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HomeMy WebLinkAbout0100 JAMES OTIS ROAD - Health 100 James Otis Road Centerville P A = 170 104 llll a�'►c�n�o � y UPC 12534 No.2® HASTINGS,MN x COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTj'g W 2 AM 9::O2 FAILED INSPECTION .n.� 'MVISION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 100 James Otis Road Centerville, MA 02632 Owner's Name: Stephen Harwell Owner's Address: 1 Date of Inspection: April 4. 2005 /1 . Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: April9. 2005 The system inspector shall subs a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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: 100 Jaynes Otis Road Centerville, MA Owner: Stephen Hartwell Date of Inspection: April 4, 2005 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 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 4 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 100 Janes Otis Road Centerville, MA Owner: Stephen Hazwell Date of Inspection: April 4, 2005 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 100 James Otis Road Centerville, MA Owner: Stephen Hazwell Date of Inspection: April 4. 2005 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''/z 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.] Yes (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 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 1.5.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 100 James Otis Road Centerville,MA Owner: Ste hp en Hagwell Date of Inspection: April 4. 2005 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: 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 SYSTEM INFORMATION Property Address: 100 James Otis Road Centerville,MA Owner: Stephen Hagwell Date of Inspection: April 4. 2005 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: 4 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAVINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonnation: Pumped in 2000-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ 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: Date of installation unknown 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 PART C SYSTEM INFORMATION(continued) Property Address: 100 James Otis Road Centerville, MA Owner: Stephen Hagwell Date of Inspection: April 4, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): 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: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" 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: 10" 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.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. 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: Cotmnents(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: 100 Janes Otis Road Centerville, MA Owner: Stephen HaQivell Date of Inspection: April 4, 2005 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: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) 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.): The D-box was level. No solids were present. 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.): 0 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 James Otis Road Centerville, MA Owner: Stephen Hagwell Date of Inspection: April 4. 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I-6'x 6'(1000 ag l.) 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.): The leach pit had S'ofliauid on the bottom. The scuin line was up to the pine The pit had suns ofpast failure The bottom to Qrade was 9'. The cover was Y below Qrade. 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 SYSTEM INFORMATION(continued) Property Address: 100 James Otis Road Centerville, MA Owner: Stephen Hagwell Date of Inspection: April 4. 2005 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. . A A � I 8 Yy lot 3 3l y� 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: 100 James Otis Road Centerville, MA Owner: Stephen Hagwell Date of Inspection: April 4, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- 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: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours map, the maps were showing approximately 30'+/-to ground water at this site. This report has been prepared and the system inspected and failed 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. 11 DATE:_11/l/99 PROPERTY ADDRESS100 ,James Otis Road --------------------- Centerville ,Mass . ------------------------ 02632 ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: (:. // 1 . 1-1000 Gallon septic tank.2. 1—Distribution box , 3 . 1-1000 gallon precast leaching pit .Based on my Inspection, I certify the following conditl 4 . This is a title Five Septic System. ( 78 Code099 5 . The septic system is in proper. working orderr9e�� at the present time . 6 . Waste water in the leaching pit is 59" below the invert pipe . SIGNATURE:1 Name: �------ Company: Jose2h_P. Macomber & Son , Inc . Address:_ Box_66 Centerville , Ma . 02632-0066 -------------------- Phone:...508_775=3338_______ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COKE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 100 James Otis Road Nama of ownerJ o h n B u s c o n i Centerville M ss . 02632 Address ofOwnw: 109 Rutland Street Data of Inspection: il�l/99 Watertown ,Mass . 