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Home My WebLink About0085 JAMES OTIS ROAD - Health 85 James Otis A= 170=160 Centerville A/FMEAb F-`53LOR UPC 12534 smead.corn a Made to USA So cy% Q r�t�wtt�c�aoue�� SH G;ws"pw=AWIFE ranustam SOVC4 0 Nir'.'a'LSiGe ^v4w'SL6k3 uommonweann of tmassacnusens f^ Title 5 Official Inspection Form I"r'I TI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r, 85 James Otis Road -ri Property Address s James Lane Owner Owner's Name rrn• information is Nam' required for every Centerville MA 02632 9/9/2015 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information I # A ' n on the computer, Sr J / u L use only the tab 1. Inspector: key to move your cursor-do not Trevor Kellett use the return Name of Inspector Key. TK Septic Inspections ,Q Company Name 38 Vacation Lane Company Address West Yarmouth MA 02673 City/Town State Zip Code 508-579-5502 S113744 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 CM 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/20/15 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. A 0 _VS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sun•Page 1 of 17 \ uommonweavin oT massacnusects Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM ' 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 page. Chy/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: 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 i c.ommonweann oT massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a% 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 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 t,ommonweairn or massacnuserrs Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information required for every Centerville MA 02632 9/9/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 c,ommonweaiin or massacnusens W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments <e 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA .02632 9/9/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 \ Vommonweann oT massacnusertS Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 91912015 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Vommonweann oT massacnuseas Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 page. City/Town State Zip Code Date of inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No is laundry on a separate sewage system? (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: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Forth.Subsurface Sewage Disposal System•Page 7 of 17 t.ommonweaim or massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wti 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f 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]/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 uommonweann oT massamuserts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 8/17/10 per boh Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 1" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 \ L ommonweaim or massacnuseus Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information is Centerville MA 02632 9/9/2015 required for 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 30" 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 17" How were dimensions determined? measured 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 is structurally sound and water tight with liquid at the outlet invert, both tees are fine,tank does not need to be pumped 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 uommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form Subsurface Sege Disposal System•Page 11 of 17 \ toommonweaiin or massacnusens Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information required for every Centerville MA 02632 9/9/2015 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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 water tight with no carryover Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 uommonweann oT massacnusens Title 5 Official Inspection Form _ Subsurface Sewage Disposal! System Form -Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number,dimensions: 1 15x36 ❑ 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.): There are no signs of failure in the leaching stones Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form Subsurface Savage Disposal System•Page 13 of 17 \ c.ommonweaiin or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 tommonweann oT massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately back of house A B 1 D 3 2 A1)57 A2)55 A3)30 61)26 B2)43 B3)66 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 t.ommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 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: 50 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: USGS Maps show.GW at 50' Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins-M3 Title 5 Official Inspection Forrrz Subsurface Sewage Disposal System-Page'I6 of 17 \ t ommonwreann or massamusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 