HomeMy WebLinkAbout0072 HILLSIDE DRIVE - Health i 2 Hillside Drive
Centerville
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Commonwealth of Massachusetts
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
rz
72 HILLSIDE DR l
Property Address
SEELEY '
Owner /
information is Owners NTERVILLE V MA 02632 6-19-17 X
required for �.
every page. City/Town. State Zip Code Date of Inspection r"jj
Inspection results must be submitted on this form. Inspection forms may not be altered in
way. Please see completeness checklist at the end of the form.
Important: A. General Information S/fir /at3q 9
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
VQ P.O. BOX 145
Company Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
5084204534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-19-17
Inspe rs Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS. THIS REPORT DOES
NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USAGE.
THIS REPORT IS NOT TO BE USED AS A BEDROOM COUNT DETERMINATION DESIGN FLOW.
13) 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
72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every 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
t 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 '/Z day flow
t5ins•3/13 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
M 72 HILLSIDE DR
Property Address
SEELEY
Owner owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
` provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-3/13 Title 5 Official Inspection Forth: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
72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
SYSTEM CONSISTS OF A 1500 GALLON POLY TANK D-BOX AND A 4 BEDROOM S.A.S
CONSISTING OF 16" HI CAP BIODIFFUSERS.
Number of current residents: UNKNOWN
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
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2016--------556 GPD 2015--------410GPD
Sump pump? ❑ Yes ❑ No
Last date of occupancy: CURRENTLY
OCCUPIED
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Mt 72 HILLSIDE DR
Property Address
SEELEY
Owner Owners Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENTLY OCCUPIED
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
11-24-14 PER AS-BUILT
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank locate on site plan):
p ( P )
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: 1500GALLON
Sludge depth:
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 72 HILLSIDE DR r
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
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.):
IF TANK HAS NOT BEEN PUMPED IN THE LAST 3 YRS I RECOMMEND PUMPING AT TIME OF
TRANSFER AND EVERY 2-3 YRS THERE AFTER FOR MAINTENANCE.
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 scum of to to of outlet tee or baffle
P
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons I
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M r� 72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
BOX LEVEL NO SIGNS OF LEAKAGE OR CARRY OVER
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M '< 72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cost.)
Type:
❑ leaching pits number:
® leaching chambers number: BIODIFFUSERS
❑ 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.):
THE VENT/OBSERVATION PORT WAS OPENED AND THE BIODIFFUSERS WERE FOUND TO
BE EMPTY WITH DAMP SOILS IN THE BOTTOM, CLEAN SAND COULD BE SEEN AT THE
BOTTOM OF THE CHAMBERS.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
required fo is CENTERVILLE MA 02632 6-19-17
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
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: NONE ENCOUNTERED AT PERC
TEST
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: 6-19-17
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:
DESIGN PLAN
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 72 HILLSIDE DR
Property Address
SEELEY
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-19-17
every page. Cityrrown 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
Assessing As-Built Cards Page 1 of 2
TOWN
•�OF BARNSTABLE
U
LOCATION x1�5�t) r SEWAGE#aOfK-y3�
VILLAGE _ASSESSOR'S MA.P&PARCEL _
INSTALLER'S NAME&PHONE NO. ,�ts A f,
SEPTIC TANK CAPACITY , f N
LEACHING FACILITY:(type) " (size)
NO.OF BEDROOMS_q
OWNER
PERMIT DATE: 11�13—/y_COMPLIANCE DATE:
Separation Distance Between the: +4eye a9^QNlI;
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
FURNISBED BY
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http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=193052&seq=2 6/20/2017
g g TOWN OF BARNSTABLE
LOCATION 7 15/de Or SEWAGE#9CD/If- t-/3B
VILLAGE C,� PF a r ASSESSOR'S MAP&PARCEL Jqn a
INSTALLER'S NAME&PHONE NOD', s 4 1
SEPTIC TANK CAPACITY f- ev
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
OWNER 'Se ete 4
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the: l P46" e- °f-6' perr,
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
h
3 -ys,Co, 3 — 4
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Main File No.017991 Pa
Bttuiiding Sketch 17ft 17ft
Bettina S 8 Lawrence W Brown -
72 FGllside Dr
Centerville Couny Bamstable State MA lip Code 02632
Steams Lending,LLC-Wholesale Fail"ttgly Room Rec w
Plot size: .27 acres Room
---rSfA9KE DE UORS REWEWEO 4f 3
� wet V—W
JB ;NZ�BUI DING DEPT. DATA ai Bath12ft
l � 0 Bau-' Firs n
FIRE DEPARTMENT DATE
20ft' {70t aft v
-BOTH,CIGNATURESARE REQUIRED FOR P RMllTING �' 11, Unf. Basement n'
Larry & Tina's wing -' W [369 Sq ft]
Patio
Total 1,200 Sq. ft. [z60'sq-ft] Pc Bedroom X
Oft 17ft
cc Shed Amber's wing total
Vic
Kitchen eft 598 Sq. ft.
X
Bdrm
a o1
W Common Rec room
Wt y z car Carport � will.be shared by all.
Living 1606 Sq ft] Its area, 166.5 sq.