02472 Name of Inspector:(Please Print) Joseph P.Macomber J r . I am a DEP oved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) C unparty Name: J.F.M a c o m b e r & Son Inc . MaaingAddress: BOX Fife Cpntervi l l P_,Mass _ n2632 Taq,I ne Number: 508 �$ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site s wage disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails �?j Inspector's Signature: G i Date: E!'l The System Inspecto shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner shall submit the report to the appropriate regional office of the Department oKnvirorirhental Protection. The original should'be sent tovw system owner and.copies sent to the buyer, if applicable,and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Pagel of11 �J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 James Otis Road Centerville ,Mass . Owner: John Busconi Date of Inspection: 1 1/1/9 9 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: �7 I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: _ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination In all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was Installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. IVQ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping-more than'fourZfines a yeardue to broken or obstnrcted pipe(s). The aystam wiltIn3s— inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 100 James Otis Road Centerville ,Mass . Owe: John Busconi Data of Inspection: 11/1/9 9 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: t)b_ Conditions exist which require further evaluation by the Board of Health In order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CPAR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.YALL.PROLTIECT THE PUBLIC HEALTH.AND SAFETY.AND THE EPWBONMENT: Cesspool or privy is within 50 feet-of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of-ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm. Method used to determine distance -41J (approximation not valid).- 3) OTHER •2 revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTiON FORM PART A CERTIFICATION (continued) PropwtyAd&*"-J00 James Otis Road Centerville ,Mass . Owrwr: John Busconi Date of Insp.ction: 1 1/1/9 9 D. SYSTEM FAILS: You must Indicate either'Yes" or"No' to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this datermination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No/' Backup of•taeWage iMo4eciBty"or•�stertt component-due�to to overloaded orcbggod-S�AS-or�cesspod. .— Discharge or ponding of stfluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level In distr-tion box above outlet Invert due to an overloaded or clogged SAS or cesspool. Liquid depth in Is less than 6" below Invert or available volume is less than 1/2 day flow. Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone 1 of a public well. Any portion of a cesspool or privy Is within 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organlo-compounds, ammonia nitrogen-and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either 'Yes" or "No" to each of the following: The following criteria apply to large systems In addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No ' the system is within 400 feet of a surface drinking water supply _ the system•Is-wiWn 200 ia+tot�tributaryr to a surfaoa drir�Icir+g w+tor+u►ply•... _ . -- ... _ - the system is located In a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 16.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4orli i I i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST pr.ptyAdr.: 100 James Otis Road Centerville ,Mass . Owner: John Busconi Date of Inspection: 1 1/1/9 9 Check If the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes No / Pumping information was provided by the owner,occupant,or Board of Health. None of the system-aompoaants.haw&JAan pna►pad4oPatJeast t+wo-awes M ardthe-system hasl eeaascai9iag wwaaal.flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ Z The system does not receive non-sanitary or Industrial waste flow. _ The site was Inspected for signs of breakout. _ All system components,.&Iuding the Soil Absorption System,have been located on the site. _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: Existing Information. For example, Plan at B.O.H. Determined In the field(if any of the failure criteria related to Part C is at issue,approximation of distance Is unacceptable) / (15.302(3)(b)) ! _ _ The facility owner.(and.n^�pant if differaw frog swear)Auersprayidad.Wllh.Infnrmatioa;Dn thnr^par ALnt SubSurface Disposal Systems. 1 i revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 100 James Otis Road Centerville ,Mass . Owner: John Busconi Date of inspection:11/1/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: UP _g.p.d./bedro m. Number of bedrooms Ides! )• Number of bedrooms(actual): Total DESIGN flow i Number of current residents: '04 Garbage grinder(yes or no):� Laundry(separate system) (yes oro:_; If yes,separatelnspection.required Laundry system inspected a or no) Seasonal use(yes or no): Water meter readings,if available(last two year's usage(gpd): 1 7� Sump Pump(yes or no): Last date of occupancy: COMMERCIALtINDUSTRtAL: Type of establishment: _ Design flow: 4 f A gpd.( Based on 15.203) Basis of design flow ltw Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)- p Non-sanitary waste discharged to the Title 5 system: yes or not& Water meter readings,if available: A Last date of occupancy: .P-1dd OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPWG4EC D d s ce,gf pfp;ma ?n: 9� System pum ed as part of iiinnnspec`tiionz(yes or no)_ If yes, volume pumped: gallons Reason for pumping: U11' TYPE O 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) IIA Technology t Attach copy of up to date operation and maintenance contract Tight Tank nn Copy of DEP Approval Other d2et �-- APPROXIMATE AGE of all components, date installedi+f known)-and source of4Rformation: Sewage odors detected when•arriving at the site:(yes or no) revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 James Otis Road. Centerville ,Mass . Owner: John Busconi Data of Inspection: 11/1/9 9 BUILDING SEWER: (Locate on site plan) Depth below grader Material of construction:_cast iron_.V140 PVC—other(explain) Distance frorrl private water supply well or suction line Diameter 111[ Comments: (condition of joints,venting,evidence of leakageeetc.) — Joints appear tight , No Pyidpnrp of 1Paka_gP S&TIC TANK: (locate on site plan) ,gyp Depth below grade: 14V / Material of construction: concrete42#netal1,AFiberglassA/A Polyethylene 4L4other(explain) AM If tank is (netall,, list age,(A Is.age_confirmed by Certificate of Compliance (Yes/No) Dimensions: �O Q 7 l�(NA? r /"i/IGff Sludge depth: Distance from top�ludge to bottom