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HomeMy WebLinkAbout0015 JACQUELINE COURT - Health 15 Jacqueline Court Centerville P A = 210 181 r I I a Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cn M , 15 JACQULINE CT �4 Property Address DILLON ~ Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 every page. Cityrrown State Zip Code Date of Inspection .ia 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 S �� When filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown 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 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 8-30-16 1 nfipecfo,' ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 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: SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. 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 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-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 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply I 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 '/z day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 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.] El ED The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system falls. 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 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 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): 2per assessing 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 r Commonwealth of Massachusetts a . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: according to as-built card system consists of a 1000 gallon tank, d-box, and 2 500 gallon chambers with stone. Number of current residents: 0 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: 2014------------276 2015--------------—183gpd--system not designed for use with garbage disposal 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: unknown Date Other(describe below): General Information Pumping Records: Source of information: I Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: s.a.s installed in 2008 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.75 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: light to moderate t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts t Title 5 Official Inspection~Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness moderate 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? wooden pole Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): If tank has not been pumped in the past 3 yrs recommend pumping now and every 2-3 yrs there after depending on usage. 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 every page. Citylrown 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 JACQULINE CT Property Address DILLON Owner Owners Name information is required for CENTERVILLE MA 02632 8-30-16 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 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box looked fine at time of inspection with no signs of solid carry over or surcharge. 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: no observation ports found t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 3050 infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no observation ports were located on infiltrators so exact level of ponding could not be determined but there were no signs of failure in general area of s.a.s. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 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•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 M , 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for VoluntaryAsses sments 15 JACQULINE CT Property Address DILLON Owner information is Owner's Name required for CENTERVILLE every page. Cityrrown M e P 0263o2de Date of Inspection 8-30-16 D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 5 ft plus 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: August of 2016 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: design plan i 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 15 JACQULINE CT Property Address DILLON Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-16 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 IAssessingAs-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION 4,-- SEWAGE#Ad?8-J�7 VILLAGE Z.y�,�w���t ASSESSOR'S MAP&PARCEL oZJ0�J 71 INSTALLER'S NAME&PHONE NO. / -1�� �,ui.�", fJ/�7P•P91�.� SEPTIC TANK CAPACITY /000 6o C 61 / LEACHING FACILITY:(typ4Z,, 'L NO . BEDROOMS PERMIT DATE: .0-1 J-Oy COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility s f feet Private Water Supply Welland Leaching Facility(if any wells exist . on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY AL �- �8.d B I - zX ¢ H10 .o�Be� 9. 6 ,4 h //www.townofbamstable.us/Assessin p y p?mappar=210181&seq=3 9/11/2016 ttp: g/HMdis la .as No. ;,�DQ U 3 PSt r._ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered,in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes JAco dopplication for Th5po5ar �pgtem Cou5tructiou der 'dual Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑.Complete System Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Oh/ Installer's Name,Address,and Tel.No. r/>t� Cuj Designer's Name,Address and Tel.No. ✓�aPt �y�`V`'�"� Type of Building: TO 1"�3 Dwelling No.of Bedrooms Lot Size � . �o sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow min,re uired) 3�� gpd Design flow providedy� gpd Plan Date `_,,)oo Number of sheets / Revision Date_ +2 -kV, Title /.//s r 9i��� /1` ric ��li (mow L�.�t4ti..Ile Size of.Septic Tank k0ob Gib efjl as Type of S.A.S. bona . - /� / c✓ S w Description of Soil A�h a Nature of Repairs or Alterations(Answer when applicable) r-All- 4�Agf /6t 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 qB�Woe Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. o2 009— 3 9T Date Issued --——————————————————————————————————————————— No. o �-3 O �7— Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS ti 3h5pa or #pgtem coow6tructiou permit Permission is hereby granted to Construct ( ) Repair (4,00 //Upgrade ( ) Abandon ( ) System located at and as described in the above Application fbr Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. AA 61 Date `I—A�d U Approved by r'/ Aq No. 2 oo ! (/Fee J�g 3 8 /,'&/ . � � �/ � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes -T"CoLtR/;,�Qpphcation for iqogaY *pgtem Con5tructfon Vermit �;�IApplication for a Permit to Construct O Repair(k) Upgrade O Abandon O ❑ stem Complete Sy stem y ❑Ind/ividal Components � GC v*�r^r �a✓- —r / Location Address or Lot No ft Owner's Name,Address,and Tel.No. /�c✓u, Assessor's Map/Parcel Installer's Name,Address,and Tel.No. /�i�„r,�� �.,�( Designer's Name,Address and Tel.No. Type of Building: '�i�'ro g"7?- Dwelling No. of Bedrooms _�,/ Lot Size (W& sq. ft. Garbage Grinder (k4rd s Other Type of Building / No.of Persons � Showers Y ( ) Cafeteria( ) Other Fixtures 'Design Flow(min. required) V3✓d gpd Design flow provided 37d gpd Plan Date J- �^ Number of sheets t /�(r / Revision Date 5nO/ /,�,1 Title 1b f s, /* J/.av ert /r ��rt�a'*�r.