Bdrm K Room
Bdrm x Ceiling mounted fire/smoke
L
/C0.1 alarms will be marked Q7
4.Oft 22ft as /
off seesaw 900.......................HILLSIDE DRIVE.......................................................................-.......................
9}(
Town of Barnstable
°V�"E'"�� Regulatory Services
} + Richard V. Scali, Interim Director
3 �rsr�.rsr.E;
' MASS. Public Health Division
L65g;. �?
pxfD. t Thomas McKean, Director
200 Main Street,Hyannis, MA 02601
Offit 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Dat : /i Sewage Permit# 1014 -43t Assessor's 1Map\Parcel 19 3 SZ
Des' Der: Installer-
Ad(
ress: 61 Address: P G
°Co`(�'( C eh l-en�11A t�'1►�- (� �z(o`3 Z
On ti 2� �'"'�- vas issued a permit to install a.
+L-e
sept}'c sytem at': t ! r t , s`l-,F' . 1 based on a design drawn by
(address)
Aj, dri:Leti '7 1 r y L_v g 1 -1
(designer)
1 .cer it that the septic system referenced above was installed substantially according to
the des' wl ich a Say ii)clut�e minor approved changes such as lateral relocation of the
distribut an bcrx and/ar Septic tank. Strip out (if required) was inspected and the soils
r-e foiirid satisfactory,
.,certify Thai`,he septic system referenced above was installed with major changes (i.e,
greater than 1 Q' lateral, relocation df th SP S or any vertical relocation of any corrlpone:nt
6f the,septic system) but in accordance with State & Local Regulations. Plan revision-or
ceiti ed'as-built by designer to Follow. Strip out (if required) was mi spected and the soils
�ere found satisfactory.
eN'�p4lLkhq�i'
I certify that the system referenced above was consuu 'i with the terms of
the I\A approval letters (if applicable) �. %.
' r '1-� k r. yin
I CIVIL
�
( sta er's Signature)
�j,g
t PJnL �
'�fi+v'rtv
k.. (Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABEP`I.TBI,IC HEALTH DIy1ION. CI{1TIFICATE
'OF C01Y-E'LL NCE-' WILL NOT BE ISSUED UNTIL BOTH T11-18 FORM'. AND AS
�+ BUILT CARD ARE RECEIV-ED'jBY`'CIE BA INSTABLL PUBLIC I EALTI3 DIVISICtN;
7HkNK,YOU.
Q:"*h�iOpesiper Certification Form Rev 8-14-13°doc
T •
No. 0 Fee l Uv i
v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftpliLatlon for -Misposal *pstem Construction permit
Application for a Permit to Construct( ) Repair(iU pgrade( ) Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No. 'T:Z ��i1r�t P �cr , Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel � �. VC
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
r, lc5 A "1�cox,5:a 1' �N i^3c' ��'��► i.�c��lc
Tfpe of Building:
Dwelling No.of Bedrooms Lot Size t;L ,,JQ S sq.ft. Garbage Grinder( )
Other Type of Building a(e-,tC�Pr.�fi \ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) y H C) gpd Design flow provided_L4 15 gpd
Plan Date ;L— 7 —%tl Number of sheets Revision Date g U41
Title
Size of Septic Tank i To 0 Type of S.A.S. (C,11 14 i C« H•2 0
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 of Health.
S /WDate
Application Approved by Date
i
Application Disapproved by Date
for the following reasons
Permit No. (� Date Issued
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:{�
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MAiSACHUSETTS Yes
Zipplicationifor MisposalOpstem Construction Permit
Application for a Permit to Construct( ) Repair(Vf/Upgrade( ) Abandon( ) ❑Complete System Et5ndividual Components
Location Address or Lot No. 72 W,2 $1 e T f Owner's Name,Address,and Tel.No.
,. !Assessor's Map/Parcel I Y -S� � \/c See1e-J
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
1c. A Z-ccwroS,\x 1-i L'000C.
Type of Building:
Dwelling No.of Bedrooms Lot Size I A ,Vw_1 sq.ft. Garbage Grinder( )
Other Type of Building CS\c)rN E\U\ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) Ll H gpd Design flow provided cU 2 S- gpd
Plan Date 2- -7 -!4-1 Number of sheets Revision Date y r r L/
Title
Size of Septic Tank_1 S� Type of S.A.S. JC.11 14 t Caw b�oe��FhUStmrS H 2(�
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) l NSte.1i N rt-0
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
i
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Date
Application Approved by -I Date
Application Disapproved by Date
for the following reasons
Permit No. I - 14 3 Date Issued
r
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 c% A A 1--NC
at 7 2-- 1-I # 11 g i TAP V Q C c-N Y has been constructed in accordance
/
with the provisions of Title 5 and the for Disposal System Construction Permit No.�a ]fp dated (1/f 3 y
i
Installer :Zb,3�1C_s A T_ AX Designer le e j-e-e- y,'.v t ✓�C $
#bedrooms // Approved design flow H 2 S— / gpd
The issuancd of "is ermit shalhnot be construed a71911F_,�,Iyj
that the system wi cf on as desJignneed. /
Date �� Inspector
-------------------------------------------------- -------------------------------------------------------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pBtrm Construction Permit
Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( )
System located at -7 1- H ► I(S i t� r �j f C r.,y
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:ConstructionT'ust be completed within three years of the date of this permit.
