HomeMy WebLinkAbout0125 KNOTTY PINE LANE - Health 125, Knotty Pine Lane
'Centerville
Ar= 191 081
u
No. ? Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppliCation for Misposal 6pstem Construrtfon Pffmit
Application for a Permit to Construct( ) Repair(e_)-IJpgrade( Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.%-X$—kNo/Ty r i:�- Owner's Name,Address,and Tel.No.
Assessor's Ma /Parcel
p
In taller's Namg,Address,and Tel.No.3-a,6—�?'��^ V 7 3 8' Designer's Name,Address,and Tel.No. 3 G c�'Y7/—S
OS C�GI U� i/V/� /`/✓I�
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33>0 gpd Design flow provided 3 o gpd
Plan Date Number of sheets Revision Date
Title `
Size of Septic Tank �Ix( vV� �•�, Type of S.A.S. `off--vim®d
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ' 1_1991 1;W - "�✓�G1C
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. O
S' Date
Application Approved by Date v�
Application Disapproved by Date
for the following reasons
Permit No. Date Issued /J
- k
Fee
t _ i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
M
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
-' 21pplitation for VspoBal �6pstem Construction permit
Application for a Permit to Construct( ) Repair(/,)-'Upgrade(4 Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 'Ar kA16 try�i�/% �'� '/= Owner's Name,Address,and Tel.No. {
Assessor's Map/P,ar`cel/ Y^ 0$/ rl5rV1/11
.Installer's Name,Address,and Tel.No.S4�"�T��- 3$
Jos tO�Gi �� �`r4s�'O �, Designer's Name,Address,and Tel.No.
,s r'NGiNrr/'i�q cua141;
Type of Building:
r`
Dwelling No.of Bedrooms I Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures /
Design Flow(min.required) 330 gpd Design flow provided -3 `Y • gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 61� Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) :U/.SrA9// A11 Gtl ,{/_,^��fJx
2 —5'a 19
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 Board of Health. ..��
Signed :;wZ,-z' -O`er-'� Date
Application Approved by _ Date �>2C,
Application Disapproved by Date
for the following reasons
Permit No. ° d/ ^ 1'7 6? Date Issued //,Y
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded Abandoned
at . 5 �
-•-- -at / .> 641/IV /-ld'4--.2,410?:5. 4=1� asrbeen::eons�trruuc`teed in accordance f
with the 1provisions of Title 5 and the for Disposal System Construction Permit No.—b/- -/,tdated SAO//1
Installer lC/���G ��/"D� Designerj�/(�/,�1/%
#bedrooms Approved design flow (�! gpd
The issuance of this
per
mit
shall not be construed as a guarantee that the system will function as designed` (�
Date 1 _# Inspector �C 3
ro a
No. - U Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Misposal .6pstem Construction Vermit
Permission is hereby granted to Construct( ) Repair( 4 Upgrade( 4--Abandon( )
System located at /;2 S� �r/t/fJ/ -V ,4/1//.�"
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. `
Date �/; �� Approved by
,
az
J<i7l
Ems"
e 0;l
i 0
l'oWn of Barnstable
�pF�HE tp�
R.eguIatory Services
I Richard V. Sca.li Interim Director
"� nfasa i639. Public Health Division
�o
\ArF°ni Thomas McKean,.Director
200 Main Street,Hyannis, ix.02601
Office: 51B-862-404 t t x 50S..790•ti b=4
Installer & Designer C>ertifieation Form
sJ-s-1 t Date: Selvage Permit# Assessor's MapTarcel
I)esi ner: ,per-'na ids f.�i5 14tC Installer;
Address: C S clC! ci— Address: `d 4A.,v- hsl
On - 5 • �C ,,Vtwas issued a pe.rinit to install a
(date) _ (installer)
septic system at
based on a design dtra%vn by
{address)
�f1 n eer `n� l Ur; �Lts f br . dated 64
( esigner.
certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box:and/or septic tank. Strip out (i.f required) was inspected and the soils
W'Cre found,satisfactory.