•-t Cra"` G�^llf.n����,r Size of,Septic Tanks 1, G�OAO / cif l�in S Type of S.A.S. ly/ �ly .. 74 41 Description of Soil ,/_.e A/.7 f / Nature of Repairs or Alterations(Answer when applicable) r��iy ,[,..,dlwr �-� JO/cif 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 oG°ealth. IJ /�+ J Signed f : �a Date _ %-r73-1v D _ Application Approved by Date 1 Application Disapproved b PP PP Y: Date for the following reasons Permit No. 009 3 $ Date Issued 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 J 14/0/>< <_r �.S�eur a.✓ at A - Tole Darr 1 , 1+'e1>114 A_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. AO'O '- 36: dated 3 Installer / . ®`J we '1�+✓ Designer/�-�,,J �,9t �tac a`,.,.•..-,ya t` a #bedrooms 13 Approved design flow '744::2 gpd The issuance of this permit shall not be� -coonstrued as a guarantee that the system will function as designed. Q Date I~ g 4-0}C Inspector IMF _�S kg - =——————————————————————— C TOWN OF BARNSTABLE LOCATION /rJzLie Gi�.� SEWAGE# 8- 3�7 VILLAGE C�T���//Z ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 9 SEPTIC TANK CAPACITY 000 Gc LX LEACHING FACILITY:(type �� 701"0 (size) Jd'yC 2 NO.OF BEDROOMS mZ / OWNER. TG�T�.�` Csrf� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility.) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY /� Li rvi. yl' �-7 FROM :down cape engineering i;4c� FAX NO. :150e3629880 Sep. 25 2008 01:33PN P1 Town of Barnstable ,.� Regulatory Services s Thomas F. Ge ler,Director Mnratt•AWZ, II M"8Fi. Public Health Division 1639., Thomas McKean,Director 20 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fzm: 508-790-6304 Installer&Designer Certification Form Date: Sewage Permit# C�XS (597 Assessor's Map1l'arcel 4>)110 Idol /Designer: loWyk- 2 /ram v1 b lnsts�ller: Orr' !I% Address: -16 a i d\ Address: r o• On a3-®� u�0 was issued a permit to install a (hate) (installer) septic system at _vGl r _t'tnl ct.�.� based on a design.drawn.by �ctreti:,) t 0(� !I tQQ 4 dated (d gner) I certify that the septic system referenced above was installed substimtia.11y according to the d.esi6m., which may incslutle minor approved changes such as lateral relocation of the distribution box andior septic tank. 1 certify that the septic system referenced above was installed with. major changes (i.e. greater. than 10' lateral relocation of the SAS sir any vertical relocation of any component of the s c system) but in aw-wdanee wi.tb.State& Local Regulations. Plan revision or i ccrt' ed -built by desigaer to follow. ZZ �►,,l OF MAs�r DANIEL A. � OJALA Onstal,ler'sS'ignature) CIVIL No.46502 (1)estgner's Signature) (A#��.x l�esiger's St:unp Ilene) lily;I'OUN TO BARNSTABLE PU13UC FITAI Tl l PIVItiIUN CERTIFICATE Off' COMPLIANCE WILL NOT BE ISSUED UNTIL B(YrH THIS FORM AND AS-BUILT CARD ARE KECEIVED BY THE IIAIZNSTA.81Y.PURI,iC I3F,AL'I'll LIVLSION. 'i'HANX Yo'U. Q:Hcatth/Septic/Designer Certification Form 3-26-04.ittx. ' r Town of Barnstable Barn P ~ Regulatory Services Department 1 aica j t BARN SfABLB. "'"9. Public Health Division Alf°MAC A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO May 19, 2008 David Holt c/o Fannie Mae 1533 Falmouth Road Centerville,MA 02632 ORDER TO-COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic stem located at 15 Jacqueline Court, Centerville, MA was last inspected P Y q p on May 10, 2008,by Shawn McElroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines . of 1995 TITLE 5 (310 CMR 15.00)^due to the following: • Back up of sewage into facility or system component due to overload or clogged SAS or cesspool. 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification to repair. Failure to repair/replace the septic system within the deadline period will result in future enforcement actin . PER ORDER OF THE OARD OF HEALTH Thomas McKean,R.S., CHO Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 9525 Q:\SEPTIC\Letters Septic Inspection Failures\15 Jacqueline.doc ,t U, Commonwealth of Massachusetts - Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments• 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 i=nancE-of on. The inspection was performed based on my training and experience in the proper function and on.site sewage disposal systems. I am a DEP approved system inspector pursuant to:Section 15.340:,of Title 5(310 CMR 15.000).The system: ❑ Passes ` ❑ Conditionally Passes ® Failk ❑ Needs Further Evaluatiop by the Local Approving Authority ` 5-10-08 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. t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 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: O B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to bed replaced or repaired. The system, upon completion of the replacement or repair, as approved'by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp•03/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (coot.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the.system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail'unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 - - 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 15 Jacqueline Ct Property Address Fannie Mae contact David Holt @ Today Real Estate 1800-966-2448 Owner Owner's Name information is Centerville MA 02632 5-10-08 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well ** Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 1/ 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. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. M 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'GSM 15 Jacqueline Ct - Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 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 an of the system components pumped out in the previous two weeks? ❑ ® Y Y P P p ❑ ® 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 CM 15.302(5)] t5lnsp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 220 Number of current residents: 0 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)): Sump pump? ❑ Yes ® No Last date of occupancy: 4-08 D ate 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: Last date of occupancy/use: Date Other(describe): t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 t ' i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A 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): Approximate age of all components, date installed (if known) and source of information: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5lnsp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18 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.): Good condition. Septic Tank(locate on site plan): 12" 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: 1000 Gal Sludge depth: 10" Distance from.top of sludge to. bottom of outlet tee or baffle 22' Scum thickness 2" Distance,from,top of scum to top of outlet tee or baffle 67 . Distance from bottom of scum to bottom of outlet tee or baffle 14' How were dimensions determined? Tape t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 16 t � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 15 Jacqueline Ct Property Address Fannie Mae contact David Holt Today Real Estate 1800-966-2448 ( @ Y ) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 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.): Tank in good condition with baffles in place. 