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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is required for every Centerville t/ Ma 02632 4-21-21
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 Si 4r 15 33
on the computer, Matthew Gilfo
use only the tab y
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return key. Company Name
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113640
Telephone Number 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
Matthew Gilfoy ;Date:'2021.00422Y13 46 42-04 00• 4-21-21
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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
1� = - Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town 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 system was in working order 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):
15insp.doc-rev.7262018 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
o
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is required for every Centerville Ma 02632 4-21-21
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�. - Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town 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
❑ El clogged
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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
�a Title 5 Official Inspection Form
t 1"
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ a Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ E] Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well:
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
P P Y P PP Y
❑ El 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.]
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ 0 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.7/28l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
1= - Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
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
❑ El Were any of the system components pumped out in the previous two weeks?
❑ 0 Has the system received normal flows in the previous two week period?
❑ 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ 0 Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
0 ❑ 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:
0 ❑ 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
r -
Commonwealth of Massachusetts
i n Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c �
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 349/GPD
Description:
Number of current residents:
0
Does residence have a garbage grinder? ❑ Yes 0 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 0 No
Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
2020- 19,000gallons 2019- 21,000gallons
Sump pump? ❑ Yes ❑0 No
Last date of occupancy: 4/5/21Date
l5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
- Title 5 Official Inspection Form
�- — b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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
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:
Owner- date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.00c-rev.726/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
-r Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town 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:
New leaching was added to the existing septic tank in 2014
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
2'2"
Depth below grade: feet
Material of construction:
❑cast iron ❑■ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town waterfeet
Comments(on condition of joints, venting, evidence of leakage, etc.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
01,
Title 5 Official Inspection Form
- a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
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:
0 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
1
Dimensions: 000gallons
611
Sludge depth:
3011
Distance from top of sludge to bottom of outlet tee or baffle
21'
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
1511
Distance from bottom of scum to bottom of outlet tee or baffle
measured
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.):
The tank was in working order at the time of inspection. The tank is not in need of pumping
at this time but should be pumped every two years for maintenance.
t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
i. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: NAfeet
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):
NA
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
-=„ =60 Title 5 Official Inspection Form
1.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
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):
Orr
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.):
The d-box was in working order at the time of inspection.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is required for every Centerville Ma 02632 4-21-21
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.):
NA
* 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:
❑ leaching galleries number:
(2) 2'x3'x33'
El leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town 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.):
The SAS was in working order at the time of inspection. Leaching showed no evidence
of past backup when viewed.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
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.72612018 Title 5 OfBdal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
. r
Commonwealth of Massachusetts
-w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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
>as � 79 Helmsman Drive
L
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town 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:
❑■ hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
�q ;p Title 5 Official Inspection Form
_ 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
0 Check Slope
■❑ Surface water
■❑ Check cellar
Shallow wells
Estimated depth to high ground water: No GW @ 120"
feet
Please indicate all methods used to determine the high ground water elevation:
0 Obtained from system design plans on record
If checked, date of design plan reviewed: 4-21-14Date
❑ 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:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
-- -- Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Drive
Property Address
Robert Douglas
Owner Owner's Name
information is Centerville Ma 02632 4-21-21
required for every
page. City/Town 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
FM D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
_- - -
FROM :down cape engineering inc FAX NO. :15083629880 May. 09 2014 10:41AM P2
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'ti��y Jj� '1'hu�a>m 1�1�:IE�R�snZ,�DP�•�ec:tou'
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1 spa ��a L l�A i�tieP�LCT tijkaamfigl 11
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On _ _ - was issued a permit try install.EL
(date) {ttti��ll�,�.'} •
stir,cyst
era at Treed au.a desig—dr cWD,b'Y
date:c3, --
i certify that the septic SysP:�rdr-7encxl. above vi3.3 410-al• according t0
thc: rl.es?gn,vlhirh.an2y n,��ltZ!ie Trainor appTovcd ch�Lges �Ltolt as latErti1 ri:1.6��t�]l0'1].of tf�r
dis�ib�rti.ou 1x1 or d/or srptia LjrLk.
