HomeMy WebLinkAbout0088 JAMES OTIS ROAD - Health 88 JAMES OTIS RD., CENTERVILLE
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UPC 12534
No.2 53LOR
HASTINGS. HN
TOWN OF BARNUAABLE /
LOCATION D i'G 11 SEWAGE# —�)J
VILLAGE ASSESSOR'S MAP&PARCEL,I` -�
INSTALLER'S NAME&PHONE NO. (✓Q/��j('/ j�j,�///f' �
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)' �� (size)
NO.OF BEDROOMS
OWNER
- I
PERMIT DATE: 10Y COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private.Water Supply Well and Leaching Facility(if any wells exist ;.
on site or within 200 feet of leaching facility) feet
Edge of Wetland and L'aching Facility(if any wetlands exist .
within 300 feet.of leaching:facility). _ feet
FURNISHED BY
713
i32 � 36-
� -
�3 3 =rz
l i
Ko. 2,ao E2 r 3,SL
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: f/
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zippgtcattou for Mtgpogal �Ippotem Cougtructtou Permit
Application for a Permit to Construct( ) Repair(0111upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lo?6 11+4y1 3-5— 077-5 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel d_?
Installer's Name,Address,and Tel.No. CIO//C �yCT� Designer's Name,Address and Tel.NWX;W&
OiIA`' �9R tea. �a� :/?,F/ If-, �t1rv�D�v� ry)GL,'
Type of Building:
Dwelling No.of Bedrooms Lot Size O sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures Q
Design Flow(min.required) � , gpd Design flow provided 6—E` gpd
Plan Date Number of sheets Revision Date
Title
Size of.Septic Tank e0 0 Type of S.A.S. �j0
5-0
.Description of Soil � �Z (�. ��
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o Health.
Signed Date
Application Approved by Date
Application Disapproved tby Date
for the following reasons
Permit No. ss10 Date Issued Co Z0Q e
IK
d
No. ZooF5' 3,Z 4 Fee
1 2'
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
zIppgicatiou for 47M.5ponf �§pgtem con truction Vermit
Application for a Permit to Construct( ) Repair(11Kupgrade( ) Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lov3i fY'� 5 /,�/ Owner's Name,Address,and TeL No.
Assessor's Map/Parcel Q U `
Installer's Name,Address,and Tel.No. (���'�'� �� Designer's Name,Address and Tel.No.1, 'i'ik 9Gw /nF—/ F'r2-
tea'7-
Type of Building:
Dwelling No. of Bedrooms 7 Lot Size / ra O sq. ft. Garbage Grinder ( )
Lr Other Type of Building � No.of Persons Showers( ) Cafeteria( )
Other Fixtures [[�� )) �-
Design Flow(min.required) '� /(h/,�4� gpd Design flow provided 77' gpd
Plan Date Number of sheets Revision Date
Title
Size of_Septic Tank Type of S.A.S. O �U
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement: ,
I The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this B�B,,00a/a��rd o%of,Health. _
g / l�ti/�� 4C
Si ned / Date
Application Approved by �r .c. ��,�( f. Date
Application Disapproved by,
Date
.Y for the following reasons
f Permit No. Q s.��V Date Issued Z Q
THE COMMONWEALTH OF MASSACHUSETTS /
BARNSTABLE, MASSACHUSETTS J
(fertificate of Compliance �
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired U raded
g P Y ( ) ( ) Upgraded
( )
Abandoned( )by tX"l-,LIA"y)
at % e ,-� /L/n j;:J5 a/f S /2/J-,) has been constructed in accordance
witli the provisions of Title 5 and the for Disposal System Construction Permit No. 2kAa '— ;T� dated q •2"
Installer �i(JI��� �� / //�1�0f� Designer ME�f2.
#bedrooms 4;1 Approved design flow I J gpd
The issuance of this permit shall ndt be c-nstrued as a guarantee that the system 111 function as designed. //�
Date I�9 Inspector W V�A�/(�� ff
--_-------- � — ---_�— — �J r-yV� �
No. &)oP ^ i Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
i.5lOgaYp.5tem CongtructtonerYiTit
Permission is hereby granted to Construct ( ) Repair ( 4-11-1 Upgrade ( ) Abandon ( )
System located at 71-� 07-1-5 IQ/::)
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 must be completed within three years of the date of this permit.
