Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0120 HOLLY POINT ROAD - Health
120,Holly Point Road Centerville A= 232-040 �'` �� for ' N0. 152 1/3 ORA 1 0% i r a3a _ ogv Commonwealth of Massachusetts oTitle 5 Official Inspection FormP� ME_M1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is MA 02632 Aril 30, 2021 .required for every Centerville p page. Cityrrown 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 5GW I IS 3&a on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Co � Company Address Forestdale MA 02644 aff City/Town State Zip Code 508-888-6055 S112843 _ 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 16.000); 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 May 4, 2021 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 (P Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville required for every MA 02632 April 30, 2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 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: 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 determine " (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years Id*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration o exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace ith a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspe ion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank s less than 20 years old is available. ❑ Y ❑ N ❑ (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is April Centerville MA 02632 A 30 2021 required for every p � , page. Cityrrown 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 duip to a broken, settled or uneven distribution box. System will pass inspection if(with/remov oard of Health): ❑ broken pipe(s ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is ❑ Y ❑ N ❑ ND(Explain below): distribution boreplaced ❑ 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): r 3) Further Evaluation is Requited 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 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville required for every MA 02632 April 30, 2021 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 absor tion system (SAS)and the SAS is within 100 feet of a surface water supply or tributary a surface water supply. ❑ The system has aseptic tank and SAS a 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 SA and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: 1 "This system passes if the well water a alysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and t e 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: l 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville MA 02632 _ April 30 required for every p �il , 2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A co of the analysis 9g PY Y and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C.4. Yes No ❑ ❑ the system is within 0 feet of a surface drinking water supply ❑ ❑ the system is with' 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is to ated in,a nitrogen sensitive area(interim Wellhead Protection Area—IWPA) or a mapped/Zone 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville required for every _ MA 02632 April 30, 2021 page. Cityfrown state Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doo•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville required for every MA 02632 April 30, 2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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): 455 GPD Description: 3-500 gallon leach chambers w/4'of stone. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2019= 156 GPD 9 ( Y 9 (gP )) 2020=268 GPD Detail: Average water usage higher during summer months due to lawn irrigation. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc-rev.7f26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville MA 02632 April 30, 2021 required for every p page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., et .): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank presen . ❑ Yes ❑ No Non-sanitary waste discharged to a Title 5 system? ❑ Yes ❑ No Water meter readings, if availa le: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Ready Rooter records: pumped 12/4/2019 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. . 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville MA 02632 Aril 30, 2021 required for every p 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: System installed 07/17/2014. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ®40 PVC El other(explain): Distance from private water supply well or suction line: n/a feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts 119 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville required for every MA 02632 April 30, 2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 28"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: 10.5'x 5.5'x 5' 1500 gallons Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 5"at inlet, 1"at outlet Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 20" (Filter in place) How were dimensions determined? Dip tube and tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Effluent filter in outlet tee cleaned during inspection. Tank is scheduled to be pumped and cleaned by Ready Rooter, Inc. Risers bring covers within 6"of grade. Recommend filter cleaning every year. Recommend maintenance pumping every two years with full time use. I t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 190f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holly Point Road _ Property Address Paul Cullotta Owner Owner's Name information is Centerville required for every MA 02632 April 30, 2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: l ❑ concrete ❑ metal ❑ Iberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of o4et tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: / ❑ concrete ❑ metal ;❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: ;� gallons �r Design Flow: % gallons per day t5insp.doc•rev.7/26M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville MA 02632 Aril 30, 2021 required for every _ p page. Cityfrown 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 flo switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): One inlet, three outlets. Speed levelers in place. No high water staining over outlet invert. Very light solids carryover. Riser brings cover within 6"of grade. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville MA 02632 Aril 30, 2021 required for every P page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): J Pumps in working order: / ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump cha er, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3-500 gal ea. w/4' of stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doo•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts � Title 5 Official Inspection Form V_ixffl- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owners Name information is Centerville MA 02632 April 30 2021 required for every p � , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level 1+"from base of units at time of inspection. Light high water staining 2"over current level (1.8' below invert). Clean stone visible in sidewall. No sign of past hydraulic failure. Riser brings cover within 10"of grade. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer / Depth of scum layer I Dimensions of cesspool Materials of construction Indication of groundwater inflow ;' ❑ Yes ❑ No Comments(note condition of soil, si s of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7r28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts - li Title 5 Official Inspection Form F a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville MA 02632 April 30, 2021 required for every p page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of rraulricre, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts WOMEN Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner owner's Name information is CenteNllle required for every MA 02632 April 30, 2021 page. Citylrown 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 buildin h g Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � n 1(7 � o p INA ,y y 1 tr 4. t •v i• �r 1 1 � t5insp.doe-rev.MAW 8 Title 5 Official!nspection Form:Subsurface Sewage Disposal System-Page 16 of 16 r Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville required for every MA 02632 April 30, 2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >5feet 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: July 2014 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: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Test hole in 2014 found no ground water at 115. Base of units 6' below grade. Slope to pond drops well below base of units. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form 190� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holly Point Road Property Address Paul Cullotta Owner Owner's Name information is Centerville required for every MA 02632 April 30, 2021 page. City1rown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION Rd SEWAGE# -D0(L-(- =3 VILLAGE Cc, `ca vex\l ASSESSOR'S MAP.&PARCEL INSTALLER'S NAME&PHONE NO.SEPTIC TANK TANK CAPACITY. LEACHING FACILITY:(type) NO.OF BEDROOMS 3 OWNER PERMIT DATE: 4- COMPLIANCE DATE: I / 1 Separation Distance Between the: G Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5, \ Feet Private Water Supply Well and Leaching Facility(If any wells exist or[' 4 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) f t 1 'e + Feet L RNISHED BY cn�+ E'�� ) ,T"" rx �n� 1a3 (C7 p �V OLr l J, t f y W/00 80 No. /�©I 1 �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: D/ _ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftPlitation for Misposal 6pstPm Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade(VI"Abandon( ) A Complete System ❑Individual Components Location Address or Lot No. taC°1 �1�( b��* o Owner's Name,Address,and Tel.No. g C �.