I aeitify that it+e si-vic systwm.-eLLacnrec LtUove -was installed withzrj ' r,Lui?;e� g (r.e-
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{l)egigncr's SiE2�atria�) - r (�fL .��siLer.°s St-smn H�Te)
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TOWN OF BARNSTABLE
LOCATION 7 9 tic/nfS/ng.rN .l r• SEWAGE#201y - /38
diVILLAGE Cc(%dcrvi)IL ASSESSOR'S MAP&PARCEL t93 - Z3y
INSTALLER'S NAME&PHONE NO. 77 - 0653
SEPTIC TANK CAPACITY /000
LEACHING FACILITY. (type) TrencAC S (Z) (size) 2 X 3 x 33
NO. OF BEDROOMS 3
OWNER r_J;,CJ S-lonc_
PERMIT DATE: S-$. /q 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
A►- a3
AZ
BZ 5p` REAR s
A3- vy'
b3
Ay- ley'
3
�£ A l
No.,;L0� �-- Fee /60
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
1 application for Vu
0 aY lit Ori tCUYtion P�Cinit
Application for a Permit to Construct( ) Repair gra fl( ) Abandon( ) El Complete System El Individual Components
Location Address or Lot No. 110wner's Name,Address,and Tel.No.
7 q HelmL 5ma L0 6+hel -5fan e
Assessor's Map/Parcel / �� 3 ��S`� J 5 3 Z
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
OfQ ty-wvoLhon Dovyn C�_n 50AV-362-45 k-1 t
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) _ 3 0 gpd Design flow provided gpd
Plan Date i112-1 I f Number of sheets Revision Date
Title
Size of Septic Tank 10 ) CLU D Type of S.A.S.
Description of Soil
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 the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board ealth.
r
Sign, Date
Application Approved by Date J
Application Disapproved by Date
for the following reasons
Permit No.Zo�� — 3 Date Issued 5
: ., No. ate/
- � - - - - - - - - - - Fee _ CSU- - - - -
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
mispo8AY *pst Construction Permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at '19 Nam,mc� an Lnoc C --n Ir-4 U
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must comp feted within three years of the date oft i' s permit
Date ��`f Approve by r
No. .-- 9 Fee` /06
THE COMMONW ALTH tOF,MASSACHUSETTS Entered in computer:
p:: Yes
PUBLIC HEALTH DIVISION - TOWN°OF'`BARNSTABLE, MASSACHUSETTS
ftpYtcation for �71U
veer 6pstem Construction �ermtt
Application for a Permit to Construct( ) Repair gra E( ) bandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. G�. `�e m ,r l V I�-n Ln Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel i44 _I / 93 t z3 �hel 5fo n e gp g _9& z _ 5 3 Z
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
,. eta �Xcavaf ian y Dov�1n C �n so k-362-q5 ki l
Type of Building:
Dwelling No.of Bedrooms A Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min. quired) 330 gpd Design flow provided gpd
Plan Date ff Z Number of sheets Revision Date
Title
Size of Septic Tank r_X �( 0 al t U(I Type of S.A.S.
Description of Soil
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 the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board ealth.
Signed J Date J<
Application Approved by Date __S
Application Disapproved by Date
for the following reasons
Permit No. / O Date Issued j
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by l'�� �X n y n+ ( ()0
at '1 C-1 {_( r C'11r7 Cl L0 n C (P nj tas-16een constructed in accordance
fs y
with the Drovisions of Title 5 d the for Disposal System Construction Permit No�14 —/3 �dated
Installer hx L Designer
#bedrooms / Approved design flow �„A gpd
The issuance of this permit shall not e c tru d a guarantee that the system will func as n •�f
Date Inspector (/
v -r u v
----- - / - -----------------
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Town of Barnstable Barnstable
Regulatory Services Department
MASS Public Health Division Zoos
" . 200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7012 1010 0000 2851 2576
March 27, 2014
Mr. James C Stone TRS,
Ethel Stone IRREV Trust
79 Helmsman Drive
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,Title 5.
The septic system located at 79 Helmsman Drive, Centerville,MA,was last inspected
on 3/13/2014 by Ricky L. Wright, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails"under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to overloaded or
clogged Soil Absorption System, the system must be repaired.
• The distribution box must also be repaired.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system with in the deadline period will result in future
enforcement action.
PE RDER OF THE BOARD OF HEALTH
omas McKean,R.S. CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\79 Helmsman Dr Cent Mar 2014.doc
Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=13995
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MASS �y .