Date - Z-°- Z o 0,5 Approved by
No. "`� Fee /00
t THE COMMONWEALTH OF.MASSACHUSETTS Entered in computer: I--- —
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for ai.5po!6ar *pgtem Cow9truction Permit
Application for a Permit to Construct( ) Repair(,P)�Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Logo
Owner's Name,Address,and Tel.No.
Assessor's Map[Parcel
Installer's Name,Address,and Tel.No. / �/ /—� Designer's Name,Address and Tel.No:-] �'� �U
ICA-
Type of Building:
Dwelling No. of Bedrooms Lot Size 1 f r �''U sq. ft. Garbage Grinder ( )
t,
Other Type of Building ✓; ` No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) /(5,a , gpd Design flow provided % �aC °�� C, gpd
Plan Date Number of sheets Revision Date
Title
f Size of Septic Tank / 4040 0 Type of S.A.S. 7:50 �_O
Description of Soil S Fa it I71A,uJ
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health._
Signed , ,f ��✓,,,r_�/rJi�-« ,/.%r' Date
Application Approved by �. �.!, � Date
Application Disapproved by,I Date
for the following reasons t'
f
s Permit No. D y, - 3 (C7 Date Issued L C�Q -------_- ------ --
�✓ —
y'=---=---------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (k ) Upgraded
Abandoned(h )by1/t� f` �t) %�J/1��• /�
r't` }
at I G .7.4») �`a C IT/ .�� �*.�f./ has
been constructed in accordance
with the provisions of Title�5 and the for Disposal System Construction Permit No. G R ; � dated " Z
Installer 1 f�- �/" «� 1*.�f/ji° °f� Designer M lE lq If 4L
#bedrooms Approved design flow r / gpd
The issuance of this permit shall not be c,onstru d as a guarantee that the system w I'f unction as designed �!
Date 1 fi'�) l i) Inspector '! -
------ --- �— r------ _—.-- =� - =— ---
-- __— No. < 3Su-- Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
1=i!5pogal �§p5tem Construction Permit
Permission is hereby granted to Construct ( ) Repair ((/) Upgrade ( ) Abandon ( )
•., System located.at �'� ,74,
r.
F
„zf 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.
PY g P
Provided: Construction must be completed within three years of the date of this permit.
C' Z ��O } Approved b �C
Date � pp y
- - y
4
1
Town of Barnstable
Op'WE Regulatory Services
( SfABLE. Thomas F. Geiler, Director� riAAN
Public Health Division
.:639 10
'F.639 ' Thomas McKean, Director
200 iNlain Street,Hyannis,NIA 02601
Office: 503-362-4644 Fax: 503-790-6304
Installer & Designer Certification Form
Date: 0,&Sewage Permit#-��Assessor's Map\Parcel
Designer: �L ►rYeJs Installer-: 1 f
_Liu
Address: V X / address: �� �o�//�/�
02532
On G� u"&,/\-11,Y 12;?Lw as issued a permit to install a
( te) (installer)
septic system at Be) U ,:� 677_'� 440 based on a design drawn by
(address) O 0
,c
dated
(design
I certify that the septic system referenced above was installed substantially according to
the design. which may include minor approved cha~Qes such as lateral reiocat:on oi the
distribution box and�'or septic tank.
1 certifv that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or ariv vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
OF Mgs9�
DAh� 'E-R
(Installer's Stgnature) No. 1140
SANI TAW\a�
(Designer's Sianatur (Affx Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COiViPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q: Health/Septic/Designer Certification Form 3-26-4-'doc,
i
�7. TOWN OF BARNS ABLE-
LOCATION J �J)�' S / ,D SEWAGE#
VILLAGE U ASSESSOR'S MAP&PARCEI,�
INSTALLER'S NAME&PHONE NO. �� 6 i
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) D, G (size)
NO.OF BEDROOMS
OWNER
I
PERMIT DATE: COMPLIANCE DATE77;����
: I
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 feetof leaching facility). �. feet
FURNISHED BY / All—E
i
`y ��
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complo-te items.5•,2,and 3.Also complete A. Signature
item 41f Restricted Delivery is desired. X FRANCIS BLACKSHEAR ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits. ^-
D. Is delivery add -different'from Rem 1? ❑Yes
1. Article Addressed to: i
1 2 If YES,'e �I�I' adcfre tielow:
❑ No
` 3. service ype;, _,���
P—vJS�t1�`� ''f10� 22210 ■Certified'Maiks ❑ ressMail
U ❑Registered — Retum Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?P tra Fee) ❑Yes
2. Article Number —
(Trensferfromservice►abeQ 7006 2150 0002 1038:.692b;
i Ps Form 3811,February 2004 Domestic Return Receipt 102595-02-M•1540 J
I � '
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
- uSC"-)S 1.
