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HomeMy WebLinkAbout0258 HUCKINS NECK ROAD - Health 258 HUCKINS NECK RD., CENTERVILLE A = 252 136 s i A UPC 12534 No.2�1533LLOR HASTINGS,MN 4 V� Commonwealth of Massachusetts W Title 5 Official Inspection Form 9 coy Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / wM 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt .� Owner Owner's Name information is ry Centerville MA 02632 Janus 4 2014 required for every , 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. Imng out forms A. General Information filling out forms on the computer, use only the tab 1. Inspector: �' / ✓� key to move your cursor-do not David B. Mason use the return key. Name of Inspector David B. Mason Company Name 4 Glacier Path Company Address East Sandwich- MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the a 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 e Wa sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of w Title 5(310 CMR 15.000).The system: ® yPasses ElConditionally Passes El Fails ❑' Ngeds Further Evaluation by the Local Approving Authority ~ N January 4, 2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspe n rm:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 January 4 2014 required for 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: ® 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: This inspection represents the conditions observed on January 4, 2014 at Noon and represents only such and does not represent the operating conditions of the system beyond this date 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 J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 January 4, 2014 required for every ry 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 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 ,•'' 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 January 4 2014 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %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 co Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 January 4 2014 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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.] 0 ® 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 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 January 4 required for every , 2014 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): 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 January 4 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Not occupied Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: 2012; 104,000 and 2013; 24,000 Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No 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 o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is I`y Centerville MA 02632 January 4 2014 required for every , page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health 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): l5ins•3113 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 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 January 4, 2014 required for every ry page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 8/17/1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) PVC tee for inlet and concrete tee for outlet. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Typical 1500 Sludge depth: 311 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 January 4, 2014 required for every ry page. Cityrrown 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 21-10" Scum thickness 2" 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 1' How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): See notes under septic tank. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 January 4 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•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 ° M 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 January 4 2014 required for every ry , 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 even with oultet inverts 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.): viewing indicated no problems. 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: leach field. no inspection port. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 January 4 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 25'x20' ❑ 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.): Probed field. No indication of damp soils Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 January 4, 2014 required for every ry page. Cityrrown 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 January 4 2014 required for every , page. Citylrown 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 UwlkY; 258 Huckins Ncck Road, Centmille, MA SK1 T'C14 Or SE-WAt;t:DISPOSAL SYSILM: include ties t4 tit(cast two permanent reterr.nce landmarks or benchmarks IoCato all wells within 100-(LoCate where puhlic water Supply Comes into house) a►° 3p ° 26 ' �pV�� �gooy4 !7-dd x 1�� xis x1 , r Corn, o `Ith of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 January 4 2014 required for every rY page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 10 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Ground water contour map and soil analysis in area. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 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 wM 258 Huckins Neck Road, Centerville, MA 02632 Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 January 4 2014 required for every , page. Cityfrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts N v Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 February 21, 2012 required for every rY page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason ,Q Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 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. l 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 February 21, 2012 Inspector's Signature Date ° i fi.T The system inspector shall submit a copy of this inspection report to the Approving Autlio7?ity(Bard of Health or DEP)within 30 days of completing this inspection. If the system is�'a sharedsysterDr has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit t%— report to the appropriate regional office of the DEP. The original should be sent to the sy tem 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. ( V t5ins•11/10 Title 5 Official Inspecti F rebsuffaceSe,age Disposal Syst •LN,2 Commonwealth of Ma ssachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is required for every Centerville MA 02632 February 21, 2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This inspection information represents the condition of the system on February 21, 2012 at 3:30 PM and only that date and time nor does the inspection guarentee the future operation of the system. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 258 Huckins Neck Road Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 February 21, 2012 required for every ry page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 Februa 21 2012 required for every rY , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is rY Centerville MA 02632 February 21 2012 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The . system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 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 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 February 21 2012 required for 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 February 21 2012 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information. Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2010; 101,000 gallons and 2011; 81,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is required for every Centerville MA 02632 February 21, 2012 page. Cityrrown State Zip Code Date of Inspection D.System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 258 Huckins Neck Road, Centerville, MA Property Address - Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 February 21, 2012 required for every rY page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 8/17/1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments (on condition of joints, venting, evidence of leakage, etc.): PVC tee for inlet and concrete tee for outlet. What is observable appears to be in working order. Septic Tank(locate on site plan): Depth below grade: 1.5 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: Typical 1500 gallon tank Sludge depth: 3"2 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 February 21 2012 required for every , page. Cityrrown 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 2'-10" Scum thickness 2" 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 1' How were dimensions determined? Scour Stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PVC inlet tee and concrete outlet tee in working order. Effluent level with outlet invert Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 February 21, 2012 required for every ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): >< Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 February 21, 2012 required for every ry 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 even with outlet inverts 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.): Viewing indicated no problems. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 February 21 2012 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 25'x20' ❑ 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.): Probed leach field area and no signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 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 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is Centerville MA 02632 February 21 2012 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owners Name information is Centerville MA 02632 February 21 2012 required for every ry , page. Citylrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 February 21 2012 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 10 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Ground water contour map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: gourndwater contour map and septic designs in the area. Also, basement is walkout and there is a minimum of an 8 foot drop in grade from the level of the leaching field and the rear yard Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form Not for Voluntary Assessments °M 258 Huckins Neck Road, Centerville, MA Property Address Barbara Leavitt Owner Owner's Name information is ry Centerville MA 02632 February 21 2012 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t r cr r♦ r, i ab 1`I' ar� 30 ' U-Qa x I p2� �x�s x � � � ♦ i 4 74' /4-7 Asa TROY WILLIAMS L_ io o SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection 1999 (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 A COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address- a 5 8 N e c Name of Owner 5 i can ..y } /�V�� �-u 4-j�r Cf_A >`..r V '�. Address of Owner: Stti p �!