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 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): t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 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.): Good condition.With stains above invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: � ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had clear signs of failure with stains above inlet invert. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name - requir information is Centerville MA 02632 5-10-08 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Buc k 6H (o 19- W.�' a-p- CIE -E- a' O F ��_ 6 E 3-/' A J 1 t5insp-03108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 15 Jacqueline Ct Property Address Fannie Mae (contact David Holt @ Today Real Estate 1800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 5-10-08 every 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: 15 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: Town maps show groundwater at greater than 15'. t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 15 Town of Barnstable Regulatory Services anxrtsrnaLE Thomas F. Geiler, Director MAM � Public Health Division AjFp�.IA Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. I QASEPTICTisclaimer Private Septic Inspections.DOC No. Fee L Tes��l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Miopozaf *potem Construction Permit Application for a Permit to Construct( )Repair(y)Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. � �� � �I :Owner's N `,Address and Ty�.l�o. `� Assessor's MapZ rcel n ° t(Ul �, f, I CJ�,�.S-ry`1 t►✓I U�t/�1 a ) / Installe' N e,Address,and el.No , Q Designer's Name,Address and Tel.No. � �0 r ► YqS �''n � 5 s 0 1�---- n Type of Building: Dwelling No.of Bedrooms &/Az_Size— sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil; Nature of Rep 'rs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provision of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i u b thi 'ZW� Sign Dat JOL 4 Application Approved by Date Application Disapproved for the following reasons Permit No. '10 Date Issued C, Fee L G l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS es 2pprication for 33izpozal &pztem Congtruction Permit Application for a Permit to Construct( )Repair V Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and T 1.No. Assessor's Map/Paiazce Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: I °\ Dwelling No.of Bedrooms of ' e--- sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date ` Number of sheets Revision Date Title ,' + Size of Septic Tank I { Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when app,licable) , LA 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 Certifi- cate of Compliance has been issued by thi ard• f Health. Signe ) JC�T/ � % r' Date, Application Approved by Date( 1 Application Disapproved for the following reasons Permit No.�5 ' Date Issued G d !' — ' ------------------------ - ----------- THE —COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Y �� (Certificate of Compliance THIS IS TO CERTI Uhat the OnPY­T-site S wage Disposal System Constructed Repaired Upgraded r Y ( ) P (� Pg ( ) Abandoned( )by at ra C s been constructed in accordance with the provisions of Title 5 and(he for Disposal System Consttion Permit No. Utl 1)1 dated I/1i/ii r, V ruc r r Installer 0 1 j Designer n The issuance of this permit shall not be construed as a guarantee that the syn 11 i`function as designed. Date I i� I�C� ' Inspector -, PIN., V _ .. --------q------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PU LIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS .)�rr" �- �,1 L Zi!405ar 6pgtCm C0115truction Permit Permission is her by granted to Construct( )Repair(A Upgrade( )Abandon( ) System locate `at , QV/,( /� i .till I !». F'1 � �1 1 ,- -�- �_1�7 n and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions: Provided:Cons,tniCtio must be completed within three years of the date of is p. Date: 11 I �s Approved'by t "M O "TOWN OF BARNSTABLE LOCATION ve SEWAGE # 2005 —C> °I VILLAGE Ge�►TC Iv� /� ASSESSOR'S MAP &LOT ' INSTALLER'S NAME&PHONE NO. a SEPTIC TANK CAPACITY nd Z j • �0�� (size) j :/7 R (JS�LEACHING FACILITY: (type) aril" U^l NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE:_JkLId— COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by C, U -box aA( y 1a g i TOWN OF BARNSTABLE 7.7 ve. SEWAGE # u �Ii:LAGE Gevt Tc ram` �� ASSESSOR'S MAP & LOT ;2/b���/ INSTALLER'S NAME&PHONE NO. SEPn^C TANK CAPACITY �Ia,n r j l LEACHING FACILITY: (type) MOO (size) '.NO. OF BEDROOM' S � / re Air Unt �f BUILDER OR OWNER Mle e S 1/ Su / PERMITDATE:. ,S� _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1 2 AF ® � -boX a�( 9 y �7 Al 36'6 9, o Aa Ba-3 � . COMMONWEAUITI.. OF MASSACHUSETTS x EXECU'I'IVl!. OFFICE OF ENVIRONMENTAL AFFAIRS a d DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED J� .11/ P ZI � J' a �JARCEL i NOV 2 4 2004 TOWN OF BARNSTABLE HEALTH DEPT. Map=21�0—L-ot:_15_ Par:_180_ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM -,I PART A CERTIFICATION e ' Property Address:_15 Jacqueline _Centerville_ :"Zy r10 Owner's Name: Ed McKay_ Owner's Address: _P.O.Box 506 W. Hyannisport,MA 02672 "' t Date of Inspection:_11/08/04_ f.. Name of Inspector: Dion C. Dugan Coy t'�i Company Name:_ 1543 Main St. Mailing Address: Brewster,MA 02631 Telephone Number:_508-8%-9390 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: A/ 71, t,L The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: *Recommend: Maintenance pumping 3—5 yrs. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different Conditions of use. Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_15 Jacqueline _Centerville_ Owner's Name:_Ed McKay_ Date of Inspection:_11/08/04_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_15 Jacqueline _Centerville_ Owner's Name:_Ed McKAy_ Date of Inspection: _I 1/08/04_ C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public)wealth,safety or the environment. , 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_15 Jacqueline --.4 _Centerville_ Owner's Name:_Ed McKay Date of Inspection:_11/08/04_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma _NO_(Yes/No)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: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _N/A_ the system is within 400 feet of a surface drinking water supply —N/A! the system is within 200 feet of a tributary to a surface drinking water supply _N/A_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone 11 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. Page 5 of I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _15 Jacqueline _Centerville_ Owner's Name: _Ed McKay_ Date of Inspection:_11/08/04_ Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection `? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up _X_ __ Was the site inspected for signs of break out`? _X_ _ Were all system components,excluding the SAS, located on site _X_ _ 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 ? _X_ _ 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: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _15 Jacqueline _Centerville_ Owner's Name: _Ed McKay -� Date of Inspection:_11/08/04_ FLOW CONDITIONS RESIDENTIAL 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):_425_ Number of current residents:_0_ Does residence have a garbage grinder(yes or,no):_no_ Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no):_no Seasonal use: (yes or no):_yes_ Water meter readings, if available(last 2 years usage(gpd)): 2002: 0/0,000, 2003:01,000 Sump pump(yes or no):_no_ Last date of occupancy:_6/30/2004 COMMERCIAL/INDUSTRIAL: N/A Type of establishment: N/A Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: pumped: 9/2000 owner Was system pumped as part of the inspection(yes or no): NO_ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy NO_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) _ "fight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: _Installed`12/15/80(24 yrs.old)_B.O.H. Records Were sewage odors detected when arriving at the site(yes or no): NO_ Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_15 Jacqueline _Centerville_ Owner's Name:_Ed McKay ' Date of Inspection:_I 1/08/04_ BUILDING SEWER(locate on site plan) Depth below grade:_30,"_ Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_N/A Comments(on condition of joints,venting,evidence of leakage,etc.): _Joints are tight,venting is through the roof,no signs of leakage. SEPTIC TANK:—YES—locate on site plan) Depth below grade:_14" Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_1000 Gallon_ Sludge depth _4"_ Distance from top of sludge to bottom of outlet tee or baffle:_26"_ Scum thickness:_<V 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: 13"_ How were dimensions determined:_by tape and rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Pumping not needed at this time,tank and tees in good condition,no sign of leakage. *Recommend: Maintenance pumping every 3—5 yrs. GREASE TRAP:_N/A—locate on site plan) Depth below grade: _ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): _ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE; SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_15 Jacqueline _Centerville Owner's Nbme:_Ed McKay_ Date of Inspection:_11/08/04_ TIGHT or HOLDING TANK:_N/A_(tank must be pumped at time of inspection)(locate on site plan) Depth�elow grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:_YES_(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.): _D-Box is.Level and is in poor condition,with some signs of carry over and no signs of leakage PUMP CHAMBER:_N/A_(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.): Page 9 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_15 Jacqueline _Centerville_ Owner's Name:_Ed McKay Date of Inspection:_I 1/08/04_ SOIL ABSORPTION SYSTEM (SAS):_YES_(locate on site plan,excavation not required) If SAS not located explain why: Type —X leaching pits,number:_one 6' x 6'w/V of stone_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): pit was located but not excavated because of a 14'white pine over it. No sign of failure._ CESSPOOLS: N/A—(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): *Recommend: Maintenance pumping every 3—5 yrs. PRIVY:_N/A(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_15 Jacqueline _Centerville_ Owner's Name:_Ed McKay_ Date of Inspection:_11/08/04_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. L O C � u A p�t,C 6 AC = 27 � A - D = 35 A - C = `f$ , Q - c = 3 7 , Ll3 V vv � CPO fq Page I I of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_15 Jacqueline _Cewterville y Owner's Name:_Ed McKay_ Date of Inspection:_11/08/04_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_14_feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: You must describe how you established the high ground water elevation: By perk test on 7/14/80, 12'deep no groundwater encountered,and by U.S.G.S.Atlas H A 692. MAPI U LOT PAR COMMONWEOAL H OF MA�SACI-IUSE'I"I'S - i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS x _ DEPARTMENT OF ENVIRONMENTAL PROTECTION f TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:JtY 'j'Ac-au i-,A1C— GT, C'EI\ITC-9V IL!-e Owner's Name: 'pµ,,,_i p 5-T cgp&�, Owner's Address: s A m A Date of Inspection: Name of Inspector: Dion C. Dugan Company Name: 1543 Main St. Mailing Address: Brewster, MA 02631 Telephone Number: (508)896-9390 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant t Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: L-zadc,�� Date: 2 /01 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments 1* Recommend: Maintenance pumping every 3 - 5 yrs. r '`***,rhis report only describes conditions at the time of inspection and under the conditions of use at that time. 'Phis inspection does not address how the system will perfor►n in the future under the same or different conditions of use. I • I Tilde 5 Inshcc-lion Lorin 6/15/2000 page I (! i Page 2 of I 1 ti OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I5 'SArCPJ L-ZING t-1 G tg--NTa-v-\j ktie Owner: -2. ii-kP -r Date of Inspection: 3 p t Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S stem Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaire The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,n or not determined(Y,N,ND)in the for the following statements. If`not determined"please explain. The septic t is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits subst tial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced ' a complying septic tank as approved by the Board of Health. *A metal septic tank will p inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less an 20 years old is available. ND explain: Observation of sewage backup o break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,sett d or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pi e(s)are replaced obstruction' removed distribution b is leveled or replaced ND explain: The system required'pumping more than 4 times a y due to broken or obstructed pipe(s). The system will pass inspection if(with approval of&Board of Health): _ broken pipe(s)are replaced obstruction is removed ND explain: I Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 15- TAGQU Ui i NfE c CN-r aRy k L4-.E Owner: S-TGj)'t£I Date of Inspection: 31:QQ 1 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 faili to protect public health,safety or the environment. 