I Permit No.G-10
j • Sender: Please print your name, address, a64 ZIP+4Athis'C ox •
I
I _4 Town of Barnstablc
$Oe Health Division
200 Main Street
! _ Hyannis,MA 02601
I
I
� ������er'�f��,�i1•j�,�t�t��:�r�:4���a�������s��F1���rt���rE:�p'��.�
_ Town of Barnstable Barnstable
OF SH jci E
ti
�t � �� � Regulatory Services Department V
-,RAICN C,WLE, f
"ss '°' Public Health Division
m
0 6gq_�e
ArFO MAt A' 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 � � Lt,onias F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
March 14, 2008
Lasalle Bank National Assc.
4828 Loop Central Drive
Houston, TX 77081-2226
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 88 James Otis Road, Centerville MA was last inspected on
March 3, 2008, by Robert Paolini, 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:
• Staining above outlet invert pipe in distribution box and damp soil shows signs
that the leaching area has been full.
You are ordered to repair or replace the septic system within One (1) year from the date
of this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE B ARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
CERTIFIED MAIL# 7006 2150 0002 1038 6926 _
Q:\SEPTIC\Letters Septic Inspection Failures\88 James Otis.doc
_�_. - -�
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' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1
M 88 James Otis Rd. / I D3
Property Address
Pedro Magalhaes
Owner Owner's Name
information is required for Centerville Ma. 02632 3/03/2008
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:
when filling out A. General Information L aS4X�
forms on the ) Q Cjj r*.S� . • '
computer,use 1. Inspector:
only the tab key
to move your T
Robert Paolini -
cursor-do not Name of Inspector ]
use the return
key. Ca ewide Enter rises,LLC
Company Name
tab P.O.Box 763 ' ,
Company Address
Centerville Ma. 02632
tam City/Town State Zip Code
(508)428-4028 S14454
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
3/03/2008
Insp or's ign ture 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.
88 James Otis Rd..•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
r
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is required for Centerville Ma. 02632 3/03/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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 ears old*or the septic tank whether metal or not is
❑ P Y P ( )
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
88 James Otis Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is Centerville Ma. 02632 3/03/2008.
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
88 James Otis Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
wM 88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is required for Centerville Ma. 02632 3/03/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
G
**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:
1
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
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
88 James Otis Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
J
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is required for Centerville Ma. 02632 3/03/2008
every page.. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
88 James.Otis Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for-Voluntary Assessments
88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is required for Centerville Ma. 02632 3/03/2008
every page. . City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
El ® 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)]
88 James Otis Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
I
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is required for Centerville Ma. 02632 3/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 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
,000
:110
Water meter readings, if available (last 2 years usage (gpd)): 2002006:110,000
Sump pump? ❑ Yes ❑ No
Last date of occupancy: . unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
88 James Otis Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
-Commonwealth of Massachusetts
- W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is required for Centerville Ma. 02632 3/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage.odors detected when arriving at the site? ❑ Yes ® No
88 James Otis Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is Centerville Ma. 02632 3/03/2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
DeDepth below grade: feet
p g feet
r
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 appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade: 16feet
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
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle
27" �
3,.
Scum thickness
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? Measured
88 James Otis Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 9 of 15
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is required for Centerville Ma. 02632 3/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
88 James Otis Rd.-12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is Centerville Ma. 02632 3/03/2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day ,
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Yes
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is Ievel.Box has one outlet Iateral.Signs of solids carryover.No signs of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
88 James Otis Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is required for Centerville Ma. 02632 3/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers. number: 4-infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:.
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system .
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Damp soil.Leaching area has been full.Stain lines in distribution box is over outlet invert pipe.
i
88 James Otis Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
•Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
information is Centerville Ma. 02632 3/03/2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
88 James Otis Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Map Page 1 of 2
Town of Barnstable Geographic Information System
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-
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
CGM ,a''v 88 James Otis Rd.
Property Address
Pedro Magalhaes
Owner Owner's Name
-information is Centerville
Ma. 02632 3/03/2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
Surface water
® Check cellar
❑ Shallow wells
Bottom of leaching 20'
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:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate.#2 annual ranges of
ground water elevations.
