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HomeMy WebLinkAbout0214 KNOTTY PINE LANE - Health 214 Knotty Pine Lane Centerville F/R 191 025 r J r 115 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for �Digaar bpotem Construction permit Application for a Permit to Construct( )Repair('Upgrade( )Abandon( ) O Complete System Xdividual Components Location Address or Lot No. t,Q I Lf L^j Owner's Name,Address and Tel.No. Assessor's Map/Parcel M Installer's Name,Address,and Tel No. Designer's Name,Address and Tel.No. STcean't _ b V 0�+i on?i�1 V.wV} z,o V aX 6a�, �a FQ t m a A f Type of Building: s4 0,4?(.. 1 Dwelling No.of Bedrooms Lot Size 1�Tsq.ft. Garbage Grinder( jk- Other Type of Building K(er>0_ No. of Persons + Showers(✓) Cafeteria( 141 Other Fixtures . -�.: Design Flow C3 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets I Revision Date Title ` Size of Septic Tank I,00 Type o S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1-, 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 e n ironmental Code and not to place the system in operation until a Certifi- cate of Compliance een rs by this B ar Health. Sign Date Application Approved by Date Application Disapproved for the following reaso 64__`�_ Permit No. `� Date Issued c.. r ':w- .i"r. _, .,,,n..r...fir..+.. _.�- a�' •"cs .. « .,. . .. � .. 'S /"" r vkN•o.� � r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: '1 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE MASSACHUSETTS Yes Zipplication for -Migo9ar *p5tem Construction Permit F .Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System Individual Components Location Address or Lot No. (�-; C,Aj Owner's NA,�5 Address Tel.No. Assessor's Ma /Pazcel ,M A (4�' C.. Installer's Na�ge,Address,an del.moo, Designer's Name,Address and Tel.No. 5:w o f �S ce �jk-�c� c�u►cor,t �0� SACS• S--r-�. 1,0 ,, �.0 f ox 6�� , �', Fa 1 maA-4\1 M A Type of Building: -O-4 FG Dwelling No.of Bedrooms Lot Size` -167�k sq. t. Garbage Grinder(IJ/p, Other Type of Buildi No. of Persons Showers(0"') Cafeteria Other Fixtures l.r r- 51 0);Z- � La U C:� Design Flow v gallons per day. Calculated daily flow 33 gallons. Plan Date 2) of k .. Number of sheets ( Revision Date Titlern � ` Size of Septic Tank G` Type of S.A.S. 5 M fl L 1)'RKZS Description of Soil CQ'+ Nature of Repairs or Alterations(Answer when applicable) t` Date last inspected: t Agreement: The undersigned agrees to ensure the cons, uction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Ti le 5 of/hnvironmental Code and not to place the system in operation until a Certifi- cate of Compliance s�bel�en is uh b this B ar of Health. Signe, a /1V.�" Date Application Approved by 6111/`�n U f��fI �� �I ' Date Application Disapproved for the following reaso s v Permit No. J' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFthat the On-site Sewage Disposal System Constructed( )Repaired (x )Upgraded( ) Abandoned( )by 52946O at 2' t<) O1'kH ;tg Ntw (r� r•1Ti .y�+ �.E ha,been constructed i accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. `d•t0 t/ S 1 dated J� 3/ u 4, Installer ' c�bec S �--a � Designer Ef-,V t V-On � The issuance of th�'j pe it shall not be construed as a guarantee that the to w,i 1 nction s designred. { Date 1 i T U�' r Inspector �N• V r —— No. —�D% ---------.--------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migoat &pgtem Construction permit Permission is hereby granted to Construct( )Repair(X)Upgrade( )Abandon SS ) System located at Z`L+ I CE n4p_c-U.