—_— I certify that the septic system re.Perenced above Was installed with major i:hangcs (i.e.
greater than 10' lateral relocation ication of the SAS or any vertical relocation of any cornpoi ont
of the septic system) but in.accordance with State & Local Regulat.ion.s. Plan revision or
cent ffed as-built by designer to follow. Strip out_(if required) Naas inspected and.the soils
were found satisfactory.
_ — f certify that the system referenced above was constructed in wit,z the terrain
Of the 1',A approval letters (if applicable)d—
oa' Fp
- _.._ •� ENE m
( lsta`leer's Signature) GlvtL
%0 35108
REGIsTE� ,
(Designer s Signattir'e) (Affix. esigne, ``OFF ere}
PLEASE RETURN TO BARNSTABLE .PUBLIC HEALTH DIVISION. CERTIFICATE
OF t'O1IPLI:ANCE WILL NOT BE ISSUED UNTIL BOTH THIS FOR1I AND AS-
Bt.;1i.,T CARD ARE RECEIVED BY T'II.E BARNS"I'ABLE PUBLIC HEALTI-1. DIVI.Sh)4.
THANK YOU.
t1:',SeF;ii rlCs�nei C`erti.f�cction Form Rev
Engineers note:This certification is limited to an as-built inspection of system components as installed prior to backfilf. The
engineer did not supervise construction of the system.The installer assumes responsibitay for all materials,wortmarship,cackfiiling
to specified grades with proper compaction and setting risers'covers as shown on the design plan.
TOWN OF BARNSTABLE
f
J OCATION j,,jeh,,,:T rV 01 V,4 L,4.z._c SEWAGE#
VILLAGE (_ Q �p Nie% ASSESSOR'S MAP&PARCEL j q]-y.V
INSTALLER'S NAME&PHONE NO. Tne X- T Sc.;QT i'c
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) P -Sc)o GC (size) l 3 X
NO.OF BEDROOMS 3
OWNER e:YG►.0 r+ V G a,o�tr
PERMIT DATE: j�-2 _ 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 ' �c %�% i
�#2Acx
h.9L
Town of Barnstable Barnstable
P� 1'
' Inspectional Services ;e'Ea�j
8ARNbZASLE,
Public Health 9� sbsq. Pbli Hlth Division
m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
CERTIFIED MAIL#7015 1730 0001 4987 9644
April 23, 2019
GARDNER, BETHANY L
125 KNOTTY PINE LANE
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 125 Knotty Pine Lane, Centerville, MA was inspected on
04/03/2019 by Shawn McElroy, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Leaching facility with standing liquid level at or above the invert pipe (per
Town Code 360-20h).
You are ordered to repair or replace the septic system within two (2) years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
omas ean, R. ., HO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\125 Knotty Pine Lane
Centerville.doc
Town of Barnstable
.nxn,sraBi.E.
9� 6� ,�� Regulatory Services Department
.orED MA'S A
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
Keaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Knotty Pine Ln
Property Address
Bethay Gardner '
Owner Owner's Name U,
information is
required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
.F.
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed
above; the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
4-3-19
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
1=r'
1� Title 5 Official Inspection Form
�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
r I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) 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.
a. 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:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
•. Commonwealth of Massachusetts
3� Title 5 Official Inspection Form� io
• i�l Subsurface Sewage Disposal System Form Not for Voluntary Assessments
125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The se system has a tic tank and SAS and the SAS is less than 100 feet but 50 feet or
Y p
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
rl'•; fir'
125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool .
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
® ❑ 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
5i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
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 facilityor dwelling inspected for signs of sewage back u ?
