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HomeMy WebLinkAbout0042 JAMES OTIS ROAD - Health 42 James Otis Road . -entervi.11e A= 171 - 219 --- UPC 10259 No.H_ 1630R NAGTINOi.UN 0 1 I r (�At LY FLov�i'. _. .. j 1 6-i k 3za33`o G• P D. •{ — �`—' --- -' ' 7 st=pTt THtv`K _ .33o X 15oyo * 4q5 G.p.D i i �n -AL PST.': �sE t obb Gill_—, \1) 3 (� _51 DEV�1i4i ,/�fzER• = 15'0 S. I� �' 1, 375"' T oTA L. 4 ZS o- P: D. .--67A'L: DA1LY PETu o c-AT o N P-AT to l N 2 M A N o 2. LESS — ZJ Tl J Q _ n Y 1 •*��Fl�f5klti .�`,Tf- � J+ _ r 3, tvo'�?SU4:s 1r, -- /o O O 8oX 11VV GAL. /it/�/. p b 6 � CtAc.N . '' 5� � s.E-orrC . • D• 5�rp ICI 1/ 1,? 'SA G'.E.277F/EO JAG 45, I 'b 'ialU NO SC-ALC / GE,�r/,cY TN,QT'TyE` �o��.r✓�4Tib/ S,41eWv f�E,�Eov G'�itifp�YS 6t//T�Ti`�E•.S/.1��'�,/it�E B,QXT�,2 ANC.fETI�/�G` .e�4l.J/•�Etil�ivr.S o.� T./E - € NYE; /�'�. j eY/LLc 14 r�i•� l h 7 c, t {� --- T/,�lS P4dN /.s ,Yo/-- l3.QS�p a�✓,4�/ysT,e - ,etiG'Y.4N,o LOCATION--__.._. SEWAGE PERMIT NO ` l VILLAGE , INSTALLER'S NAME&ADDRESS BUHADER OR OWNER � DATE PERMIT ISSUED DATE COMPLIANCE ISSUED t) ~ '3 �- �a t�K 13 t t a� 0 �owN �)�� � 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 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. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Carmen E Shay cursor-do not use the return Name of Inspector key. Shay Environmental Services, Inc. Company Name rQ 185 Ashumet Road Company Address Mashpee MA 02649 "0 City/Town State Zip Code 508-539-7966 3080 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 F rther Evaluation b Local Approving Authority 9/17/08 Inspector's Sig—nature Date �. The system inspector shall submit a copy of this inspection report to the App oving Authority (koard of Health or DEP)within 30 days of completing this inspection. If the syste is a sham system or has a design flow of 10,000 gpd or greater, the inspector and the system wner shalhubrm��the report to the appropriate regional office of the DEP. The original should be sent tW'e sy t M 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. 42 James Otis Circle,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 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: leach pit has No liquid- 5.5' effective depth available per stain line B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not 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 42 James Otis Circle,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 1 , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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. 42 James Otis Circle,Centerville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 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 %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. 42 James Otis Circle,Centerville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 I I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 every page. CityFrown 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. 42 James Otis Circle,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 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 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)] 42 James Otis Circle,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 tt Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 330 Number of current residents: None 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: Unknown 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: Last date of occupancy/use: Date Other(describe): 42 James Otis Circle,Centerville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1985 - BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 42 James Otis Circle,Centerville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3.5 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.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 6' x 8' - 1000 gallon Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1" 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 14" How were dimensions determined? Measured 42 James Otis Circle,Centerville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 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,lnlet tee in good condition, outlet tee in good condition Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El-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): 42 James Otis Circle,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 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 D-Box Present Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One outlet to pit. D-box in fair condition - 3' below grade Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 42 James Otis Circle,Centerville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 r , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Ma 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 every page. CitylTown 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: 1-6'diam x 6' D ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length.