(le and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructio m s o t d ithin three years of the date of thi Date: Approved by s `1 j� TOWN OF BARNSTABLE C LOCATION �I 1�NEJtT`F SEWAGE VILLAGE `S-fir ASSESSOR'S MAP &LOT C" INSTALLER'S NAME&PHONE NO^ a> SEPTIC TANK CAPACITY LEACHING FACILr Y: (tyl� (size) c Flo r�10 NO.OF BEDROOMS BUILDER OR OWNER if TzMC� PERMUDATE: COMPLIANCE DATE: Q 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 LAZ dC� r1 f Town of Barnstable Regulatory Services Thomas F. Geiler, Director BARNSTABLE, MASS1639. `0$ Public Health Division p'F01A0'rA Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Designer: sy)� &U1M,0WM-kq Installer: � � �C. Address: r r` �( (� Address: On 6\9Z(4_ Cwas issued a permit to install a (date) (installer) septic system at CQ04Z11iNbased on a design drawn by // (ad ess) Ul dated 1i JV4 esigner) r— T� I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' 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. (H OF MqS (Installer's Signature) moo? CAR. EN y�N u SHAY No. 1181 esigner's Signature) (Affix De ��,� ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVIS N. 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 r TOWN OF BARNSTABLE _ LQC_Ai1ON �I lwl3TT`F tY - SEWAGE # VI►QLAGE Y ASSESSOR'S MAP & LOT r INSTALLER'S NAME&PHONE NO : u n SEPTIC TANK CAPACITY 'Zjt=G _LEACHING FACILITY: (type) ,_ (size) NO.OF BEDROOMS BUILDER OR OWNER PBRMTI'DATE: 3 COMPLIANCE DATE: a 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 � _. �- . D x .. ���� �' � F r �C( f , mil` - '. V�' 3�3� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a� TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 214 Knotty Pine Lane Centerville, MA 02632 4SSESS0Rs*w Owner's Name: Mary Webster Q Jyo. Owner's Address: Date of Inspection: July 9, 2004 Name of Inspector: (Please Print) James M. Ford FAILED INSPECTION Company Name: James M. Ford Mailing Address: P.O. Box 49 Osteryft MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT l 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 Fu her Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: July 13, 2004 The system inspector shall sub 4a 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: 214 Knotty Pine Lane Centerville, MA Owner: Mary Webster Date of Inspection: July 9, 2004 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 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 214 Knotty Pine Lane Centerville, MA Owner: Mary Webster Date of Inspection: July 9, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ 214 Knotty Pine Lane Centerville, MA Owner: Mary Webster Date of Inspection: July 9. 2004 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 i Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level-in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] 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-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 "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 214 Knotty Pine Lane Centerville, MA Owner: Mary Webster Date of Inspection: July 9, 2004 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 15302(3)(b)]. 5 i Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 214 Knotty Pine Lane Centerville, MA Owner: Mary Webster Date of Inspection: July 9,'2004 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: 1 Does residence have a garbage grinder(yes or no): Yes 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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Qpd 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 information: Unavailable 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: Approximately 1981 -per owner 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: 214 Knotty Pine Lane Centerville, MA Owner: Mary Webster Date of Inspection: July 9, 2004 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: 2' 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: 3" 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: 12" 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 liguid 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 214 Knotty Pine Lane Centerville, MA Owner: Mary Webster Date of Inspection: July 9, 2004 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 broken down structurally. Dirt was caving in on the sides. The D-box needs to be replaced. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 TOWN OF]4A.RNSTABLE LOCATION all zr•� J A L SEWAGE # VIt LAGS �;Q�►at�.,II� ASSESSOR'S MAP,& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I OM LEACHING FACILITY: (type) Pn— Cox�J (size) /M NO. OF BEDROOMS BUILDER OR OWNER M4 PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching f cility) Feet Furnished by 4 S'0Cc. Iin i a � a3 I a O L 0 CATION SEWAGE PERMIT NO. VILLAGE �d 7— 72 a e�? ksL��T;-r-V I N S T A LLER'S NAME i ADDRESS GUILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED h 1 � e k. Pi-I, I 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: 214 Knotty Pine Lane Centerville, MA Owner: Mary Webster Date of Inspection: July 9. 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000Qa1.) 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 4'of water on the bottom. The scum line was up to the inlet pipe. The leach pit was in hydraulic failure. 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 a �•'s Page 10 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 214 Knotty Pine Lane Centerville, MA Owner: Mary Webster Date of Inspection: July 9, 2004 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 3 aq 10 0 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 214 Knotty Pine Lane Centerville, MA Owner: Mary Webster Date of Inspection: July 9, 2004 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 maps, 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 1VoL Fiz$.....J�_4.. ....�....... l THE COMMONWEALTH OF MASSACHUSETTS BOAR® F- .H AXTH Appliratiaan for Mipaaiittl Work aaniitrnrfiaan rruti# Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System a ........................ .......................... ..... ....... p ............ oc�tion l,,ddress oa Taot No,P°_ .... fw..�.... .� �.. .__..._. Y.......... ......�k_ _-_ .�. ._.. .yet_.._....(,��.�.�......-....,I\.�. .-_ ` ner Across a --------•--•....._.. Installer ddress UType of Building ze Lot____.. .__.__}.fit _Sq. feet Dwelling—No. of Bedrooms_______________ Expansion ttic .( ) Garbage Grinder ( � Other—Type of Building ___ No. of ersons___.___ Showers — Cafeteria a Other fixtures -----•--•------ --------------- . -------------•------- -•---•- W Design Flow...............��_____.__.____gallons per person per day. Total daily flow......... _.__ _..4_...............gallons. WSeptic Tank—Liquid capacityZgallons Length................ Width................ Diameter................ Depth __________-. x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area_.Z ..sq. ft. Seepage Pit No_____________________ D meter._._.._.._...__.___. Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box Dosing tank ( ) '-' ' t' Date_._a Percolation Test Results Performed by.. .... ? �1�42A/ Test Pit No. 1.�•-__ _..minutes per inch Depth of Test Pit.... Depto ground water.la/.� �e r Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil......... ._� -.,,..� _ _____t,�__ /1, F,�___ C� /. ... ram C ............................................ W --------------------------------- ��.��. •- -- � _,�� UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ------------------------------------------------•-•------------------------......•-•-•••••--•-_•••-----...__...•--•--------•--•---------•••••-•-------••---••••••--•-•-•---•----••---•...........•-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of=11E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate o� i has been issued ed b t ,-b��f lalth �^ - p /� Compliance �OQ r ate Application Approved By............. �._....