James Otis Road Property Address James Lane Owner Owner's Name information is required for every Centerville MA 02632 9/9/2015 page. City/Town 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 Z 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 TOWN OF BARNSTABLE LOCATION � ee , (n 1,a SEWAGE # 01`0_ 3� VILLAGE C � ��( ASSESSOR'S MAP & LOT D - 6 INSTALLER'S NAME&PHONE NO. 90dox a4B SEPTIC TANK CAPACITY /C� LEACHING FACILITY: (type) & 0—gi' r{.S (size) NO. OF BEDROOMS BUILDER OR OWNERC PERMIT DATE: COMPLIANCE DATE: 7 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 141� � v52. Pz y �� Q3JL� No. <� �- f Fee �---" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIPPYicatiou for Migpogal *pgtem Congtruction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. � J77wcc �S. �� Owner's Name,Address,and Tel.No. J c f�—rya cesi�/� 111P f� /�' Assessor's Map/Parcel Inst Iler's Names, ddress,and Tel.No. � yyo�. �( Designer's Name,Address and Tel.No. /`obi soy •2.5/6- �'� r.-�7 ,,�1✓1.,� �/�.S ,r2�/� Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33-0 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank ��/� Type of S.A.S. .,W&VI Description of Soil n IL Nature of Repairs or Alterations(Answer when applicable) 4Y%kZ 1276jneK WI 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 nvironm al Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board lth. Si ed ; Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. ac o Date Issued t No. 6-20/0 0 ;:w; - el` Fee �n 4 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH.DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for 0igb5al *pgtem Congtruction iermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. �yYJ�S 07�s e(—^� Owner's Name,`Address,and Tel.No. Assessor's Map/Parcel Installer's Name, �!Address,and Tel.No. 41g0 1,7 S.7 Designer's Name,Address and Tel.No. *117 />e, rog�-zyG i9a9GNl�r /l/l,�f s G(�Ut` Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided gpd r Plan Date Number of sheets Revision Date Title Size of Septic Tank 1&2_0 Type of S.A.S. _-2-V 0 V/G/I- Description of Soil Nature of Repairs or Alterations(Answer when applicable) 12- r 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 nvironm at Code and not to place the system in,operation until a Certificate of Compliance has been issued by this Board of lth. Si ed Date Application Approved by Date (o Q Application Disapproved by: ' Date for the following reasons Permit No. �4 �� ^32 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,tha the On-site Sewage Disposal System Constructed ( ;) Repaired ( Vle Upgraded ( ) Abandoned( )by_ S'Ljzo at 't'S has been constructed in accordance / with the provision of Title,5 and t for Disposal System Construction Permit No. �oPCV0 '"3�� dated W w Installer /`,i Designer #bedrooms 3 Approved de flo Q gpd The issuance of is p mit shall not be construed as a guarantee that the system w 1 fu o as desi ed. Date 1 p Inspector V. L/ .? / `3 No.. c�,-.r�'tl "' ``/�3 'Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS Digo al *paem Congtruction permit Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) System located at � ��j- eS 1 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction 7ust b 7 completed within three years of the dat(by this p i . Date l0 Approved V t Town of Barnstable "'E' 1.� Regulatory Services Thomas F. Geller,Director BA NSTABL&. MAMPublic Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 503-362-4644 Fax: 503-790-6304 Installer & Designer Certification Form f� 1 �f bo Date:CJ G`v Sewage Permit# Assessor's Map\Parcel l76 Designer: Installer: f Address: Address:4*34A� Volt U � 6h�1lsL1 tt_ z— On D was issued a permit to install a (date) install( e (�)� r�) septic system at Jogs gs 01 7 AO based on a design drawn by (address) dated 0 G� (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. ,I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' later relocation of the SAS or any vertical relocation of any component of the septic syste but in accordance with State & Local Regulations. Plan revision or certified as-built b designer to follow. c AR MEYER stall is Si a e) No StEO (Designer's Signature) (Affix Designer's Stamp Here) e A-d swCV-e . PLEASE RETURN TO 1A.RNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. y Q: Health/Septic,'Desiiner Certification Form 3-26. 