- El 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.): SAS fuctioning properly, No Riser present . No liquid in leach pit, Top of pit is 3.5 feet below grade, 4.5' effective depth remaining per stain line 42 James Otis Circle,Centerville•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 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 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.): 42 James Otis Circle,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 � f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 42 James Otis Road — Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 —--- -- 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. I QC' L V_ ! `_ 10 T%n �. Z� 3y.5 Z (� 3� 3 3 ??t--- �.-}a� Zc 42 James Otis Circle,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 /4 Permit Number: Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: \�J c, `Ji UN\S ���p�Q _ Lot No, Owner: C' T��C1�. ` C'h \ Address: Contractor: �J�CX% -:^Address: I( C���>�]f`r�0 1��CnSh�( 'c2 1 f i Notes: ��v e `C C9t1 T STEP 1 Measure depth to water table to nearest 1/10 ft. ..................... ......,.................,. .Date Gt� mon /day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site.and determine: OA Appropriate index well..................... 5DO OBWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well Woo month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water•level zone (STEP 2B) determine water level adjustment ................. STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ,2 i = 3e cj 2- Figure 13.--Reproducible computation form, �,��,, �C t1 C VIr", s , Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 42 James Otis Road Property Address George & Lillian Haddad Owner Owner's Name information is required for Centerville MA 02601 9/17/08 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: 25 feet 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: Performed frimpter calculations per BOH ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: refer to plans on file and groundwater Adjustment data 42 James Otis Circle,Centerville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 - No..BS....._I®� Fims THE COMMONWEALTH OF MASSACHUSETTS BOAR® qF HEA TH /-71 � ,4 OF...... ............................ App iration for DispAtittl Mirkri Tonstrurttnn rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst C!/��" g�/ ..... •,�� �-J.. -•--•---.... ......... ...............L; `f" ........ Locatio Address r Lot .............. ......... . ......._......... ........................ ............... ... .................-- W Address ��---- ................. . .._..:r""'r_.."'..........-. - ,.l -= ,...... Installer ��11gMf 0�( Address Type of Building rr �^"• S r l2 ��• Size Lot._ ' ..Sq. feet O T- Dwelling—No. of Bedrooms............................................Expansion Attic (A4 Ga age Grinder (A( aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( O Otherfixtures .........................•••---•..............•---•-..-------••-•--•------•---------•---.._.......•-•-----•-•---••--.......-••--••-•-..........------ W Design Flow....... L__.�J......�..........gallons per person per day. Total daily flow......... ._. ...Q..............gallons. WSeptic Tank—Liquid capacity/ '....gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.._6_.X__'�'_.. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,� Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rM, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P1 -•------•------••------•----••-•----•••----•----•....-•-•-------•-•------••-•-•.................................................... 0 Description of Soil................................................................................................................................................................... .. x --------------------------------------•-----------......---------.------------.....---------------------......----------._...------------------------------------------------.....