__ .. . Z �j •--_ -•---••--•--•---•-•-•-- Date Application Disapproved for the following reasons:................................................................................................................ ---•----------•-----•-----•-•----•----------•----•-•-•--------------------•-••------•_--••••--•-.........._.....•-•...----••------•---------•-•--•-•---------•---------------------•--••................ Date PermitNo....................z--------••-------------------------- Issued....................................................... Date No_010- Frzs...........74 0'" THE COMMONWEALTH OF MASSACHUSETTS BOA R D,T 1-1 E<A I/}{T, H ,� ---••--•......................................... Appliration for Bispoottl Work omitrnrtion Vamit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at ......G�4t. J ...... --- .................e*"•�- - - --- .......... .---•--. dressoca ` orwLot No. .L . d_'•--- A O . , ..................................... r �.- ----wc --------. ner Ad t j nsta er ddress Type of Building ize Lot............................Sq. feet Dwelling—No. of Bedrooms................ ...............Expansion ttic ( ) Garbage Grinder Other—Type T e of Building ersons....... ........... a ,�• YP g ----------•--•-•-----------. No. of P ._. Showers ( �) — Cafeteria ( ) d Other fixtures ----------------- - W Design Flow...............�. _...............__.gallons per person per day. Total daily flow._....... .L __.__._._.._--_gallons. WSeptic Tank—Liquid'capacityl�! gallons Length............... Width................ Diameter................ Dep . x Disposal Trench—No..................... Width.................... Total Length.......:............ Total leaching area.__��_. --sq. ft. Seepage Pit No.__--•_---_----__•• D eter.................... Depth below inlet.-..........-....... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank .( ) /,, , . Percolation Test Results Performed by----_-----�—L{�`'�'� o%�� ""—'7 Date---,;'� � - :l Test Pit No. 1________________mmutes per inch Depth of Test Prt---- ,�,........ Depth' to ground water_./'___-_ :(., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ..... ----------------------------------------------------------------------- D Description of Soil........ ��.__.r !� � x 'l {`" �, rV cue , ' . - U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TiTL� p 5 of the State Sanitary Code— The undersigned further agrees not tA place the system in operation until a Certificate of Compliance has been issued by th bo rd of h lth. �1 ! �7 Applica ton A proved BY �" Ly / $ Date Application Disapproved for the following reasons:........................................................................................------------------------ --••-•---•-------------------••-----•-----------------------..............---------------......----•----•._......_....-...--•----•----------------------------------------------------------•------------ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ' BOARD HEALT ........../.. .t' .. „rc,r.......OF........... :.. 1 .... . .. ............................... Trrtifirate of f implionrr THIS^TO CERTIFY, The In widual Sewage Disposal System constructed ( ) or Repaired ( ) by........... ------------------------------------------------- •-------------- Instai •• at ................ .....16=e .... .1 +�,. i!z^. �,tt� ..._.._.... ----------------------- has been installed in accordance with the provisions of TI: IE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.--- - ........ dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFILATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � DATE...............................odl/s • � Inspector.