1. Sy em will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the syste is not functioning in a manner which will protect public health,safety and the environment: _ Ce ool or privy is within 50 feet of a surface water _ Cess of or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail un s the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in manner that protects the public health,safety and environment: _ The system has a se is tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tri tary to a surface water supply. The system has a septic t and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank an AS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method d to determine distance "This system passes if the well water ana is,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds in ates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate 'trogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the anal is must be attached to this form. 3. Other: P rci,. c 3 i...•.....• Page 5 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 15 5(�GQut?t�rhG CrN'CEi2.V i L(-E Owner: f"Ai L-�F T. Date of Inspection: 31-1-1 o Check if the following have been done. You must indicate.`yes"or"ntZ"as to each of the following: jYeNo 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 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: Yet no �_// _ Existing information.For example,a plan at the Board of Health. _J Determined in the field if an of the failure criteria related to Part is at issue approximation of distance ( Y PP is unacceptable)(310 CMR 15.302(3)(b)) P P 1 I { Page G of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: IS SACctj Cr, _Cat,4!Cgf—\1 t U-G Owner: 9*1 Lie `3. s-Ttsi!:krN Date of Inspection: ;113.10► FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): ,3 Nwnber of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): Ll-2 Nwnber of current residents:_— Does residence have a garbage grinder(yes or no): /v Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no):hW Water meter readings,if available(last 2 years usage(gpd)):.W /"9,000 gals. ign SG ,000 gals. Sump pump(yes•or no):16 Last date of occupancy:S►_t2RRA xl fLy COMMERCIAIANDUSTRIAL Type of establishment: )JIA Design flow.(based on 310 CMR 15.20 : gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: PUMarC,D iof' .2000" O wNER Was system pumped as part of the inspection(yes or no):AW If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: T�E 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) ' 2 _ Tight tank _Attach a copy of the DEP approval P ' _ Other(describe): Approximate age of all components date 'nstalled(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): .tn I Page 7ofII OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15' C-1 . LI►a'Te-tt\/r u.a Owner: -rr1��P S, 5-rGf�fl Date of Inspection: 31�10 BUILDING SEWER(locate on site plan) Depth below grade: / Materials of construction:_cast iron �/ 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): V01MI-6 RA!z errGN?, V�5-Al-fW& AT RaoF. AID SlaA)S 4/- LA&tr", SEPTIC TAM{: (locate on site plan) Depth below grade: r Material of construction:concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /000 GAL Sludge depth: I " Distance from top of sludge to bottom of outlet tee or baffle: .21 Scum thickness: lot Distance from top of scum to top of outlet tee or baffle: 4 „ Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: by tape and rod Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): /PV.%Q1A)6 14JOr Al,646ARA Rt r915 610,E rfi-Alk .4A/6 rp�s Ly 6M,6 * Recommend: Maintenance pumping every 3 - 5 yrs. GREASE TRAP: (locate on site plan) Depth below grad . Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): f i ; i.. r,,,•.,,.,• ;.... rr.,..., an�nnnn 7 Page S of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1S Owner: 5=cF-ffl Date of Inspection: 31 z\o I TIGHT or HOLDING TANK: ^^(guile must be pumped at time of inspection)(locate on site plan) Depth below grade: /T Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:�(if present must be opened)(locate on site plan) It Depth of liquid level above outlet invert:Q 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:Y((yes ocate on site plan) Pumps in working ordor no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): P B .'fill,. G Lu•nr.rl:nn I�.rrn. /,/I S/'1/1I 1l1 H Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 YAc-og-9�LINt: G-C, Gt21J"�t�R-�J�Lt_G3 Owner: V�IyAiL,p S .STCtai� Date of Inspection: 3 2r SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: j�e I eaching pits,number:1�114 6 X,1. A T' t-✓/! d� 5�,�1,E leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): b r was 13 u r lyo r Hx cA v. &.b 8-ocew%6 of tz p,hW r7' Ainr� L©e,4frA ovAER Ali NO -516.,us or- CESSPOOLS:yguration: cesspool must be pumped as part of inspection)(]ocate on site plan) Number and co Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): " Recommend: Maintenance pumping every 3 - 5 yrs. PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: P P Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.): - ---- —- ------ --- -- -------------- ---------...-_......------- - -----.._.......-- ----- i...•...... ,,., r, —' in tnnnrl L I'abc 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 15 -:TA LQj t--_i_tNE Cr. Cc-N-CO LV i LL, Owner: (O►+u L%P z . s-r�afl Date of Inspection: 01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. O C A C = A A - D = 3s 6 Its" C J 7 4 ` C = 36' w y P � a r i 3t a �Y i i Page I I of I I r a OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 15 -yAcgo GLitJG- CT ER.1 I Lc.rc Owner: ?ifI L_i P -:S. S-T&� Date of Inspection: 31-)--1 o t a SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water y feet Plea a indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high round water elevation: f Al M No........................ Fps.................... THE COMMONWEALTH OF MASSACHUSETTS _ BOAR® OF HEALTH .dV...... ..........O F..... .°1.. .''� .................. Applira#ion for Disposal Works Tonstrnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .......... �? :, e_ �5 n eo�,�n ---------••--- s�- c --- -.__....... ----------------------------------------- • - �� -•Locati Address � o Lot No. Owner _ — _S: i} dd ss lr..`.....c.. '..) ...........`-•---�---•----•--•-•-•............. ...... !......... c'�•i_.: _ .. ................................................ M Installer Address Type of Building ? Size Lot�� .�......Sq. feet U Dwelling No. of Bedrooms__...__._3______________________________Ex ansion Attic�•. g— p ( ) Garbage Grinder (NC) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---•---------------------------•---•---•-------------......---------------------...---------..__._...._....-----.....----------....•-••---••---•-•-••- W Design Flow ........... .........gallons per person per day. Total daily flow..