Date M � Approved by
XFINITY Connect Page 2 of 4
i
Pad '1 W1$PM M IMP
a� T I X 1 J I 6� lone
Town of Barnstable
t, Regulatory Services
'" °• Richard'V:ScalL Interim Director
( � i Public Health Division
t`sa►, Thomas Mc.'Kentt,Director
200 Main street,ayianais,]l4A'OU01
09io: 501462-4644
'FaXz 508-790-630i
lniuCo++'tr r Gcrtiflt atiion form for Alter- 84ivc$ a;te
Properiy-Address:
Uscssor's 11t1&nrcel: 19-3—O 5�-
_
Lropsr Qwller4tiamc:
lc aacoidance wit Massachusetts DEP altenia+tivt S)'stcm aPpr oval 3c xers,the iollov i4td Ce?lificeitUor
intorii upon, L regwree by Une Oivtier of record. "fie Chmer of record trust plF=an 'Y' in We
uppfl a b It bras next to each line certifyiaie the irforr"U 1ori.
}f,oa 1\i�ai
Ij I naive been provided a mpy of the We 5 VA'ta-1knlogy Approvdilevers,
(15 page Sumdard Coodilions lever and the 5peci is 5.ecau10109y Jw kx)
l r'' l havG bem provided wits the o vner's Njanual
1. 1 have$eeg provided with Cale Operation twd M riance Manual
For Systaans iaista3lled tinder it Fj--nd-E Use tlpurtov�sl,I aggee w fuli it ay
rewpomibilitiz s to p+c�'ide a DwA Notice as tequirsal by 310 OWL 15:287(1,0)
and the A,pM-val
L !fi For Sys 'ns nstslied Lander la R-ctrledial Ilse.Approval,i agree to-fulfil my reT' sibilitias 1-0
FraiJide tiVriti i nnt]fiCation of the Apprrvnl to any new 0wner,..as required by
310 CUR 15 287(S)
FW 04 If the desiga does not provide R)r the use of Surbage grind ers,the resuiciior.is and eusrood
and Rsxepted
QW Q Wi)cthex or cotcovared by a"t—ranty f'aitdersta0d the rcgttim—nr to repair,r.placc,modily
or talm my miter action as required by llie 1)eyeat>mt or thu LAA,if the Department arr the .
J.,AA dctumines the Systonn to be failing to Frntcct pu•lic bmIth wid sgety:acid the
envirorimt,m,as defined in 310 CMR 15.303
James JI Seeley ame o camply wish a l ierms and condition kh"ive.
11112/14
Pi t}' cr&Statute D°M
Note.• Tbk rtiritl mm5t be vnhmittcd aionR Ivith the se lie svctem dison.gal is,orl.s nermit
€AppHe`itio dar sil- LSA hV t4tuts ;xmikidini tray Construction! 'C8lairslunsyr'ades l<'atit. and
Wifh aut affnreE<ate fstwnel and rvikh eorlv+`ntiitittAl Ar€ietl cratctaa or credited tieea�ia
cr°ateria.
Q:i3'��[its��ha��cewnctce:tM1h�rirgige
http://web-mail.comcast.net/zimbra/h/printmessage?id=598662&tz=America/New York... 11/13/2014
Town of-Barnstable P#
_ /
Departi pient of Regulatory Services
a Aj Public Health Division Hate
ai.5 A,fP 200 Main Street,Hyannis MA 0260I
pa,
Date Scheduled d ' ' Ma.
Time Fee Pd,
Soi uitability Assessment for Sews zs j
Performed.By: � � �`' � F�d�S y2 Witnessed 6 :
Y
LOCATION & GENERAL INFORMATION
Location Address -2 2 �.g,'/l s,'e�t �,^L Owner's Narn- -—
Ja.h M
CG�t�it/e l L4 MA- Address _2?
Assessor's Map/Parcel: /9 3 6S 2 Engineer's Name AX, C_& f't?'6
NEW CONSTRUCTION REPAIR x Telephone#
Land Use Slopes(%) � � 2— Surface Stones
r`
Distances from: Open Water Body�ft Possible Wet Area —ft Drinking V 'e Wei17_�ft
Drama a Wa N 6� ft Pro ert Line G r
g Y ` P Y 1 ft .Other` T ft r
rs
SKETCH:(street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands n[roximity to holes) -;,a,
7 f
&f
w
Parent material(geologic) �yf t�l9CtS Depth to Bedrock /0. Ai/Z—
Depth to Groundwater. Standing Water in Hole: NQ G C0 Weeping from Pit Face Nam'
Estimated Seasonal High Groundwater / _z_
DETERMINATION FOR.SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: __--In, Depth to soil mottles: -
,, DcYth-ta w.• ping fr n:side of oba:hole: —in, groundwater Adjustment fl.
