- ----------------- — — page. City/Town _ State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ElHave large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue ® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 353 GPD l5ins.doc•rev.6116 Title 5 Official Inspection Form:Sunsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Haviland - Property Address Richard 0 onowsky _ Owner Owner's Name information is required for every Centerville MA 02636 December 7, 2017 — ------------------------------- --- --- page. City/Town _- — J State Zip Code Date of Inspection D. System Information Description: 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No 2016=444 GPD Water meter readings, if available (last 2 years usage(gpd)): 2017= 188 GPD` Detail: Irrigation on water meter. High readings during summer months. 2017 reading was for first 6 months without much irrigation. -- Sump pump? ❑ Yes ® No Current 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/scl t., Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to'the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Haviland Wa-y _ Property Address Richard Ogonowsky_ Owner Owner's Name information is Centerville MA 02636 December 7, 2017 required for every ----- -- — page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Ready Rooter records: Pumped 11/03/2017 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 9 ❑ 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.00c•rev.6/16 - 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 20 Haviland Way __._.... ..... Property Address Richaq Ogonowsky__ _ Owner Owner's Name information is required for every Centerville MA 02636 December 7, 2017 --. - ---- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Septic tank and SAS installed 03/19/2001. D-box replaced prior to inspection. See attached COC. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'10" Depth below grade: feet Material of construction'. ❑ cast iron ® 40 PVC ❑other(explain): Distance from private water supply well or suction line: N/Afeet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): _ Depth below grade: 1.5feet 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 10.5'x 5.5'x 5' 1500 gallons Dimensions: 1 Sludge depth: — t5ins.doc•rev,6116 1ifle 5 Official Inspection Fotm: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 20 Haviland Way_ Property Address Richard Ogonowsky_ Owner Owner's Name information is Centerville MA 02636 December 7, 2017 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 34" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" DD Rtube and tape measure. How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. liquid level at outlet invert. Risers bring covers within 6" of grade. Outlet is under brick walkway. Light solids. Tank was umTed it November 2017. 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 sc urn.: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.doc•rev.6116 ritle 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 w 20 Haviland WaY Property Address Richard Ogonowsky Owner Owner's Name information is required for every Centerville MA . 02636 December 7, 2017 - ---------- — ----- --- page. Cityrrown _ _ — State 'Lip Code _ Date of Inspection D. System Information (cons.) 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 purnping: Date Comments (condition of alarm and float switches, etc.): 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doe•rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Haviland Way Property Address Richard Ogonowsky_ Owner Owner's Name information is Centerville MA 02636 December 7, 2017 required for every ll ----- --- -- page. CiWfTown _ — State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan): 0„ Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, two outlets. Speed levelers in place. New. No solids. Riser brings cover within 