of outlet tee ortnaffleC� —' Scum thickness:��_a. Distance from top of scum to top of outlet tee or baffle: j Distance from bottom of scum to bot7tonj of outlet t e or baffle- How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structure;4ntegrity, evidence of leakage, etc.) PUMP the septic ank PvrPy 2-1 gParc TnIPt- & o„f 1 of toes-ara in place . Jbj:q>iid level at the the—atttl shows bNEASEfRAP.2&U (locate on site plan) Depth below grader Material of construction:A24concreteAL&netalAAFiberglass kJAPolyethylene&other(explain) AV Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:1410 Distance from bottom of scum to bottom of outlet tee or baffler Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Grease trap is not- :rPGPnt revised 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Pr.p,tyAd&—: 100 James Otis Road Centerville ,Mass . Owe: John Busconi Date of Inspection: 11/1/9 9 TIGHT OR HOLDING TANK:_ 0—(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction:UAconcrete JAmetaWIFiberglass4/APolyethylene4�lother(explain) Dimensions: Capacity: gallons Design flow: 04 gallons/day Alarm present dA Alarm level: Alarm in working order:Yes 4LR No W Date of previous pumping:AM Comments: (condition of inlet tee, condition of alarm and float switches, etc.) light or o inQ tan s are not present . DISTRIBUTION BOX:_v (locate on site plan) Depth of liquid level above outlet invert: Comments: (note-if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — -— Distribution box has one lateral . No evidence of solids carry over . No evidence of 1Pakngp intn nr not of the hay , PUMP CHAMBER:1(h4f (locate on site plan) Pumps in working order:(Yes or No)� Alarms in working order(Yes or No) /7 Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pump chamber is not praaPnt revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:100 James Otis Road Centerville ,Mass . Owner: John BUsconi Date of Inspection: 1 1/1/9 9 SOIL ABSORPTION SYSTEM(SAS)._/ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers,number: leaching galleries,number:= leaching trenches, number,length: leaching fields, number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: ! Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.) Loamy sand to coarse sand _ No signs of hydranlir failure or z and i ng Qni 1 c era dry VagetatJ Gn IS normal ■ Llatse water is tt belaw the invert �,p±pe to the pit . CESSPOOLS: (locate on site plan) Number and configuration: L/ Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) o Cesspool's are not present . Comments: (note condition of soil, signs of hydraulic failure,level of pending,condition of,vegetation, etc.) Cesspools are not present . PRIVY;/�jve (locate on site plan) Materjals of construction: Dimensions: l� Depth of solids:/ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Privy is not present . L. revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORuAnoN(corttirxiad) PyW.MAd4..u: 100 James Otis Road. Centerville ,Mass . Owr"e; John Busconi . Dn. of{rup.cslon: 1 1/1/9 9 SX TCH OF SEWAGE DISPOSAL SYSTEM: Include ties to it Isast two permanent reference landmarks of bsnchm►rks lows ►II wells wlWn 100 (Locate whirs publlo wale, supply comes Into house) d! of )0 6 •6'Q revised 9/2/ Ion rn P O t; Rd I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 James Otis Road Centerville ,Mass . Owner: John Busconi Date of Inspectional 1/1/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater JAL Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record bserved.Site (Abutting property, observation hole, basement sump etc.) t determined from local conditions Checked with local Board of health Checked FEMA Maps __jZChecked pumping records _zchecked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used Water Contours Map . Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11of11 nrn,�r,-nr•.s+-.-.,-.n..-mr•..m.,r�„r.,.Rrs,art:,,-.,,..N,,.rt�nn,.,sn„Y ntt...arn•n TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I •••rr'f•r••.-•.:e-T.tir.-..:rnrtr.+n•rrCrrtrwlrJrstlrr+r•7nrrt•i r'1VT'R7 It/ewIT1lR��rt tr/•r. Lrtrr'-•r.-1.-..^ -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 100 James Otis Road Centerville,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME John BuscDrii PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber & Sow Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 790 _ 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at D his address and that t 1 ii } e r formation re ooted is true a P , ccurate, and omplete as of the time of ,inspection , The inspection was performed and any ecommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form, System FAILED* The inspection which I have con icted has found that the system fails to Protect the jiublic health and the environment in accordance with Title 6 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Date ne copy of this ctert.ification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF H$AL711, * If the inspection FAILED, the owner or.""operator shall u d within one year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3.10 CMR 16 . 305 . partd .doc TOWN OF BARNSTABLE LOCATION .-AP 4'�WS a,71-5 AW SEWAGE # VILLAGE ass ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ,tAr LEACHING FACILITY: (type) (size) J NO.OF BEDROOMS BUILDER TTOR OWNER�� PERMDATE: ice—;P?7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 leacYn , cty Feet Furnished 1, C 9/./�, r o 31e u� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS D ° ENVIRONMENTAL PROTECTION • NTER STRE TON, MA 02108 6)7-292.5500 Rio WILLIA.%IF �AELD JUL 15 1 �997 TRL'D1'C0.\1 Govcmor N Sc:rctar ARGEO PALL CELLUCCI TOWN OFBARNSTABLt DAVID B STRUH: Lt.Govcmor S URFACE SEWAGE DISf' L SYSTEM INSPECTION FORM Commissionc y\P� T A — �, 71FICATION Property Address: 100 James Otis Rd, CentervillMdress of Owner: Date of Inspection: J/1 /9 (If different) Name of Inspector: Osep P. Macomber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Joseph P. Macomber & Son, Inc . Mailing Address: bOX 66, Centerville , Ma . 