Index Well.#— Reading Date: index,%V01evel._ Adi.factor Adj,OroundwaterLevel o
PERCOLATION TEST bate 1 ,2� Time G�
Observation
Hole# I Time at 4"
Depth of-Pere �6 �' Time at 6" `j' 77
Statt Pre-soak Time® 1/',) _ Time(9"-611) ,.
t6^ End Pre-soak
Rate Mini/Inch. C Z-
Site Suitability Assessment: Site Passed__-_Q� Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division ` Observation Hole Data To Be-Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland you must first notifythe
P
Barnstable Conservation Division at least one (1) week prior to beginning.
Q:\SEFTIWERCF0RM.DOC
DEEP.OBSERVATION HOLE LOG Hole# I
Depth from Soil Horizon Soil Texture Sod Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure;Stones;Boulders..
rt Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color. Soil k . Other
Surface(in.) •. (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
44
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture, Soil Color Soil Other
Surface(in.) (USDA) (Munsell) 'Mottling (Structure,Stones,Boulders.
dConsistency,
DEEP OBSERVATION HOLE LOG H016#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling, (Structure,.Stones',Boulders.
0
i
Flood Insurance Rate Map:
Above'500year flood'boundary No_ Yes .�
Within`500 year boundary No—A Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area for the soil absorption system?
proposed
If not,what is the depth of naturally occurring pervious material? ..�.
CetXtification
I certify that on (date)I have passed the soil evaluator examination approved by:the
Department of Environmental Protection and that the above analysts was performed by me consistent with .
the required arcing,expertise and experience described in�10 CMR 15.017.
Signature Date
Q:\S•EPT[QPERCFORM.DOC
TOWN OF BARNSTABLE
LOCATION v9, mll .. Dt 1 SEWAGE#
VILLAGE �-l{'` I I ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY WtV i S `G\-) �IbPrt2
LEACHING FACILITY.(type) IP I xish (size)
NO.OF BEDROOMS `///
OWNER 1M <iee
PERMIT DATE: COMPLIANCE DATE: r
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well 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 y
within 300 feet of leaching facility) Feet
FURNISHED BY
Pik
No. . _ — I Fee
a
THL�6MMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplication for �N5 o� Y *p.5tem� Coaztruction Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. -7 5 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel (C1.3
Installer's Name,Address,and Tel.No. Designer's Name,Address 7//A
o.
Type of Building: (q.14 -'
Dwelling No.of Bedrooms �`` Lot Size o 2� sq.ft. Garbage Grinder ( )
Other Type of Building �)005 e 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 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Crl
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 rd o He
Signed av�
Date
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. �_Uj/-3 0 y Date Issued
No. _ ( T Fee kvr^
'''I M Entered in computer:
TH GMONYVEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippYicat.ion for �Bigogal i§pgtem Conotructiou Verm tt
Application form Permit to Construct( ) Repair(:;;Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. -7�L Wt,'s Oe Owner's Name,Address,and Tel.No.
ce+�trfQ�l�f' 5� ,
Assessor's Map/parcel `C�s 0rJ 2 K
Installer's Name,Address,and Tel.No. 'F Designer's Name,Address and a/No.
—0oosl cp
Type of Building: Gl -� -7
Dwelling No.of Bedrooms �LL Lot Size o o�7 sq. ft. Garbage Grinder ( )
Other Type of Building V)00 No.of Persons Showers( ) Cafeteria( )
b �
Other Fixtures
Design Flow(min.required) gpd Design flow provided /gpd
Plan Date Number of sheets Revision Date
Title. �
i
Size of Septic Tank Type of S A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) C PSJ c
J'-fi1M �a. 1500 .Cl DN �1 of r c,% tt. s J its C c t,
v
Date last inspected: d
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. /f f
Signed ; jQQ" "`- Date .
Application Approved by / N F� Date
Application Disapproved by:r i i Date
for the following reasons
Permit No. )vCUr Date Issued 7 / (/
T' -
)�I� f THE COMMONWEALTH OF MASSACHUSETTS
If
( BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (graded ( )
Abandoned(
i by
at r e(J has been constructed in accordance
with the provisions of Title,55 and the for Disposal System Construction Permit No. dated—7Aild
Installer ��,G Tl 3 G(m3a Designer
#bedrooms Approved desig&5t
gpd
The issuance ,f thi permit shall }o bed onstrued as-a guarantee that the system willas designed, �' a
Date Inspector
----------------------------------=—==------
z
No. � �L � Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
�Diopo.zal ,p5tem Construction Permit
Permission is hereby granted to Co (- ) Repair ✓ Ups jde ( ) Abandon-, \ y
System located at 7*. /jiff 5/Oe D;Iye (P&1r1V171 1&
4-
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditio��Fo
Provided: Constructi h must be completed within three years of the date of t
/ W/
Date !2- Approved by
TOWN OF BARNSTABLE
LOCAT J11ION �rl�l r S i aJ e 17 w SEWAGE#
_';TILLAGE (:eA-Rry ASSESSOR'S MAP&PARCELSa--
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY CQ,SSOQb
r
LEACHING FACILITY:(type) P17 Lx G^ (size) 07 S7-DA,,_
NO.OF BEDROOMS
OWNER W A(ki,/
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY q—'A Spci.T, FDi c1 Y101
A
/3 AL (3.