6" of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order / ❑ Yes ❑ No* Comments (note condition of pumpp/chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Haviland Way_ Property Address Richard Ogonowsky_ _ Owner Owner's Name information is Centerville MA 02636 December 7, 2017 required for every _—__-- — page. Cityrrown _ —_ State Zip Code Date of Inspection D. System Information (cost.) Type: ❑ leaching pits number: — — ® leaching chambers number: 2-500 gal w/4' stone Elleaching 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.): Chamber located and inspected with camera. Liquid level 1' below invert. Clean stone visible in side wall. No sign of past h dy raulic,failum_ Units have 4'of stone around and 1' between. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth -top of liquid to inlet invert - Depth of solids layer Depth of scum layer Dimensions of cesspool ! -- Materials of construction,/ Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Haviland Way — Property Address Richard_Ogonowsky _ Owner Owner's Name information is MA 02636 December 7, 2017 required for every Centerville_ 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.) / Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 t5ins.doc•rev.6116 - i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Haviland Way _ --- Property Address Richard Ogonowsk_y Owner Owner's Name information is Centerville MA _ _02636 December 7,2017 required for every Cityfrown State Zip Code Date of Inspection page. —__—_--D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately - 3 O Title 5 offidal inspection Form Subsurface Sewage"sPosal System page 15 or 17 t5ins.doc•rev.6116 + Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Haviland Wav _ __.__. -- Property Address Richard Owner Owner's Name information is Centerville MA 02636 December 7, 2017 required for every -- -- — —- page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water . ❑ Check cellar ❑ Shallow wells >5 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 02/18/2000 If checked, date of design plan reviewed: pate ❑ 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: niaps.massqis.sta-te.ma.us/oliver.Uhp You must describe how you established the high ground water elevation: Test hole to 150" (elv= 88) in 2000 found no ground water. Base of SAS at elv= 88 per engineered plans. Accessed local qround water and to o m .n�No hh�c round water.in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 16 of 17 t5ins.tloc•rev.6116 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Haviland Way Property Address Richard Ogonowsky Owner Owner's Name information is Centerville MA 02636 December 7, 2017 _ required for every _ --- -- -- page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 6, 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -----------------------------------. No. �— �� Fee 76 THE COMMONWEALTH OF MASSACHUSETTS ___N��PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal �bpstem Construction i3ermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construc/tio mu be c1lmpleted within three years of the date of th a t. Date / Ll_l_!._. —_-- Approved by -------------------------------------------- '1'IIE COMMONWEALTH OF MASSACHiJSETTS BARNSTABLE,MASSACHUSETTS eertifitate of compiiante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓ ) Upgraded( ) Abandoned( )bye :% 1CYJ has been constructed in accordance j!/ at��c��_�sj.�_��_��_._..��Z�.�¢.�__� dated with the provisions of Title 5 and the for Disposal System Construction Permit No��%�7 t Installer �a Qz--- _K --'-� llesigner #bedrooms _- __ Approved design flow gpd The issuance of this permit s/hall no be co s _tntcd as a guarantee that the syste ill En ' n a esi ed. /^ Date lcr?!�%-. �/ Inspector — No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Disposal 6pstem Caristruttiari 3permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. `Q,A <JJ4 Owner's Name,Address,and Tel.No.