02632-0066 Telephone Number: —775-3338 CERTIFICATION STATEMENT I cenify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ZPasses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: i =.rj Date: /—:;I The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: AI SYSTEM P SSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 1 5.303, Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: d>D One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes;.0o, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:11www.magnet.state.ma.usrdep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 100 James Otis Road, Centerville, Ma. 02632 Owner: Roland Durocher Date of Inspection: 7/1 /9 7 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: .(JO Cesspool or privy is within 50 feet of a surface water A45 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. ,()�} The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. �N7TYi The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (rovlted 04/15/97) Pay• 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 100 James Otis Road, Centerville, Ma. 02632 Owner: Roland Durocher Date of Inspection: 7/1 /9 7 D) SYSTEM FAILS: You must indicate ei;•.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303 The bass for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No i<Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the stribution box above outlet invert due to an overloaded or clogged SAS or cesspool r Liquid depth in-s�is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped _. Any portion of the Soil Absorption Syslem, cesspool or privy is below the high groundwater elevation Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well.with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Q LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No NNo 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 100 James Otis Road, Centerville, Ma. 02632 Owner: Roland Durocher Date of Inspection: 7/1 /9 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and'the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. l!/ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. Y The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. A AO J� _ All system components, efcluding the'Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: — The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) P&go 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 100 James Otis Road, Centerville, Ma. 02632 Owner: Roland Durocher Date of Inspection: 7/1 /97 FLOW CONDITIONS RESIDENTIAL: Design flow 00 R.p�/bedroom for S.A.S. Number of bedrooms: Number of current residents Garbage grinder (yes or no):_A:�o Laundry connected to system (yes or no): e,5 Seasonal use (yes or no):A)D Water meter readings, if available (last two (2) year usage (gpd): �tc1—/_3O1 Sump Pump (yes or no) A�C) Last date of occupancy:' /—_y_9, COMMERCIAUINDUSTRIAL: Type of establish nt: AW Design flow: allons/day Grease trap present. (yes or no) /Ad industrial Waste Holding Tank present: (yes or no).4& Non-sanitary waste discharged to the Title 5 system: (yes or no) V%later meter readings, if available: Last date of occupancy: /M OTHER: (Describe) Last date of occupancy: 2 GENERAL INFORMATION PUMPING REC D and so rce of infor tion: r— ZA) go System pumped as pan of inspection: (yes or no)_ �— If yes, volume pumped: allons Reason for pumping: TYPE OF YSTEM Septic tank/distribution box/soil absorption system 4 Single cesspool VQ_ Overflow cesspool 'Vd Privy _ � Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: �t /S Sewage odors detected when arriving at the site: (yes or no)/IP (revised 04/25/97) Page 5 of 10 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 100 James Otis Road, Centerville, Ma. 02632 Owner: Roland Durocher Date of Inspection: 7/1 /9 7 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _ cast iron 40 PVC _ other (explain) Distance from vivate water supply well or suction line Diameter CpMments: (condition of joints, venting, evidence of eaka a etc.) r / a rJdlVTy re /L C /a r /� /' D/41 ypty'T" G e SEPTIC TANK: ��/ft �J (locate on site plan) tr Depth below grader /' Material of construction: Yconcrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance,!,(Yes/No) Dimensions:. r r! d 6-r2 r4 k Sludge depth:_ It Distance from top of sludge to bottom of outlet tee or baffle:v7 Scum thickness: e- Distance from top of scum to top of outlet tee or baffle:. Distance from bottom of scum to bottom of outlet tee or afflez� How dimensions were determined: Comments: (recommendation for pumping, condi 'on of inlet and outlet tees or baffles, depth of liquid Lev I in relation to outlet invert, structural integrity, ev dence of I akage, e c.) owl— 14 .f 7i- ';Res' /V!" qWM J ) GREASE TRAP:,_ (locate on site plan) Depth below grader Material of construction-tAconcretW meta 1,1?AFiberglasWA_Po lye(hyleneV�other(explain) Dimensions: 09 Scum thickness:_ Distance from top of scum to top of outlet tee or baffle:I" Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 4 5P 1 -h !S ,u� (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 100 James Otis Road, Centerville, Ma. 02632 Owner: Date r: Inspection:Roland Durocher 7/1 /97 TIGHT OR HOLDING TANK:xt&JL(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade Material of con struct ion:AlAconcrete4L0 meta LrJ/QFiberglasVAI PoIyethyIene,,(Aother(explain) m n i n D e s o s._ A/'A Capaciry: Njq gallons Design flow:_ gallons/day Alarm level:_ 41A Alarm in working order _ Yes; _ No Date of previous pumping: Comments. (condit n of inlet tee c ndition of alarm and float switches, etc.) �ib�z�' 7- DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: lelb Comments: (note if level and distribution Lh equal, evidence of solids carryover, evidence of leakage into or out of ox, etc.) zw' © PUMP CHAMBER:ld2X�O (locate on site plan) Pumps in working order: (Yes or No)_,eP,4 Alarms in working order (Yes or No)-A& Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (rrvioed 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 