>��rv��l Pr Fri C uklem�-Ilb` Assessor's Map/Parcel Installer's Name,Address,and Tel.No. fig_ 6�S-r Designer's Name,Address,and Tel. o.$� -�-a� P�c��`� �cxsGi�r �a..srT'v.� w\.o, \`��-� EIiSS� . Type of Building: Dwelling No.of Bedrooms ` , Lot Size �k 's ( sq.ft. Garbage Grinder Other Type of Building _- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3_JS gpd Design flow provided `(Ts- gpd Plan Date �( ` a ( (`- Number of sheets Revision Date Title Size of Septic Tank �'O© �,4(� Type of S.A.S. SQJ 6a( Cav,c Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,�,_c_ 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. Sign d Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Zo I q" 2z3 Date Issued 7/)I l z0rY No.mg- 2_z3 ' IV O P-� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ► PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plication for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(%j<Abandon( ) Complete System ❑Individual Components Location Address or Lot No. \Q<Z� k1i::�C�� �'�sw.� Owner's Name,Address,and Tel.No.Sb'Z?- 7r- Or.17 Assessor's Map/Parcel �,r`C�)l i Installer's Name,Address,and Tel.No. S71Z) De'signerzs'Name,Address,and Tel. o.�`T- Type of Building: . Dwelling No.of Bedrooms �� Lot Size (4 � sq.ft. Garbage Grinder( ) Other Type of Building _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' Flow Design min.required)g ( q ) gpd Design flow provided � �S- gpd M1„ -Plan Date (�-( Number of sheets ( Revision Date Title', Size of Septic Tank Type of S.A.S. _�Cb (ZA Cciv\c Description of Soil Nature of Repairs or Alterations(Answer when applicable) 9<i �, ( ���> D t 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 A - Compliance has been issued by this Board of Health. r Signed Date kr 1 I ( 4(; Application Approved by vcs Date_ 1 1/h 17,01 y Application Disapproved by Date for the following reasons Permit No. Zo I q- 2 Z3 Date Issued-i I 00t y THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Z.0 V-275r dated Installer r- V,, .—� ���-�\ �,5 Designer-=N�sN #bedrooms Approved desig ow 0 r gpd The issuance of this permit shall rent b const�77 guarantee that the system wil�nclion 'esiig4edDate (f t1l,� Inspector L v Y -------------------------------------------------------------------------------------------------------------------- =----------- No. 7� Feed Ov vim' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit , Permission is hereby granted to Construct( ) Repair( ) Upgrade(,� Abandon( ) System located at , and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constryction must be completed within three years of the date of this permit Date 20 Approved by Town of Barnstable yoke TOw�, Regulatory Services hP �•N Richard V. Scali,Interim Director BA LE MAS& * Public Health Division y A89. �ArEaMPtA10 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Desi ner Certification Form Date: 7/18/2014 Sewage Permit# v—K -�4 Assessor's MaplParcel 232/40 Designer: J. M. O'Reilly&Associates, Inc. Installer: Address: 1573 Main St, P.O. Box 1773 Address: Brewster, MA 02631 boa�� a��. CDO') /6 / On © 9c� ,. 'novas issued a permit to install a (date)) (installer) septic system at 120 Holly Point Road, Centerville based on a design drawn by (address) John M. O'Reilly, P.E., P.L.S. dated 4/21/2014 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may PP g include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation ofthe SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built-by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was consttucte�d -com fiance with the terms of the I1A approval letters(if applicable) . ZN OF Mqs� a gJOHN M. Gcr+ O'REILLY ro (Installer's Signature) 4 0 CIVIL in NO.36200 eOF�FGISTEF'������ (Designer's Signature} (Affix Debi'" "g .0' —SOnp Here) c wvvvvv PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doe 2 pig C i 17 _ 3'•65/8" _3'-8" 3'-8"_.3'-85/8 —1 �10114"-�7-6"—' -—T-8"_— 1'-101/4. 8 8_�-- _8 B------ O ------------- ❑i RAISE CEILING TO—ram Wtchen Im REATE TRAY CEILING i i 1 i 18'-8 12" 17'-9' I 15'-3 12' cr_ I I \ _ - \ RA SE OO ,CEILMG TO 000 OO i I -- Master Bedroom \ v..CREATE TRAY CEILING O Dming Room 13'-7"x `' 9 \\, Livin m i I — �. -' CASED OPENING WITH — �� A - ` ____-__TRANSOM ABOVE ------ -N114" --- ------- ---------------012" 5'-51/T' HANDRAIL ATNEWSTAR1 �V DN Laundry1119 CI. �m 0112" 7-1" 8'-0' ' 0., P.R. Mudroom Garage ®. ALIGN NEW WALL - -B B- i WITH EXISTING 0 i M.Bath ® Office ❑ ❑ _ x 13'-6" I 9'-8"x 13'-0 2'_6. 8'-4a 9.4. 2'_6" ; O O I i O F I 6'-712 A A 6'-71/2" Cullotta Residence Al 24'-4" 23'-8" I 120 Holly Point Rd-Centerville,MA Nov.17,2013 x � 7 t u jf 70'-3" i� Y, Liven and Dining Room 5un Porch Master Bedroom \ g 17'-2" x 13'-T 13'-0" x 20'-0" 34'-0" x 18'-0" 00 0 j Kitchen M 18'-0" x 9'-3" CO _ Garage Bedroom 2 Bedroom 3 1 3'-0 x 13'-G" 9'-8" x 13'-G" n 24'-4" 23'-8" 22'-3" First Floor Plan .