i
Q a
� 3Fs a� PT
a �0 38
cC J k
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE.5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 72 Hillside Drive
Centerville, MA 02632 LA Zo
Owner's Name: Walter Walker
Owner's Address:
Date of Inspection: September 14, 2007
WAR 11� �sZ
Name of Inspector: (Please Print)James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my c
training and experience in the proper function and maintenance Qf on site sewage disposal systems, I am a=DEP =>
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_,,
✓ Passes
Conditionally Passes
Nee urther Evaluation by the Local Approving A=tithority �>
Fail (y) �rl
Inspector's Signature: Date: September 2 2007 -v
The system inspector shall sub t a copy of th i.sl 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 Conunents
****This report only describes conditions at the.time of inspection and under the conditions of use at.that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
- J
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 72 Hillside Drive
Centerville MA
Owner: Walter Walker
Date of Inspection: September 14, 2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not detennined(Y,N,ND)in the for the following statements. If"not detennined",please
explain.
The septic tank,is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is.replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will .
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 72 Hillside Drive
Centerville IM
Owner: Walter Walker
Date of Inspection: September 14 2007
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,.safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well"- Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for colifon-n
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of anunonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other.
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
' Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 72 Hillside Drive
Centerville, MA
Owner: Walter Walker
Date of Inspection: September 14, 2007
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the.ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructedpipe(s). Number
of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or.privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ ✓ Any portion of.a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have detennined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
. Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes to any question in Section E the system is considered a significant threat, or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contactthe appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: .72 Hillside Drive
Centerville, MA
Owner: Walter Walker.
Date of Inspection: September 14, 2007
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 he SAS, located on site?
✓ Were the septic tank manholes uncovere I,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 Abso ption System (SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a pl n at the Board of Health.
✓ Determined in the field(if any of the fai ure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72 Hillside Drive
Centerville, MA
Owner: Walter Walker
Date of Inspection: September 14, 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] .
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings; if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of infonnation: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank, distribution box,soil absorption system
Single cesspool
✓ Overflow cesspool
Privy
Shared system(yes or no) (if yes;attach previous.inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe): -
Approximate age of all components,date installed(if known)and source of information:
A new pit was installed in 1992-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 72.Hillside Drive
Centerville, MA
Owner: Walter Walker
Date of Inspection: September 14, 2007
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Commments (on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank)
Depth below grade: 20"
Material of construction: concrete _metal fiberglass _polyethylene
✓ other(explain) Concrete cesspool block
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 6'W x 8'T x 9'bottom to grade
Sludge.depth: --
Distance from top of sludge to bottom of outlet tee or baffle: --
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:
How were dimensions determined: Measuring stick
Continents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
The cesspool was dry. An outlet tee was present. The cover was 20."below grade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 72 Hillside Drive
Centerville, MA
Owner: Walter Walker
Date of Inspection: September 14, 2007
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments (condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Continents (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.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
8 ,.
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 72 Hillside Drive
Centerville, MA
Owner: Walter Walker
Date of Inspection: September 14, 2007
SOIL ABSORPTION SYSTEM.(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -(1000 aQ
leaching chambers, number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Commments (note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.);
The leach pit was dry and clean. The scum line was approximately Pup from the bottom. The cover was 12"below rag de
There did not appear to be any signs offailure.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to.inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Hillside Drive
Centerville, MA
Owner: Walter Walker
Date of Inspection: September 14, 2007
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.
L--,3 A, r3
Q a
3 aL �-
2- G0 3
10
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: 72 Hillside Drive
Centerville, MA
Owner: Walter Walker
Date of Inspection: September 14, 2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 45 +/- feet
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 local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers_-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
UsinY,Barnstable topographic and water contours maps, the maps were showing approximately 45'+/-Around water at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected.
11
: • Town of Barnstable
�' pp 7HE tp�
Regulatory Services
snar+srns Thomas F. Geiler,Director
's639. ��� Public Health .Division
rEDMAyA
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
TOWN OF BARNSTABLE
9, r
LOCATION 7,�L 1,04Z f/®� ®�ILI£ SEWAGE #
VILLAGE C4;k T L)/" ASSESSOR'S MAP & LOT -GAT
INSTALLER'S NAME & PHONE NO. X.,>.&
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ZaSl&L .01 (size) 6,�e)d
NO. OF BEDROOMS % PRIVATE WELL OR LIC WATE:R�__
UILDE R OWNER elGC CC��S��
DATE PERMIT ISSUED: ��-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
d
1
N
4 i v
,: •�1� I��IO r
THE COMMONWEALTH OF MAS CHUSETTS
BOAR® OF HEA TH
TOWN OF BARNSTA LE
, pphratiun for Dispnm1 Workii nnutrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal
System at:
.. • - -��. .. 'lS�`Q mac'- - . ............................... � 1'LLi.. -1���1' ...............................
Loc ti n-A dre
..-or Lot No.
O er Addr s
Installer Address...
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms......... _.._ ............Expansion Attic Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfix res -----•-•-------•--••------------•---------------------••-----•-•-----••--•------•--------••. • ......_............_......----
W
Design Flow............. . ..........gallons per person per day. Total daily flow....................... ..a...............gallons.
WSeptic Tank—Liquid capacity/l�._....gallons Length................ Width................ Diameter._..-f..... Depth....�i........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq, ft.