____._.::;; .....................gallons. ___ WSeptic Tank Liquid ca.pacity_7� gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench-N _____________________ Wid .................... Total Length....... ____ Total leaching area............__.._..sq. ft. Seepage Pit No........_(._........ Diameter... c_5._..... Depth below inlet.... .......... Total leaching area.:"_2:0_l..sq. ft. Z Other Distribution box ( ) Dosing t,� ( ) - '" Percolation Test Results Performed by..._-&� - --- -- ___:-___/_�-_��_� ..... Date._.__~,lY:.?�a_______.._. a "��`{ Test Pit No. I................minutes per inch Depth of Test Pit..........._........ Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ L.`. ..._._. --------•---------=--•- U .................escri Description of Soil---- -- . .. -...... ---------•-----------•-•-------•----------------•----------------_. ...------••-•--------------.......------------•--------- •--•--...-----•-..._---•----•--......--•------•-•-- W UNature 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 TI'Uj 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. J C \�'p��, Sig d � -=...x .__ � .._..... -a ---......D Date Application Approved By........f• � � •— ..... ................ Date Application Disapproved for the following reasons---------------------------------------------------------------------------------•-----....................._ -•---•-•-•..............•---...._...----......_..----------•--.....------------•.._....----••-•-•-•---_..._....•---•-••-•------•------••------•---•---••-•-••--•------.................................. Date Permit No......................................................... Issued_.�j_`�_7_ _—X—// ------•-----••------ ...--- Date No................ --- FEs. `-� ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD',OF HEALTH ............1.............................�v OF....................................... Appliration for Disposal Works Tonstrnrtinn Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: q CCU-1 c• -•-•-•- --. .............. ... -- ------.........---..............-----------------------.........--- . U Location-Address l t - •-- - Ca �'Y, Ca S ��., � ........--- —..... ............ ................................................... .......................'.... ............ ................................. 'i 'i ddre C J c -`'� Owner ss e `� .........................----------------•....------.....----------.....-•-------•-----•..._..----•- Installer Address _ UType of Building Size Lot.1-L�.. --"-..........Sq. feet Dwelling—No. of Bedrooms----------=...............................Expansion Attic ( ) Garbage Grinder (ND aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ----------------•--------------•----------------------._...--------- W Design Flow_..--_--`---............... .gallons per person per day. Total daily flow..._....:3. ._..............._...gallons. WSeptic Tank Liquid ca.pacity.l�-..._.gallons Length................ Width....._.._._...._ Diameter._-____......... Depth................ Disposal Trench—Ng..................... Wid Total Length......... --------- Total leachingarea.__....._........-/_s ft. Seepage Pit No......... .......... Diameter...!. .-.._. Depth below inlet............... Total leaching area.r.j9�-►-Q-l..-sq. ft. Z Other Distribution box ( ) Dosing ( ) Percolation Test Results Performed b- •......... Date.... ../.y'.. .............. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit................ Depth to ground water........................ i T -- �V....... ...... . ------. ..--- .-p !ODescrlPtion of Soil . . �-r U -••-•-•-••-•-•-•••••-- --•-••••--•-....•----•-•-...-••---••••-•-•••......-••--•-••••-•--•--•-••••-•---...--•-•--•--•--••--•----••-•-••----••---•--••---••-•--••...........-•----•-•---•-•-••-•-------••- W x -----•-------------- ------------------------------------------------------------------------------•------------------------------------------------••-------------•---------------............-•---•... 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 TI111Z-4 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. Sig d .......... Application Approved By......... _. Hate 1 .. = �� ................ - Date Application Disapproved for the following reasons---------------------------.................._................................................-................. •..............•-------------•------•----.....-----------•-----•----•-----------------------•-------•-•------------------------------------------.....-----------------------------------...-•--•....... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF.......... ... .'� ........................... Tntifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (f or Repaired ( ) by..........` .4::. n . co. �L2 �-�..... ` Installer at-••••--•-• . =�••\........3--•----•-.--....�C..Gti.v C_�...)` � C U.I1 � �-------------------------------- has been installed in accordance with tl e' provisions of T `' I he State Sanitary Code as describ d•in the application for Disposal Works Construction Permit No.( __.._... dated__..f ."_.S".��............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. tr;"" �'` DATE------- `•t. 1.................... Inspector (�� -`._... THE COMMONWEALTH OF MASSACHUSETTS BOARD _OF HEALTH ......... \ :..........n............OF............ No.......... 3 FEr., ,t ....... x Dis.Vosal Works Tnntrnctuan Prrmit /Permission is hereby granted.. � � �`. f '.. `. �......?.�..��✓�� to Construct ( .--fir Repair ( ) an Individual Sewage Disposal System ..•....... . . ._ .........................................--•- . \ 1�__ ----------•----•--•-- -.. Street as shown on the application for Disposal Works Constructio P Non Dated. 1 � s '. . .n _. _- . DATE........... G."C��._.._..-----•-•------------•------- Board of Health 4�, FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS GOV2„T JZ O 150 C/o • 49r 6.1?D. - c4 F'Ck�A.I: PIT - uS� IOcac� CyAt;` `x qt�1� cs . 1 .o z 'E�,o G.F?D. TOTAL 7VESIGIJ = TbTnL. 1=)A0 L-( FLOW t 330&F.. . GF_tZG�L.�Tl01.1 2LYt"E : 1°10 I-M I U, oQ P�T MIS u d8a 24048 Jor �' ��• 97o _Z ' -Boy � 96� SEvnc (000 960 1uV� i1�K 't, . �:', 6.2N✓CL�' GAL. �6•Z 9�'d ' A q ; PIT i'• D -s, si3w� . • �EC�.T��tt_L� p:-.�`S" E�L.��D ~, -SamC PIZ,Oy="i LE� -- sroNes L.vCATIotJ CEN-rC-- I C _ a►_�- ,,r-CA 1. >A'T / /Bo `7 3` 8o pL A t�l R=-p G tZE�.1 GE 1�� � Gt�tZTt{=� TE-lAT Tf-IG FO V NpA'(Idt�iN�� W►TN T►-A 51pE lrll-ice L.O T Q� 4 Q1JD SCTOAGV VGQt)i�EMi-.�.ij'S -' Toww ac= 'U \P N T A L E P" ,N $►�•, z q O pG .5 -j v g/.SL KTr tZ t;• u•!� tic. -' tZcGtS rc=r1~u t-Ati� �ue-vaYotz •� LJOT tanSc� va.a Aw a�Tt~�vt�t_G �,C•�55• TI-t _ iwS;rcJAALi.Wi i,�Jc_.ir_�{ "floc:: c , ,1•lcwt� n.F�4'�-l<_A►-�T Jf'�ME:_S MtT� . t.. -nr: 1<_(--h 'Tr l)ls'1'("C'_M1►Jl'- LC>- l-1WL •,a ATizl _ A G E PERMIT NO. LacoN . " 1-LLAGE _ C ill• ��%(�/� - ,: «. . .- �INSTA LLER'S NAME i ADDRESS r s U I L D E R OR OWNER _ t DA T E P E R M I T I S S U E D o DAT E COMPLIANCE ISSUED ,. r � .. a -- /�� .' ti ■ V �, r . No ...5 6 Flcs...3.0.................