� Cullotta - As-Built Plan -i 55EP 13 _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information I 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. DOUGLAS A BROWN INC Company Name P.0 BOX 145 Alf Company Address (( � CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 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 pursuanf=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 2' 8/5/13 Inspector's Si ature 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 doeiknot:address how the system will perform in the future under the same or different conditions of use. / 3 t5ins•3/13 Title 5 Official Inspection bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM CONSISTS OF 2 CESSPOOLS AND 2 LEACH PITS AT TIME OF INSPECTION SYSTEM MET MINIMUM PASSING REQUIREMENTS. CAN NOT PREDICT FUTURE PERFORMANCE. 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 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a 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 Forth:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 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, :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 nitrogenIs'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 �f t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® 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•3113 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 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ❑ ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information h n o the maintenance of proper 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 R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 every page. City/Town State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF 2 CESSPOOLS AND 2 LEACH PITS THAT APPEAR TO ALL BE CONNECTED EVERYTHING WAS OPENED AND FOUND TO BE IN WORKING ORDER WITH NO SIGNS OF FAILURE EVIDENT THE CESPOOLS HAD A SMALL AMOUNT OF WATER IN THEM BOTH PITS WERE DRY THE LEACH PIT WITH THE LOWEST ELEVATION WAS DRY AND HAD NO GROUND WATER INFILTRATION Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2011------107 2012---- 130 Sump pump? ❑ Yes ❑ No Last date of occupancy: UNKNOWNDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpa) 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 Lt5ms3/13Water meter readings, if available: 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 �M 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: UNKNOWN Date Other(describe below): SYSTEM APPEARS TO BE ORIGINAL. CAN NOT PREDICT FUTURE PERFORMANCE 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): 2 CESSPOOLS AND 2 PITS ALL CONNECTED t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts _ v Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: POOLS APPEAR TO BE ORIGINAL PITS SOME WHAT NEWER 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): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 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 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 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.): 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 W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 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 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(re uired . Is copy attached? El 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 every 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 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.): 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 _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 2 ❑ 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.): 2 CESSPOOLS HAD SMALL AMOUNTS OF LIQUID AT TIME OF INSPECTION BOTH PITS-WERE DRY THE PIT WITH THE LOWEST ELEVATION WAS USED FOR DETERMINING GROUND WATER Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 AND 2 PITS ALL CONNECTED 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 M 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is required for CENTERVILLE MA 02632 8-5-13 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 120 HOLLY POINT RD Property Address PARMENTER Owner Owners Name information is required for CENTERVILLE MA 02632 8-5-13 every page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M s 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name requinform r on is CENTERVILLE MA 02632 8-5-13 requiredd 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: NONE AT 4 FT BELOW BOTTOM OF PIT 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: AUGERED IN BOTTOM OF LOWEST PIT TO 4 FT BELOW NO GROUND WATER INFILTRATION AT 3:25 PM ON AUGUST 2ND 2013 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 