9 P 9 9 P
® ❑ 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?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
7 Title 5 Official Inspection Form
�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 4-2019
Date
t5insp.doc•rev.7/28/2t118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
;Ci Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is Centerville MA 02632 4-3-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
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 below):
3. Pumping Records:
Source of information: Owner---pumped 10-2018
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons -
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
f
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1980's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 30"feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Knotty Pine Ln
,I
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
24"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
6r
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
26""
Scum thickness 0
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
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f w
z,,_•T,;;, 125 Knotty Pine Ln
Property Address 3
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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.):
8. Tight or Holding Tank (tank must be pumped at time of i nspecti on)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Knott Pine Ln
1. •T,_, Y
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
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
9. Distribution Box(if present must be opened)(locate on site plan):
I
Depth of liquid level above outlet invert N/A
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
/ Title 5 Official Inspection Form
0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r a r1
125 Knotty Pine Ln
Property Address _
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: . ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
0I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Knotty Pine Ln
Property Address I
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town I State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was fillled beyond capacity and into riser at inspection.
12. 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
f
Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f /+N
125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
C Commonwealth of Massachusetts
r� Title 5 Ofi'icial Inspection Form
5 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1._ 125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewalge Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or be i chmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attalched separately
Uo
D.
�. 3 �, :46
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 or 18
' r Commonwealth of Massachusetts
Title 5 Official Inspection Form
0t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y ry
125 Knotty Pine Ln
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
s Commonwealth of Massachusetts
Title. •, 5 Official Inspection Form
� ws
i'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`Fs r. •T,r�
125 Knotty Pine Ln i
Property Address
Bethay Gardner
Owner Owner's Name
information is required for every Centerville MA 02632 4-3-19
page. City/Town I State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certificatlion: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure iriteria) and 6 (Checklist) completed
D. System information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Ex l lanation of estimated depth to high groundwater included
p 9
t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
T�JNi!0�"BAISTABLE
SEWAGE#
Z,pCA'�LQN 'f
c°�� �U t�l e ASSESSOR'S M"&LQT
II�STP i i..E 'g:NAlir & ' i4tdE No
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MACfi)N I�. ACII 'X (ty } (side);
o 'off si ni .00
WILD R OR
P3ERMUDATE G(31vIPLI NCE:DATE'
Separation Distance Between:Eire Fee4
iv(axiaum AdNsted Groundwater Table to the Bottom of PIP,€ity
Pnvate g�atargupplye11 andg F ��wills exist
mac:
un silo ar vntiva.?.00 feet of ieaciting far�izy)
Edge o€wetaad ancl'I.cachiag T�aal�ty(if any wetlands exist Feet
vnthla 3oo fec of:teaciiins f Y� G
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Town.of Barnstable P#VHWE
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Departinentof Regulatory Services. 'tJ
]Public Health Division "MAn
_ Date
200;Main Street,Hyannis MA 02601 I p3
�a►rub� r .�+
Ma.
Date Sclieduled 1✓
Time Fee Pd.
( U d
Soil Suitability Assessment for ,Sewn e disposal s
Performed By: Pe Cr' C �Q- �"l✓-1'� Witnessed By:
LOCATION&t GENERAL INFORMATION
Location Address Owner's Name �1
1 Z S l�n.cs C, Y1 C
c1t V) v►1 t? Address 1'ZS lac N -i p c/*�
Assessor's Map/Parcel:
Engineer's Name
NEW CONSTRUCTION REPAIR Telephone`# _s� — f 77—�3('�
Land Use S�o�Q �-C t I Slopes(4'o) 3 Surface Stones
Distances from: Open Water Body r S ^- •ft Possible Wet Area/"d�4 ft Drinking Water Well 7/-S'� ft
Drainage Way / G—e ft Property.Line S t t/ ft Other ft
SKETCH:(Street game,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
1�t
/ ®d
2 1
a .. .y ..,....: _� _....., _�._ ._._.____._.. .. _ __ ...... .. .... . ..
Ka L)SA
Parent material(geologic) Depth to.Bedrock.
Depth to Groundwater. Standing Water in Hole: a - Weeping from PltFrace
Estimated Seasonal High Groundwater . a f ✓ Z
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing td obs.hole: _____ la. Depth to Soli motties; in. -
Depth to weeping from side.of obs.hole: in, Groundwater Adjustment at.