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Logged In As: Parcel Detail Tuesday, Mar 2014
Parcel Lookup
Parcel Info
Parcel!---.--193-234_....._.._.__.__._...-----__..---_..___._._._____._.-.__. �-I Developer'LOT 5
ID` Lot
Pri
Location 179 HELMSMAN DRIVE Frontage I
Sect
Road'
Frontage
Vill age�CENTERVILLE � Fire;C-O-MM���___.._______..__._...-__..__________.__-)
District
Town sewer exists at this
-- Road 2008
address!No Index
Asbuilt Septic Scan: Interactive 5�' , 4� .
193234 1 Map
Tx t
Owner Info
_
Owner DYER, KATHLEEN A&STONE,JAMES C TR� C0 W 'ETHEL L STONE IRREV TRUST
Owner
Streetl 179 HELMSMAN DRIVE Street2 i
City CENTERVILLE State MA Zip 02632 Country
Land Info
Acres;0.34 Use Single Fam MDL-01 Zoning;RC Nghbcl 0105
Topography Level ( Road?Paved
Utilities;Public Water,Gas,Septic v �— Location
Construction Info
Building 1 of 1
Year�1986 ------ �-- Roof Gable/Hip���—��-��� Ext Woodhingl Se�����
Built Struct Wall
Living, 3.2—___._._.______ Roof r_...___ _...._._... AC r___ __.__.__-.._.___.__.
Area 1352 Cover jAsph/F GIs/Cmp ( Type!None
-_ Bed
Style jRanch !Drywall 12 Bedrooms
Wall Rooms ,
_ _.....___.. ._.___ Int ____.__—_..___.__. Bath 14x �
Model!Residential Floor Hardwood Rooms 12 Full
Heat r—_�..____;-__..___._ Total
Grade;Average Type;Hot Water Rooms F6 Rooms ��
Heatr_..--.--___._..- Found-
Stories 11 Story Fuel'Gas ation 1Poured Conc.
Gross
Commonwealth of Massachusetts
Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is
required for every Centerville Ma 02632 3/13/14
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
I n
on the computer, ��Jl,
use only the tab 1. Inspector:
key to move your
cursor-do not Ricky L. Wright
use the return Name of Inspector
key.
Excavation
Company
ry Company Name
14 Teaberry Lane
Company Address
�. Sandwich Ma. 02644
Cityrrown State Zip Code
(508)477-0653 S14595
Telephone Number License Number
c
B. Certification 12t
i
I certify that I have personally inspected the sewage disposal system at this address iand that UTP
information reported below is true, accurate and complete as of the time of the inspection. The inspee n
was performed based on my training and experience in the proper function and maintenance ofbn situ
sewage disposal systems. I am a DEP approved systeminspector pursuant to Section 15;$40 of
Title 5(310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/13/14
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Ins io orm:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/13/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/13/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
_ Inspection Form
. Title 5 Official Ins ect o
p
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/13/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/13/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•3/13 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 79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is Centerville Ma 02632 3/13/14
required for every
page. CitylTown 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
El El information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 79 Helmsman Dr.
Property Address
P
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/13/14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d n/a
9 ( Y 9 (9P ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/13/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
2. W Title 5 Official Inspection Form N
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/13/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good working order no sign of leakage.
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal.
Sludge depth:
6"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is Centerville Ma 02632 3/13/14
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
31"
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 appeared to be in working order,Tees present no sign of back-
up.Liquid level equal with outlet invert.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
. 21 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' M
79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/13/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/13/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box is starting to deterate with roots groing into it.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/13/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ 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 appears to be in hydraulic failure, water level was 3" below invert at
time of insp. with sign of backup over invert.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is Centerville Ma 02632 3/13/14
required for every
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.):
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is required for every Centerville Ma 02632 3/1:3/1,4
page. Citylf own 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
^arz6 ,,
13 .
3-s3
yy,y
13
1
e/ ❑3
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�,M ,.•''r 79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is Centerville Ma 02632 3/13/14
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
rear of dwelling drops off
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 79 Helmsman Dr.
Property Address
Ethel Stone
Owner Owner's Name
information is Centerville Ma 02632 3/13/14
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r
L 0 �. I T 10 i S E ' '61I T iR#0.
] MSTA L.LER'S NAME A A D V R SS
i U I.i. D , R OR OWN ER
DATE PERMIT I S S V E 0
DATE. C 0 M P L I A N C E iSSUED
,0 `K
'�� f
3z
i
"" LOCATION i SI WA P � �,�IT N42.
/. ® r- .