Seepage Pit No....... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fst Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
a .--------•••---•----------------------•-•-------•-•----•--•-------•--------- ---•-•.....----------- .
Description of Soil...Q._-Z�:9..4, �. �
x - -- ................
U .....•-•-••-••---...-•-••.......................•.....------••---••-•-•-••-•-•--•---.......-••-------•---...--------•••••-•...-•-----••-••-•-------•...--•----•-•-•-•----...
W
x Nature of Repairs or Alterations—Answer when a llcable._. '�D•t�____.. /7—
U P PP P.
oo
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant has een 's e0AVthe bo d oj health.
Signed ......
Dare
ApplicationApproved By .... .. . . --------------- ----- - ------------------- --- -- ----- ... .......................................
Date
Application Disapproved for the following reasons: . .... ............... ---- ...........................--- ............
------------------------------------------ ......-----------------------------------------------------
J— e
PermitNo. -------- ................... Issued ---...------....... .-. ..
j
9
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLEIt,
.
Applirutinn for Disposal Works Tonstrnrtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
..........�� �f LDSZO .... ��_�-/..LJ ............... ...... , � .:. --.......................
-------------
Location-Addres or Lot No.
Owner
� ' �.15%. 7� _ C.c7�c� � / .........
Address
a
..------• • -- -••---......••.. ----
.........
Installer Address
Type of Building Size Lot............................Sq. feet
1•-1 Dwelling_No. of Bedrooms___.._ ..._/__......�_e............Expansion Attic ( ) Garbage Grinder ( )
`k Other—Type of Building .............. No. of persons............................ Showers
Pk g -------------- ------------------P•--------•----- ---- ( ) — Cafeteria ( )
Other fixtures .------••--••-------------- -----------------.........-•-••-••..... •-------•-.........----•---...•---
W Design Flow.............• ...........gallons per person per day. Total daily flow._._.........._ ...............gallons.
WSeptic Tank—Liquid capacityZ' gallons Length................ Width................ Diameter----I....... Depth....l.'.....
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....... - --__. Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth"to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
....................--------------•--......--•------------...-•-----••---------•---••--•-••----•---.........------------------------------------------•-----
O Description of Soil--r ==` �� '11 •�SG�%Sd/( -`__' ...........�� s1�If�J•_8�_T'U �5 .... S Li�11�------
x
(� -------------------------------------------------
---------------------------
.----------------•---------------------------
••--••------------------------------•---------•------------•-----•------------------------------•--------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable._��h_.____,'IA4 ......................... , _-- ion
.............. �ll_a .................
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance-has een 's/�/ueedd bb-)tthee board o health.
Signed / n L1 .``/ .....a = -------------A �n'�y
c Ll�p
Application Approved BY ................. �� � !- TT'i( / -/`r�/ -Ie; � -»ae
Vy..,. t
`�" L Date
Application Disapproved for the following reasons: -- - ------------ -�
........................................... ..... ---- -------------- ------------------------------- ...................................- ------------------
------- - ------- --
�- �------- Date
s
Permit No- ------------- �...- Issued /� --..C,7
�Date -�----'--j
f ` d
THE COMMONWEALTH OF MASSACHUSETTS
BOARD-OF HEALTH
TOWN OF BARNSTABLE
Certtfirate of (foutyltalttre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ----_---------------- r 7 /L(3 1------(l-wtv ----- --------------------------------------------------
Installer
has been installed in accordance with the provisions of TITLE 5 -f he State nvironmental Code as described in
the application for Disposal Works Construction Permit No. ------ --- ------ .. ..._..-- dated ------------------------------.-.---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRU9D AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -�- ./ - -�------------------------------------ Inspector ----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.....1 y FEE.
0...
Disposal Works Tonstrurtion jkrufit
Permission is hereby granted............... G --------Z�S/-----.......................................................
to Construct ( ) or Repair (-,SG,) an Individual Sewage Disposal Syst
at No............................... .............//l�Sil ..... -----------em � ......
as shown on the application for Disposal Works Construction Permit Street
No- _A_r�07jDated__ ��11 / `J
Board oe Health
DATE.. -- = /... -------•-••-.
FORM 3860E HOBBS Q WARREN.INC..PUBLISHERS
' Y .. - • t �•Q/`(/I IT l.lf j^"' / V/P4, �J yl �41 •�V V'� C.�� �/ �u.tffC
- ./k•,�..n�•_�� • ��/1,1� ' _ ` ,C':e r•' '.