88 James Otis Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
t, Town of Barnstable
�F 1HE Tp�
Regulatory Services
BARNSfABLE,
Thomas F. Geiler,Director
1639. A��� Public Health .Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
not does this Division agree with any technical observation s and interpretations
contained within this report.
In addition b receiving this re y g port the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
TOWN OF BARNSTABLE
!LOCATION � SEWAGE #
AGEC 7ei I/f/ ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. e77 r c A Je 4-1 s-e - t "C, td �
SEPTIC TANK CAPACITY
LEACHING FACILITY yK I Tof rrAS (size)
NO.OF BEDROOMS
]BUILDER OR OWNER
PERMPTDATE: -'I f fCOMPLIANCE DATE:
i,
14-
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
13 ,
r
A , 3 QI L
133 �
TOWN OF BARNSTABLE
LOCATION ,�f .74,M cS' a T,S- SEWAGE # C /�✓
VILLA ASSESSOR'S MAP&LOT — n
INSTALLER'S NAME&PHONE NO:__, -A I r 7-?8 d j(
SEPTIC TANK CAPACITY s a v
LEACHING FACILITY:T
(size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
3
17C i� '
No. / - � Fee '
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _�
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0(pplitation for 30igo5al *p5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System individual Components
Location Address or Lot No. -yoM.(i OTt S Owner's N e,Address and Tel.No.
Assessor's Map/Parcel �` ` C)2
Installer's Name,Address,and Tel.No. .7 Designer's Name,Address and Tel.No.
s7-
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 -3�30 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ��t 5`l` 000 A r Type of S.A.S. ` C� cC <<--
Description of Soil Cvw-2SP
Nature of Repairs or Alterations(Answer when applicable) 7 SI
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been e Signed Date A I M
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued v
�..•.� No. Fee
�4' w THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y
es
- - �- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS
gpprication for Migool *pgtem Congtructiou Vermit
- Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System $dndividual Components
Location Address or Lot No. 3rM S CZ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 1"70
L�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
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 gallons per day. Calculated daily flow ��� gallons.
Plan Date Number of sheets Revision Date
Title
Size,of Septic Tank s T 6. Type of S.A.S. Cam+
Description of Soil ��I CC)A(4_ C J Cis' ll
r
,• Nature of'Repairs or Alterations(Answer when applicable) X wy f IAV !>o,�- e
- ,t_� �.� fT�� cj � �. U..� . _S/fir r7`
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the Xfor�edesenbqd on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the sy4temnn o eration until a Certifi-
cate of Compliance has been iss -t#is-Ret ea i-
Sigried .—'yr Date
Application Approved by Date
Application Disapproved for the following reasons
• 4
Permit No. 9 9.% Date Issued ^ v
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded
Abandoned( )by fWf -y_, -
at Aja a A M - r OV7 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. r dated
Installer Designer v3 e
The issuance of 1&�s 11 of b construed as a uarantee that the s st wil function as des , ed. 1 j
Date g Inspector y
t� -
---------------------------------------
No. r' ✓ Fees-�J
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS
Mizpoar *potem Conotruction Permit
Permission is hereby granted to Construct )Repair( )Upgrade((,,,)Abandon
System located at ('w,e c "Ji t
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must
st be completed within three years of the date of th rmit..
Date: 7��T'` Approved ..--
i
116i99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AIND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERT IIT (W=OUT DESIGNED PLANS)
I, �,V:'::�_ � 5,`{� , hereby certify that the application for disposal works
construction permit signed by me dated /� �{'-1 concerning the
property located at F9 7i4-M(=S OTI S meets all of the
following criteria:
/"The failed system is connected to a residential dwelling only. There are no commercial or business
es associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
ma;dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
//Method when applicable]
• If the S.A.S. will be located with 2M feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the ma.-dmum adjusted
groundwater table elevation,
Please complete the following: /
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation ' _the MA-K High G.W. Adjustment .
f
DIIERENCE BETWEEN A and B 410
SIGNED : G- DATE: `
[Sketch proposed plan of system on backl.
q:health folder.cat
r�
n r
Town of Barnstable.
Department of Regulatory Services
• Public Health Division Date—
xnxeresrA
Miss e$ 200 Main Street,Hyannis MA 02601
163
Date Scheduled -
Time Fee Pd.