V1LLAGGE
IN57A LLER'S NAME A A D D RESS
8 UILD1 R OR OWNER
DATE PERMIT ISSUED
DAT E C0MPLIANCE iSSUED .� _ _
d
� J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
Application is hereby made for a Permit to Construct (&-l"Or Repair an Individual Sewage Disposal
system t.
Installer Address
Type of Building Size Lot,,,o S q. feet
Garbage Grinder
Z Other Distribution box Dosing
Percolation Test Results Performed by... ...... Date...
Agreement:
The undersigned agrees minstall the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLI'LlE 5 of the State Sanitary Code The d igoed further agrees not.to place the system in
opera *o until a (;,ertificate of Compliance has been issued by the board of th.
' ' _-� -_'-'--............... '---.---'--'_'_---
Date
~�nn1�a600 8y-------=�����zs��^�_- ____-'-________ ____
- Date
Application Disapproved for the following reasons:................................................................................................................
---------------------------'--'----------'--'---------------------'-------'----'-------------'----
��
Permit 2�n--'��ze����-�--�y���---'_-- Imaze�-----_----------------_---'-
Date
------'---'-''''''
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
QF HEALTH
Application is hereby made for a Permit to Construct (4 ) or Repair an Individual Sewage Disposal
re
........ .. .......... ....t........................... ..... .................... ........................................
ow re
1.4 ?& ....* .......
Type of Building nstaller Size .....Sq. feet
Design gallons per person pecdu�. Total daily
Septic Tank--L�n�� gallons.
Length ����� - -.-_-__--.
Dispouu Trench--No .................... Width.................... Total .................... Total leaching area....................ag ft.
Seepage Pit No.-----.--- Diaoetcr-'.-.-.---' Depth below inlet.................... Total leaching area..................sq. b.
�� Distribution |
^~ Percolation Tea Reao�m Performed .� �
� Test Pit No. ] per inch Depth of Test Pit.................... Depth to ground ..
Test Pb No. per inch Depth of Test Depth to g '
0Description of
| ~ Nature of Repairsor Alterations Answer- when applicable...............................................................................................
.......................................................................................................................................................................................................
- Am^=e"="t'
The-undersigned agrees to install the oforedescribc Individual Sewage Disposal System in accordance with
the provisions of I TIE 5 of He State Sanitary Code The undersigned further agrees not to place the system in
ope-ral-ion until a ertificate of Compliance has b issued by the board o;f Ith.
' � ^ _-n"m
pp��utnoo Approved Bv_----'����]��.z��^�-'�'����,z����� ______-- ��--��''�-��«�
�~ Date
Application Disapproved for the following reasons:..............................................................................................................
---'----------'--------------------------------'---------------------'---------'-------------------
»"te
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............OF -&z�
Date
T I CERTIFY, T the Individual Sewage Disposal System constructed (--�) or Repaired
has been installed in accordance with the provisions of TITLE 5 of he State Sanitary Code as described in the
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO�STRUED AS A GUARANTEE THAT T14E
SYSTEM WILL FUI$CTION SATISFACTORY.
THE COMMONWEALTH OF MASSACHUSETTS ,
BOARD OF HEALTH
0 F...Z,�
uispollakt%p ( it " utit
Perffiission,�Ishgpr b ted................... ...... ...................................................................................................
OZ y gran
ispos
at Nonr;�* =J_ j=_-. !
as shown on the application for Disposal Works Construction Permit No-:.. ............ Dated...........
FORM 1255 A. M. SULKIN. INC., BOSTON
S//!GL'E F�tiy/G Y -- 3 BEo.2ooM ----�- ` /
`A10 . G --,
4.2 45'e G.e/�t/OE:2 �"�¢ i. ►.!�`rt E S-4a Sz=
0.4/LY ALoW _ //D X 3.0 330 G.PO.
`�/SE /•000 G 41 .
n/S.�Z'2S,4L O/T•--USE /044 �S',[1�
s/OEW.QLG .Q-41:54
t r t
TOT.4.L v.4/LrFLo1�/= .330 G.Pv,
�.. Av o,e s
may\
P'i7ER G
FACHARD r r 1
SULLIVAN
No. 29i33 BAXTER ;. +-r
Na 2404$
-rgo (�,p = ?2,•�* .�G 7Z•.o ;a;� Tu�F.vo=?c5�0 f.
tom. FG• ��„ .-�• � .