Index Well.# Reading Date:. Index Well level r Adi,factor _•Adji.0mundwater l.duel
PERCOLATION'TEST Date Thee
Observation
Hole# �1 Time at0"
Depth of Perc -Z�S�\k,,^ Time at 6"
Start Pre-soak Time Q 'rime(9"-6")
End Pre-soak
Rate Min:/Inch. G -z"
Site Suitability Assessment: Site Passed . Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Iiole Data,To Be Completed on Back-----------
4**If percolation test is to:be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:ISEPTIC\PERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole# t
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(Ia.) I (USDA). (Mansell) Mottling '(Structure;Stones;Boulders.
Consistencv. Gravel)
"
I
DEEP OBE ERVATION HOLE LOG Hole# Z
Depth from Soil Horizon' Soil Texture Soil Color Soil, Other
Surface(in.) (USDA) (Munsell) Mottling (Structure„Stones,Boulders.
,-- Consistency.% ravel
7- ! -,�d i a°f 1L wiz
Vkj
36.-�3z
i
DEEP OBSERVATION HOLE LOG Hole#
Depth.from 5oil,Horizon Soil Texture Soil Color Soil Other '
Surface(in.) — (USDA) {Mansell) Mottling (Structure,Stones,Boulders.
n iste ngy,9b Grave
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Sal Color soil Other
Surface(in.) (USDA) (Munselq ._ Mottling (Structure,Stones,Boulders.
Consi ten ra
Mood Insurance.Rate MI F:
Above•500 year lIJ'boundary No_ Yes-9-1 4
Withim500 yeariwundary 'No. Yes
Within lOb yearflald boundary No Yes .. o
Depth of Naturally Occ rrin2r 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? Ye f
If not,what is the depth of naturally occurring pervious material? r _
Cert-fication I certify that on -
I have passed the soil evaluator examination approved by the
• l (date)
Department of Environmental Protection and that the above analysis was performed by me consistent with
the.required tr ' ` g,'ex j'ertise and experience described in 110 CMR
Signature
Date '� Z
QAS,SPTlC1PERCF0RM.D0C
No. `®'� —3,t; N Fee IOd
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V/
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftpYication for Misposal 6pstrm Construction Permit
Application for a Permit to Construct( ) Repair()6 Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components
Location Address or Lot No. ().5 KNo'Y P(u6 0W 6_ Owner's Name,Address,and Tel.No.
Cc�YtE�veeC.� DGTNA,vY 44P_bNF�
Assessor's Map/Parcel 1X'5 KuDT?Y P lXl€ LiQ CEyj-rC"�-v!�
Installer's Name,Address,and Tel.No.S08—47`7—,;?87 7 Designer's Name Address,and Tel.No.
OAPCwt p6 La./rW[kcsiSS U-C N
i A
s S
Type of Building: p� �
Dwelling No.of Bedrooms 1' Lot Size �D1�5� sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) IY A gpd Design flow provided �� gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
RU466 U)L)6� EAU4 HOUSE; I2 5(:T 'd_'v, 7540 C,
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 Date T/� /
Application Approved by Date
Or
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
Fee wV
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_
Yes
PUBLIC HEALTH-DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2ppYication.for Misposat 6pstrm Construction Jermit
Application fora Permit to Construct( ) Repair(X 'Upgrade( ) .Abandon( ) [:]Complete System ❑Individual Components
Location Address or Lot No. (as 1<N077 y (fit)J6 Co WC-' Owner's Name,Address,and Tel.No.
CCA.rTER-11,_L6_ 13F_-rt4A" / CARIOPEIZ
Assessor's Map/Parcel /9/ O (15 uDT'7 P j)u L]V GE1JT&.V(L
Installer's Name,Address,and Tel.No.508-47'7-S87 7 Designer's Name,Address,and Tel.No.
�K�ss c c c NIA
Type of Building:
Dwelling No.of Bedrooms Lot Size 1(0,553 f sq.ft. Garbage Grinder( )
�- Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures A
Design Flow(min.required) NA gpd ,�„Design flow provided #4 gpd
Plan Date Number of sheets Revision Date
P Title 'r
" Size of Septic Tank Type of S.A.S.