,boil Suitability Assessment for Sewage Disposal
Performed By: Witnessed By:
i
LOCATION& GENERAL INFORMATION a/
Location Address J}15 !7S Owner's Name ® DnW,(�,����j f 4 tj� 2 Q �
Address � T'd"�"3 &n j I`e/
Assessor's Map/P4rcel: r 63 I Engineer's Name
NEW CONS1RU4 170N REPAIR Telephone*
Land Use U / Slopes(30) Surface Stones
7 2 Ub 7�U ft Drinking Water Well ? Wft
Distances from: 0 n Water Body ft Possible Wee Area —
LIJ r-- I
r j U inage Way 7 ZS ft Property Line 2 U ft otherft
name,dimensiods of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
S s« '
I
µ't.
CP
w
j OD
t
. i
F I
Parent material(geologic)
Depth to Bedrock
Depth to GroundwaWr. Standing Water in Ho1e:' Weeping from Plt Free
�tl
Estimated Seasonal;"igh Groundwater t
DtTERIYIINATION FOR SEASONAL HIGH'WATr"R T'ADLE
Method Used:
--in. Depth to soil mottles; In,
Depth dbperved standings'obs.hole: , — in. Groundwater AdJutltment tt•
Depth toiweeping from side of obs.hole i A ,faetoY,�,._ AtU�droundwater Level.,,�,e,
Index Well# � Reading Date index Well level i— �
PERCOLATION TEST n$te 24 T1"s"
Observation' l I Time at 4" AA—
.Hole# i
�n`/ Time at V
Depth of Pere AL5
i Time(9"-6
Start Pre-soak Time.@ -
End Pre-soak
/D
Z sue,
Rate Min./Inch
X Site Failed; Additional Testing Needed(YIN) —
Site Suitability Assessment: Site Passed y,_______
Observation Hole Data To Be Completed on Back-----
. Original:,Public Hedlth Division •
***If P ercola#tin test is to be conducted within 100' of wetland,you must notify the
Barnstable 6.1 servation Division at least one(1)we&Prior to beginning-
first
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)
AV PH
A 1phmi4 S*re b �'
/1011 u t o f l b R- 616
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)
ld !�¢ N 4
3�"132y �lilco �irr,�o 2
DEEP OBSERVATION HOLE LOG Hole#
Depth from' Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) ' Mottling (Structure,Stones,Boulders.
Consistency,%aravell
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
on ist I
Flood Insurance Rate May: x
'--. Above 500 year flood boundary No— Yes '`'--
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist,in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring per 'ous material?
Certification
I certify that on D (date)I have passed the soil evaluator examination approved by the
Department of Environ :-1—
tal Protection and that the above analysis was performed by me consistent with
the requir trat ' ,expertise and exp rience described in 310 CMR 15.017.
Signature Date b9 • yS•0�
Q.\SEPTICIPERCFORM.DOC
No.__�2.,.?�:_�' ...`� Fxs... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEA .TH
............. I"' S`....OF...... -----------------------------
Appliraiinn for Dwpaiial,lVorkii Tomitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System-a-- - ...................
-- .. ....__.. .. ---- ..
Location-Addr ss or j o
.. ....._.._.. . . ............................................... .......... . .......
Owner Address
-._ "--------------------•-------------------- ---....... . . •...........................................................
Address
Q Type of Building Size Lot...l �,I ...Sq. feet
U Dwelling—No. of Bedrooms............ .___..•.............Expansion Attic ( Garbage Grinder (�ob
`4 Other—Type T e of Building ._..... No. of persons............................ Showers
G.� YP g ------•-------------- P ( ) — Cafeteria ( )
a' Other fixtures .----••------------------------------------------- .
W Design Flow...............�.412-.1'''..._._._.._.._..gallons per person per day. Total daily flow.........._15.3.t4..................gallons.
WSeptic Tank—Liquid capacity/.&V.-pgallons Length.........:...... Width................ Diameter................ Depth......._........
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
,.
Seepage Pit No.......�..2S�iameter..._________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by....................................................................•••-• Date........................................
Test Pit No. 1...........:....minutes per inch Depth of Test Pit.................... Depth to ground water----------_.............
GL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -----------------------------------•--------------••-------•------------•--.........------------•---.........................................................
0 Description of Soil.........................................................................................................................................------------------------••----
x
w
............................................................-...........................................................................................................................................