� a� Assessor's Map/Parcel o?C ��" � tl�� Installer's Name,Address,and Tel.A.50 l�� 6'aS� Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank $�� o i Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ��p -a -r�- LA-,,'L� Q Q- 3 . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hgaftk Sk ed Date ( c� Application Appfoved by Date Application Disapproved by Date for the following reasons Permit No. 7V / Date Issued No- ./ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: IV PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for MispoSal i�pstrm Construction Permit Application for a Permit to Construct( ) Repair("Kupgrade( ) Abandon( ) Q Complete System �ividual Components Location Address or Lot No. Owner's Name,Address,and Tel.No 'IF C] i-i.ev t`4'lc� Cl_j4 r Assessor's Map/Parcel 3 ` a<b t 1t �� ( `►. ', rcQ Ky Installer's Name,Address,and Tel. .�$�—QZ7.So�'S� Designer's Name,Address,and Tel.No. l �o ti -r Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank , Oc) � ( Type of S.A.S.S Description of Soil i I Nature of Repairs or Alterations(Answer when applicable) a�.p G P� QZA 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 the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt . S' e Date �'07 Application Approved by Date Application Disapproved by Date for the following reasons t Permit No. Date Issued ---------•------------------------------------------------------------------------------------------------------------------------------ _, THE COMMONWEALTH OF MASSACHUSETTS 0-/- BARNSTABLE,MASSACHUSETTS Certificate of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V) Upgraded( ) Abandoned( )by Z n_CS?,A at ��' �Sa (yam ,, Q t a a has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ,3b dated /C)I zLh Installer�`e.t,cSZu ��`` �• ,��-(� ^` Designer #bedrooms `� Approved design flow _ gpd The issuance of this permit shall not be co'strued as a guarantee that the systernMill`function�as�,esigned. Date !cam 1 7) Inspector( --------------------------------------------------------------------------------------------------------------------------------------- No. Fee 75 ..� THE COMMONWEALTH OF MASSACHUSETTS 0`7<PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Misposal 6pstem Construction Vermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at ��p_ ;T c�d �.Q�),AS� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. i i Provided:Construction must be c mpleted within three years of the date of th permit. {— Date Approved b F COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OFFICE OF E01k- 41A LSAT rfFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ' 2 '5 MAY -4 PIM 4: 10 5V• DIVISION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 20 Haviland Way f _.. T� Centerville -" F'•°.�E� : Owner's Name: Rich Ogonowsky �u �� Owner's Address: .� Date of Inspection: 4/15/2005 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O. Box 371 Sandwich, MA 02563 Telephone Number: (508)888-6055 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: asses Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: �-- Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. 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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 Haviland Way Centerville Owner: Rich Ogonowsky Date of Inspection: 4/15/2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. 