4"doc r v TRANS. NO.: CITY/TOWN: APPLICANT— ADDRESS: s / 40 DESIGN FLOW: -5'3 0 gpd REVIEWED BY: DATE: /�- N/A OK NO All Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 LX CMR 15.220(4)(u)] Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for / components) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways,parking areas etc.) 1310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] V Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(401 daily flow septic tank capacity(required and provided) soil absorption system (required and provided) whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (i)] Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(1)] Percolation test results match loading rate? [310 CMR 15.242] . Certification statement by Soil Evaluator [310 CMR 15.220(4)(j)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Sheet 1 of 7 Address N/A OK NO Location of every water supply, public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of private water supply wells (/ Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR / 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(o)] I� Stamp of designer [310 CMR 15.220(1) and 310 CMR. 15.220(2)] Stamp of Registered Land Surveyor (required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR. 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not> 36" deep (unless Local Upgrade Approval or LUA requested) [310 CMR 15.405(l(b)] Address Sheet 2 of 7 J N/A OK NO Size OK? [310 CMR 15.223(1)] Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees (no less than liquid depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3)(0] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<1 000gpd, two for systems >1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] VIZ H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] Mau=t Compa�trnentI�anks � 0 Required when other than single-family dwelling or flow>1000 r CMR 15.223(1)(b)]mpartment 200% daily flow; Second compartment 100% w [310 CMR 15.224(2) and(3)] through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address Sheet 3 of 7 N/A OK NO BUILDING SEWERANDOTHER,PIPING 5 z Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below water line (when water and / sewer cross, see 310 CMR 15.211(1)[1]) v Cleanouts required/provided ? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphon problem/(leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" 1310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sump 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] Capacity,(emergency storage above working--design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and(8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)] Address Sheet 4 of 7 N/A OK NO . SOIL ABSORPTgTQN=SYSTEMS (SAS) GENERAI L � Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR / 15.240(1)] V Required separation to groundwater? [310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or / >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole (if>2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate P minimum- 4'maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)] Width 2'minimum T maximum [310 CMR 15.251(1)(b)] 100 feet - maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater (3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] �BE�,J��AAS�{Maximum size of bed=or felcl`5000p " �� _ � � � minimum 2 distribution lines [310 CMR 15.252(2)(a)] ` Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10' minimum. [310 CMR 15.252(2)(f)] Bottom area used mi calculations only[310 CMR 15.252(2)(1)] Address Sheet 5 of 7 N/A OK NO "v p%3 3`� '9i h �'63" ,L i'a.� -`34 Yd.x �`e -1 '•�M 'DIED THE PLAN INhvOLvE 1; h „�„ Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems >2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and VA Remedial Use Approvals] If used in gravelless system -make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly (>2000gpd) good to note on plan [310 CMR 15.254(2)(d)] Construction in fill - Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] Gra�elles stem' MA�4 t�o=�a-lLetters) T Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Alternutza�e Se ticF k` p� � ..., �... �,a�� Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance s� �,w�� i;: t _ter ',i , s a „fix �f�� q �r.. •' Are the variances listed on the plan? [310 CMR 15.220 (4)( )] RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed - [Refer to 310 CMR 15.414] Address Sheet 6 of 7 N/A OK NO Is the system in a Designated Nitrogen Sensitive Area (Zone H for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15.216(l)] "' "�*"�''`- c &4 s ,t e "s MlSLCL'mllA11 eDlLS y 4. �'_ ., may. s Pumping to septic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] ..r Address Sheet 7 of 7 DEEP.OBSERVATION HOLE LOG Hole# f Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency.%Gravel) ZV 01 21 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) -- /0/V4¢17-, D /l CIL Cc--1Yae 9n V Z'J 7 o DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary , No= Yes Within 100 year flood boundary No, Yes- Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious aterial exist in all'areas observed throughout the area proposed for the soil absorption system?.. If not,what is the depth of naturally occurring pery us material? Certification ' `•� 4 date}I have passedhoI certify that on il evaluaior examination approved by the Department of Environments Protection and the above analysis was performed by me consistent with the required tra' ' pe se d4!!