Description of Soil
^4
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
r
Compliance has been issued by this Board of Health.
Signed Date
1�
Application Approved by Date 1 12-v)
Application Disapproved b Date
for the following reasons
Permit No. Date Issued
Tli E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
` Crrttftrate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( )
Abandoned( )by CI04&w&,t�
at 1,45 ��u C/L,- LA/ CCN7i<l.L�l(CL has been constructed in accordance
T
with the provisions of Title 5 and the for Disposal System Construction Permit No. I - dated 12 Zv 1
i
P P
°f 3
Installer C 0ael bil-_ 91122[PA0( e, Designer
#bedrooms AIA Approved design flow gpd
The issuance of this pe it shall n t be construed as a guarantee that the system it funn.tion as�designed. 0
Date Inspector i;091/%! fv
No.7p I 3'�� � Fee��Dl7oJ
C/ ,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
;Disposal *pstem Construction permit
Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( )
System located at I aS K1'JO`--7'y P1 IJ —_(_}�JE= C ]� L✓LCL�-
and as described in the above Application for Disposal System Construction Permit. The applicant recognized hi duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Co struction must be completed within three years of the date of this permit.
Date Approved by
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
ff DEPARTMENT OF ENVIRONMENTAL PROTECTION
w F
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A RECEIVED
CERTIFICATION
Property Address: 125 KNOTTY PINE LANE CENTERVILLE, MA 02632 �� MAY 1 4 2002
Owner's Name: WALT KAPLAN ,
Owner's Address: 125 KNOTTY PINE LANE CENTERVILLE, MA 02632 TOW►NEOF B NSTABLE
Date of Inspection: 3/28/02
Name of Inspector: (please print) JOHN GRACI �
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O..BOX 2119 TEATICKET, MA. 02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
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:
X Passes
_ Conditionally Pas es
_ Needs Furthe aluation by the Local Approving Authority
Fails
Inspector's Signature: 1� Date: 3/28/02
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspecti n. 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."file original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERT'TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****This report only describes conditions al the time of inspection and under the cuudiliuus of use 111111111 lime. "Phis
inspection does not address how the,system will perform in the future under the same or different conditions of use.
,
w
Ti11P S Incnartinn Fnrn, /,/I s/?non '
Page 2 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 125 KNOTTY'PINE LANE CENTERVILLE, MA 02632
Owner: WALT KAPLAN
Date of Inspection: 3/28/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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 oe 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.
n/a The septic tank is metal and'ove120 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: n/a
n/a 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: n/a
n/a 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
do
ND explain: n/a
s
' Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 125 KNOTTY PINE LANE CENTERVILLE,MA 02632
Owner: WALT KAPLAN
Date of Inspection: 3/28/02
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 n/a
**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:
n/a
f
Page 4 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 125 KNOTTY PINE LANE CENTERVILLE, MA 02632
Owner: WALT KAPLAN
Date of Inspection: 3/28/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or.clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped PUMPED 3 112 YEARS AGO BY OWNER.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is,less than 100 feet but greater than 5G ieet 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 ffacility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this forma
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design : ow 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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
_ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)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
"ves" in Section D above the large'system has failed. The owner or operator of any large system considered a significant threat
under Section L or failed under Section D shall upgrade the system in accordance with 3.10 CMlt 15.304. I he syslcni owner
should contact the appropriate regional office of the Department.