100 James Otis Road, Centerville, Ma. 02632 Owner: Roland Durocher Date of Inspection: 7/1 /9 7 / SOIL ABSORPTION SYSTEM (SAS): ;locate on site plan, if possible; excavation not required, but may be approximated by'non-intrusive methods) If not determined to be present, explain: Type: 1 leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length:�_ leaching fields, number, dimensions: overflow cesspool, number: Alternative system: 4J Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of pond i g co dition f vegetation, etc.) / , r l � � CESSPOOLS: (locate on site plan) Number and configuration: 1�19 Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: y Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) A$ 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: .e�-6s Depth of solids: V1,1 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) t 1_zlk'Y A9 !t/Dr �/G3c�JT (r•vi.ed 04/25/97) ➢.g. B of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 100 James Otis Road, Centerville, Ma. 02632 Owner: Roland Durocher Date of Inspection: 7/1 /97 SKETCH OF SEWAGE DISPOSAL SYSTEM: mciude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3� xot Pag• 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 100 Janes Otis Road, Centerville, Ma . 02632 Owner: Roland Durocher Date of Inspection: 7/1 /97 Depth to Groundwater��eet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record —zObservanon of Site (Abutting property, observation hole, basement sump etc.) —zDetermine it from local conditions /Check v,,ah local Board of health Check FEMA Maps Check pumping records —41"Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) We have installed two septic systems on James Otis Road Centerville . No water encountered at 161 . Permit#96-400 56 James Otis Road Permit#91 -12 65 James Otis Road Centerville (revised 04/25/97) fag. 10 of 10 1 t•'r+�T r\ T�Tr\Tff.-m"n R'f T+R TT,.T r:•.1.+!'TnT:TT�nn•1 TTL 1•.I�ITan IRS Tm�i.�fTv Tart-+•r.--.- _ ._ . (\ TUHN OF Rarnctahl g WARD OF HEALTH S011SURFACF SFHAGE DISPOSAL SYSTFM IN31'FCTION FORM - PART U CEWPIFICATIU"i �- {...�.�.� ... •-� ..��T.T.!1,•n:*anTT.1T1r7'r.T'-r •.1 nIR+r• �rTwT\•RIR1Tmrt�1'Y l�mnTrt1'\"r\rv-Tr�r•-.� -rr.-• r• - _ I -TYPE OR PRINT CI.EARL)'- PROPERTY INSPECTED STREET ADDRESS100 James Otis Road, Centerville, Ma. 02632 ASSESSORS MAP , DLOCK AND PARCEL # OWNER ' S NAME Roland D urocher ®� PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & ''Son , Inc . COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066 Strvvt Tovn or Clty 5tat. t;P COMPANY TELEPHONE (508 775 -3338 FAX ( 508 ) 790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa-1 system n . this address and that the information reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance o . on- s : te sewage disposal systems . ChZ ecck one : � S.yst,eln, PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 , Any failt( re criteria not evaluated are as stated in the FAILURE CRITERIA sectiojj o .` this form , System FAILED \ The inspection which I have con�uc ted has found that the system fn . ! s to protecC the }public health and the environment in accordance with Ti le .5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . .' e 1Inspector Signature =ra Date ne copy of this c rtIfication must be provided to the OWNER , the DUYER ( where. appIIcable ) and the DOARD OF IIIIAL7'll • If the Inspection FAILED , the owner or 'oporator ehall upgrade the eyotem ir.hin one year oC the date of the inspection , unless allowed or require(: oCherwise as provided in 310 CMR 16 , 305 . partd . dcc �G W (n Z7 7 � ti THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection_ Junc 8, 1995 Acung Dircctor of the jA ion of Watcr Pollution Control No. ��J e� t r Fee V(� THE COMM LTH OF MASSACHUSETTS Entered in computer: Yes -11 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication fir Mk;poAY Opmem COttetrurtion permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /oQ S�c�L 6 rs Owner's Name,Address and Tel.No. Assessor's Map/Parcel C e i�— ✓(/ I� `� �` °� � '\� Installer's Name,AdZZ,' Tel.No. Designer's Name,Address and Tel.No. S44 Z4 0"W 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 d gallons per day. Calculated daily flow 3�� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank i�-`�—' '' , Type of S.A.S. = _ Description of Soil . _ e� Nature of Repairs or Alterations(Answer when applicable) a✓ ' 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 be b card o _ Signed Date ZA—\S`o�� Application Approved by Date y'Y S : Application Disapproved fo the following reasons Permit No. 2WS�—/S,�— Date Issued No. ) O< —/S Fee Idd THE COMNiGNWRALTH OF MASSACHUSETTS Entered in computer: _ = Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS =" Y ZIppYicatiou for Migpogal *potem Cougtruction Permit r. Application for a Permit to Construct( . )Repair( 1)�Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./DO Sp, 6, `S Owner's Name,Address and Tel.No. Assessor's Map/Parcel /7a - /O »Installer's Name,Add �`'d 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 n gallons per day. Calculated-daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank G'a- ULb( , _�,Type of S.A.S. 1 a.`��r 6;�,.�C-,-\ Description of Soil ram„ C L�,, g� _/� N" ° l ' 3 S t�'.F3y)( / 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 Certifi- cate of Compliance has been issued by this Board of Health. _ Signed \ Date L� ���'0 � �^ Application Approved by l . , �A Date G/--f i-r-, �" Application Disapproved f r the following reasons _ � t Permit No. Z 00 c — i S. Date Issued ! o THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Coutpriance THIS IS TO CERT , hat the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(v< Abandoned( )by 1b0_ --\, ! 'Zee I 1 L_ - _ at V==Ljn=n has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Duo t- / Q dated ; Installer� t`n.