XVV
• 6 e_ /.Y1/. BOX
�. ��''d G6.(o S.EPT�'G
N W-/ '.�/y` P TAn/.�G .
... y Ta/%s. f /iV✓.
e :. D✓AIiyEO :r //Vr/
.rr�.vE G6. CG� OE.�T/F/EO PG Pr-
Do PLA.t/
open
Tf/rQT T.yE' 'FouM1PXTIO►4 S V4Wc/ �_�a►.t' 3 �( �°7. . :.
YE/.vG.
/a�V,D,fE7'1�/1G.� .2EQv/�'EkI�NTS oP THE ,C�,E6'✓sr�,eEO�.a.vo.SlieciEy�Ps
Tox/.v oi�'�Ae►,�,bTf�,Bt•-t'.r Q.v� /.S.Ivor- �sr�.2t�ict c' o
�1.4sr
-�'g� � Tylt�o!_,•ev /•f iS/Oj-13.QfEp GIN.4 it//iY•ST,2—
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PFTER
SULLIVAN RICHAARD
No. 29733 : " BAXTER
c/STV Na 24048
FR� `�Q 'A�,�/���4
ss/ON.p I to Nb ,
1
� l•ZB'Sb
SYSTEM PROFILEALL!SYSTEM COMPONENTS SHALL BE
MARKED WITH MAGNETIC TAPE OR
COMPARABLE MEANS FOR FUTURE LOCATION. NOTES
PROVIDE MIN. 20" DIAM WATERTIGHT (NOT TO SCALE) `..�'
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE OBS. PORT WITHIN 3" OF FIN. GRADE 1. DATUM IS APPROX. NGVD
\ TOP FOUND. EL. 77.1'
2. MUNICIPAL WATER IS EXISTING
MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE RE(IUIRED OVER SYSTEM 67.0 - 68.0' rr3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. d.
PRECAST H-10 "`
RISERS (TYP.) oc Sgf ice R
4. DESIGN LOADING FOR ALL PROPOSED PRECAST
.. 2'¢ 69.8' 4">aSCH40 PVC 2" DOUBLE-WASTED PEASTONE UNITS TO BE AASHO H-10 0
,.: PROP. TEE PIPES LEVEL 1ST 2' OR GEOTEXTILE F,)a3RIC
63.5 5. PIPE JOINTS TO BE MADE WATERTIGHT. i
10" EXISTING 14"
TEE SEPTIC TANK** TEE ° ° ° ° ° ° ° ° ° ° ° °
° ° ° ° ° ° ° ° ° ° ° ° ° ° �� '° ° ° ° ° ° ° ° ° ° ° ° ° ° ° 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE Oakst'
000 0 0 0 0 0 0 0 0 0 0 0 ° ° 0 0 0 ° ° 0 0 0 0 ° 0 °
68.4 63.0' °°°°°°°°°°°°°°°° °°°°°°°°°°° °°°°°°°°°°°°°°°° °°°°°° ° °°°°° WITH 310 CMR 15.000 (TITLE 5.)
O°OQ°O°°O°OO°O°° 6""MIN SUMP °°O°O°O°O°Oo°°o°°o°°o°°o°°o°°o°°o°°°°°o°°oc°°o°°o°°o°°o°°o°°o°°o°°o° °°o°°o°°o °° o°°°°°o ,
GAS BAFFLE °"°,°,°,°°°°°° 12 MIN INT. DIM. o00000000000000000000000a°0000t c0000000000ON E 0 OROo 0 00°°0° 60.85
7. THIS PLAN IS FOR PROPOSED WORK ONLY AND
63.25' 63.08' 4" PVC SET AT ,005'/' SLOPE NOT TO BE USED FOR LOT LINE STAKING OR ANY on s
ON 24" DOUBLE WASF(ED 3/4" 1 1/2" STONE OTHER PURPOSE. Thee Wequaquet
MIN. 2" WALL THICKNESS 2 - 32' X 3' w. X deep trenches Lake
8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. �o : z
6" CRUSHED STONE OR MECHANICAL 5. 9.9. COMPONENTS NOT TO BE BACKFILLED OR
0
COMPACTION. (15.221 [2]) CONCEALED WITHOUT INSPECTION BY BOARD OF Qo 0
HEALTH AND PERMISSION OBTAINED FROM BOARD
(64 % SLOPE) ( 1 % SLOPE) OF HEALTH.