/ce escribed in 310 CiVIR'15.017. Signature -e. Date �/ Q:1$EVnOPERCFORM.DOC Town of Barnstable P#J 30 1� ogTME - �y� '� Department of Regulatory Services t►srtaruats, i Public Health Division Date. y �o �6J¢ 200 Main Street,Hyannis MA 02601 FO MKt h Date Scheduledilo Time . Fee Pd. ;t, • �UU Soil Suitability Asses 7 wZtf or Sewage Disposal Performed By: � �J � Witnessed By: 0. (�� )er LOCATION& GENERAL INFORMATION Mc. Location Address S /�aZ/ Owner's Name G 2r.3-L, Address Assessor's Map/Parcel: �� Engineer's Name L. S- e¢�� Uv NEW CONSTRUCTION f- REPAIR Telephone# "Pie 3C/9 7� Land Use Slopes M Surface Stones Distances from:' Open Water Body Aft' Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line L170 ft Other ft SMTCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) Du �^ I 'N PJ � 1 y Parent material(geologic)4 8, <✓-evS14j— Depth to Bedrock Depth to Oroundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater 12 DETERNIINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Ob—se—rvedstpnding in obs.hole: ln. Depth to soil mott in. Depth to weeping from abs.hole: in, Groundwater AdJustment ft�/A- Index Well# Reading Date: Index Well level s ,thctor, ,o�_ Adj.Gtwundwate PERCOLATION TEST Date Z 1 °'!i'itne- W ervatiop A., ,L Hol Hole# '`� Q � Time at 4" (�_� � Depth of Perc Time at 6' Start Pre-soak Time @ f L ��n� 71me(9"-6") End Pre-soak Ate Rate MinJlnch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICVERCFORM.DOC f oF1�T Town` of Barnstable Barnstable P Regulatory Services Department P&Ma,caChy �' RA'ANST'ARLE. MASS. Public Health Division ArfD� 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205009304 5/11/2010 Paul McBrien Jacqueline McBrien 85 James Otis Lane Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 85 James Otis Lane, Centerville MA was last inspected on April 15, 2010, by Sean M. Jones, 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: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. J Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER O OF T BOARD OF HEALTH has McKean, R. Agent of the Board of Health 1'( u i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owners Name information is required for every Centerville Ma 02632 4/15/2010 page. City/rown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information on the computer,filling out uler 0� , use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Company Address Centerville Ma 02632 Cityfrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 Cn `.. 1 S 4/15/2010 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. L ��v t5ins-09/08 Tide 5 Official Inspection Form:Subsurface Sawa Disposalmag 0 f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. Cityfrown 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: 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville _Ma 02632 4/15/2010 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 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. Cl ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "f 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ❑ ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name informatrequired for Is Centerville Ma 02632 4/15/2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): yes Detail: 2008=57,000 total= 156 gpd 2009=48,000 total= 132 gpd Sump pump? ❑ Yes ® No Last date of occupancy: vacant approx 6 months 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of.the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments aY 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original system 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet I 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.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: feet Material 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 gallons Sludge depth: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y � 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 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 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank was located but not excavated/opened. 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working.order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..''e 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution bow was located but not excavated/opened. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts I ON Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. City/town State Zip Code Date of Inspection D. System Information (cont.) 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.): Water level in pit was 1' below inlet invert at time of inspection. Scum buildup on top of inlet pipe, heavy black stains around cover and rim and black saturated dirt all indicate that the leach pit has been overfull before resulting in a failing inspection. 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 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 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing`attached separately O J � a®�P l 2' A-',I a 54i.64 A-3c (02-. p z b@ 3-1 Y:� 33' t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. CityrFown 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: 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: I ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was not determined. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 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 85 James Otis Rd. Property Address MCBRIEN Owner Owner's Name information is required for every Centerville Ma 02632 4/15/2010 page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 V_ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION / TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ' Property Address: 85 James Otis Road Centerville, MA 02632 Owner's Name: Helen Groffman Owner's Address: Same Date of Inspection: April 13, 2001 Map: 170 Parcel: 160 Name of Inspector:(Please Print) James M. Ford �FC� Company Name: James M. Ford Mailing Address: P.O. Box 49 ApR `O Osterville,MA 02655-0049 T Telephone�Numbery (508) 862-9400 oyF_q Feq O?QQ� CERTIFICATION STATEMENT Cry I certify that I have personally inspected the sewage disposal system at this address and t the' formation reported below is true,accurate and complete as of the time of the inspection. The inspection was per o ed 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 N Further Evaluation by the Local Approving Authority Fa s Inspector's Signature: Date: April 15, 2001 The system inspector shall subracopy 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 Coriiirients ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 85 James Otis Road Centerville, MA Owner: Helen Groffman Date of Inspection: April 13, 2001 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 1.5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system;upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not 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: 2 r Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION' (continued) Property Address: 85 James Otis Road- Centerville. MA Owner: Helen Groffman Date of Inspection: April 13, 2001 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. r System will fail unless the Board of Health-(and Public Water Supplkr,•if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system l a; a septic tank and soil`absorptiori system(SAS)and the'SAS is withina00 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 85 James Otis Road Centerville, MA Owner: Helen Groffman Date of Inspection: April 13, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet,but greater than 50.feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for.coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 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. 4 ' yy Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 85 James Otis Road Centerville, MA Owner: Helen Groffman _. .. Date of Inspection: April 13, 2001 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'si&s' of break out? c} 4,, ✓ Were all'system components,excluding the SAS,-located on site,9 ✓ 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: Yes No ✓ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t SYSiiM;INFORMATION Property Address: 85 James Otis Road Centerville, MA Owner: Helen Groffman Date of Inspection: April 13, 2001 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): 330 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): No Water meter readings, if available(last 2 years usage(gpd)):. 2000-24,000 gals.; 1999-48,000 gals. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALIMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd 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 Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped on Oct. 9198-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was gtantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy.of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval _ Other'(describe): Approximate age of all components,date installed(if known)and source of information: _Apr. 12 1985-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E ' PART C ` 'SYSTEM'INFORMATION (continued) Property Address: 85 James Otis Road -- _• Centerville. MA Owner: Helen Groffman Date of Inspection: April 13, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water'supply well'o'r suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" 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: 1000 gal. Sludge depth: ]It Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present. The liquid level was even with the outlet invert. There were no signs ofleakage. Scum and sludge were minimal. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle-. Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee.or baffle condition,structural integrity,-liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C :, . SYSTEM"INFORMATION (continued) Property Address: 85 James Otis Road Centerville. MA _ Owner: Helen Groffman Date of Inspection: April 13, 2001 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: Rallons Design Flow: gallonstday 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) k Depth of liquid level above outlet invert: -- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was not dui;up There were no signs of failure from the leach pit. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 � � v Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` ' • PART C SYSTEM'INFORMATION (continued) Property Address: 85 James Otis Road. Centerville. MA Owner: Helen Groffman Date of Inspection: April 13, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'w/]'stone leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: _... . _ . .. overflow cesspool,number:. Innovative/alternative.system _Type/namq.oftechnology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pit was dry The scum 4ine.was 3'up'from the-bottom': There were no 'signs of failure:.Thelbottom-wgrade was approximately 9. The cover was Y down. Recommend installing risers to bring cover within 6"of grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool:_ Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t ,SYSTEM'INFORM'ATION (continued) Property Address: 85 James Otis Road Centerville, MA Owner: Helen Groffman Date of Inspection: April 13, 2001 Map: 170 Parcel: 160 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. f3A�k Nc�+d BIL Al- - S8 a . A3 c�a Av- s � y Qc�.. 33 " 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,•,, SYSTEM INFORMATION (continued) Property Address: 85 James Otis Road Centerville, AM Owner: Helen Groffman Date of Inspection: April 13, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth td ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: t' You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the map'were showing approximately 26'+/-to groundwater at this site.. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. I1 AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION , ��me-S 0 S R�- SEWAGE# 75' 3(O VILLAGEn �/Ve 1 ASSESSOR'S MAP&LOT r70 /!00 INSTALLER'S NAME.&PHONENO. . SEPTIC TANK CAPACrrY IO2b C-41 LEACHING FACILITY: (type) P-r (size) �X� I ST'Q,la NO,OF BEDROOMS 3 1} /� BUILDER OR OWNER t1Ev\ a f' 4n PERMTTDATE: COMPLIANCE DATE: y ! XF r 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(lf any wetlands exist . within 300 feet of leachin facility) 1 / Feet Furnished by S. Ford S %c ��t5 S!/13��do/ I AI - S-7 A' A3- lob' 83� ei Co A4- 5►, a 'Qy 33 .3 Y http://issgl2/intranet/propdata/prebuilt.aspx?mappar=170160&seq=1 4/14/2010 i TOWN OF BARNSTABLE LOCA-FION O�f JAMLS SEWAGE # �S' 3 CO VII.LAGE *CPS++�i✓��L ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /02b LEACHING FACILITY: (type) JI P,T (size) (pX — SrartL NO.OF BEDROOMS -3 BUILDER OR OWNER e- 6 t i"ivi/-1n PERMIT DATE: COMPLIANCE DATE: 4I l 8 S" 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 leachin facility) f Feet Furnished by�. FOB StIJI L ,j�S'Esta✓ 9/,,JV 2 1 gl �oZ (3AG) Nucnd A,;- G-A- t-1'b I'A3- Ga� - 133, S(c A4- 51 ' a Qy 33 O 3 y No _.—? .. Fxs........ .c.�... ........ - /4 THEBCOOMAO�N DALT C FH SALT ET S �b .....T ... ...OF ��. .............1—.. . ... .... . --------- ........ Appliration for Big oiial Works Cfontitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal 0 Sys! .. tion. dress I or Lot Gr........................ ..... ^--^--......... -,Owner � Address a ............ ... ... . . ... e �y.'�."`a°"'`3... ........................ .............. .'..... Installer Address Q Type of Building Size Lot..... ..Sq. feet Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building ............................ No. of persons.....................--.---- Showers ( ) — Cafeteria fixtures . .........................................................•••-•••--•----•--•------------...--------•-•--'--------.....---•-'------... ...._.. w Design Flow.......... ............gallons per person per day. Total daily flow--..... ..................gallons. WSeptic Tank—Liquid capacity..'.?gallons Length................ Width................ Diameter--.............. Depth................ x Disposal Trench—No. -.- ._..._ ._.. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...-.-- - ..- l�lameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution b x ( Dosing tank ( ) aPercolation Test Results Performed by.......................................:..•---......._•---.....-------_... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......--................ 914 Test Pit No. 2................minutes per inch Depth of Test Pit.--................. Depth to ground water....................---. ix ...................................................•--......------'-........---...--•-•-......--•---.........................................................O Description of Soil........................................................................................................................................................................ x 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 TIME 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by the a of Health. Signed ..