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 Pass7'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 F` ND explain: r` ,r 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): l broken pipe(s)are replaced r obstruction is removed ND explain: r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 Haviland Way Centerville Owner: Rich Ogonowsky Date of Inspection: 4/15/2005 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(I)(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 fi6et of a bordering vegetated wetland or a salt marsh r 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 I 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: r' i Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Haviland Way Centerville Owner: Rich Ogonowsky Date of Inspection: 4/15/2005 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 _jZ Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow _AZ 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 50 feet of a private water supply well. _ _Z 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 forma K(Yes/No)The system fails. I have determined that one or more of the above criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E..-or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner sholaId contact the appropriate regional office of the Department. Page 5ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 Haviland Way Centerville Owner: Rich Ogonowsky Date of Inspection: 4/15/2005 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 _ _ZWere any of the system components pumped out in the previous two weeks? __�Z_ 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? AZ _ Was the facility owner(and occupants if different than 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 ,Z Existing information.For example,a plan at the Board of Health. t,, _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 Haviland Way Centerville Owner: Rich Ogonowsky Date of Inspection: 4/15/2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: H _ Does residence have a garbage grinder(yes or no):h�� Is laundry on a separate sewage system(yes or no):0�if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use: (yes or no): -� v.y' `� -2, Water meter readings, if available(last 2 years usage(gpd)): Sump Pump(yes or no): 0c'-'-) Last date of occupancy: 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):_ ,f 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: L,..:, Was system pumped as part of the inspection(yes or no): r, If yes,volume pumped: I ,;�cz� allons--How was quantity pumped determined? vL-'N 41-Ai zz Reason for pumping: TYP F SYSTEM _AAeptic 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 al components,date+installed(if known)and source f information: C3 � m Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 Haviland Way Centerville Owner: Rich Ogonowsky Date of Inspection: 4/15/2005 BUILDING SEWER(locate on site plan) Depth below grade: 10 ` 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: Material of construction:_Izconcrete_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: Sludge depth: (4 Distance from the top of sludge to bottom of outlet tee or baffle: tom' Scum thickness: P," 4, • �,� %" �.: e,.•;;c v� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:—\,,.',��.j i��. ,;,, ,�_, --y ,�,<_ Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 1 ° � `!-�l�`L\ v.``.. cJ ��.c�.�'• ` J'�+_.,.r-ti_ cam•' .. _ lL...._ GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc,)'. Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 Haviland Way Centerville Owner: Rich Ogonowsky Date of Inspection: 4/15/2005 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal fiderglass_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.): f DISTRIBUTION BOX:—Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: O.' Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): `emu�lr: r S _ �...' ..'.J.,.� �� 'ti'�� C..ra ru-+�1 c�•..+�..r -c� �.r., (� /�� f� a PUMP CHAMBER: (locate on site plan) , Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): J,. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Haviland Way Centerville Owner: Rich Ogonowsky Date of Inspection: 4/15/2005 SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required) If SAS not located explain why: Type l _leaching pits,number: Teaching chambers,number: �.4 �:"c�,,� 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.): 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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 Haviland Way Centerville Owner: Rich Ogonowsky Date of Inspection: 4/15/2005 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. LA 6 10 / 1\ J � i v . a Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 Haviland Way Centerville Owner: Rich Ogonowsky Date of Inspection: 4/15/2005 SITE EXAM Slope i,/- Surface water Check cellarf Shallow wells Estimated depth to ground water Meet 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: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the 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: VI' t c Sr�r r '� +• ' c_ �j<' C c,j 1� c Ja / c V� (C 1 FEECOMMONWEALTH OF MASSAC14USETTS v I' Board of Health, j3A APST A�L L �. /1-( APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for P it to Construct(Lrepair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location 11 �q V a-A P Y 4 M Owner's Name v C O 1 L-'e Map/Parcel# , Cl 3 0! Address o Lot# a / 9 Telephone# Installer's Name CA ACl 0 w�, Designer's Name *,K)�ee. Sul.LAtA &,.,s0L74i;t, Address A-Aj S Address 90 � .."buSTd2 9,60 /1ili gs-lbWS M1 Telephone# cosis I Telephone# yd - Type of Building U) "U— Lot Size 5 00 sq.ft. Dwelling-No.of Bedrooms 3 Garbage grin)Uo) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures a 7 Design Flow (min.required) 3 J ® gpd Calculated design flow 3 Design flow provided 3S 3 gpd Plan: Date q— 18^(:>0 Number of sheets 3 _ Revision Date Title 5 t-k Description of Soil(s) 5-e2 )-A o-� Soil Evaluator Form No. 0' '016 89 Name of Soil EvaluatgfbYuCk' MU/ ate of Evaluation 00 -it 476908 1 1 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above des ribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a es to of to place the system in op ati until a Certificate of Compliance has been issued by the Board of Health. Signed Date L ions ._. a fig` ,� 1�'/! •,!.�. � ;�. .i` • .. No. C ' t FEE . c� A n Board of Health, fi R I✓ST A fS L G' MA. / APPLICATION FOR DISPOSAL.SYSTEM M CONSTRUCTION PJL.11nMIT Application for P Tit to Construct(L*-Vepair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components ," Location J�/�,�A PP Owner's Name V" Map/Parcel# 1 3 ,'Il Address '9 ( _^-�o �/`I Lot# a / 9 Telephone# ) Installer's Name CA A C,-rG (b C S Ta, Designer's Name k A)�ee Su vLX--" �C,,S o C T'I'V Ad'dress Pov . W,l (S Address ��y 1'3 -{••")v 9,R y A ( Mlt P S-10UJS M I r- Telephone# Telephone# (,{�a d awu-- � z Type of Building Lot Size :� 00 Q sq.ft. Dwelling-No.of Bedrooms 3 Garbage grim) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) 3 O gpd Calculated design flow 3 3 0 Design flow provided S gpd Plan: Date /— ��- Number of sheets 3 Revision Date Title i e Description of Soil(s) 5-eE' Q h4 N-1 Soil Evaluator Form No. #' g9 Name of Soil EvaluatYuCPv /47o ate of Evaluation y6C? a . DESCRIPTION OF REPAIRS OR ALTERATIONSf k The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a es t of to place the system in op ratio until a Certificate of Compliance has been issued by the Board of Health. Signed Date I ions• 9 U � `G!R No.r ICE'V S / ` FEECOMMONWEALTH OF MASSAC14USETTS .r" r� < Board of Healthy't l�N4 6�l•t ST19 91 MA. 7 ,, �sj_ oCERTMCATE OF COMPLIANCE (r[ a Description of Work: ❑Individual Component(s) mplete System The µndersigned hereby certify that the Sewage Disposal System; Constructed (4epaired ( ),Upgraded ( ),Abandoned ( ) by. a of7 19V12.bgN> WAY , &.A"e tv" / has been installed in accorda ce with the pr visio s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.