- c Designer / The issuance of this e t shall not be construed as a guarantee that the sum will fun tion as designed. Date 1-t ® �7 Inspector No. Fee L� r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ligpogar *p!tem Com5truction Verrait Permission is hereby granted to Construct( )Repair )Upgrade( )Abandon( ) System located at t At-,e 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. //tt Provided: Construction must be completed within three years of the date of this e t! Date: l t 5 U r Approved b D. /'+ A Z �� ,� PP � . y No. -••---- FEs...�$. ::... THE,C,OMMGNWEAL-TH OF MASSACHUSETTS,�" AR® OF HEALTH ...-- ..OF...... ... ...................... ..... --------.-.-.-..--------•----•---- Applirttiiun for Uiupuuttl Morks Tunirurtiun rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systen x� � L;1�9 �' Locatio ­A dre No. nner/ Address •-•••••••• ,..... f—"-- "-....,•--•--•......................... .... Installer Address Type of Building Size Lot..e�47,MP Sq. feet Dwelling—No. of Bedrooms....... —'..............................Expansion Attic (/#0 Garbage Grinder (.A,):) p1,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ................................................. W Design Flow..................Z":7................gallons per person per day. Total daily flow...........a- __._-: ......_.........gallons. WSeptic Tank—Liquid capacit/,O.... allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.... _ 'Diameter.................... Depth below inlet........................=Total leaching area.................. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................................................•-••-••... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R: O Description of Soil...... �. `'" -•---•--•-••..:.....................•••.•-- W U ------•--•-•----------------•--------•-.....------------------................------------.....-•---.......---------..............-••---------•---------•----.........------------..............--•---•- w U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------•..._........•-•••••••••.........--•-•--•-••-••-•--...........-•--••••--•--••-••--••--••••-••••-•-••••--••--•••••••-••-•••••-•••••••••••••••••-•••--••---•-•--•---•••- Agreement: Th t ndersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the pr vis ors of iITLF, f t State Sanitary Code— The undersigned further agrees not to a the system in ope do until i of mpliance has been is e by the bo ealth. Signed. ...--••••--•••-•................ ................•••....-••••-•............._ ............... s!Y� Date Ap is do proved By...`, �.....��.:. *.` .......... ..... Date App ca on Disapproved for the following reasons:-------•---------•-------------•-----------------------•----••-------------------........_...-••-•••--....----•- -•---••....-••••-••-•-•••••••-•••-•••••••••-•••••--••••-••-•-••-.........-••-•••-•----••................•--•.............-•••••-••---•-••••......-••-••••-• .......................................... Date PermitNo--------------------------------------------------------- Issued....................................................... Date v� .r TH4A COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 r ..I.,.°...........OF. .r C t Appliratiun for Diipu.ial Works Tonstrnrtion rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: y r, . 1 / . .�- -----r,r _-,r......... . ^. ..................... �� Location-Address �'or Lot No. c.. r.E, r r ! { , i j-- t. f r f" 4 r Owner i Address W Installer Address Type of Building Size Lot_._ r`.y_.::'_::..'._:.Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( .',) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther"fixtures----------••... •-••--••----•-- . W Design Flow......__.:._f... A: ................gallons per person per day. Total daily flow........................................:...gallons. WSeptic Tank—Liquid capacity.'z........gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..................._sq. ft. Seepage Pit No.............. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2.......I---------minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------------------•-••-----------••-------------••-•-•-•-•--------............................................................. 0 Description of Soil------ V,4 - ?'e- -----------------------•-•-------•----------....---•--------......-----------------......_......-. U ---•--------------------•-----......_.......---•---••--•---------------•-•-----•----------••-•------••---••-----------------------------------......---------------------------...........-------••---•. W --- ---------- .......................................... --- VNature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------•--------------------------------------••---••----•----------...-•----------.....-----••-•-•••••••-•---•-•----••----•••--•-••••--•-•--••-•••••-•-•-•--•---..........--••---- Agreement: The ndersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the pr is•ons of TITLE S f th State Sanitary Code— The undersigned further agrees not to place the system in ope do ntil I' of mpliance has been issue&by the board of-'health. ! Signed...............................I 4 rs t . Ap ica(io proved By... / „ . Date Date" ApPI cainon Disapproved for the following reasons:-•-•---••-------•-••-------------•-•------•----------...--------•--•-------------------•-•=•-••••-•---------•--- --••-•..........•-•-•----••---•-•...............................••-•---••-•-----------.................--•------•---------------------•---------------•--------•-----------•-------•-----•-----•-------- Date PermitNo......................................................... Issued....................................................... Date f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... CIrrufiratle of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-----------------------j4.n1aA.........Z. ---s-------...------.....-•--•--•-••-----------...-----..........--•---..... ---•-----.........--•---......---.....-----•-•-•--•--•--------. �;` ..-.•�- ,,,,.Installer / -l-- at +w"-t---•..".^ .... -•--'�'-s J'! .:":a. 3_a------- -- ----------- CP,c��6�= has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......."1�.'G:"�a 39..__.