120 HOLLY POINT RD Property Address PARMENTER Owner Owner's Name information is CENTERVILLE MA 02632 8-5-13 required for 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 Lt5ins3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 fi2o� l � ► � R Ge Cess�� rQ1 o� y' below n r 44 t( Town of Barnstable P# �p1XE Department of Regulatory Services yBARNffABMA9 Public Health Division Date I 1 ao 14 q M 3 9 0 r67q. 200 Main Street,Hyannis MA 02601 Date Scheduled ✓, f . �i Time Fee Pd. Soil Suitability Assessment for Sew -e Performed By: // _ Witnessed By: LOCATION&GENERAL INFORMATION Location Addres Owner's Nam S. "_ I Address 1019W Assessor's Map/Parcel: a�1 17, Engineer's Name NEW CONSTRUCTION Cl REPAIR X_ Telephone# Land Use � hK�- Slopes(%) Surface Stones /Al�'� Distances from: Open Water Body`9 ft Possible Wet Area ' ft Drinking Water We`ll tJH ft Drainage Way IV� ft Property Line _ft Other f i _ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)I � ";Jj Parent material(geologic) Depth to Bedrock � .... Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face NA ` Estimated Seasonal High Groundwater y`P DETERMINATION FOR SEASONAL RIGH WATER TABLE Method Used: - w��j.. �� V Depth bserved standing in obs.hole: in. Depth to soil mo,es: ' in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date Time Observation t . Time at d.OV Hole# S t➢ Depth of Perc •Zip Time at/' Start Pre-soak Time Q Time(9"-6") �1 �'A K End Pre-soak 0•�%�� Rate MinAnch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) N 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 notify the Barnstable Conservation Division,at least one(1)week prior to beginning. QASEPTICiPERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel low 2/2 y: F�4- - yN 5 Goa 7 �a DEEP OBSERVATION HOLE LOG Hole# dL Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel Z �5 Z 2 L 7. G-1 S ;o i�.-6 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel orz7h, 2 3 -A-17 S L— CZ l iZn 3 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) _ Flood Insurance Rate May: Above 500 year flood boundary No Yes X Within 500 year boundary No�"♦ Yes / Within 100 year flood boundary No 11( 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 proposed for the soil absorption system? M _ If not,what is the depth of naturally occurring pervious material? Certification I certify that on f ', (date)I have passed the soil evaluator examination approved by the Department of Envir nm ntal Protection d that the above analysis was performed by me consistent with the require mi ,expe a xperi a describe 10 CMR 15.017. ignature Date 'Z I Q:\SEPTIC\PERCFORM.DOC I CENTERVI LLE, GENERAL NOTES : 501L TE5T LOGS: SYSTEM DE51GN CALCULATIONS: MA �p A.) NEITHER DRIVEWAYS NOR TEST HOLE 1: EL= 4G,0± SEWAGE DESIGN FLOW:PARKING AREAS ARE ALLOWED OVER SEPTIC SYSTEM BEDROOM D DWELLING @ I I 0 GPD = 330 GPD UNLESS H-20 COMPONENTS ARE USED. DEPTH FROM SOIL SOIL SOIL SOIL OTHERA SURFACE HORIZON TEXTURE COLOR MOTTLING LEACHING CAPACITY REQUIRED: B.)THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UN- (INCHE5) (USDA) (MUN5ELL) L BEHIRO MS M ) @ I i GPD = 330 GPD REQUIRED 0�yj LESS CONSTRUCTED AS SHOWN, ANY CHANGES SHALL BE APPROVED IN WRITING. 0-G A LOAMY FINE SAND I OYR 2 2 NONE SEPTIC TANK CAPACITY REQUIRED: 9L C.)CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE LOCATION OF ALL G-34 LOAMY FINE SAND 7.5YR 5 8 NONE 3G-1 28 I ME I COURS N I YR 3 NONE WATER EL=35.5+- DAILYFLOW= 3 GPD @ 00 0 = GGO GAL. REQUIRED 1 UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. SEPTIC TANK CAPACITY PROVIDED: 1I CONSTRUCTION NOTES: 1500 GALLON SEPTIC TANK(MI . LLOWED) ��\ LOC(JS LEACHING CAPACITY PROVIDED: 5EAR5E POND 1• LAKEVIEW AVE TEST HOLE 2: EL= 44.0± NE(1) 33.5'X 1 2.8 'X 2.0' LEACHING CHAMBER CAN LEACH: 1 DEPTH FROM 501L SOIL 501L SOIL OTHER Vt=[(33.5 X 12,83) + (33.5 X 2.0)2 + (12.83 X 2,0)2]X 0.74 GPD/5F=455,10 GPD 1 .)ALL CONSTRUCTION SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE, SURFACE HORIZON TEXTURE COLOR MOTTLING 455 GPD> 330 GPD REQUIRED TITLE 5, AND THE REQUIREMENTS OF THE LOCAL BOARD OF HEALTH. (INCHE5) (USDA) (MUNSELL) 0-24 A IF LOAMY SAND I OYR 2/2 NONE NOTE: A GARBAGE DISPOSAL IS NOT PERMITTED WITH THIS DESIGN. 