a
Page 5 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 125 KNOTTY PINE LANE CENTERVILLE, MA 02632
Owner: WALT KAPLAN
Date of Inspection: 3/28/02
Check if the following have been done. You must indicate "yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period`?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection '?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site'?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if ahy-of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
S
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 125 KNOTTY PINE LANE CENTERVILLE, MA 02632
Owner: WALT KAPLAN
Date of Inspection: 3/28/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 'Number of bedrooms(actual): 3
DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no):NO
Water meter readings, if available(last 2 years usage(gpd)): nl% 2,WU— I_j G(Z Z)
Sump pump(yes or no): NO 1b Z �on-0
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 31.0 CMR�15.20.3): n/agpd
Basis of design flow(seats/per'sons/sgft;etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the'Titie 5 system(yes or no): NO
Water meter readings, if available: n/a,
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records fi°
Source of information: PUMPED 3 1/2 YEARS AGO BY OWNER
Was system pumped as part of the inspection(yes or no): NO
If yes, volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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): n/a
Approximate age of all components,dateinstalled(if known)and source of information:
1972 RV OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
I
I
Page 7 of I I t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 125 KNOTTY PINE LANE CENTERVILLE, MA 02632
Owner: WALT KAPLAN
Date of Inspection: 3/28/02
BUILDING SEWER(locate on site plan) '
Depth below grade: 42"
Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 36"
Material of construction: Xconcrete metal fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a 'Is age.con rmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: IOOOG L 8' 6".H 5'.7',W 4' 10""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle:0"
Distance from bottom of scum to bottom of'outlet tee or baffle: 0"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFUL LIFE.
GREASE TRAP:_(locate on site plan) .
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recQmmelldat,ions,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage;etc.):`
n/a
•o
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 125 KNOTTY P1NE LANE CENTERVILLE,MA 02632
Owner: WALT KAPLAN
Date of Inspection: 3/28/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:n/a
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.):
n/a
PUMP CHAMBER:_(locate on site plan)
i
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
n/a
G
R
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 125 KNOTTY PINE LANE CENTERVILLE, MA 02632
Owner: WALT KAPLAN
Date of Inspection: 3/28102
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF
FAILURE. PIT HAS NEVER HAD MORE THAN 3' OF LIQUID IN IT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
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: 125 KNOTTY PINE LANE CENTERVILLE, MA 02632
Owner: WALT KAPLAN '
Date of Inspection: 3/28/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
I
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LIDS
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I 0 GI
C-
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AC a`/�
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Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 125 KNOTTY PINE LANE CENTERVILLE, MA 02632
Owner: WALT KAPLAN
Date of Inspection: 3/28/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record - If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,'installers-(attach documentation)
NO Accessed USGS datat ase-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+ FT.
P�}
�D
t
T OF BARNSTABLE
ION 0� O SEWAGE #
�* LAGE ASSESSOR'S MAP & LOT �iI-00
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) r a� lI!1 (size)
NO. OF BEDROOMS
BUILDER 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 facilitynr Feet
Furnished by
e ,
AA) S�^
n� 13
�$ �q o
AQ A Q i
C
6p,) L
Cc asp
® C �°N
TOWN OF BARNSTABLE
LOCATION � � rc �► SEWAGE #
iLAvE zi?w60IVrIle- ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. i',hM 44 D0/Q Cy0-"
Y t
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: 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 of leaching facility) Feet
Furnished by
U
d
�F
f
I �
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS
NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must.first obtain the necessary
signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL., 367 Main Street,
Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law.
Fill in please: - Date: M c �,o
APPLICANT'S NAME: Q„
�' YOUR HOME ADDRESS:
AAA p
70
' BUSINESS TELEPHONE # HOME TELELPHONE #: 3 ti► � e-
. ,
NAME OF CORPORATION`.
NAMLOF NEWISUSINESS_C.rj�g=
TYPE OF BUSINESS
IS THIS HOME OC6UPATION? NO
ADDRESS OF BUSINESS_ri25 0„Q MAP/PARCEL NUMBER (Assessing)
. �j�Cob I��yoao
When starting a new business there are several things you must do to be in compliance with the rules and regulations of the. Town of
Barnstable. This form:is to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth Rd.
& Main Street)to make sure you have the appropriate permits and licenses required to legally operate your business in-town.
1.. BUILDING COMAkISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
_ Auth rized Signature**
COMMENTS:
a.
2. BOARD OF HEA4TH
This individu6ji ha een inf the p r if'require ents that pertain to this type of business.