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........... own........ ... OF...:.......Barnstable .-- A V iratinn for Dhipsal Works C omundinn unfit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal Sy tem at: /.............J.LQQue).axe.Q...CQur±....................................... Zot_117-............ ............................... Location-Address r Lot No. - .Q-.5...KA_.. th Barnstable............................................ ........... : ............. -----------------..............------.... Owner Address a Vetorino Bros. Barnstable ....---••-•••. ....................... -•-------------•-•-------------------•-•-......•-------•••-----....---•--••-•••..--•--•......... Installer Address Type of Building Size Lot_..15i.021._..__..S feet Dwelling—No. of Bedrooms....._.....................................Expansion Attic ( ) Garbage Grinder (NO) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow...........1:1Q........................gallons per person per day. Total daily flow.............'33-Q......................gallons. WSeptic Tank—Liquid capacity1000_gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length...._................Total leaching area....................sq. ft. Seepage Pit No........./_---------- Diameter.....6...._._..__. Depth below inlet... ........... Total leaching area_.dL......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by......VA. XV�4..*...&Yf............................... Date..7.-14.m8Q................. Test Pit No. 1................minutes per inch Depth of Test Pit---1 .......... Depth to ground water-__!�_�_t� ..... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •------- ----------....... ---------------------------------- ------------------------- .•----------•---------•......... Description of Soil....0-2___loan__&-_sub. soil________________ x 2 6 gravel U -----•--------------------- --- 6-12 med_-sander---gavel-------------------nO---water__7-14-80 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 TITI.,i:, 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. Signed ............................. ....9-Mna ........ Date Application Approved By---..:--- ........................... ........ Date Application Disapproved for the following reasons:------••------•----------------------------------------•------•-------------•-------------------------••-....... ....-•.............................•---...------•-----......--•--...-•--•------•--••--------------------------------------•---------------•----------------•------------------............... Date PermitNo......................................................... Issued....................................................... Date No{✓ 3-5 � Fxs.........,?. ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ...........Town....................OF............Barnstable.............................................. Appliration for Disposal loorks Tonotrnrtuan .ermit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ...............j�QEgUO.1 M4.4aU..xt•------..---------------- ............Lot...#17...=....�.: /�.4. •------------..... Location-Address or Lot No. ..............Jaya•.Ke....Smith........................................... ............. a�natab1V..-----...--•--------•--------.........--•--•---•-------- Owner Address ............... atarino...Bras...----...---------.......----•----........... ............Barnstable ... Installer Address 159,021 Type of Building Size Lot........... ................Sq. feet Dwelling—No. of Bedrooms.........2...3...........................Expansion Attic ( ) Garbage Grinder (N9 aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures -------•----------- ----------•------------- W Design Flow............1,10.......................gallons per person per day. Total daily flow..............33-Q.....................gallons. WSeptic Tank—Liquid*capacity.1.000gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length............. Total leaching area____----•..-_---_---sq. ft. Seepage Pit No.........../.-------- D ........ Depth below inlet..... Total leaching area....A-jLZP....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........ ..1.._�t.7.. ............................. Date...7!t1 --80............. Test Pit"No. I................minutes per inch Depth of Test Pit-----PL_-------- Depth to ground water....N o''-c'-__ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 ----------------------------------- •------------------- •---------------------------------------- ------------------------------ ----------- .:................. D Description of Soil.....-Q-2._.loan._A..s.ub..�oil..................... W .. e. --- asya . fto--•-••--- 4:- 4 U. Nature of Repairs or Alterations—Answer when applicable__________________,_............................------------------------------------------------- Agreement: ----••--•-- ------------ ----------- -------- ibed The undersignedagrees to install the aforedes d ividual Sewage Disposal System in accordance with _ the provisions of TITLE 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. Sined ..., "� _.._.... ................................ ... t� .)ate �f% Application Approved By...... :.... ---• �!- S.... ..o v Date Application Disapproved for the following reasons---------------••---------------•---•--------------- -----•---------- -- ......-----•---------------------------------------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............Tovin..............OF.........Barnstable.......................................... (Intifirate of Tnntplinurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by--------Yetorino...BxatherB........................................................................................................................................... Installer at..........Lot 15-_Jacqueline• Court:--.Cgntery llex MA► has been installed in accordance with the provisions of TITLE] 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....... .............. dated......................................:......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... '2.....2 y`-��-----•-----•----------------------------- Inspector....-----. .. _ .................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable G,, ...........................................O F.............._..._.................................................................. �- No..... U.:-5.... FEE....3.....--........ Bispos tl Works Tunstrnrtuan rranit Permission is hereby granted-•--- Petorino_-Brother... ........ to Construct (X or Repair ( ) an Individual Sewage Disposal System at No...Z!Ot._1 ...Jacqueline Court,...Centervjle, � Street as shown on the application for Disposal Works Construction No..................... Dated,......................................... DATE•_-.L.-����� Board o ealth FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS LOCATION SEWAGE PERMIT NO. GAT 1:"- I7 JA VILLAGE INSTALLER'S NAME i ADDRESS _ R U I L D E R OR OWNER { SM ITt DATE PERMIT ISSUED 7-3-0 .