•••. .... ................... D J '-- _ a ........._. te Application Approved By -'-....-----' Q'.:. ".1 ....._. . /� ....... Date Application Disapproved for the following reasons:------'....---••.............'----------'-------------.....---....------------...._-•----. .......----------- .......... .... .... ...------.........---------'...........--•-.... J C w Date Permit No. ........ •---••--------------•----•-.. Issued------•..4. •---1- '•-- -- ............... THE COMMONWEALTH OF MASSACHUSETTS Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at; Locati on Address or Lot OKI Type of Building Size Lot.... TLLSq. feet Z Other Distribution bok Dosing tank ------------------------------------------------------------------------------------------------------------------------------------------------------------------- The' undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the pro isions of TITLE; the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance I as b6n issued by theboard"of health. Date Application Approved By .. -------------- Date Dat THE 'COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ' ..........................................OF...................................... ' ��/ nIr��ifir�V4r �»� Tompliattrr � THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) orRep'ired ( l -'------------------------------------------------------------------------------------------------------------------------------------------------------- '-----------------------............ Installer ^uL.---------=r.'-----------------------------------------------'----_---_--.----_---------_-----_--_-------'_'----'----- ` has been installed in accordancewith the provisions of TITLE 5.of The State Sanitary Code as Oescribed in the application for DisposaLWorks Construction Permit No---- ..... dated........7_11,_1..<��s................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUED AS AQUARANTEE TAAT THE SYSTEM WILL FUNCTIft SATISFACTORY. Ins DATE �� ~�- / ~ ector . ~, .^ ^. - K THE oowwomvvsALr* OF mAssxoHuscrrs r BOARD OF HEALTH , ...........................................OF..................................................................................... No. F - Permission is hereby . _-_-----..-----'--'—_-__--___'---..-.—__—.________ to Construct or Repair an-T—ndividualSvohso � at N '--'—_--______________.___...________ Street un shown oothe application for Disposal WorksDated....../I- .................. .......................................=r......—._--'--.----_-_________._ /� _ Board of Health C��TE'---/._...---��—'~^'—.--_—. .................... FORM /umm ^� . ' . | 51bjGLr= FAwLY� - wd GAcx%^cvE �jiilNDEsQ. I I ¢43 • CUnaLY FLOW s 110 X 3 = Zi30G•Pc �oo.ov ~a}" a309150% = 14916.R usE vo0 C�A�. AIR t D15Po5AL PIT 1 F l' Q ;P^ + ^� VA S 1 D4wfAl� AR.CA s 1 go S.r tern 56.P Qtit o rjo S F$oTTOM AREA A.. pF•G .ZS9 �r- 13ti {' , A 'ToTA1- p6•S►6N * .425 G•PD. 4 1. # 41 T oT DA I — PE2COL.AT10►1 RATEi 1111N aa» T s w i'$_ ; ts,oc)04 t oc'. �M OFP1 HER mot* MCHARD "tn 5Jt.1.'.v.n4 .��i/l/( �I S o BAXTENo 24 R h0 104A FGrSl Top FWD*S8 ' i 4M L` loov INS• 5v�a01l.' Qu DIST. INS. C. ��F•$ t BoX �,L TANK r *' • ,•' ' I.EAG►1 INV. INV. t �. P IT Y -t `f2AN W I TIA 54 > WASUGD n 6•fuNb +' E czT I F I C D P t-oT PLAN , i it PR.oFILG w 1 W0 SGAL.E �jCAL•E L L&jit �ATPc 11 /ID/ No UJATIIu_ P REF 6st6►r ctc CE iwTt,FY 'THAT TNi"c �ou+J��TIO►� SNo1KN N,W SOW GOMPt-`(5 WITN'TH� '��p,� li AND SEs'fP.�AGK LZ6QVIR.EMENY> OF 'YNE 4L.AQ E SMpt,[.• (�G 'ToWW OF 'FAT eiTA(� ANV IS "Or LOCATED WITNIIJ •rN6 GI.GOD PLAIN 3 of � n D AT E 11-Imo. Q I� 6AXT E cz a IJ` L- INC. a it REGIST�Tt6�'►.A►ID•SuR.Vic o� Tu1S P�Q►.I IS Norr an5�o ob AN os'rER.vILLFr • M�`+5• : :_. �W,5-r utAeWT SVQVey 1� -rNE o1= SETS SUou�^ N t L I►.1 �.cT INE�j APPLICA►�•r LA4 7M/4LL �d u a O L)r,QA, T 10N -`' SEWAGE PERMIT NO. .7t.,o Rd • -3G VI LADE d,c.a.[.u.✓ -fc� INST LLER'S NAME & ADDRESS �- 3UILDEIII OR OWNER DATE PERMIT ISSUED � l $ DAT E COMPLIANCE ISSUED LI— or C.z N g SIC M ` IdZ� d 0 CENTERVILLE b 2 � N PARCEL ID: O W p O 171/177 PARCEL ID: Q g rn 171/168 y J 1 LOCUS o 54.6 54.6 X 150.00, LOCUS MAP 54.7 _ ELEc. o LOCUS INFORMATION X 53.0 PLAN REF: 386/92 SHED 1 *- TITLE REF: 14003/174 PARCEL ID: MAP 170 PAR. 160 IN STATE ZONE 11 8.S' GAS 1 ZONE: "RC" "GROUNDATER PROTECTION" (GP) 54.4 '' 1 FLOOD ZONE: "C" PARCEL PATI ID' S4.8 % ! % �33 GAS 1 COMMUNITY PANEL: 250001-0015-C DATED:08/19/85 7, 0 I GARA — 1 TM 2 CE , 52.7 SEPTIC SYSTEM o "' 54.4 DRIVEWAY 1 REPAIR PLAN 38.0' ;,' , " __ 1 0 LOCATED AT: 1 Q #85 JAMES OTIS ROAD - DB #85 - — 52.5 CEN TER VI LLE, MA. ABANDON AND/OR REMOVE I 1000 GAL 3-BEDROOM,; W 1 PREPARED FOR LEACHPIT PER TITLE V 54.9X TANK TO REMAIN) �' DWELLING �� o o X54.O0 MARIE SOUZA LOT 260 T.O.F. % W 1 AUGUST O8, 2010 ELEV.=55.0' X 54.8 PARCEL ID: TBM 1 �c 170/160 COR. BLHD _ �F ti 1 � AREA=15,000 S.F. ELEV.=55.0' WARD ' W o� A. " MEYER 9TONE No. 1140 54.0 X GISTS PARCEL ID: 1 7 T s GISTS 170/162 150.0p, 1 La I L? 13 PARCEL ID: ( 1 E. A. S. 170/159 51.9 SURVEY, INC. F 141 ROUTE 6A 20 0 10 20 j SALT POND BUILDING P.O. BOX 1729 s SANDWICH, MA. 02563 GRAPHIC SCALE . 