__.. dated......6p/_9�.�....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL fUNCTION SATISFACTORY. DATE.......:......7..l .�. ... Inspector------ - --.. ... .... .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................oF...................................................:................................. No" t�` - „.,., e�.`�'.''..... ............... gispaoal Worko %Tonptrnrtion "prrmit Permission is hereby granted. =` ...............{�..�..-••••--•--•...•-•---•---•----••-•.............•••••-••-••-•-•••--••••--••-..........--•--- to Construct (-,) or Repair ( ) an Individual Sewage Disposal System at No.....•L>-i-.....G-o-9......... ....• _ ............. (2A''c� Street b!y�� as shown on the application for Disposal Works Construction Permit No.' M_ Dated.......................................... .......•---•-.....------•- _ -- Board of Health DATE.............. ..J ................................ FORM 1255 A. M. SULKIN, INC.. BOSTON T ' pEsi�/v O -° . '... S11/6LE FA I/'/L Y °- 3 BE0�2ao ✓1 "` Lo T ,o A10 GL1.2BAGE G,e/�t/OE.2 ,.;g 7)' i 4-1 .4.....-------""°"��`" 7 1,<//f = 3�0,�(/So/-�9�G.P.I. AVJ11 --- 0 y � `�'' N , ,S/OEW,eLL A eE4 BoTToMA.P-Ed = So S.� �o ToT4 4 OE,S/61t/ _ '17z2-5-GPo. 4n Lo-r 1- '2. .� � ow OE.S/G�c/ P.E'.2G�L4T/O�✓.2�1T�.' /"/.V 2•N/it/. �.�LE� _` ��o W �' • .�� J N r: tic.2-c4S fvu. 29"33 TESTf,/GA-- P-Z8o3 (1o7- Zo¢j IZ�I4 f 83 VV 6aL /yi✓ BOX /.v✓. GAL. 34 I i2AJCL Ta d G1 50' . . .rATz.vE S , S3.4' CE2T/F/EO PG oT ,�1�4�t/ i r r=G f1 re� $AUD f�'� SI.GLE ��l�SU 0.4TE 1"�(�`� d'��1°►�`'� f�GQ.V ,QE.�E.e,E�Vc� 13' L I �c 4 LOT— �n9 nJo wat'iav- CC / GEeri,Cy TN,47-T//E ROIJ 04 T`t 0,Av SIX0WV f1E.�'Eov G'aMPL•ys !Ad/T/,!T,yE.Si.OE<,/,tiE B,eXT�,2€',t/J�E, /•vC. A-V,O.SET9ALA-- T//E ,E�E6isT�P�p��✓o.S/ie✓Eya�S ror✓.c/ aF B-421v sT,1 B LL` L Oc�Tfl> y✓/Ti�,r/�S/ T,�✓E �L c1oOPG.4/�(/, T-t C . T/1&'Pz--dry / r i✓oT n/ ,a.v /IV-57e ' svAz��y�rvo TyE o�.�s�r. Ta EST,dI�L/.S,c,/ Lar' G/NE,,S i i t 9/16/03 Notice: This Form Is To-Be Used For the Repair Of Failed Septic Systems.Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM hereby certify that the engineered plan signed by me dated A 141 «'5 concerning the property located at Cti?n meets all of the following criteria: • This failed system is,connected to'a residential dwelling only. There.are no.commercial or business uses 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. The applicant may use historical data to conclude this fact or.may conduct deep test holes an&percolation tests at-the site without a health agent present. • 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-be located no less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 6 B) G.W.Elevation 3 +adjustment for high G.W. _ DIFFERENCE BETWEEN A an SIGNED:__ �, DATE: i �S NOTICE Based upon the above information;a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptie\Percexemp.doc 14 Permit Number: Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: `°�f Cn Lot No, �(��i Owner: \ Address: 4 Contractor: l ",.�'� Address:�?� Notes: ". —� ZNJ STEP 1 Measure depth to water table tonearest 1/10 ft. ................................................... � ........................... .Gate � mont Ida /year STEP 2 Using Water-Level Range Zone and Index Well Map locate site:and determine: OA Appropriate index well.................... OBWater level range zone ............................................. STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... (26 month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water•level zone (STEP 2B) determine water-level adjustment ............................... STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .......................... ....................... .., h Figure 13.--Reproducible computation form, 15 TOWN OF BARNSTABLE LOCATION AD( ::T E5 of/l SEWAGE #'72 �5"` VILLAGE t^ SSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S\CF QQ K, LEACHING FACILITY: (type) .Cc—1�W�iC� (size) 3� �C to t K t NO.OF BEDROOMS '3 BUILDER OR OWNER_ 5r-15M'C PERMIT-DATE: > lt � 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 Teaching facility), Feet Edge of Wetland and Leaching Facility(If any wetlands exist within'300 feet of,leaching facility) Feet Furnished by d �� Q < a9� tt paw Town of Barnstable �FZME Toy, Regulatory Services Thomas F. Geiler,Director * saRNSfABLB • 9� M� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 4/19/05 Designer: Shay Environmental Services, Inc. Installer: Robert Septic Services. Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street MA 02536 Yarmouth, MA On 4/15/05 Robert Septic Service was issued a permit to install a (date) (installer) septic system at#100 JAMES OTIS CIRCLE, CENTERVILLE, MA based on a design drawn by (address) Shay Environmental Services, Inc. dated 04/15/05 (designer) I certifythat the septic stem referenced above was installed substantial) according p y y 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' lateral relocation of the SAS or any 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 M1488 '---. oo� CAREMEN N U SHAY 'Iffstaller's Signature) No. 1181 FGlSTE� SANITAR\P� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE 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. Q:Health/Septic/Designer Certification Form TOWN OF BARNSTTABLE LOCATION `. D� ��NJ S CST1'S K0*f';, SEWAGE # f Vi``LLAGE — ( SSOR'S MAP & LOT ' INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY " -T \ 000 �A • LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUELDER OR OWNER PERMITDATE: 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 IA B C y r -10' min. from `NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. ALL OUTLET PtrES FROMTHE Existing Foundation E house to septic tank PROFILE VIEW OF ADDITION TO L DISTRIBUTION eox sHAu BE 1z - CONCRETE COVER D-BOX cover must be LEACHING SYSTEM SET LEVEL FOR AT LEAST 2 FT. I 13 iSeptic tank covers must be - } TOP OF FOUNDATION = ELEV. 100.00 (Assumed) within 6 in. of finished grade ``` T within 6 m. of finished grade f- 3 5 OUTLE • . ''�.''