�`� k- 5 Ale� Date of Inspection: 3�/8 /y c� c l / �� Name of Inspector:pector:(Please Print) Troy Williamsiamc Gr 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Troy W7iliams septic Inspections Mailing Address: 19 Hummel Drive, So. Dennis NSA 02660 Telephone Number: (508) 385-1300 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: S/I-. l J Date: —1 / 9 9 The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttm system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. revised 9/2/ ? , � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corrtirxxed) Property Address.owner: 258 Huckins Neck Road,Centerville, MA Date of Inspection: Ruth Cutler March 18, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: N/-) 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. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed rev i s e d 9 J i c ` Page 2 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 258 Huckins Neck Road, Centerville, MA Owner: Ruth Cutler Date of Inspection: March 18, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: IV/9 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the Public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic.tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic Compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER 9/2/98 „ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 258 Huckins Neck Road, Centerville, MA Property Address: Ruth Cutler Owner: March 18, 1999 Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due-to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)• Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: N/1 You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator.of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property address: 258 Huckins Neck Road, Centerville,MA owner: Ruth Cutler Date of Inspection: March 18, 1999 Check it the following have been done: You must indicate either `Yes" or "No' as to each of the following: Yes, No Pumping information was provided by the owner, occupant, or Board of Health. — None of the system components have been pumped forat least two weeks and-the system has been,receiving'normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. v _ As built plans have been obtained and examined. Note if they are not available with N/A. 3C/ _ The facility or dwelling was inspected for signs of sewage back-up. 1L/ _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. `r _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manhole*w"uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: v _ Existing information. For example, Plan at'B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,a / 115.302(3)(b)I approximation of distance is unacceptable] The facility owner(and occupants,if different from owner) were.provided with information on tha. SubSurface Disposal Systems. propermaintenaacevt rev 2 ,�48 Peer 5 of I I SUBSURFACE SEWAG E DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prop"Address: owner: 258 Huckins Neck Road, Centerville, MA Date of Inspection: Ruth Cutler March 18, 1999 FLOW CONDITIONSRESIDENTIAL: Design flow: 116 g,p,d./bedroom. Number of bedrooms(desi n): 9 .� Number of bedrooms(actual):3 Total DESIGN flow Number of current residents: Garbage grinder(yes or no): Y155 Laundry(separate system) (yes or no):,ALO; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no): A10 G Water meter readings,if available(last two year's usage(gpd): /Q= QC)O Sump Pump(yes or no): NO a/l° y 7 — 20,1 6001 0/6 v, Last date of occupancy:-3-1c. V�. d. COMMERCIAL/INDUSTRIAL: A///? Type of establishment: Design flow: apd ( Based on 15.203) Basis of design flow Grease trap present:(yes or nol_ 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information- LI G r System pumped as part of in pection. (yes or no)�L/O If yes, volume pumped: gallons Reason for pumping: TYPEPF 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed fif known) and source of information: Lrr ems- 1.,-1 I t. s um I/c yl �i� �ey Sewage odors detected when arriving at the site: (yes or no) AtO revised 9/2/98 P.ge6ofII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 258 Huckins Neck Road, Centerville, MA Date of Inspection: Ruth Cutler BUILDING SEWER: March 18, 1999 (Locate on site plan) Depth below grade: Material of construction:_cast iron Z40 PVC_other(explain) Distance from private water supply well or suction line Diameter /' Comments: (condition of joints, venting, evidence of leakage,etc.) All 142 rimer �I�...( Ic + )1� - SEPTIC TANK: (locate on site plan) Depth below grade: g � Material of construction:V/concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance (Yes/No) Dimensions: 7 X // X i7 /SO O c.//a h Sludge depth: ,3'' Distance from top of sludge to bottom of outlet tee or baffle:A Scum thickness: a/' 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 dimensions were determined: / lea b, + Plow►n. Comments: (recommendation for pure ,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structur"tegrity, evidence of leakage,etc.) V L //Lc J �,� h / f—S `I U{ o;-I `r �ti '" -- /t v-, ti o r , . x-rt.. v dt a� S to c J. der G12EASE TRAP. (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2 19P Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Address:owner: 258 Huckins Neck Road, Centerville,MA Date of kispection: Ruth Cutler March 18, 1999 TIGHT OR HOLDING TANK:�11(Tank must be pumped prior to, or 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 Alarm level: Alarm in working order: Yes No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:—/ (locate on site plan) Depth of liquid level above outlet invert: t v Comments: (no .if.level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box; etc.) - t-, rh�S /O �- ✓ r.. l vl o. 0.. t. 1wJ t �_ a►, v r h in PUMP CHAMBER: /V�/� (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.) revised 9/2/98 1"o A,f II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 258 Huckins Neck Road, Centerville,MA Date of Ir-Pection: Ruth Cutler March 18, 1999 SOIL ABSORPTION SYSTEM(SAS)' (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: 0 t,<_ �D ' - �S— � overflow cesspool,number: X / ILI" l` 7Y r /`it Alternative system: Name of Technology: Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.) u. ✓ ✓ .