----------••--•-•---•- w U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -••-----------------------------•--••------•----....-----...........------......----•-••------•-•-------•----...-----------------•--•------------------------:..........--••-------------------...-•---- Agreem Iders,igned agrees to stall the .aforedes911� l Sew ge Disposal System in accordance with the rovi s of . a of State Sanitary Cogn urther agrees not to place the system in o er n ' '- mpliance has been id health. e? . Ay - Signed f. . i Date plica PProved BY F -- � .._.. Date ppl- tion Disapproved for the f o to ing reasons---------------------••-•---••----------------------------------------------------------•-------•-------•----.... ------------------------------•-------•--------•-••-----•-•---•------- - ------------------ Date PermitNo......................................................... Issued....................................................... Date l 1 1 V) No....................... Fxs............................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c,c 7 e.. ...OF......... ...:. r '----- --- ----• ......--•-----------------------------•------........----•-----...... , ppliratiun for Disposal Works Tonstrurtion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - m r Location-Address or Lot No: Owner r Address a .....................................................' •-•---•-•-------....................... .....✓ ——........... ......•••••--•-.....-•--- Installer Address d Type of Building ` '" Size Lot_.-_f.......::.........Sq. feet.- Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ')' aa Other—T e of Building ............... No. of ersons........_.__.........._.____ Showers YP g --------•---------•------------------------P ( ) — Cafeteria ( ) 04 Other fixtures _....... W Design Flow.......s......................................gallons per person per day. Total daily flow.......................... ............ .....gallons. WSeptic Tank—Liquid capacity............ allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ................... Width.................... Total Length.................... Total leaching area....................sq. ft: Seepage Pit No---------_---------- Diameter.................... Depth below inlet.................... Total leaching area..................sq.ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by........................................................... ------••------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit............_....... Depth to ground water-__----____-_-__---_-__. fs.I Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -... •----------------------- ------------------------------- ..... .---------------- •.............. .... ----------------------------- ----•------- ---------------- 0 Description of Soil..................................................................................................................................................... V .----------------------------------•--••-----------.....-•-------•--------••----...-------•••--------•------------------------•---•----------------•-----•-----•-•------------------------------------- W U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ---------------------------------------------------•--------------------•--•------•-........-----•------•-•------------------------------------•---------------------------••---•----.....-••-•••------• Agreem e dersign5o agrees to •nstall the aforedescribed Individual Sewage Disposal System in accordance with the rovi Iis of f State Sanitary Code—The undersigned further agrees not to place the system in o er n mpliance has been issued by the board of health., Signed.--.. . 1 Date Applica4• PProved BY -------•-•- Date Appl' tion Disapproved for the f ollo ing reasons:---------------------------------------------------------- ............................................... Date PermitNo......................................................... Issued—.,,-,---I .......................................... -Date, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F..............................................................I...................... Trrtifirate of Toutpliunrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY--•-•------------------------------------•------------------------ ---.-------------•------ -------------------••--------------•-----------------------..