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
-- -----------------------------------------•----......
Agreement:
The un rs red agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisio s iIT 5 of the State Sanitary Code—The undersi ned further agrees not t p e the system in
operation nt' rti pliance has been i u by th o d of health.
Sined----- --•-••-•--._...... • .............................................. --••---•--•••--• s J
Date
A licatio ved BY1 -• y� r�=
..........................................................
Date
Applicat• isapproved for the following reasons:---------•------------------------------------------------------------------------•--•-••-••-•••-•..........----
..............................................---•••-•-••-••......---••--••--•.....
Date
PermitNo................................................ ------ Issued-----•-•-------------------------•-----•---•------•---.
Date
-----------------------------------------
No. y:.�° _ FEic... ...................
THE COMMONWEALTH OF MASSACHUSETTS
n BOARD OF HEALTH
ApplirFa#ion, for Disposal Works Tonstrurtiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
..._..._. - h
x+
-'F Location-Address,. w ,/_ f or:Lot No:
r.. t Y t t f 1 e I, (_
tl_.... ........:..:..................................................... ... +f
.e .. / r Owpner Address ...-•----•---^----------------------
..m.:...� r............. �... ......f_ {..:............................................ ........... r.___..__l.._.............._.......................................................
� ` Installer Address -
Q Type of Building Size Lot..: _-./ '`.-.'_...Sq. feet
aDwelling—No. of Bedrooms............. - .......................Expansion Attic (z,)``S Garbage Grinder
aOther—Type of Building ............................ No. of persons..............._............ Showers ( ) — Cafeteria ( )
dOther 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---------------i..... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
rX Test Pit No. 2................minuttes per inch Depth of Test Pit.................... Depth to ground water........................
ODescription of Soil.........................................................................................................................
x
U •--•-•--••••---•-•-•-•-•-•--••-••-••-----•-•-•-•--••-•••-•-••••-•---••---•-•...••.............••-•-••-••-••-•-----•---•-•-----•-•-......-•••--••---•..................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
7-•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to plzce the system in
operation nt' rti f pliance has been issued by the board of health.
Signed.............. .............. `.: .�r . .......................'
CM
Date
Alicatio ved By..... -•-••- -•-----••-•----•-••-••'-...... .......-•--••-------------•-.._.........._
Date
Applieat' isapproved for the following reasons: --------------•-•••-••.....'-
---------------------------•--------...---------------------------•------------------....................................................
Date
PermitNo.........................................--•--•'•__.... Issued----••-•-------•--------------------"•---•----•-'-----
i Date
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF............................................................................
(ffrrtifiratr of TuntpliFattrr
THIS IS,TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
�,L »r'
by .....--................ -----------. ....................................•...........
r'Pv °trot' In Ilea
..........................................................._. .............................................................
has been installed in accordance with the provisions of TI LF gf State Sanitary � described in the
application for Disposal Works Construction Permit No �"' .r.___
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............. U-----•--•------.----------•---- Inspector.... YJ
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.............••------.... FEE........................
Disposal nrkn Tnnstra uan rrutit
Permissio is hereby granted..... ............................................
............•... ••••--•...•--•--••-••-••••-•--.......•--•..................••..••---
to Construct ( ) or_•epair Q. ) -an andividuaL.Sewage 21S osal S
at No
--------------------------------••.-•----•--
Street
a G 4'
as shown on the application for Disposal Works Construction Permit-.- F "'_' _.. Dated _ ---
......................................................................................................
- Board of Health
i
DATE ..
FORM 1255 A. M. SULKIN, INC., BOSTON—)-
A�
ka1.1
OA/LY �LO1.r/ = //D X 3 = 3.30 G.P.o _
_!/sE �000 GAL.
L.o-r ! I
d/.S�i2S,4L �/T•--USE /OGO �S',Q�
3 7 '
.SO G./?O.
7-OT.Q� IJ.4/L}�fLo{.�/= 3.3D G••��, p vl � �r �
�5
G' RICHA:RD
A. PETER -
EsR:1ru� lo` SULUVAN
No. 23733
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/
TEST f/a�GE P Z 802 (CoT z o 3,
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l No
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w9lL'TLr �:� L.o 7-
/ GE2T/�Y Tf/.4T THE
AAvo SE QAGf� .eE4lJ/�E�IENTS O� T.'.'� .�EGisr�ecD.Gclvo slietiEya,P�
ToW.v of g q�ti' s T9$G-E" .Q�vO /S �vaT-
L occrE.v �sTE.21�i�tc m- �sl�.�.