( a✓ c ti �+z c✓rG v�. of CESSPOOLS: 6q (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_N/.9 (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2 /98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 258 Huckins Neck Road, Centerville, MA Date of Inspection: Ruth Cutler March 18, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100•(Locate where public water supply comes into house) i a6 ' ly' a►' 30 ' oo �goo�� ►I�� D-fed x 77 01 d . revised 9/2/98 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Address' Owner: 258 Huckins Neck Road, Centerville,MA o Date of ln.spection: Ruth Cutler March 18, 1999 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope ✓ Surface water L/ Check Cellar ./ Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site 1Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps o Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation . (Must be completed) Lt�av(� � Ivl S raL�4. x / h t�rG-d�cow. �C�/: ► �tw c r�'7 �c-/�.l i } �o c w f tc1�. U�, f• ' w l 4, / 4. �� s U i y t!, 3✓o at 1, w t c►� .14r- c. j. !3° f/u w o { c c. /f'; i ) / C-L s tiD 4t �a G.; y � � �Jh� L✓K }�� ltJ� , vs (7 Cj revised 9/2/98 Page II of II THE COMMONWEALTH OF MAS?A:CHU,*,--TTS BOARD OF HEALTH ..................OF... ..................................... Appliratiou for Ui"viial Works T omitrurtion Vautit Application is hereby made for a Permit to Construct ( �-or Repair an Individual Sewage Disposal System at: ............... .......... ............................/..�.......................................................... Location L No. ddr4 0 — .....? ............ . ... ................ ....6744�. ... ..... __2w.................... 0 er Address A i.,s`ta1,1e,r--------------------- ------------- ---------- ---------------------------------A'd"d'r'e*,s-s----*----------- . ....."---------- Type of Building Size Lot.........!V ---a.Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ....................................................................................................................................................... Design Flow...............55.....................gallons per person pFj day. Total daily flow..............47-'S.................__gallons. 9 Septic Tar ik—Liquid capacity./�Wgallons Length Width-S Diameter-----.-_--_-_.. Depth.A.L #_ W 'S' ig Disposal qMi—No..................... Width... Total Length..._.451:1V... Total leaching area......-.0 ---19;100�O Seepage Pit No.---____..--_--____- Diameter.................... Depth below inlet_...___._......_.... Total leaching area..................sq. f t. Other Distribution box Dosing Ank Percolation Test Results Performed by----&466Cr .... Date- w_� Test Pit No. I-------Z._..minutes per inch Depth of Test Pit......V6 ----- Depth to ground'-?a er..e ----------- Test Pit No. 2....... minutes per inch Depth of Test Pit..._ _._. Depth to ground water-----/_V."........ .......................JF.....................................0i.................................................................................... - o & 0 D scription of Soil.x .....jd....Z.f...... 4 . --cr, ..................... .....1601-V40.1..4L ----lo U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ..................................................................................... ...... ..... ................ ApplicationApprove y------- ...... ................................................................................. . .... .... ...­.............. Date n Y->-- ---------------- Fr �7 Application Disapproved f e ollowing reasons:.................................................................................................................. ................................................. ................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date 112 DI ' JM Vim THE COMMONWEALTH OF MASSACHUSETT6 BOARD OF HEALTH, Appliration for Uhqpwial Worka (Somitrnrtinn remit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at .............. - 2 .. .. _ .....-•--- .....-••-•-•........ _........-----• --••••-----•-- • -•••-•-• ............-•................. p t"S Locatio ddr �� Owner Address a � ••.. .. � .� ......_... ----------------- _ / ............... � Installer Address Type of Building Size Lot________ _�:�`� .Sq. feet Dwelling—No. of Bedrooms.................. ......................Expansion Attic ( ) Garbage Grinder (n aOther—Type of Building ---------------------------- No. of persons-----_...................... Showers ( ) — Cafeteria ( ) QOther fixttWes _....._..•---.........•.... ..........•. ••-•••......-••-••. ------. --------- •-- ---------•-------------------- W Design Flow________________ .......................gallons per person peg- day. Total daily flow...... gal .