2.) SEPTIC TANK(S), GREASE TRAP(5), DOSING CHAMBERS)AND DISTRIBUTION INSTALL: <� 5OX(E5)SHALL BE SET ON A LEVEL STABLE BASE WHICH HAS BEEN MECHANICALLY 24-48 B FINE AMY SAND 7.5YR 5/8 NONE ONE (1) - 1 500 GALLON SEPTIC TANK f COMPACTED, OR ON A G INCH CRUSHED STONE BASE. 48-84 C I FINE SANDY LOAM I OYR G/31 NONE ONE (1) -3 OUTLET DISTRIBUTION BOX(H-20 Rated) LAKESIDE DRIVE 84-1 1 1 C2 !ME DIU C USE SAND I OYR.7/3 NONE WATER EL=35,0± THREE(3) - 500 GALLON LEACH CHAMBERS WITH 4'OF STONE ALL AROUND 3.)SEPTIC TANK(5) SHALL MEET ASTM STANDARD C 1 1 27-93 AND SHALL HAVE m SIX(G) - 24"DIA RISERS AND COVERS TO WITHIN G"OF FINISH GRADE AT LEAST THREE 20" DIAMETER MANHOLES, THE MINIMUM DEPTH FROM THE BOT- TOM OF THE SEPTIC TANK TO THE FLOW LINE SHALL BE 48". PERC HOLE 3: EL= 4G.0± o NOT TO SCALE 4.)SCHEDULE 40 PVC INLET AND OUTLET TEES SHALL EXTEND A MINIMUM OF G" DEPTH FROM 1501L 501L 501L SOIL OTHER ABOVE THE FLOW LINE OF THE SEPTIC TANK AND SHALL BE INSTALLED ON THE SURFACE I HORIZON TEXTURE COLOR MOTTLING CENTERLINE OF THE TANK DIRECTLY UNDER THE CLEANOUT MANHOLE. (INCHES) (USDA) (MUN5EL) Z L.C, PLAN # 20233C 0-8 A LOAMY FINE SAND I OYR 2/2 NONE g DEED CERTIFICATE # 189571 5.) RAISE COVERS OF THE SEPTIC TANK AND DISTRIBUTION BOX WITH PRECAST 5-23 5 LOAMY f IN E 5AND7,5YR 5/8 NONE °' ASSESSORS' MAP 232 PARCEL 40 CONCRETE WATER TIGHT RISERS OVER INLET AND OUTLET TEES TO WITHIN G"OF 23-47 C I I FINE SANDY LOAM I CYR G/3 I NONE U FINISH GRADE, OR AS APPROVED BY THE LOCAL BOARD OF HEALTH AGENT. 47-G2 C2 I MEDIU COUSE S ND I CYR 7/3 1 NONE PERC AT G2" "I G.) PIPING SHALL CONSIST OF 4"SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL LEGEND BE LAID ON A MINIMUM CONTINUOUS GRADE OF NOT LESS THAN I%. 7.) DISTRIBUTION LINES FOR SOIL ABSORPTION SYSTEM (AS REQUIRED)SHALL BE DATE OF TESTING: 3114114 ® EXISTING CONTOUR PERCOLATION RATE: LESS THAN 5 MIN/INCH IN MEDIUM TO COARSE SAND LAYERS. 4"DIAMETER SCHEDULE 40 PVC LAID AT 0,005 FT/FT, LINE SHALL BE CAPPED WITNESSED BY: MATT FARRELL, EIT, J,M, O'REILLY*ASSOCIATES, INC. - -32 PROPOSED CONTOUR AT END OR AS NOTED. DONNA MIORANDI, AGENT, BARNSTABLE HEALTH DEPARTMENT x 12.34 EXISTING SPOT GRADE 5.) OUTLET PIPES FROM DISTRIBUTION BOX SHALL REMAIN LEVEL FOR AT LEAST WATER ENCOUNTERED 2'BEFORE PITCHING TO SOIL ABSORPTION SYSTEM, WATER TEST DISTRIBUTION USE A LOADING RATE OF 0,74 GPD/SF FOR 51ZING OF SOIL ABSORPTION SYSTEM, 24x5 PROPOSED SPOT GRADE BOX TO ASSURE EVEN DISTRIBUTION. GROUNDWATER: - W- WATER SERVICE LINE 9.) DISTRIBUTION BOX SHALL HAVE A MINIMUM SUMP OF G" MEASURED BELOW USE ELEVATION 34.8 FOR ESTIMATED HIGH (1988 NVAD) -OH- OVERHEAD UTILITY SERVICE THE OUTLET INVERT, GROUNDWATER ELEVATION PER THE BARNSTABLE HEALTH REGULATIONS -U- UNDERGROUND UTILITY SERVICE 10.) BASE AGGREGATE FOR THE LEACHING FACILITY SHALL CONSIST OF 3/4"TO _G- GAS SERVICE LINE 1-1/2"DOUBLE WASHED STONE FREE OF IRON, FINES AND DUST AND SHALL BE O TEST HOLE/ BORING LOCATION INSTALLED BELOW THE CROWN OF THE DISTRIBUTION LINE TO THE BOTTOM OF THE 5T SEPTIC TANK SOIL ABSORPTION SYSTEM, BASE AGGREGATE SHALL BE COVERED WITH A 2" 1 CERTIFY THAT IN OCTOBER 1095, 1 MATTHEW FARRELL PASSED THE DB DISTRIBUTION BOX LAYER OF 1/8 TO 1/2 DOUBLE WASHED STONE FREE OF IRON, FINES AND DUST. EXAMINATION APPROVED BY THE MA55ACHUSETT5 DEPARTMENT OF 1 1.) VENT SOIL ABSORPTION SYSTEM WHEN DISTRIBUTION LINES EXCEED 50 FEET; ENVIRONMENTAL PROTECTION AND T E ABOVE ANALYSIS WAS SAS 501L ABSORPTION SYSTEM WHEN LOCATED EITHER IN WHOLE OR IN PART UNDER DRIVEWAYS, PARKING AREAS, PERFORMED BY N515T ITH TH REQUIRED TRAINING, EXPERTISE Reserve RESERVED FOR FUTURE TURNING AREAS OR OTHER IMPERVIOUS MATERIAL; OR WHEN PRESSURE DOSED, AND EXPE CE QE IN 310 C 15.017 `� UTILITY POLE 12.)SOIL ABSORPTION SYSTEM SHALL BE COVERED WITH A MINIMUM OF 9"OF ` ® CATCH BA51N CLEAN MEDIUM SAND (EXCLUDING TOPSOIL). AM DATE: �� / Existing Deck 13.) FINISH GRADE SHALL BE A MAXIMUM OF 30"OVER THE TOP OF ALL SYSTEM C/I w FIRE HYDRANT TO BE REPLACED COMPONENTS, INCLUDING THE SEPTIC TANK, DISTRIBUTION BOX, DOSING CHAMBER ,°. WITH NEW DECK WELL AND SOIL ABSORPTION SYSTEM. SEPTIC TANKS SHALL HAVE A MINIMUM COVER m 0 DRAINAGE MANHOLE of 011, 7, �'/ ^� D _ ■ _ CONCRETE BOUND, FOUND 14.) FROM THE DATE OF INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL O TOP OF BANK RECEIPT OF A CERTIFICATE OF COMPLIANCE,THE PERIMETER OF THE SOIL ABSORB- Existing Stairs Existing Tree \ \ \ 44 '� -X-X- LIMIT OF WORK TION SYSTEM SHALT.BE STAKED AND FLAGGED TO PREVENT THE USE OF SUCH TO BE REPLACED Existin 9 TO BE REMOVED 00 AREA FOR ALL ACTIVITIES THAT MIGHT DAMAGE THE SYSTEM, \ 80 WITH NEW 4'WIDE Gas Line - ----°- FENCE \ \ a� > / 15.)THE BOARD OF HEALTH SHALL REQUIRE INSPECTION OF ALL CONSTRUCTION \ -o \ I STAIRS EDGE OF CLEARING BY AN AGENT OF THE BOARD OF HEALTH (OR THE DESIGNER IF THIS SYSTEM RE- ova 1 2"Dak - - - EDGE OF WETLAND QUIRES A VARIANCE)AND MAY REQUIRE SUCH PERSON TO CERTIFY IN WRITING \ \ , --_ <` Reserve RESERVED FOR FUTURE THAT ALL WORK HAS BEEN COMPLETED IN ACCORDANCE WITH THE TERMS OF THE \ T G I / / Existing Paved driveway TO BE REPLACED WITH Reserve RESERVED FOR FUTURE PERMIT AND APPROVED PLANS, 48 HOURS ADVANCE NOTICE IS REQUESTED, 1 Area I G, 117 SF± G�-G�� G a '. STONE/SHELL I G,) SOIL REMOVAL: ALL TOPSOIL, SUBSOIL AND THE FINE SANDY LOAM (A, BAND C I ~ �:., / I ` IN TP' 2 TP3) SHALL BE REMOVED DOWN TO THE MEDIUM TO COARSE SAND LAYER, ELEVATION 41,8±, AND FOR A D15TANCE OF 5 FEET AROUND THE S.A,S, AREA TO BE ` k \\\\\\\\\ yy yr yr :W W' W W WAG° BACKFILLED WITH CLEAN "TITLE 5"SEPTIC SAND, COMPACTED TO MINIMIZE SETTLEMENT. 