-`''i'- " (`,rode over Septic Tank - 99.00 Grade over D-Box - 99.00 de over SAS - 99.OU 3" of 1/8" - 1/2" Washed Peastone 2 KNOCKOUTS 3/4' to 1 1/2 Washed Crushed Stone r : , i OUTLET I (� 12• INLET ' 4• PVC(CAPPED) INSPECTION PORT TO BE / - 6• g ;. u S e 0.02 3 HOLE H-10 \ I t) INSTALLED AND TO BE WITHM! 6. OF GRADE 3' Maximum Cover .. S_001 DIST, BOX Top OF System- Dev. -96.00 u� 16' EXIST. or Greater v EXIST.PIPE n. 1,000.GAL: r 15, S� 0.01- per foot ttl" Effective Depth --15.5'--- 4".- SCH. 40 Te FROM EXIST. FOUNDATION rn SEPTIC TANK n 11 H-to N zo' PLAN SECTION CROSS-SECTION p � � 5 Units P 6.25' = 30' � CONCRETE FULL f'ouNDAno u, it iri rn 0.83' (10 inches) ` v a N 3, 3 agi a N 6 n'af 3/4--1 1/z � a N N 31.25' 3 HOLE H-10 DISTRIBUTION BOX SYSTEM PROFILE V •* NOT To SCALE c compacted stone > v m JAJ 37.25' �:,o Not to Scale - c u M 4' 4' 11 Effective Length m_�as v.ti«I.v flame n4nv I L0 c 4)S i 11'y W S❑IL ABS❑RPTI❑N SYSTEM (SAS) GENERAL NOTES 6 In.of 3/4"-1 1/2" q -_ compacted atone Q EPfective Width INFILTATROR HIGH CAPACITY (H-20 L❑ADING)/ GE❑RGE ❑'BRIEN NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE 0 1 Contractor is responsible for Digsafe notification . ® (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. OZ Bottom of Teat Hole 1 Oev.=68-Da - 2. The septic tank and distribution box shall be set w NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" Groundwater Obmved _ NONE OBSERVED- level On 6" Of 3/4"-1 1/2" Stone. - - 3. Backfill should be clean sand or gravel with no r stones over 3" in size. 4. This system is subject to inspection during installation PERCO I O T S� by Carmen E. Shay Environmental Services, Inc. -- /1 5. The contractor shall install this system in accordance with Title V of the Massachusetts state code, the approved plan Date of Percolation Test: APRIL 8, 2005 and Local Regulations. Test Performed By CARMEN E. SHAY, R.S., C.S.E. Results Witnessed By WAIVER(per Barnstable B.O.H.) 6. if, during installation the contractor encounters any soil conditions or site conditions that are different EXCAVATOR: Shay Environmental Services, Inc. Percolation Rate: Less Than 2 MPI ® 48" from those shown on the soil log or in our design installation must halt & immediate notification be Test Hole made to Carmen E. Shay - Environmental Services, Inc. No. 1 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. DEPTH SOILS El FV. 8. Instal( Tuf-Tits gas baffles or equals on all outlet tee ends: 0 Loay 99.00 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Sand oSS 10. All solid piping, tees & fittings shall be 4" diameter 10 YR 3/2 2��t Schedule 40 NSF PVC pipes with water tight joints. 0'-12' A 98.00 _- 1 (�(1^J^ r 1 U 1. Municipal Water is Connected to ALL OF The Residence and Abutting Loamy Properties Within 150 Feet. Sand 10 YR 5/6 THE PROPERTY LINES ARE APPROXIMATE AND 12"-27' B 96.75 COMPILED FROM THE SURVEY PLAN GENERATED BY - y BAXTER & NYE of OSTERVILLE, MA oomy Sand ., SITE PLAN OF LOT 609 JAMES OTIS ROAD, CENTERVILLE, MA" 2.5 Y 8/6 1 "� i 27"-38" c, s5.00l I DATED DATED JULY 8, 1985 28� .00' AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Medium IT SHOULD BE USED FOR NO PURPOSE OTHER THAN Sond THE SEPTIC SYSTEM INSTALLATION. 2 .4 132" C, 88.00 "- 25.5'--- �- �- EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE Failed NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE 10 Leach Pit FROM THE EXISTING LEACH PIT TO BE DISPOSED OF AS PER BOARD OF HEALTH SPECIFICATIONS. _ �;. { Box :.�.�. � WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY BUT ARE OVER 100' FROM THE PROPOSED SAS. Perc #1 Depth to Perc: 42" to 60" H ASSESSORS MAP 170 PARCEL. 104 TEST HOLE #1 Perc Rate= Less Than 2 MPI PROJECT BENCH MARK O Observed Groundwater None Obs -------_- I ELEV.- 99.00 LEGEND TOP OF FOUNDATION EXISTING U ELEV. 100.00 (Assumed) 7 -1000 GALLON _ _ ENCLOSED SEPTIC TANK � �\ o [Q4X 1 DENOTES PROPOSED DECK PATIO SPOT GRADE 2-18' DIAM. ACCESS MANHOLES e 6 DENOTES EXISTING _ .. 104.4 SPOT GRADE I x =� f EXISTING 3 BEDROOM '11 PL PROPERTY LINE 11 INLET - HOUSE ni n� ou ET 1 �96r f-- PROPOSED CONTOUR i CO #f 00 %.� �• THE DISTRIBUTION 0VEANDOR THE 6 COMPONENT I11 - - - - - - -97 EXISTING CONTOUR SET DEEPER THAN 6 INCHES BELOW FINISHED I GRADE SHALL BE RAISED TO WITHIN 6" OF STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE 1 ,p� - INSTALL TUF-ATE GAS BAFFLES OR EQUALS: I! � DEEP .TEST HOLE O(.. PLAN VIEW IL i 1 PERCOLATION TEST LOCATION 3-24• REMOVABLE cavERs ` LOT #603 _ 6 FOOT STOCKADE FENCE t i .r ♦ • its -' 4• 1 ii 3r min. clearance ; I is MtET r I I 15,600 Square Feet +/- f --- - I. INLET 1 J 8 min I 12 min. Inlet to outlet 6•m6. -. �f LI Id level OUTLET . ) <`' � Il ASPHALTI �_ C t. PLAN f 5. -7. 5' -r 1 DRIVEWAY I Cam.: i . 4'-0• min. uq"d depth -- ----------;---------- -: ------------ Q F PROPOSED SEPTIC SYSTEM U P G BA D E "a a I > 5.00 2 ' PREPARED FOR - 4 -10• CROSS SECTION END-SECTION I ; I --- ----- STEPHEN HAGWELL TYPICAL 1000 GALLON SEPTIC TANK -------=-------- -------- -� -------- ------------ ---------------------- 100 JAM ES AT CIRCLE NOT TO SCALE CENTERVILLE, MA I _ JA 1.'.l �J 0 7' tip`` R 0-A - --- Des'tgn Calculations PREPARED BY: - �� Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) (40 FOOT RIGHT OF WAY) ?� Y -7 Garbage Grinder: No a 'C 1 N �l1 R i'l l� 1 Y I . A�A Leaching Capacity Proposed: 330 Gal-/Doy Minimum (Min. Per Title V) cll/ Septic Tank : 2 x 330 Gal./Day = 660 USE EXIST. 1,000 GAL. Septic Tank. �H NVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch N Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. 273.8 gallons 0' BOX 627 Sidewali Area: 0.74 gal./sq, ft. x 78 sq. ft. 58 gallons 0 20 40 50 A.. �r'i TSRti EAST FALMOUTH, MA 02536 ryP� 'Providing: 331.80 gallons -- � -NITAR\ TEL/FAX 508-539-7966 Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, I SCALE: 1"=20' DRAWN BY: CES DATE: APRIL 14, 2005 TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' of WASHED STONE SCALE: 1"=20' PROJECT#SD724 FILENAME: SD724PP.DWG SHEET 1 OF 1 ON THE ENDS., NO STONE UNDER.