�' f bons. Septic Ta>� Liqu d capacity gallons Length ____ Width _. Diameter __. ......__. De t Disposal `I each 45' —No.------_- ------ Width_. ° ........... Total Length---- ---- Total leaching area--- .. Seepage Pit No.........------------ Diameter_'_______________- Depth below inlet----:............... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results'.. Performed by _ ='�`' I'._a. `''�!� '.`�' _ ...........-. Date_ _ _.._..' Test Pit No. 1........ :----minutes per inch Depth of Test Pit-----�Z.t....... Depth to ground water____:r �- �k`. 44 Test Pit No. 2.......-E�-----minutes per inch Depth of Test Pit..... '._.... Depth to ground water.... ........... J.� cs"" may. - r ..............-_ .J> /F ......................................... O Dfscription of Soil i--0_�-J f t:I "t' o f p�C...._ r /b r���' ! i � f....................................... r�i ter rT o ¢ C si .a U �•-.-. U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ---------------------- :-----------------------------------------------------------••-•-.......-•-•••--•-•-•-•--------•----••.........--•------•--................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of�'T T p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certincate of Compliance has been issued by the board of health. gn'd---•-••-••-•-••--.....-•-•-......_..•----•----•----•-•-----••--•---••--•......--•••-•- ....--••-- ................... 7By..-.\ Application Approve ----r•..... . •_.......---•- Date Application Disapproollowing reasons--------------------------------------------------------•------•••--------------•--------------------------.--_.. --•--------••--•-------------•--------•-•-....------------------------------.------------------------------------------- Date PermitNo....................................................- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS r ' BOARD OF HEALTH .................OF.... ........................................................... �rr�ifirtt� ,af f�unt�li�nrr Tr�.IeO JERTIFY, That the jAividual Sewage Disposal System constructed ( ) or Repaired ( ) by j Grp .........................•---------•-•-•-•----------------------.......•-•--_.._ ...... --•------•--_..._ Installer has been installed in accordance with the provisions of The State Sanitary Code as described in the application for Disposal Works Construction Permit No................................____._.. dated-.------------------------------------------------ THE ISSUANCE O THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL UN 1?�1 SATISFACTORY. DATE..... ?...d Inspector--•-•-- -------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � �tf�•-� � _ !� � :.......................... . ®F.... � No......................... FEE........................ Perr 'o eby g ated ,.. ----- = ........................................................... 011-1 to Construct or Repal<r"iir'�idly' alwi5posa�� atNo. ......-----•-••---••-•-•-•••••-----•--•-•--•----••••-•................ Street as shown on the app'cat in r isposal Works.Construction Permit No Jam:- Dated.......................................... i Board of Health DATE.........................................-•-................... ................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS LOCATION ,?5—t S,EWAGE PERM NO. zr'-/d0 4 c►Gnl s VILLAGE CzdTcAvi,)I INSTALLER'S NAME ADDRESS e U I L D E R OR OWNER DATE PERMIT ISSUED =F DAT E COMPLIANCE ISSUED �117 / Ixaq# -Lp _ J —---- --t 0'-4'----- EA.31= It Al- A!OTI,S Lev. -4144 1_rM --ALt_ E4E�. µ!►.° AP,•F b&jECo UPoQ A u LLEVA'T- _ ' _ . �-•---- - ----=-� !G t-1 ._:�" _..,C) F•EE�+- C' PI�CLY ALA of I51-010M / � ''-� Uw1 CIT►-fEV&-)tSE SPECAF1Ell. F"+PrE 5. -rc> Alo L. 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"`VA T/G �Pl�e�- Df3 E.f' it/_ ,o/T5 ¢i:,n.iFoP�6a _- �L���__--�'-+� �EYf-%C (r.r�lY< ,&y AmECICA►� FICFC. ;r ►JoT _ 5CA4E HIC7TTG sc.r�E CW 6QUAt. 1 : TA►y K g QF cl.d F;0CC.E D _ t41711 ELFi�TP-IG wEli.pEa 1 T2b4r 6o R �l S� fiL 2�iri KJOT 083E�VAT/o1 YA+jc coaC. t5 400o P9F TEST ;0 eA/STl!g✓f lVV4I.!O9F �r*' TI BvILT r♦v'N PrA�nT wOLw E►wH►�.o NL�Iw�j{ti`t"fQ"f w tc.t��,°.:•L,..�^ "[ ._;. ` J�dL�. )J !•': E �'� �`� / ror aC Lc.w.I L LCV. r F I1..1 t5N 6[AOE. � IAJf S*1 6Q,a.47C F C-�e♦ ve CA'a�*` AJbTE; /�F�rJIS►f CsPPtE _._4 .2.. Tm'►4ic 4,i,4,7 `t 3 LWACW-04(7, AT- J� ez- 41.34V f•�qe ..Ae�t-w '•, / ,�"r, ryry .-....:__�.___— .y. _ � -•-��- r�. �ff T[.+/7 W A�1j 1Ei� �1 c:,> LLOW f r POND I14V 4 ( "4;+fi'_'S 4 D&E OF WATER - _ . . � SEPTIC TA►JtiG 30100 �. � TYPICA!_ �>=w•A►CTE SysTrM s�yn�s�>< _ �N EX157imcr OW EL-L-\t,1.�.� 38 f40 l� 4 MAP SECTION PARCEL, G T 4DD�4 O 0 ESS 41 lo PROPOSED OINEL�,l NG ,G OC�4 /Y Tl� o• .,. k y \,3 ) DES!G N Ge/7Eef.4 g4 _ 40 R�peso Ci�vTlt uL1 "r�! • ;' ✓ ' 47 \ ,qp,L� r J l\V -- _ F 6E0 QCi[7/>~75 _.._ �._ A EX/�7 `�CAf LcL. v i2� PROPOSED SE#AGE PISP©SAL SYSTEM Ira o '' �•✓�,,_ /t/ti M f��� O _ Lam/, -. Qi coo_` �; PE[Sa n/5 �`'EC ATE D�F'Bc�M _._. .3Co yiE'aP• °dlr�L c`d/ i2A'lNAfl�►S2a 1 /rr��,�� u/ A �} ` flre_ / i? '1lrA Y ,.- r P.CDLAJ7 � ? NLI.k987 3 a1 / /E.�L f !�l( fi,. 1�1 r /ll �g. '1 f,,' � 6r,+ILL S _ r ( S / ' l fi*U�//n/6 �t'€Q ul�f1� •. tEMIT � . p _ w:_ ,... .....! 1 , C', `zs17 i 46AeW1A/C ?OrowA eo_ PK2C;JPUSE0 LEAGHIriC> PIT E,.t�l►.er�c2. 30PT. v1 _ � � � R,>�1 ►� & '-IDNEY 'UTLEtR A2eov/ E,.iG1Na✓EQinJr. iNc 100 °a C-_APAKtSIat-J AL�+c�GN i 01 j e2 t 57 HOLLY C� !�T RV, CO h: C EN T Eu. f 3 I E M A SCALE- DATE: S"IET RAR'.E OND a� A-' ,NOTED IM Py l 1164 DRAWN 9y CHKO 1Y: APPO BY: MAN No. - ?�, ' -- '