Authorized nature**
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTRORITY)
This individual.has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
1
� y -
LEGEND
N
—— 98 —— EXISTING CONTOUR
_
x 100.98 EXISTING SPOT GRADE o Moon Penny
G EXISTING GAS SERVICE Ln
W EXISTING WATER SERVICE s v 3 � Z
r
TEST PIT '9a Y
BENCHMARK �01' Mene sha Ln °=T
LCP 32g57 B o0
L
LOCUS
Woodvole Ln Co(\eton `n
C
•o
PROPOSED S.A.S.
2-500 GALLON CHAMBERS
SURROUNDED W/4' STONE LOCUS MAP
NOT TO SCALE
S 11'31'40" W
100.00'
x 101,22 x 1 .59
15' 1-2;1 ?) TP-1
.: 18, 10 �:.JTP-2
FIRE PIT�REA
BENCHMARK '-= NOT DISTU B
TOP SONO TUBE 10L61
EL.=102.17 1 lam \ x 1
/ \ N
EXISTING LEACH PIT IBM
DEC `'ram x 100,63
TO BE PUMPED, FILLED
WITH SAND & ABANDONED SHED 0�.14 \ EXISTING SEPTIC TANK
( \ 0 (TO REMAIN)
TOP OF TANK, EL.=100.03f
BRICK SUN INV.(OUT)=98.70±
/ PATlO ROOM
z
102.22
C EANOUT \,Cn OD
102.04 m ONo
a ,'1,02,29 BH x 101.61 C�; No
100 N
60
z EXISTING
102.44 HOUSE(#125)
T.O.F.=103.04 + 101.69
102,33 HM
x 101.96
102 42 r LOT 12
,:.�.
L MP n 16,500±S.F. + io
00
01.63 a �F�q y% .84
. � 101,24� A� /
x 100.69
/ 0.0
100.50'
` W
CONCRETE TRANSFORMER
05 5, �g`00" :.::�. �, 98,95 FOUNDATION
—5 �— edge of Pavement
99,56
99.79 PI NE LAN
KNOTTY
100,11
of AOS PARCEL ID: 191 -081
o� PETER T. ti� PROPOSED SEPTIC SYSTEM UPGRADE PLAN
McENTEE 125 KNOTTY PINE LANE, CENTERVILLE, MA
CIVIL
o. 35109 Prepared for: Bethany Gardner, 125 Knotty Pine Ln, Centerville, MA
G/ E OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO.
GARDNER, BETHANY L Engineering Works, Inc. 1"=20' P.T.M. 165-19
125 KNOTTY
OT E, PINE
MA 0ROAD
2 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO.
CENTE (508) 477-5313 4/25/19 P.T.M. 1 Of 2
r
NOTE: TO PREVENT BREAKOUT, FINAL GRADE
SHALL NOT BE AT, OR BELOW, EL.=98.5
SEPTIC TANK PROPOSED D-BOX FOR A DISTANCE OF 15' FROM THE EDGE
OF THE PROPOSED S.A.S.
INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT PROPOSED S.A.S.
OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE
INSTALL RISER & COVER OVER ONE CHAMBER AND
T.O.F.=103.Ot SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT
F.G. EL.=102.Ot F.G. EL.=101.9t F.G. EL.=101.6t F.G. EL.=101.7t
MAINTAIN 2% SLOPE OVER S.A.S.
5
t48*
L = 30' L = 13'
® H0(PVC) @4•SCH40(VC) 2" LAYER OF 1/8" TO 1/2"
DOUBLE WASHED STONE
as $ as (OR APPROVED FILTER FABRIC)
14" s 2' EFFEXISTING LIQUID DEPTH-1 BaOEM a ---3/4" To 1-1/2- DOUBLE
LEVEL 4' 4.8' 4' WASHED STONE
GAS � INV.=98.30 PROPOSED INV.=98.13
INV.=98.70t D-BOX EFFECTIVE WIDTH = 12.8
EXISTING INV.=98.00
EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS
SURROUNDED WITH STONE AS SHOWN
NOTES: H-10 RATED
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP CONC. ELEV.=98.8t
INVERTS, PRIOR TO INSTALLATION. BREAKOUT ELEV.=98.50
INV. ELEV.=98.00 ease
2 -BOX SHALL BE SET LEVEL AND TRUE TO eases
GRADE ON A MECHANICALLY COMPACTED SIX aaaaaaaaaaa
aaaaaaaaaBa
INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.=96.00 Lw
310 CMR 15.221(2). 4' 8.5' 4'
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 4' OF NATURALLY OCCURRING VARIES-REFER TO SKETCH
PERVIOUS MATERIAL -
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 5' (MIN.) ABOVE G.W.