/vW l/ -% �-�- T//!S fL..s�v /.S �YoT I3,4fE0��✓,41V
-!/'L/.Eil/T•fv,2l/Ey fji�/O T.yE a�f,S�T,.,�
S/�lr/it/.yE�Elr✓.S.Nv!/GO A07-!mac USEp
To 1XI'l for- L/NE,S
IUD-1o2
LQ; 'ATION cc e 1 SEWAGE PERMIT NO.
ap to
VILLAGE
INSTALLER'S NAME&ADDRESS
BUILDER OR OWNER
' DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
r
e '
f
r
LEGENDz.
PROPOSED CONTOUR
8 PROPOSED SPOT GRADE a
j 1h�8 mm �5,
C9 �g
BENCH MARK ="5a5 — -- `''aa� a; x
j, — 98 EXISTING CONTOUR F-.., `` �'
PAINT SPOT ON j + 96.52 EXISTING SPOT GRADE 5y oS
BULKHEAD CORNERi1
ELEVATION = S9. 4O CEO r t $ W— EXISTING WATER SERVICE 1,', ,r r��
BARNSTABLE CIS DATUM TEST PIT pa �' �o '4� vEbens h_R
j Oj 7 f
6
i Q�r
d1 dip
58
Rd- +
LOCUS MAP N.T.S.
\� �I GENERAL NOTES:
ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
1 v "\N BOARD OF HEALTH AND THE DESIGN ENGINEER.
\ 1 OR\ Existing 1,000 go X• j 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
Septic rank 1 OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE
\ 1 WATER -\ + 1 LOCAL RULES AND REGULATIONS.
\.GATE O
'
_ 1--__ _- --- yj8• 2 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
TER LINE ta$.2� TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
� 1 DESIGN ENGINEER.
\ 1 r\ 0 j 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
n FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
t v ' a�J� jj ENGINEER BEFORE CONSTRUCTION CONTINUES.
0 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
p o\ 1 JQ TH-1 1
O\ \ Z 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
VIATHE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
O .1 \\ 20 rt .9 t Z s tt I 95 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
O� \'\ 1 O 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
-13 \, \\ TH-2 B. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
\ jj TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
O L \ 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE
VIA \' ohs %O THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
\\�\ Th CONSTRUCTION.
\'\ `t O I 6 =' 10. EXISTING LEACHING 'TO BE PUMPED, CRUSHED AND FILLED
AREA �� 16601 S f I - , - ' PS� N / / 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION
12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY
AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY
13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING.
��� 0 �qss 14. NO WETLANDS WITHIN 150' OF PROPOSED LEACHING.
-58 Q 9 15. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPECIFIED)
DARR
ME0. 1140
-a
0
SU/7
sist °
rm SANI iAR\A�
din. kit room bath room • ®�
O rrn both �o PROPOSED SEPTIC SYSTEM AS—BUILT PLAN
liv, bed bed 88 JAMES OTIS ROAD, CENTERVILLE, MA
gar rm room room Prepared for: Mike Dedecko
I. MAP. 170 Engineering by: Surveying by: SCALE DRAWN JOB. NO.
SURVEY REFERENCE: LOT-103 DARRENMM,MEYER,R.S. Bco—Tech Bavirnnmenw 1"=20' DMM
PLAN OF LAND BY BAXTER & NYE, INC. 1ST FLOOR DEEDBOOK.-20790 PO BOX981 EAST ,MAo2537 (508) 364-0894 DATE CHECKED SHEET NO.
DATED: MAY 8, 1984 ,t DEED PAGE. 104 50�8-W- 22 09�01�08 DMM 1 of 2
y
ELEV. TOP
FOUNDATION
(Existing)
= 59.57�A�F.G.EL: 58.5 F.G.EL: 58.5 F.G. EL: 58.5 � FINISH GRADE=58.5
4
MAINTAIN 2% MIN SLOPE OVER LEACHING AREA MAX. COVER OVER LEACHING = 3.0 FT.
JV
COVERS TO WITHIN 6 OF GRADE 6" INSPECTION PORT
=° W/IN 6" OF FINISH GRADE
6" . _ 4" SCH 40 PVC 4" SCH 40 PVC
a o 0 0 0 0 0 0 0 0 0 0 0
:e ®S=2/o t0"I " ® S= 190 MIN. - ' .