•. : i 1 ' l THE COMMONWEALTH OF MASSACHUSETTS BtOAR , HEA TH ......70, ............)OF...... . a� � ,,,........................ ... Dtspoo orkii Tonotrttrtu� t rrntit Permissionereby granted '•-•-•• ! r�f�c�......................... to Construct (�),�r�R%( ) a ndivi.ual wage Dispo System /� at No. -..1 lJ •! "e.._.. �. ---✓...��`--------------------------------------------------•- -....--•----.-•---- Street as shown on the application for Disposal Works Construction Permit No..................... D ted........................................... 58 ,Krff of Health DATE...................... - -•-•-•-••-•---•-•---•.. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS r cD Y .('-• . ( ' . Imo ' � ; Q v a Y 407- moo . 4 8 3 7, 1 itAU L T N ti •c- r x OWE . LBERr Wl .. Nu tu3�a f LEGEND. r EXISTING SPOT ELEVATION -:, O CERTIFIED PLOT PL:A'N EXISTING CONTOUR ---- O -- — Jv y FINISHED SPOT ELEVATION H� L r �.ca A. xNU ~may P/nr .:� FINISHED CONTOUR Q---�- � ` JET IN APPROVED„, BOARD, OF HEAI.TN DATE AGENT SCALE+ /._4D OATEN b'// l8 f3,q sr� LOREDG£ ENG/NEER/KG CQ !K , 1 CERTIFY THAT THE PROPOSED EGISTERE RE0ISTL4191) JOg pp, '! a ! BUILDING SHOWN ON, THIS PLAN CIVIL LAND' CONFORMS TO THE ZONING .LAWS OR GARNS 4E - ASS. 71.2 'MAIN ST. CH, 9Y HYANNIS,' MASS. _ SHEETJ.OF PATE EQ. LAND SURVEYOR • 20 FT. MIN• N07F /F E/TNER ?HE SE PT/C TANfC OR Zz-,4CY11VG P/T ARE tjOR& 7-,qA V /2"BEt01v`� /D FT. MIA/ rRAV.=,, A 24`O/AMETEK COiyCRET.E. COSIER SNALL BF ,BROUGHT TO 4/4AOE.ie,AN k7x7•RA CONCRETE 4 PVC P/PE Ne,4VY CAST/RO/Y CO//�R SHALL l3E USF1� ✓ v CDi�ERS - P/TCN IF/N .DR/VE=AWAy :. �//B E'ER 2 MNV. CONCRETE t Wrl Co VER CLEAN .SA/V O �AC.�f F/L L _ L/QV/O LEYEL _ z LAYER +' !i MIN.P/TGN GAL. D/ST, ' • ° • • • ' • ' ° 04o y�/ASHFiD.S72'JNE %4 SEPTIC TANK • • • • . • a • • • • e • ° BOX v e o • � ® • • • • • • .0.•AF i 75 • r • • DEPTH • • ' . WASNED STOkF 00 „:;•: 2.i = 4-7 1 vPD ° ' • • • a • • • • • d:v PRE['ASTSEEPAGE `7S /NYP/R'T l•tEb//IT/ 1S vPD a y�� • • i •. • • • • • e `o P/7 OR EQU/V. • • a E=93:0 INYERT AT 41//4D/IVG /O/0 FT PiTcs+Pac�r! : 549 G.Pa 6 FT: D/AM. y INLET SEPTIC T.�NK /va S Fr l t? FT. O/AM. LC(SEE raeut.aT7oiv� . D1/TLET SEPTIC TANK f o0•3 Pr/NdET D,15MAOUT/ON BOX "0-ate GROvNo /1�/9TE/�Ti4BLE SECT/ON OF O(METD/STR/®!lT/ON 99:9 ICT, ' /MLET.Y.EACNING =V7- 992 fL SE1,4/AGE O/S/®O`Si4 J. .SYSTE/a'J 'TABlJL.ATlON LE�4Cf///VG fs/T DIMENSION A ` SCALE DES/G/V CR/TER/•4 D//sfi�/VS/ON 8�—FT'• 44 NUMBER OF 6EDR04MS D/MEN3/ON C _FT. / CARQA-EDISPOSAL UNIT d SOIL LOG SOIL TEST TOTAL EST/NfATEG FLOH/ 33g GAL.IDAy SO/L TEST / SO/t TlcST 2 NUMBER aP t,EAC/vlNZ P/rS_„L— f-FtEK ID/.3A-LFY, pATF GF Sa/L TEST S/OE 1-1-ACH/N6 PER P/7 FT. O— Z' RESULTS AVMV&SSFD BY BOTTOM LEr4CN/NG PER P/T�SQ. /rT. ^t PER C0LA770W MATE ^IIAV/NCN I TOTAL LEACH/NG AREA 26(. SQ. FT. ova SO rL- /WNCOI-gT/OIV RATE At-2 M/,V.//NC/'J. a RESERVE LEACHING AREA 26i(- SQ. FT. Z P . CU r4/2-5,c- LGr 2�L% ESN OF Mqs � ��' �'r,.ef, 6 -•l 3 C-E-71V7EkLI L.L4C-" 4? s9 � A'BE o JOHN G 5a�rkf RQBERT 7f� htLFtSE f a y i '► ELOREDGE ENCrINEERIJVG CA IVC. / ELLIS Ha.10951 Q 'p 9j r 7/2 MA/N ST. E4- $e;3 1 �No:, 4 A. \"O9 FP� .2f'r HYANN/3 MASS. � ' ' �N� SUR���-•,_' GROUNO JN/aTER Ar EL,E1/. JOB NO. l O SHEET�-'OF � SECTION A -A �"'"�' ' r [1101 10' min. from *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. VENT PIPE (O Least 24 Inches tall) Auou1LETPPESf1t0MTFfExisting Fou,datlan se to Schedule 40 PVC r/Cnorcoal odor Filter PROFILE VIEW OF ADDITION TO LEACHING SYSTEM osTRIeuTION Box sNAu ec �� ! � r. w,` septic tank _ SET LEVEL FOR AT LEAST 2 FT. 12' T� ff FUKMTMN " ELEV. UMA9 tAsvAw& Septic tank cow• must be 1rR1rn 6 in. of finished Trod* _ Grade over Septic Tank -92.00 Grade over D-Box- 9200 over SAS - 92 00 ' 3 - S'OUTLET = 2 3' of 1/8' - 1/2" Washed Peaston K►roacOUTs 3/4' to 1 1/2 ' Washed Crushed Stone OUTLET 12' eat �•• l V'• a/r k`� <I S - 0.02 3 HOLE H-10 Top Load - Elev. -8&75 / t 10' EXIST. s-o.m a qST. BOX 3' Maxhnum Cow M< ' �-.y,X214 Kim"NRl�lrt-t EXIST.PIPE In H 1,000 GAL Greater S- 0.01' Tap of SAS-Ekw. -68.2s ` ° R (n p 10' per foot or greater s 1AS'� 4" - SCH. 40 T` FROM EXIST. FUINDATION LAJR R SEPTIC TANK ! _ 0"Effective Depth t.75' J W rya,,y- 4.ld �r ^9�rn.