a ` R Y� • f
?` CONVENTIONAL SAS... " --99 --EXISTING CONTOUR o N
FOR ILLUSTRATION ONLY-DO NOT:INSTALL ja, x 100.98, EXISTING SPOT GRADE
3-500 GALLON CHAMBERS W/4' STONE W EXISTING WATER SERVICE
12.8' x 33.5 S.A.S. FOOTPRINT
GAS EXISTING GAS SERVICE r ��
BENCHMARK BOTTOM SIDEWALL TOTAL
AREA AREA AREA U UNDERGROUND WIRES
TOP/CONCRETE BOUND 429 SF 185 SF 614 SF -6.H.W---OVERHEAD WIRES
EL.=99.22 TOTAL CAPACITY = 0.74 GPD/SF(614 SF) = 454 GPD TEST PIT s
0
9 N BENCHMARK We ua uet
9, fence k x 96.5}0 100.22'x 9 .s4 9L5o LEGEND °his° �\\
CONNECT PIPES TO \
LOWER KNOCKOUT x 99,12 -1 Tp 2� 62 2 3
EXISTING LEACH PIT �, _ o _ 3 8 92,65 92.53 91,98 a 1�3,P0 3 1i
TO BE REMOVED 90,80 s P
SEE NOTE 11 yl 1 _ 97, \ LOCUS MAP
97.4 NOT TO SCALE
24 16" H-20 BIODIFFUSERS IL E- -- x 93,20
CONNECTED BY LOWER 100.14 x -� 6 8 97,27 97.6 93,80 GENERAL NOTES:
KNOCKOUT ACCESSORY
VENT �0'I I I 98 8 APARTMENT 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
~ T.O.F=98. 1 f BOARD OF HEALTH AND THE DESIGN ENGINEER.
I 1 I r7 98.10 97.571.AL 14
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
4-I-ICI EXISTING SEPTIC TANK OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
1NV.(OUT)=93.63 LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW:
100.82 1 -1-J G S o� PATIO j` -310 CMR 15.405(1)(b):
INSPECTION PORTS 7, 3 S C•97,90 1) A 5' variance, S.A.S. to slab on grade, for a 5' setback.
-- U) 2) A 3' variance to the 3' maximum cover requirement, for up
3F11 96.68 t to 6' of maximum cover. S.A.S. shall be H-20 and vented.
40 MIL POLY LINERS
TOP OF LINER, EL.=93.5 p Y97.74 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
BOTTOM OF LINER, EL.=91.0 0 0 I0° J TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
N DESIGN ENGINEER.
TINGo97,80 HDUSE(#72) CA4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
Z PORx 97 5 (? FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
101.45 / T.O.F.,=98,4t' m ENGINEER BEFORE CONSTRUCTION CONTINUES.
(slab on grade)
5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
7,97 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
�13g THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
102,25 x 98.08 x 97,96 o HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
x 97, 5 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
98.44 X :.',.-PAVED ';.,:.;` 97,51 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S.
f 97,91 9 04 OR�IrV+EWAY 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
�p AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
103.34 00,84 0CK RET. AL� T ( DIRECTED BY THE APPROVING AUTHORITIES.
I 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
LOT 99 28 �: ,' I THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
Y101.46 A I CONSTRUCTION.
_MBL 193-52 I 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
5�12,215 fSF x .1.< 9'0� IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
104,07 •83 �'�:'.:'' REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
105,55 100.00 100,22 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
-- S 14'43 50 W �. INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL.
CB 101, 4 ;.•.::.:.. \ 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
106.45 107.35\� \� OF Mgss NOT CONSIDERED TO BE A PROPERTY LINE SURVEY.
U 101,97 Z 100,50 98.96 � q�y PROPOSED SEPTIC SYSTEM UPGRADE PLAN
107,81 PETER T. GJ
M CIVIL 72 HILLSIDE DRIVE, CENTERVILLE, MA
PLAN REVISION - /5/14 HILLSIDE TRIVE No. 35109 Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
ADD 3 UNITS FOR 425 SF (NOMINAL) p� ofG/SZE`� ��� Engineering by: SCALE DRAWN JOB. NO.
OWNR OF RECORD A Engineering Works, Inc. 1"=20' P.T.M. 104-14
n
SEELEY, JAMES J g g
72 HILLSIDE DRIVE UTILI Y POLE 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
CENTERVILLE, MA 02632 -l ` (508) 477-5313 2/7/14 P.T.M. 1 Of 2
y NOTE: TO PREVENT BREAKOUT A 40 MIL POLY 59.6'
LINER SHALL BE PLACE 5' OUTSIDE THE 49.1'
S.A.S. AS SHOWN ON SHEET 1 [::18.
TOP i OF LINER, EL.=93.5 - - - - 30.4'
-
BOTTOM OF LINER, EL.=91.0 PROP. 1
SEPTIC TANK ,• PROPOSED D-BOX r- S.A.S.
INSTALL RISERS & COVERS OVER INLET & PROPOSED S.A.S. CHARCOAL I I _ _ _ 300
T.O.F.