(MIN.) TEE'S ARE TO BE 14 ( ) e S= 1% �MIN-)
4" SCH 40 PVC
INV.56.30 INV.55.9 ° ° ° ° 0
h INV.55.7
EXIST. OUTLET BAFFLE
PROPOSED DB-3 ° ° ° ° °
f•- -., H-10 DISTRIBUTION BOX
'. :. . 34'
Art Am AM
INV. 56.55 EXISTING 1 ,000 GALLON SEPTIC TANK i INV. ELEV.= 55.0
GAS BAFFLE TO BE INSTALLED ON ) CONTRACTOR SHALL VERIFY ALL EXISTING arr �s nsnzw sar 9�, �/N NOTES: 1
OUTLET TEE AS MANUFACTURED BY PIPE INVERTS PRIOR TO CONSTRUCTION PER TI TLE 5
TUF-TITE, ZABEL, OR EQUAL 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT EL. = 55.50
GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.=55.0
INCH CRUSHED STONE BASE, AS SPECIFIED IN
310 CMR 15.221(2) 'v v;- s 24" 30 5"
3) REPLACE EXISTING 1,000 GALLON SEPTIC DIMIINI/ERT
TANK WITH 1500 GALLON SEPTIC TANK BOTTOM EL.= 53.0 1
IF FAILED, DAMAGED, OR UNDERSIZED. „
4) INSTALL INLET & OUTLET TEES AS REQUIRED 4B 50 48
SEPARATION 6.43 FT. I �46"
SOIL LOGS SEPTIC SYSTEM PROFILE BOTTOM OF TH-1 EL: 46.57 SOIL ABSORPTION SYSTEM (SECTION
DATE: AUGUST 29, 2008 N.T.S. DESIGN CRITERIA
SOIL EVALUATOR:.,JDARREN MEYER, R.S., CSE NUMBER OF BEDROOMS: 4 BEDROOOM DESIGN
WITNESS: TOM McKEAN SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF)
HEALTH AGENT DESIGN PERCOLATION RATE: <2 MIN/IN
Elev. TH-1 Depth Elev. TH-2 Depth r DAILY FLOW: 110 G.P.D.
--L- DESIGN FLOW: 440 G.P.D.
58.57 0" 58.60 p"FILL A LOAMY SAND GARBAGE GRINDER: NO (not designed for garbage grinder)
58.07
10YR 4/2 SEPTIC TANK: 440 gpd. x 2 = 660 gpd USE EXISTING 1.000 GALLON SEPTIC TANK
l A LOAAYMRY�ND 6" 57.60 g 12" LEACHING AREA REQUIRED: (44-0) = 594.59 S.F.
57.74 10"
LOAMY SAND .74
e LOAMY SAND � )10YR 6/6 USE FOUR 4 INFILTRATOR 3050 UNITS WITH 4 FT. STONE
10YR 6/6 55.60 C1 36" ON THE SIDES & 2.1 FT. STONE ON ENDS: 34' L x 12.16' W x 2'D
55.57 36" BOTTOM AREA: 34 x 12.16 = 413.44 SF
C1 SIDE AREA: (34 + 12.16) X 2 X 2 = 184.64 SF
TOTAL SQUARE FEET PROVIDED = 598.08 vs. 594.59 REQ'D
MEDIUM PERC®55.25 MEDIUM DESIGN FLOW PROVIDED: 0.74(598.08 S.F.) = 442.58 G.P.D. vs. 440 G.P.D. req'd
SAND SAND
S
2.5Y 7/4 2.5Y 7/4 P� EN M. PROPOSED SEPTIC SYSTEM UPGRADE PLAN
MEYER 88 JAMES OTIS ROAD, CENTERVILLE, MA
46.57 144" 47.60 132" " No. 1140
Prepared for: Mike Dedecko
PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) Q Engineering by: Surveying by: SCALE DRAWN JOB. NO.
NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED C�SjE
. DARRENM.MEYER,R.& Eco-Tech n2vhvvmenW N.T.S. DMM
�H!TA??, POBOX981
1 EAST SANDWICH,M402537 (508) 364-0894 DATE CHECKED SHEET NO.
' ( 508.362-2= 09/01/08 DMM 2 of 2