LEACHING BOTTOM TH 1 EL. 55.0' 10. CONTRACTOR SHALL BE RESPONSIBLE FOR
FOUNDATION- EXIST. SEPTIC TANK 8' D' BOX 10' FACILITY CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP
VERIFYING THE LOCATION OF ALL UNDERGROUND &
* **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NOT TO SCALE
THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE WORK.
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON H-10 SEPTIC TANK IF NOT SUITABLE. 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 193 PARCEL 234
SHALL BE REMOVED 5' BENEATH AND AROUND THE
PROPOSED LEACHING FACILITY.
12. EXISTING LEACHING FACILITY SHALL BE PUMPED
AND REMOVED OR PUMPED AND FILLED WITH CLEAN
VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE SAND.
13. PROP. SEPTIC SYSTEM > 100' TO WETLAND
IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR X\7.66 HELMSMAN DRIVE
BY HEALTH INSPECTOR
PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED
BY THE BOARD OF HEALTH REVISED DURING A PUBLIC 0 ,��o SYSTEM DESIGN.
HEARING HELD ON AUG. 4, 2009 0 ( r.81 - - 76 a�x76.26
�S ,76.90
x/'X
97� 5� 2 GARBAGE DISPOSER IS NOT ALLOWED
3) FAILED SYSTEMS ONLY SOIL ABSORPTION SYSTEM , L EXISTING 2 BEDROOM DWELLING
INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW � �' 76.6 DESIGN FLOW: 3 BEDROOMS � 110 GPD = 330 GPD
PROP. VENT WITH CHARCOAL FILTER /
GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) AND BUGSCREEN FINAL PLACEMENT BY x77.6,
( 77 USE A 330 GPD DESIGN FLOW
AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS
CONTRACTOR WITH HOMEOWNER tij0 / � W 75.8
BE LOCATED MORE THAN SIX FEET BELOW GRADE. CONSULTATION) �• i 77.2s z
4� x77.59� SEPTIC TANK: 330 GPD (2) = 660
i (3 1 73. RE-USE EXISTING 10100 GAL. SEPTIC TANK **
� X 77.�34 78 1 � \
/ / 77.01 2.39 LEACHING:
I X77.�2
TEST HOLE LOGS 6.78 � SIDES: 2[2 (32 + 3) 2 (.74)] = 207 GPD
75.64 BOTTOM 2[32 x 3 (.74)j 142 GPD
I 70.03
ENGINEER: DANIEL E. GONSALVES, SE GARAGE i I TOTAL: 472 S.F. 349 GPD
WITNESS: DONNA MIORANDI, RS I EXIST. DWELL. I USE (2) 32' LONG x 3' WIDE x 2' DEEP
TOP FNDN. = EL. 77.1' LEACH TRENCHES OF PERF. SCH. 40 PVC PIPE AND STONE
DATE: 4/18/14 I BENCHMARK: SILL
PERC. RATE _ < 2 MIN/INCH ► �68.35 = ELEV. 70.3'
76.59 7 .4 70.27
CLASS I SOILS P# 14337 77.2 i DECK I I 0� 67.45
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1 ELEV. z ELEV. x -- --►N 0 .65 J DRIVE 1 66.31 MA
4 4 ' Q 9.8 6 APPROVED DATE BOARD OF HEALTH
o 65.0 O 66.o R� . WALL 73.90 .37
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A A X 79.38 2 E OF / \_ 2- L�L 65.57
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34 62.17 36 63.0 A ' A 79 HELMSMAN DRIVE
` 65
10N CENTERVILLE
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PERC 7 - - PREPARED FOR
' B&B EXCAVATION/STONE
FS FS
/ 63.74
APRIL 21, 2014
2.5Y 6/3 2.5Y 6/3
63.18 0r r,n `� ��N Ck'�'q,9 1, off 508-362-4541
fax 508-362-9880
C,a,?�1!E A i DANIEL
: A. I downcape.com
EXIST. DWELL o. �.>� A �f i,
i
down cope engineering inc
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120" 55.0' 120" 56.0' � I �_ °+c - '
4�?�,ke rT���° 3 ' ,F civil engineers
Scale: 1 = 20' I n ` s. land surveyors
rsNO GROUNDWATER ENCOUNTERED
939 Main Street ( Rte 6A)
14-073 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675