• �COVER SET TO 6INSTALL RISER & WATERTIGHT°
OUTLET AND SET TO 6" OF FINISH GRADE OF GRADE INSTALL INSPECTION 'iPORT OVER END UNIT VENT
1• �
F.G. EL.=99.3(MAX.) m
I PROP.1
EXISTING F.G. EL.=97.3t F.G. EL.=97.2f 1 , W I S.A.S.I ACCESSORY f MAINTAIN 2% GRADE (MIN.) OVER S.A.S. I I W S A
APARTMENT
x.• ou. xr ow I, _1 I I �•! T,0.F=98. 1 f
L = 24'. L = 6' 2 INSPECTION PORTS P
® S=1% (MIN.) @ S=1% (MIN.) (MINIMUM)
4"SCH40 PVC 4"SCH40 PVC PATIO
3 .z L
�o,• I - - �a° 6' 11.3" TO
INVERT
8.5'
ADD
GAS BAFFLE INV.=93.17 PROPOSED INV.=93.00 3 ROWS OF 8 UNITS AT 6.25'/UNIT
INV.=93.63t D-BOX INV.=92.94 EFFECTIVE LENGTH = 50.0' EXISTING
EXISTING 1500 GALLON SEPTIC TANK HOUSE#72)
PLASTIC TANK EXISTING(VERIFY) SOIL ABSORPTION SYSTEM (PROFILE) T.O.F.=98.4f1 CAR
EXISTING i ESTABLISH VEGETATIVE COVER PORT
' NOTES: BACKFILL WITH CLEAN NATIVE OR
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE PERC SAND TO TOP OF CHAMBERS
INVERTS, PRIOR TO INSTALLATION. r,•, :.;:; • ••;•;•.;.••;•• S.A.S. LAYOUT
2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT EL.=TOP EL. •a.•,;'••, "•'
TOP ELEV.=93.33 ___
GRADE ON A MECHANICALLY COMPACTED SIX 75
INV. ELEV.=92.94
INCH CRUSHED STONE BASE, AS SPECIFIED IN - --�
310 CMR 15.221(2). BOTTOM ELEV.=92.00 III III IIIII�II
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' MIN. ABOVE HIGH GROUNDWATER 2.83
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 4'(MIN.) NATURALLY OCCURING EFFECTIVE WIDTH=8.5'
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. PERVIOUS MATERIALS
EXISTING SUITABLE
BOTTOM OF TP, EL=86.0 _ MATERIAL
76
3 ROWS OF 8 - 16" (H-20) ADS BIODIFFUSER UNITS PROFILE
SEPTIC SYSTEM PROFILE WITH NO SEPARATION BETWEEN EACH ROW & NO STONE j
TYPICAL SECTION T
N.T.S. N.T.% 16"
0� '� SOIL LOG 11 1
CONNECT PIPES TO
LOWER KNOCKOUT I�-18.8'---I DATE: JANUARY 28, 2014 (REF#14,275) i-34"�
DESIGN CRITERIA --T-_T_-__ SOIL EVALUATOR: PETER McENTEE PE(SE#1542) SECTION END CAP
I ' _ I T -_ WITNESS: DONNA MIORANDI R.S. HEALTH AGENT
NUMBER OF BEDROOMS: 3 (HOUSE) + 1 APARTMENT = 4 TOTAL I I I I - I -1- ELEV. TP- 1 t DEPTH ELEv. TP-2 DEPTH 16" HIGH CAPACITY (H- BIODIFFUSER UNIT
SOIL TEXTURAL CLASS: CLASS I I-I-I-1 97.2 A 97.0 A 011 MODEL 16" HICAP UNITS MUST BE STAMPED H-20
DESIGN PERCOLATION RATE: <2 MIN/IN I I I I LOAMY SAND LOAMY SAND
L,,I �I-I-i 96 5 10YR 4/2 96.3 10YR 4/2 LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT
DAILY FLOW: 440 GPD I I I I B 8B 8 EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY
DESIGN FLOW: 440 GPD �'� LOAMY SAND LOAMY SAND DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
GARBAGE GRINDER: NO I I I I 10YR 5/64, 10YR 5/6 SIDE WALL HEIGHT 11.2"
94.7 30" 94.5 30" OVERALL HEIGHT 16"
LEACHING AREA REQUIRED: (440 GPD) = 594.6 SF I-I-I-I C C OVERALL WIDTH 34" 4640 TRUEMAN BLVD
I I PERC HILLIARD OHIO 43026
• .74 GPD/SF
II ,
LI-IJ 44"/56" 13.6 CF
EXISTING SEPTIC TANK: 1500 GALLON CAPACITY PLASTIC TANK 99PUB
� 8 5, CAPACITY (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC.
PROPOSED D-BOX: 1 INLET,,r4 OUTLET (MINIMUM), H-10 RATED MED.2.5Y SAND
i ED. AN
MED. 6/ , MED. SAND PROPOSED SEPTIC SYSTEM UPGRADE PLAN
USE 3 ROWS OF 8 - 16 H-20 ADS BIODIFFUSER S.A.S. CONFIGURATION
/ NO STONE IN THE CONFIGURATION SHOWN 72 HILLSIDE DRIVE, CENTERVILLE, MA
- SIDEWALL AREA: NOT APPLICABLE Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF OF BIODIFFUSER)
86.2 JOB. N0.
" . 86.0 132" SCALE DRAWN
132 Engineering by:
24 UNITS x 6,25 LF x 4.73 SF/LF = 709.5 SF P.T.M. 104-14
PERC RATE <2 MIN/IN. "C" HORIZON Engineering Works, Inc. N.T.S.
DESIGN FLOW PROVIDED: 0.74 GPD/SF x 709.5 SF = 525.0 GPD NO GROUNDWATER ENCOUNTERED
12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET N0.
ACTUAL BOTTOM AREA = 8.5' x 50' = 425.0 SF
(508) 477-5313 2/7/14 P.T.M. 2 Of 2