---- ----------•------------ Installer at...................................................................................................... - 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 CONSTR D AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................12L.'6=0 ..................... Inspector.................... ....... ..... -•--•...••• ----•- THE COMMONWEALTH OF MASSACHUSET S BOARD OF HEALTH . Jam. S ' ..........................................OF.............._......_................. No. ....... � FE -- Disposal Rurks on,�trttrtiun p rutit g Permission Is herebyranted........... Q.t.f ®R.-r.....__..._.Q.R...:......................................... .......................................................... --- to Construct (}O or Re air ( ) an Individual Sewage Disposal System at No............................c....-•--6-0:.......iTh!1^0.........at1s Street ��! r� as shown on the application fore Disposal Works Construction Permit No._.._.,.(..._�.___... Dated......................................... -----•--• . • --•-•-------------------- Board o ealth` DATE............. ��.�g� -•----••-•---- f FORM 1255 At M. SULKIN, INC., BOSTON s- 4Es/ /v o,4 7"•4 . � y 3 '� S3`o G. P D. 5Ep-rj c. TfA[�K _ .536 x 156 • G.P.o _..... :::: ..l�S .:.: 14004l ,..TV.►J'IC., ice . 25' ul > > >s'a,c.. 20 M 3 51 OEWA 1.a_ AR-CA• ' 15'o S, F. 3'75' On?. p. � � � Fxisr. _.gOTT`fl�l'. r -.�IVG.� SO S•F;... .. �� —'-- - l(, y 1 i TTAL TcSiGK3 - 4zs- e: P. D. PER�oCATioN P-ATC- ; �° iN Z HIO o2: LESS ' � -" S rQ. taw s`fza R�y Co. tI 'P� Th ITS � ,�.- ,� s'i�;�..,.�''.✓^-•h.+.'/��,.,,'.,s 1', , yj- ?. f Gr .b FG• �� o$ �.FG a l E � /D O O /.f/✓. D- /coo Box /NV GAL• t y C A N / (� P //Vl/. Sb 0 ji 3 f .1 .✓ © ,; �� 7c 1 r A z 5A A c,E,2TiF/Eo PG or F�t.4�✓ N v : W-45HC--D54 :• r r 57-o AJ E �,b Ae"D A � No SC-ALE / GE•er/,CY Tf/,4T T,�,�.E Fv,;s�;�c�R7-Ya.�/ S�1awti . ��� �� ,yE,�E-a.V G'O�/f��Y.f W/T//T,y�'Si��,G✓ici� B,axr�,e //YE; /eve. A�S/O.SET1�/J« .e�QUi�Ekl�NrS o� T.y� i2.EG/ST�,P�=J>,L.4N0.SU.e!/Eya,P� AJ 7h'W A-a7•- I3.4SEO d n/,4it//rY.ST,e- ✓r�K��yE,�E.DN.5.4/G�U�-lam�/aT 13:� USEp� 7 . i TOWN OF BARNSTABLE LOCATION 42- Qc- es QVLS 7P6 SEWAGE# � y ��� ASSESSOR'S MAP&PARCEL VILLAGE � t�. INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY b� LEACHING FACILITY:(type) rip, (size) Co (o NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist On site or within 200 feet of leaching facility) MIA Feet Edge of Wetland and Leaching Facility1f any wetla e within 300 feet of leaching facility P' Feet FURNISHED BY R R 10 24 -V°,T 31,� 2-8, ��� Q-S 29 LOCATION--"pv A 4- SEWAGE PERMIT NO. u • VILLAGE , INSTALLER'S NAME&ADDRESS d o 1x� BU11bgit OR OWNER v DATE PERMIT ISSUED Q 17S -,7 DATE COMPLIANCE ISSUED ��.�� I. . . � �. _� . iy ao 13' � �� 0 :� �O cv�' ILJ�T} , ; R=25. 00 6=90`0000 %� a Tan�25.�fl 9 ,' ?9 , co s O S 6 40 , / 2� / o l: 41 J � CapeSury \ \ / 7 Porker Road Osterville MA 02655 (508)420-3994 (508)420-3995 /ax copesurv@copecod.net C582_lg1 .23/MAR/12 �6', 0 5 10 15 20 30 40 FEET Lot 266 REFERENCES: Assessors Map: 171 Parcel: ' 219 Plan Book 386/91 L=39.27 R=25.00 ZONE: RC 4=90'00'00" Tan=25.00 Setbacks: Front: 25' Side: 10' Rear: 10' O O/ Lot 170 Lot 265 V I OHO, V O rS . O O Lot 264 4� L=39.27 � t R=25.00 4=90°00'00" Tan=25.00-,,,4.4. Lot 614 / 15,783±SF F (o # 42 Lot 615 1 sty w/f Dwelling Al 35.7' ^^�/ O 1 s ty w/f Lot 613 25.6' Shed 10.0. .0 11.6' 16'- I certify that the structures shown hereon conform to the setback requirements of the Zoning Bylaws of the PLOT PLAN town of Barnstable. At 42 James Otis Road BARNSTABLE Professional Land Surveyor Date (Centerville) NOTES: MASS, DATE: 08/MAR110 SCALE: 1"-30' 1.) The structures shown were located on the ground 0 15 30 45 60 FEET by conventional survey methods on 04/MAR/10 and 08/MAR/10., PREPARED FOR: John H & Cathy M Wright 2.) The property line information shown hereon was 134 Monomoy Circle compiled from available record information`. Centerville MA 02632 3.) This plan is not for recording and is not to be PREPARED BY: CapeSury used for construction layout or deed description purposes. 7 Parker Road Osterville MA 02655 DWG # C583_3gl FIELD BY. RRL/MLL (508) 420-3994 / 420-3995fox ��r a 0,? Yy y 'i f if , 1I, }�- t' I III .•I {' ;I i' ,� I' •I' ; �` �, III `I. I . f� j� t ' i- ' !--J_ I!! ij ! i I�i i 1 1 1 i , l. l — iI 'I-'-' ILL i � I�_IIji i: ;ai i t - v. `i , , j Y;n I i-- -- I ' -I �-1 II \ � I--�' kl.._�! i i �__I I I -�--I_-_ i ! 1�.__-f.-___�-_-' 'i _--'i1 •1 i - , T + } 1 i i I ' II ; ;. = SCALE: ('�1;:�r J- APPROVED BY: DRAWN DY yih� r CJIP-MCA'• :,1 V 1:- .. �';;.:,'. i RA N M