-ZICOV S 7 dated IZ6174ro. Approved Design Flow 3 (gpd) Installer Designer:V A Al�t—SUV,V'A/ OCAtSU(-'O nspector: 1(AQA1L,-1 ,,�it 1 t,��,v1 J Date: The issuance of this permit shall not be construed as a guarantee that the system will function as.designed. No. 12 45rT/V-S- //�-, I � FEE /40r-)l Board of Health, D�P0SAL SYSTEM CONSTRUCTION PERMIT G-76 Permission is hereby granted to; Construct(- j Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system" at Z7 H 19 V I L A BU D 1 /19 / as described in the application for Disposal System Construction Permit No. ?iU�- � dated ,Provided: Construction shall be completed within thr e years of the date of ermit. 1 al conci' oris murbe met. t Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date � � ; � Board of Heal � / { f. TOWN OF BkRNSTABLE LOCATION ✓� ��" SEWAGE VILLAGESSESSOR'S MAP & LOT � i INSTALLER'S NAME&PHONE NO. 0_ '� SEPTIC TANKIc APACITY (size) t./U LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE:_2 ' 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 Feet " on site or within 200 feet of leaching facility) Edge of Wetland and Leaching'Facility (tf any wetlands east;:: within 300 feet of leaching facility) Feet' i Furnished by j i 2- 3 27 y J�� i TOWN OF BARNSTABLE LOCATION _ � kta e �.�,.e C ��.i SEWAGE # -)22-21 VIL. AG %=-.r'ci ASSESSOR'S MAP& LOTS `Q' cj J INSTALLER'S NAME&PHONE NO. CJ a SEPTIC TANK CAPACITY LEACHING FACILITY: (type) --S (size) 1 140. OF BEDROOMS J BUILDER OR OWNER `v F / /� PERMITDATE: � �� An)� 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^�:�ti� jo o, Lie + � `TOWN OF B STABLE �o/�31®' LOCATIONgW� l SEWAGE , W,.LAGE TLQ SESSOR'S MAP & LOT 3,� - INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I:EACHING FACILITY: (type) (size) ,5mnal,Ion NO.OF BEDROOMS BL'III..DER OR OWNER el PERMIT DATE: 4 ' COMPLIANCE DATE: 31119 IO I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility)- Feet Furnished by I s: 2 21 3 27 4 n T3q r `I CB RES. ZONE.' "RF " �p�� - - 0 (fnd) OFFSETS. S FRONT 30' o SIDE 15' REAR 15' Kn FLOOD ZONE.' "C" � W ASSESSORS MAP 193 0 sR m co AS LOT 250 PLAN REF. 386127 TERM �j DEED REF 6504188 M� gAv 0 x p�or��'1p�� Off, —___ 1 B`9- AS LOT 252 _ cl �2pN �Y Cp _ — B —— \ x� 100 0 107 TP 4 m -- �'t�3 1O6 ----- LOCUS MAP 62.4 .�I �— 10$'�--- N / rP 11 r 3103 - SITE & , zy h AGE' PLAN AS LOT 249 0 \ AREA= 15,000 sq/ft `� cU PREPARED FOR \ �\ p AS LOT 251 GUY COLLE'TTI ' 3 `\ LOCA TED\ � 2 1 � \ 3 PROPOSED' t g HA VILAND WA Y D 105 3HSd� i r \ 18 y\ to? 0 .! 1�.°m\r' BARNSTABLE' (CENTERVILLE) MA, p' 0. 1 1� SEPTEMBER 18, 2000 AS LOT 248 \ ti 100 o •' �" o� 26 z�� ' ELEV 100' ASSUMED )"A WEE SUR VE Y CONSUL TA N TS \ O 10, W` e� TOP OF CATCH BASIN P. O. BOX 265 103 _\ �ER (fn��' UNIT 5, 403 INDUSTRY ROAD \ 5. O :=_-: _ p' MARSTONS MILLS, MA. 02648 \ -DI Now 10 - PH.(508)428-0055 — FAX(508)420-5553 g GRAPHIC SCALE N t� IAA 30 0 15 30 e0 120 muili Hy cis 2 �' NO.749 (fnd IN FEET 1 inch = 30 ft. i i Y y SHEET 1 OF 3 JOB NUMBER-_52271E 11 ------ 4 7VP OF FOUNDATION _ 20' MIN. 10' MIN. CONCRETE CO VERS 4" SCHEDULE 40 P• VC MIN. PRrH 1/8 PER FT. 27LAYER OF VENT EL =103' / ♦ ♦ ♦ ♦ / ♦ ♦ / / ♦ CONCRETE COVER WASHED S717NE BiVAX ♦ i i i ♦ / / / ♦ / ♦ i i i ♦ / / . EL=102.5' 4" CAST IRON PIPE 12. X/ / ♦ ♦ ♦ / / ♦ / ' ' (OR EQUAL MINIMUM 1lA 1 A(AX ' PI?L^H 114 PER FT. RISER CLEAN ER MIN. FLOW LINE SAND INVERT 1 10" 14" EL=100.5' EL.__101_75' MIN INVERT —2.0'— 0 00 0 0 0 0 0 0 0 00 B - 10125' INVERT s" SUMP LEVEL o 0 0 0 0 0 0 0 0 0 0 0 =98.0' INVERT EL.—___ INVERT o 0 EL.=101.5' EL.=_101.0 EL.=102. 75' 4' 4' INVERT (TO BE PLACED ON FIRM BASE) DISTRIBUTION EL.=1 MECHNICALLY COMPACTED OR 6" OF STONE. BOX o GALLONS719 IF MORE THAN BE W4 TER TONE OUTLET ESTED 26' X 12.5" TRENCH FORMATION p SEPTIC TANK PLACE ON 6" STONE SOIL ABSORPTION DOUBLE WASHED STONE SYSTEM (SAS) H-20 PROFILE O F BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV. = 88.0' (TEST PIT #6) NO OBSERVED WATER TABLE (2125100) ELEV.