1 inch = 20 ft. BUS:(508)888-3619 CELL:(508)527-3600 SHEET 1 OF 2 J 1264 t 'TOP OF FOUNDATION EL=55.0 " 4" SCHEDULE 40 P.V.C. OBSERVATION PORT F--10' MINIMUM MIN. PITCH 1/8" PER FOOT W/SCREWCAP TO GRADE EL=54.5 EL= 54.3 _ - - ........L 54 7 6" MAX. •••»>:.........� ...,. ;..., EL= 54.5 54 6 6" MAX.'-" ;::: >..,... :: : ,.,., aaa•,•............. 9" MIN. RISER COVER ISER & CON C. ............... COVER COVER dn EL= 53.08 RISER & 2.9' CLEAN SAND FILL 2 8'f LEVEL I INVERT PER 310 CMR 15.255 16' EXIST. COVER FOR 2' EL= 51.35 21' S= .015 -.►I EL= 51.68 EXIST FLOW LINE 4.0' s=.o1 � EL=52.4 (INNER 10" 14» INVERT " INVERT INVERT 12 INVERT EL=52.08 1 MIN. EL= 51.88 EL= 51.56 6" SUMP EL=51.39 �8" EL= 50.68 (EXIST.) 4 GAS 8" BASE OF MECHANICALLY BAFFLE COMPACTED SAND PROP. DB3 32.0' DISTRIBUTION 24-QUICK 4 STANDARD INFILTRATORS EXISTING BOX (34"W X 48"L X 12"H) EACH Z 1 ,000 GALLON TANK SOIL ABSORBTION (TRENCH FORMATION) (TO REMAIN) PROFILE OF SYSTEM (S.A.S.) 8.5' X 32' °°� SEWAGE DISPOSAL SYSTEM (NOT TO SCALE) BOTTOM OF TH #1 ELEV.= 42.4 GENERAL NOTES I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPARTMENT OF (NO GROUND WATER) ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR 15.017 TO CONDUCT 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE FOR SUBSURFACE DISPOSAL OF SEWERAGE. DESCRIBED IN 310 CMR 15.017. I FURTHER CERTIFY THAT THE RESULTS OF MY DESIGN DATA 2. AT LEAST ONE ACCESS PORT OVER TANK TEES SHALL BE SOIL EVALUATION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, ACCESSIBLE WITHIN 6' OF FINISH GRADE, WITH ANY REMAINING ACCESS PORTS BROUGHT TO WITHIN 6" OF FINISH GRADE. ARE ACCURATE IN C DAN 310 CMR 15.100 THROUGH 15.107. 3 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE NUMBER OF BEDROOMS........._____-- CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE GARBAGE DISPOSAL.................-_ N0 -_ UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEN THEY EDWARD A. STONE, CERTIFIED SOIL EVAL ATOR TOTAL ESTIMATED FLOW MUST WITHSTAND H-20 LOADING. (110 GAL./BR./DAY X 3 BR.) 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION ------ OF ALL UTILITIES PRIOR TO ANY EXCAVATION. 330GPD X 200% = 660 GAL 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE TEST PIT RESULTS: USE EXISTING 1000 GAL. TANK OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. INSTALL: 6. FINISH GRADE SHALL HAVE A MINIMUM OF 2% GRADE SOIL TEST DATE: AUG. 2, 2010 » OVER THE S.A.S. AND DISTRIBUTION BOX. 24 QUICK4 STANDARD INFILTRATORS (34 W X 48 L X 12 H) 7. SEPTIC TANK SANITARY TEES SHALL BE CONSTRUCTED OF B.O.H. AGENT: DAVID W. STANTON, R.S. AND BACKFILL WITH CLEAN SAND FILL PER 310 CMR 15.255 SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE SOIL EVALUATOR: EDWARD A. STONE THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND SOIL CLASSIFICATION................__1 LOCATED DIRECTLY UNDER THE CLEANOUT MANHOLES. BACKHOE: RODNEY FISHER f3p DESIGN PERCOLATION RATE..... 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT EFFLUENT LOADING RATE......... ELEVATION OF THE OUTLET PIPE. TH#1 EL.= 54.4 PERC RATE<2MIN./IN. @60 REQUIRED LEACHING CAPACITY.....330 GAIDAY 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES. 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS ELEV. DEPTH (IN.) HORIZON TEXTURE COLOR MOTTLING OTHER LEACHING CAPACITY PROVIDED.....335 GA AY BAFFLE, 4 INCHES IN DIAMETER AND CONTRUCTED OF 4" PVC. 54.0 0"-4" A LOAMY SAND 10YR4/2 --- ----- (3) ROWS OF (8)INFILTRATORS X 4.72 S.F./L.F. 11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND FIRST TWO FEET OUT OF THE DISTRIBUTION BOX SHALL 52.8 4"-20" B LOAMY SAND 10YR5/6 --- - 96 L.F. X 4.72 S.F./L.F.= 453 S.F. BE LEVEL. 48.9 20"-66" Cl COARSE SAND 10YR6/6 --- 10%GRAV. 453 S.F. X .74 GPD./S.F.= 335 GPD 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION TO EAS SURVEY, INC. FOR B.O.H. AND DESIGN 42.4 66"-144" C2 COARSE SAND I 2.5Y7/4 --- ------ ENGINEERS REVIEW AND APPROVAL. NO GROUNDWATER 335 GPD PROVIDED 330 GPD REQUIRED = 5 GPD RESERVE AAA TH#2 EL.= 54.4 ��,oF►�assky Hof S�1 CONSTRUCTION NOTES: L, f ELEV. DEPTH IN HORIZON TEXTURE COLOR MOTTLING OTHER o�' EDWAR� ��, D SEPTIC SYSTEM DETAIL PAGE . . 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND A M. '` #85 JAMES OTIS ROAD ..ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING 53.9 0"-6" A LOAMY SAND 10YR4/2 --- ----- q S-Tp►�IE `� MEYER c' .r' WORK ON THE SITE. " CENTERVILLE, MA. 2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE 52.9 6"-18 B LOAMY SAND 10YR5/6 --- ----- o No.28 �® No. 1140 WITH DEEDED OR ZONING REGULATIONS.. OWNER / APPLICANT 48.7 18"-68" Cl I COARSE SAND 10YR6/6 --- 10%GRAN. �FGr A�� AUGUST 08, 2010 IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. sXE 42.4 68"-144" C2 COARSE SAND 2.5Y7/4 --- ------ s i0 A P SgMI TAR\ 3. ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING TAPE OR A COMPARABLE MEANS. NO GROUNDWATER , 0 SHEET 2 OF 2 J# 1264 I