5 EARS E POND "TITLE 5"SAND SHALL MEET THE SPECIFICATIONS OF 3 10 CMR 1 5,225(3), 5AS `' \ NEW WATER SERVICE LINE CONSTRUCTION IN FILL, A 51EVE ANALYSIS MAY BE REQUIRED BY THE LOCAL _t `r A GREAT POND I,';�' I 1, \\ a. _ C APPROVING AUTHORITY, INSTALLER SHALL REVIEW WITH LOCAL AUTHORITY, PRIOR TO SYSTEM INSTALLATION, I : • �� / �, ELEV. 34.3 (10/30/13) a 17.) DESIGN ENGINEER SHALL INSPECT THE SOIL REMOVAL AREA, PRIOR TO THE ° SOIL REMOVAL PLACEMENT OF ANY TITLE 5 SEPTIC SAND, INSTALLER SHALL COORDINATE THE BOARDI G �� v ti: b r s \ +l \ a N SEE NOTE 1 5 INSPECTION SCHEDULE PRIOR TO STARTING THE SYSTEM INSTALLATION. �" VEG ATED WET ND `I I \ v ;. c 15.) EXISTING CESSPOOLS, A TOTAL OF 4 PITS, SHALL BE PUMPED, FILLED AND / ,;; '!,; / 1\� O l�� 2• d' ��p ' ABANDONED. {V L / / * \ E w i .� 6 �h I ( 8 i,. \ i 19,) IF THE CONFIGURATION OF THE DRIVEWAY IS MODIFIED TO BE OVER Ti1E SYSTEM, I I " \ v Ile H-20 RATED COMPONENTS SHALL BE USED AND A VENT INSTALLED ON THE S.A.S. / r+' / v ' m ' (� 4 C,•3= `� DESIGN ENGINEER SHALL BE NOTIFIED OF ANY CHANGES MADE TO THE DRIVEWAY 4.0' 85 8.5' 8.5' 4.0' /2 Existing ' ' �Gui V LOCATION, PRIOR TO PROCEEDING WITH THE INSTALLATION OF THE COMPONENTS. / /Area 20.) PROPOSED EXIT LINE : PROPOSED SEWER LINE B ELEVATION AND LOCATION 6 SHALL BE REVIEWED AND APPROVED BY A MA. LICENSED PLUMBER PRIOR TO THE INSTALLATION OF ANY SEPTIC COMPONENTS. PLAN VIEW I \ r °n / ; (; A ( CLEAN-OUT W _ y -6 U Z5 Utility Pole#550 SCALE: I" = 10' o / I \ 49.90 / / (D O a� W O L JTP t , I RESERVE AREA Existing Tree / TO BE REMOVED �o� Existing Cesspools h to be Abandoned 48 -TOTAL OF 4 PITS- �v q�' v BENCHMARK: Top of Concrete Bound EL=4G.70± (NAVD 1 988) PLAN SCALE 0' THIS AREA IS SERVED BY TOWN WATER. PROPERTY 15 LOCATED WITHIN THE ZONE II OF A MUNICIPAL WATER SUPPLY SYSTEM: LIMITED TO ONEN) BEDROOM PER 10,000 SF OR AREA: EXISTING 3 BEDROOM DWELLING TO BE UPGRADED, NO EXPANSION IS PROPOSED FLOW PROFI LE: INSPECTION NOTE: NOT TO SCALE G COVERS TOTAL PRIOR TO FINAL INSPECTION BY THE ENGINEER, SYSTEM 24"DIAMETER CONCRETE COVERS NEEDS TO BE COMPLETE INCLUDING BUILDUP FOR COVERS. RAISED TO WITHIN G"OF FINISH TOP OF FOUNDATION GRADE (OR AS NOTED) EL- 49.9± (SEE NOTE#5) ' Proposed EL= 47± + + ►�a \ xistn =4 _ Existin EI=4G,0_ �r��Z�i OF P,d,�s .� Ry"i Br E �45�. .} 45.4± 30"Proposed y„ JO^I iCJ 14' „ e JOHN 1v9. ems (9 Min - 30 Max) o ��i CDO'REILLY 43.5± CIVIL r O'RE LLY N0.48733 rr, v -W Paul C u l l otta 2"LAYER OF 1/8"- 1/2"STONE(SE NOTE#10) O.36200 '" o k. 22 SUSAN CARSLEY WAY, SANDWICH, MA I 0 " ' 3/4 1-1/2 STONE (SEE NOTE#10) 4G.4± 44.25 EXISTING 14 44.00 42.75� - PIPE'A' 3" 43.G7 43.50 N N 410" � 51TE SEWAGE D15PO5AL 5Y5TEM DE51GN 4G.50 T 4 2 DROP GAS BAFFLE 120 HOLLY POINT ROAD, �CENTERVILLE MA PROPOSED INC.PIPE '0 USE GALLON SHOREYLEACH PRECAST J.M. OTEILLY & ASSOCIATES, I C SEE NOTE#20 500 GALLON LEACH CHAMBERS 5•9± • • Longest Run WITH 4'OF STONE AROUND 9' 24' LONGEST RUN 37' 1 500 GALLON DB-3 ! (END VIEW) O 20 40 GO Professional Engineering & Land Surveying Services SEPTIC TANK LEACHING CHAMBER 4-EL= 34.8± HIGH GROUNDWATER D-E3OX (PER BARNSTABLE BOARD OF HEALTH REGULATIONS) SCALE 1"=20' 1573 Main Street - Route 6A 33,5'x 12.83'x 2.0' 508 896-6601 Office Brewsteroa 1773 H-20 ( ) MA 02831 (508)896-8602 Fax DATE: SCALE: BY: CHECK: JOB NUMBER: G:\AAJobs\CullottaG838\dwg\GB38-Sewage Plan.dwg 4-2 1 -2014 A5 Noted JMO KEF JMO-G838 No. ..... YEI?..S.. �............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, -..... ...../ t. -------OF.............Z ------------- Appliration -for 13ii usttl Workii Tonstrurtion Vrrnift Application is hereby made for a Permit to Construct ( ) or Repair ( an Individu• Sewage Disposal Sys at � �----- ••------------ --------------------------------------•---. Locat' ddress or Lot No. ---•-----•-----•--------------------------•---- Owner Address a , Le.2��" d am`------./ C............................. -----......-----------•-------------------- Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms_ _ _-----------------------------------Expansion Attic Garbage Grinder `L4a Other—Type of Building --------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q Other fixtures W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width.---_-..--__- Diameter--------- Depth---------------- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter..._................ Depth below inlet.................... Total°leaching area------.-----------sq. it. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date--•------•-------------•--------------- W a Test Pit No. 1----------------minutes per inch Depth of Test Pit-.-_--_-__-_.._----- Depth to ground water........................ �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........... 9 --------•---------- ------------------------------------------------------------ ...................••------•••---------..:.