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. LEACHING SYSTEM SECTION
NO G.W., EL=90.4 -
SEPTIC SYSTEM PROFILE
N.T.S.
r///b,kK OF HOUSE
GENERAL NOTES:
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER.
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
LOCAL RULES AND REGULATIONS.
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE SUN
DESIGN ENGINEER. 1R010m
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ENGINEER BEFORE CONSTRUCTION CONTINUES. '7 _
5. ALL ELEVATIONS BASED ON AN ASSIGNED DATUM. CK
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF N �j
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. �
8. THERE ARE NO WELLS WITHIN 100' OF THE PROPOSED S.A.S. a'- --0j- GO
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS _J
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE ( '
DIRECTED BY THE APPROVING AUTHORITIES.
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING SEPTIC LAYOUT S.A.S.
CONSTRUCTION.
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
IN THE AREA AND FOR 5' ONOF
REPLACE WIITTHB CLEAN HSAND AS SPECIFIED ALL
IN SIDES
MR THE
5(3).S. AND SOIL LOG
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE DATE: APRIL 24, 2019 (REF#15,961
INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. SOIL EVALUATOR: PETER MCENTEE PE(SE#1542)
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND WITNESS: DAVID STANTON R.S. HEALTH AGENT
NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH
101.4 0 101.5 0
FILL FILL
100.9 . A 6" 100.9 A 7"
LOAMY SAND LOAMY SAND
10YR 4/2 10YR 4/2
100.4 B 12" 100.4 B 13" .
DESIGN CRITERIA LOAMY 10YR5/6D LOAMY 10YR5/6D
Tr______ 'T 98.9 28" 99.0 30"
NUMBER OF BEDROOMS: 3 BEDROOMS j 1 BOTTOM AREA I I C � PER28"/46 C
SOIL TEXTURAL CLASS: CLASS 1 320.0 S.F. 00
DESIGN PERCOLATION RATE: <2 MIN/IN �� r--�� COARSE SAND
COARSE SAND
DAILY FLOW: 330 GPD �----J 3'7 2.5Y 6/4 2.5Y 6/4
DESIGN FLOW: 330 GPD
I--12.8' 5% GRAVEL 5% GRAVEL
GARBAGE GRINDER: NO 8'S
EXISTING SEPTIC TANK:1000 GALLON CAPACITY PERIMETER=75.6'
SAS DIMENSIONS 90.4 132" 90.5 132"
LEACHING AREA REQUIRED: (330 GPD)=445.9 SF SKETCH PERC RATE <2 MIN/IN. "C" HORIZON
.74 GPD/SF NO GROUNDWATER ENCOUNTERED
USE 2-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN
SURROUNDED BY 4' DOUBLE WASHED STONE-ALL SIDES 125 KNOTTY PINE LANE, CENTERVILLE, MA
SIDEWALL AREA: 76.4'(PERIMETER) x 2'(EFF. DEPTH) = 151.2 SF Prepared for: Bethany Gardner, 125 Knotty Pine Ln, Centerville, MA
BOTTOMAREA:............................................................... = 320.0 SF
Engineering by: SCALE DRAWN JOB. N0.
TOTAL AREA:.................................................................. 471.2 SF Engineering Works, Inc. N.T.S. P.T.M. 165-19
DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
(508) 477-5313 4/25/19 P.T.M. 2 Of 2