- O DAT E COMPLIANCE ISSUED r ,hh � � ® '�� y� _h� �� _ . . ; {���� � a . ,;� r .. x TOWN OF l ARNSTABLE LOCATION, � e lvn SEWAGE # VILLAGE— ASSESSOWS HAP&LOT016 Irl 1�;_ ;8�- INSTAL4ER'S NAME&PHONE NO. lw- SEPMC TANK CAPACITY LEACHM FACILITY: (type) (Size) NO.OF BEDROOMS„ 13MDER OR Stpration Distunw-Domeen flie: MAXinium AdjuSted,Groundwater"Pabic to(lie Bottoul orizachingFu0ility pit private Water SUI)ply Will and Leactilng Vacility (If any W415 exist 0tk site or within 200 feet of leaching fArili-ty)I Edge of Wedmid and LeacWng Facility(If Any wetlands exist within 300 feet 41c, W I IfIrlat ) Feet Furrdshcd by, -19- uo' ,�-o- IIE �-�-sa' 6�3q' [�1^r IGIJ DATA , ' �iLYsI..E: t=A^ntt..�( - 3 'R»vtizno�vt iaa•,� . �10 C-+AfLSL�G.E vR11.J[:�1✓•rL r�alt_�r FLAW = tto 3 t S30 �•P•v. �So.3S' — Ic 15c % • USA• 1000 C=.A L... � � �POSAL PIT uSE_ logo GAS, , 2.S • t'75 U.P.D. Pir f so, A,UN �. TOTAL -lP e6%6 J a .425 (,..P D• ;�. �aey► rAJO + . IOTA L 1 gat 0-( FLCvI/ s 330&RD. if I•� r�Nr � � Ilj PMOCC>.&T101J WATE S I"ILI SM I W*O2 L". MCP l AL N h`$i-,P�eAryui ^�v, • yy A, JOr 04 24. , � '��"•; �^r �r� T ZONAL ENS\ Tar 1:wo c 10%.0 D „ . a. .�'^ .•. luv.9 9 -` ,�`�.y ,rl'Ppe Joao i►ni ,� ' • sv2so.L 4'�pb IW. fsAd.. qF� 'SOX 9g•� $apm 1 c IM/. I I..;_ we 1000 9g R ' IµK IW •t GQA✓EL j GAL.. .?e"Z 9><� PIT �p {lai4 WAS►1!'D • � • ' MED/vA4 STOWF-- s LZ C•EtZTtF1ED PLO`r PL.A.1J Pazo>~'t L.E=-- IbGAT1 otJ = Cr gTEp V(L%_E L i c> SemA,%...+G- No WAre,e /�yc/Bd pLAtJ RG PGIZE►•1GE.. ••� � C G R T I F=� T�•1 A T T{-i G rou wa,�T I a r.>, ,UAW I.! ----_------ 4' -if:t;l_a�,1 GvIPL�IS fit/IT" TI-1` �ji Dti..t_I►-3tr LoT 1 -7 .' A1JD SETL'SAGIG � T OF TN . 7V:raUjCEAtc ?LAN W:z9 o P6. 5{ZcGIS t.J Wo 5uQv�Yov i < 05TF-aV%i-LG a 14CA�,ei. PLAW 15 CGV 0" WOT ZAS A" tIJSCQsJMc=1J �•uc;•i�� ��ar , vF�,�T'�, S11oe.�l.p APPL-I r•A`I''lTr. NAMES IG. SM IT 9 SYSTEM PROFILE MARK DS WITHCMAGNETICTTAPE OR BE I- ALL SHALL NOTES (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. We uQ uet 1. DATUM IS APPROXIMATE NGVD Q Q ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (SEE VENT NOTE ON PLAN) Lake PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE 2. MUNICIPAL WATER IS EXISTING TOP FOUND. EL. 46.8' ��• \ 45.5' 290 SLOPE REQUIRED OVER SYSTEM 46.0' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. oc MINIMUM .75 OF COVER OVER PRECAST PRECAST H-10 4. DESIGN LOADING FOR ALL PROPOSED PRECAST RISERS (TYP.) UNITS TO BE AASHO H-M o 20 44.0'f 4"OSCH40 PVC11/ r n +. 4"SCH40 PVC o e d . ., PIPES LEVEL 1ST 2' 2' DOUBLE WASHED PEASTONE 5. PIPE JOINTS TO BE MADE WATERTIGHT. ed 1000 GAL OR GEOTEXITI E FABRIC , Gr 42.67 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE \�EXISTING EXISTING 10' SEPTIC TANK 14" WITH 310 CMR 15.000 (TITLE V.) Locus h neon TEE TEE ,n n *42.6 f 000000000000 0 og� 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND P GAS BAFFLE::' 00 42.22 - 0 2.8' AT SIDES Route 28 0�0 NOT TO BE USED FOR LOT LINE STAKING OR ANY 42.40' 42.23' go5� 2' 0.8' AT ENDS OTHER PURPOSE. ::; .. ':+ ..... •; .:•,•: oo§o 00-25 EL. 40.22' " 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. 9. COMPONENTS NOT TO BE BACKFILLED OR DEPTH OF FLOW = 4' 6" CRUSHED STONE OR MECHANICAL 3/4" TO 1 1/2" DOUBLE WASHED STONE CONCEALED WITHOUT INSPECTION BY BOARD OF TEE SIZES: COMPACTION. (15.221 [2]) HEALTH AND PERMISSION OBTAINED FROM BOARD INLET DEPTH = 10„ (4) H-20 3050 INFILTRATORS N OF HEALTH. = 10. CONTRACTOR SHALL BE RESPONSIBLE FOR OUTLET DEPTH 14 CALLING DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION OF ALL UNDERGROUND & ( 1 SLOPE) ( 1 SLOPE) 35.0' BOTTOM TH-1 OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF LOCUS MAP NO GROUNDWATER FOUND WORK. FOUNDATION EXISTING SEPTIC TANK 20' D' BOX 3' LEACHING - 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SCALE 1"=2000't FACILITY SHALL BE REMOVED 5' BENEATH AND AROUND THE *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **SEPTIC TANK SIZE AT 1000 GALLONS THE INSTALLER SHALL CONFIRM MIN. PROPOSED LEACHING FACILITY. ASSESSORS MAP 210 PARCEL 181 ` UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 12. EXISTING LEACHING FACILITY SHALL BE PUMPED LOCUS IS WITHIN AP OVERLAY AND ESTUARINE PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM AND ITS SUITABILITY FOR RE-USE AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. WATERSHED PROTECTION OVERLAY DISTRICTS LEGEN D 99- EXISTING CONTOUR X 99•1 EXIST. SPOT ELEV. --C� PROPOSED CONTOUR �� (98•4) PROPOSED SPOT EL. BENCH MARK CORNER OF TH1 CONC. BULKHEAD EL. 46.1 SYSTEM DESIGN. TEST HOLE 43 YY GARBAGE DISPOSER IS NOT ALLOWED 2= SLOPE OF GROUND UTILITY POLE " DESIGN FLOW: 2 BEDROOMS @ 110 GPD = 220 GPD FIR HYDRANT 44 � E USE A 220 GPD DESIGN FLOW __.. _ _ - _ _ NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING WOODS SEPTIC TANK: 220 GPD (2) = 440 TEST HOLE LOGS LP **RE-USE EXISTING 1000 GAL. .SEPTIC TANK �s 45 SSA LEACHING: DAVID FLAHERTY R.S., SE2755 Q SIDES: 2 (30 + 10) 2 (.74) = 118 GPD ENGINEER: �lb 01 LAWN WITNESS: DONNA MIORANDI, R.S. �� BOTTOM 30 x 10 (.74) = 222 GPD TOTAL: 460 S.F. 340 GPD DATE: SEPTEMBER 8, 2008 c'R6, -1 O 0 v� EXISTING PERC. RATE _ < 2 MIN/INCH Off' 2 BR USE (4) H-20 "3050" INFILTRATORS lb DWELLING WITH 0.8' STONE AT ENDS AND 2.8' AT SIDES 12348 a TH-2 CLASS SOILS P# TOP OF L=23.78' FNDN 20.0 R=25.00 ELEV. ELEV. EL. 46.8' off4 46.0 p" 4 46.0' WOODS :` LAWN CFO 'A A 47 2 6' M A LS LS ' LOT AREA APPROVED DATE BOARD OF HEALTH 15,026E SF\ / 6» 10YR 4/2 7» 10YR 4/2 •,t. 45 = � TITLE 5 SITE PLAN B B 46 <o� OF LS LS �5 PROVIDE VENT WITH CHARCOAL FILTER 0 O ® 15 JACQUELINE COURT 23„ 10YR 6/6 441 ' !, 10YR 6/6 �c� o (CENTERVILLE) BARNSTABLE MA 24 44.0 AND BUGSCREEN (FINAL PLACEMENT \y / , , "37 42 WITH HOMEOWNER CONSULTATION) PREPARED FOR I, O 1___1 G00 BORTOLOTTI CONST./ PERC C C VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH \ / 'fie TODAY REAL ESTATE MAY BE IMMEDIATELY GRANTED BY THE BOARD OF �e, DATE: SEPTEMBER 8, 2008 MCS MCS HEALTHAGENT OR BY HEALTH INSPECTOR \ G� REV. DATE: SEPTEMBER 9, 2008 (3050S) PAPERWORK AND HEARING REDUCTION PROPOSALS Ja off 508-362-4541 2.5Y 5/6 2.5Y 5/6 APPROVED BY THE BOARD OF HEALTH REVISED I fax 508-362-9880 DURING A PUBLIC HEARING HELD ON NOVEMBER O"OF'��S downcape.com 15, 2005 Scale: l"= 20' a, ��"JF�A 5% GRAVEL 5% GRAVEL ss�c o DANEL down c4pe e/1 in«rin nc a DANIELA. G� o A 8 �1 3 FAILED SYSTEMS ONLY - SOIL ABSORPTION '1 °iAI �} OJALA civil engineers ) 0 i 0 20 30 40 50 FEET � CIVIL' cn g 132" 35.0' 120" 36.0' SYSTEM INSTALLATIONS PROPOSED MORE THAN 502 �N°'4000 land Surveyors THREE FEET BELOW GRADE WITH PROPER VENTING �' ° �d � G,STe"'t' tgti s ° o� ( 939 Main Street ( Rte 6A) NO GROUNDWATER ENCOUNTERED (PIPED ,TO THE ATMOSPHERE) AND WITH H-20 , , ® s� _�.. M i, �� � LOADING, BUT IN NO CASE SHALL THE SAS BE Wit, `,dam YARMOUTHPORT MA 02675 LOCATED MORE THAN FIVE FEET BELOW GRADE. DATE DANIEL A. OJALA, P.E., P.L.S. 08-221 BC`?TCLOTTI_TODAY RE.DWG (DD!=)