__ 88.0' SEWAGE DISPOSAL SYSTEM NOT TO SCALE GENERAL NOTES 1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM 719 D.E.P. INSTALL TWO (2) ACME DESIGN CALCULA TIONS: TITLE 5 AND THE TOWN OF _BARffZ4BLE____ RULES AND 500 GALLON LEACHING REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. CHAMBERS (H-20 NUMBER OF BEDROOMS . '3 2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT 70 SPACED P APART WIPE GARBAGE DISPOSAL NO WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" BETWEEN & FOUR FEET OF DOUBLE 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF 719TAL ESTIMATED FLOW WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR 07THIN WASHED S?iONE S�'DES AND ENDS ( 110__CAL/BR/DAY x -.I-- BR) 330 CAL/DAY 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE 26 X 12 5 USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS EXISTING SEPTIC TANK CAPACITY 1000 GAL 4) ANY MASONARY UNI75 USED TO BRING COVERS To GRADE SHALL SOIL CLASSIFICATION . . . . . . . . 1 BE MORTERED IN PLACE. DESIGN PERCOLATION RATE . . . . . < 2 MIN./IN. 5) NO DETERMINATION HAS BEEN MADE AS 719 COMPLIANCE WITH 5' OVERDIG TO APPRO.L' 6' EFFLUENT LOADING RATE . . 74 DEEDED ZONING REGULATIONS. OWNERAPPLICANT 7 OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY ORITY. DOWN TO WHITE FINE SAND LEACHING CAPACITY (AREA X RATE) 353 CAL/DAY 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCA VATION CONTRACTOR HORIZON "C2" RESERVE LEACHING CAPACITY . . . 353 GAL/DA Y IS TO CALL "DIG- SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS PRIOR 719 7) CONTRACTOR ISM717CING VERIFYRK ON SITE GR DES AND ELEVATIONS AS WELL AS (26 X 12.5 X . 74)+(26 + 26 +12.5+L2 5 X . 74 X 2) CAL/DAY/S.F. SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE 8) PARCEL IS IN FLOOD ZONE___C=____. 9) LOT IS SHOWN ON ASSESSORS MAP _193 AS PARCEL SHEET 2 OF 3 JOB NUMBER___52271E R/ -• r \r w 4 SOIL TEST PE'RC. 9689 DATE OF SOIL TEST 2118100 SOIL TEST DONE BY BRUCE MURPHY, Rs WITNESSED BY: DONNA MIORANDI PERCOLATION RATE 2 MIN./ INCH AT _48=__ INCHES OBSERVATION HOLE 1 ELEV= roc'__ OBSERVATION HOLE 2 ELEV.=_104'_ DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH HORIZ TEXTURE COLOR MOTT. OTHER 0-3" O ORGANIC 0-3" 0 ORGANIC 3"--12" A SANDY LOAM 10YR 6-1 3"--12" A SANDY LOAM IOYR 6-1 12"--3' B LOAMY SAND 10YR 5-8 12"--3' B LOAMY SAND 10YR 5-8 36'-90" Cl FINE SAND 25YR 7-2 PERK 4' 48"-132 Cl SILTY LOAM 2.5YR 5-4 90"--144" C2 SILTY LOAM 2.5YR 5-4 NO WATER DAMP AT 11' OBSERVATION HOLE 3 ELEV= 103__ OBSERVATION HOLE 4 ELEV= 107'__ DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH HORIZ TEXTURE COLOR MOTT. OTHER 0-3" 0 ORGANIC 0-3" 0 ORGANIC 3"-12" A SANDY LOAM IOYR 6-1 3"-12" A SANDY LOAM lOYR 6-1 12"-42" B LOAMY SAND 10YR 5-8 12"-42 B LOAMY SAND IOYR 5-8 42"-144 CI SILTY LOAM 2.5YR 5-4 42"-144 Cl FINE SAND 2.5Y 7-2 NO WATER NO WATER SOIL TEST DATE OF SOIL TEST 2125100 SOIL TEST DONE BY BRUCE MURPHY. RS. PE'RC.IjX9698 WITNESSED BY: DONNA MIORAh0I PERCOLATION RATE < _5_ MIN./ INCH AT _ 100 INCHES OBSERVATION HOLE 5 ELEV.= 102__ OBSERVATION HOLE 6 ELEV.= 102.5'_ DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH HORIZ TEXTURE COLOR MO TT. OTHER 0-3" 0 ORGANIC 0-3" 0 ORGANIC 3"-6" A SANDY LOAM IOYR 4-1 3"-5" A SANDY LOAM IOYR 4-1 6"-36" B LOAMY SAND 10YR 5-8 5"-36" B LOAMY SAND IOYR 5-8 36"-72" Cl 36 SILTY LOAM, VARIOUS �"-54 Cl SILTY MED. SAND IOYR 6-8 CLAY BANDS COLORS 54 -84 C2 FINE SAND 2.5Y 7-2 72"-84" C2 WHITE FINE SAND 2.5YR 7-3 - 84"-144 PERK " C3 COMPACTED HARD Z 5Y 6-3 84 -150 C3 COMPACTED HARD 2.5YR 6-3 SAND SAND NO WATER NO WATER SHEET 3 OF 3 JOB NUMBER 52271E ___ _____ THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA - 2 s. 10 ,.MER rUp4racs 'nES AO ._ It.Of - __ I a:0 C►t 0" _10:fi" — __.. 11'.fa' I •tl - Q ' r i .:A" I:t' :tin V•.�Y :.�. IS:dC' C+ - e• �f rz AIMCM NOUS[ t. N 4:2 N SECTiD 4LG 4 CAPYKAG -t'SHEAT"IM9 -01MGW.. a — T 3:a." S.t1 Eai IS:O - '1:0' tat �ArINS 11 ric.�.aas.�I1- - M11Ei110G1C b, acaulla KLTL(ifilll 2• -RT�MS yll/L.If/YEt1.- _ 2r( 0►1[ .►w �hlAO. '— ... 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