---•••--..._•-----.........•---- r, 0 Description of Soil------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- x W V Nature of Repairs or Alterations—Answer when applicable.____e - wow P ----- ------ Agreement: , The undersigned agrees to install the aforedescribedA Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Cod _ The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ue the boar4health. s r- �~ �1Date Application Approved BY ----- ---- --- -- ------.. eApplication Disapproved for the following reasons:................................ .................................................... .........................................•--•--------•---------•-•••-•-----•--:...---••---•--...--------•....--•--•-•------•----------•-••---•--------- .......................................... Date PermitNo.............................................----------- Issued.--•-_'T' . -7 ---------------- ate ..b........... THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH . _. . ......... AVVIirtt$iun -for R.gvlaiittl luorko T anuitrnrtinn Prrnlit Application is hereby made for a Permit to Construct ( ) or Repair ( an_Individu• Sewage Disposal Sys at: e L L �/ia• —ocat ddress or LotNo... Owner Address ---------------------------------------------------------- p e Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling No. of Bedrooms_ ...................................Expansion Attic ( ) Garbage Grinder ( ) U g— pa, Other—Type of Building ____________________________ No. of persons..-__...__-_-__________-___- Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width----------- Diameter___-_..._.._____ Depth_-------------- x Disposal Trench—No. .................... Width-------------------- Total Length------------------_:Total leaching area-------------. -----sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet___-____-___-..._--_ Total leaching area...-._________.S(1. 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_.--__---_____.__-_----- fT Test Pit No. 2................minutes per inch Depth of Test Pit---------------------- Depth to ground water--------------------- ------------------------------------------------•-------------------------------•---•--•-•-•..•••.•--•------.......•--.......................................................... Descriptionof Soil -----•----•-----------------------------------------------------------------------•-•-•- ••------•----------------------------------- x W ----•----------------------------•---- -••-•----•-•....................................... ---------------------------------,...................................................................... . V F+/ `i Na ure of Repairs or Alterations— swer when applicable ' ------------------------------ -Agreement: The undersigned agrees to install the aforedescribe Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Cod — he undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i u the board of health. ----- --- •--- Date Application Approved BY---- --------- . . ....... Application Disapproved for the following reasons: ---------- ---------------------------------------------------------------------------•-------=-----------------------=-----------------------------. ---/n. -------------------------------- Date ' PermitNo......................................................... Issued..••-/ -� �L--•�-•---•------•---.... THE COMMONWEALTH OF MASSACHUSETTS ' BOARD HEALTH .............................. OF...... :. �^'"' !--:..----•-.............. �rrfi$irtt gf f�um�littnr.e TO CERTIFY, T at.the Individua ewage Disposal System constructed ( ) or Repaired bY -----•-• / -=-----------------•-----------••-•-----------------------------------••---------•-.--- Installe ar` `'' • l ------------ has been installed in accordance with the provisions'of:articl I f The State Sanitary Cas desc ibed in the application for Disposal Works Construction Permit.No............. .......... dated-.!/ARAN THE ISSUANCE OF THIS CERTIFICATE MULLNOT"6E CONSTRUED AS A EE THE .SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................... ------------------------------------------------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r` N *�...OF............ "' ` -- -:................................ FEE ....... inVa Workii ClI,aniAvurti Vrrmif f Permission is her. Y grant -------- --- -- --- -•• ........... -•----......--•-•--••••.. ... to Con r, ct ( ) epai�n7in l Sewag isp ystem atNo.--- - . -- -•------•-- ---•-•... •i Str _ as sh n on the application for Disposal Works Construction P No------- ✓'__.. D .. .. .................................... Board of Health DATE.. .. ' ' FORM 112 5 HOBBS & WARREN. INC.. PUBLISHERS - . c �--- Sewage Permit No. _LOCATIO --���.� �`�©i�j— VILLAGE INS TALLER'S NAME & ADDRESS _ _ BUILDERS NAME & ADDRESS DATE PERMIT ISSUED DATE COMPLIANCE ISSUED PROPERTY OWNER � ,C C 77 G��EL Ilk- Oil- �