�Yyf..,nr I PLAN SECTION CROSS-SECTION CONCRETE FUL Fot1Nc1► o o co � 0.83' (10 inches) 5 Units E 625' SYSTEM PROFILE 6 In.of 3/4--1 1/2- d 9 3 31.25' 3' 3 HOLE H-10 DISTRIBUTION BOX Not to Scale compacted steno • o e * ao NOT TO SCALE ° ; 4' 4' 1 37.25 m>tela+ar:c«.s,wo no•Naho wR� t 1, C r.+ -2 5' Effective Length 6 k,.of 3/4'-1 1/2" 10 SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES compacted stone Effective %kith NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE n m INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN 1. Contractor is responsible for Digsafe notification Bottom of Test We I oev.=60.00 (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. vObs. Groundwater - Test Hole 1 Elev.; NONE OBSERVED 2. The septic tank and distribution box shall be set NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18- /EFFECTIVE HEIGHT IS 10' level on 6 of 3/4"-1 1/2" stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. PERCOLATION TEST 5. The contractor shall install this system in accordance with Title V of the Massachusetts state code, the approved plan and Local Regulations. Date of Percolation Test: AUGUST 30, 2004 LOT 17A Test Performed By. CARMEN E. SHAY, R.S., C.S.E. g{'O # 6. If, during installation the contractor encounters any Results Witnessed By. WAIVER (per BARNSTABLE B.O.H.) , soil conditions or site conditions that are different Excavated By. SHAY ENVIRONMENTAL SERVICES, INC. ,' O�� from those shown on the soil log or in our design installation must halt & immediate notification be Percolation Rate: Less Than <2 MPI Failed made to Carmen E. Shay - Environmental Services, Inc- , I Leach Pit 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. -Test Hole ,'� 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. TEST HOLE 1 79,64, 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. No. 1 6 i ELEV.= 92.00 20' r ----------- - 9 32.5' ' - 10. All solid piping, tees & fittings shall be 4" diameter DEPTH SOILS ELEV. � 37.25' 0 92.00 /' Schedule 40 NSF PVC pipes with water tight joints. Sand ::, �itE,;L. ` 11. Municipal Water is Connected to ALL OF The Residence and Abutting Loom 4" PVC t,� • ��e 'zi g� Properties Within 150 Feet. 10 yR 3/2 VENT .' S i A, 91.25 `''•'* : .9f THE PROPERTY LINES ARE APPROXIMATE AND Lsana i� 9a COMPILED FROM THE SURVEY PLAN BY ELDRIDGE ENGINEERING ' D-Box ��� '' ENTITLED - "CERTIFIED PLOT PLAN OF LOT #20 KNOTTY PINE LANE, j Io rR 5/6 of 1 i CENTERVILLE, MA DATED OCTOBER 14, 1981, e"- 30" B• 89.501PROJECT BENCH MARK t 0 EXIST. 1000 al. �/ �� AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Mod. TOP OF FOUNDATION Septic Tank g 20'S IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 2s5Y7/4 ELEV. = 100.00 (Assumed) DECK ,� ,�AND � THE SEPTIC SYSTEM INSTALLATION. 130'- 1441 .00 EXISTING LEACH PIT/CESSPOOLS TO BE PUMPED OUT AND FILLED IN PLACE OR REMOVED TO FACILITATE INSTALLATION OF NEW SAS. GARAGE EXISTING - ��� � NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE 3 BEDROOM ,' , FROM THE EXISTING LEACHPIT/ CESSPOOLS TO BE DISPOSED HOUSE --- �' i ' OF AS PER BOARD OF HEALTH SPECIFICATIONS. - -LOT #19 - - - - _ - - � � _ - -____.------- _ _ _-. _-- -- - - NO WETLANDS-ARE PRESENT WITHIN 200' OF THE PROPERTY ij1214 LOT #20 ASSESSORS MAP 191, PARCEL 025 Pere #1 6j• I i ,•- ,'Depth to Perc: 30" to 48" 17,671 Square Feet t/- LEGEND '� ► I � � Perc Rate= Less Than 2 MPI m i i Observed ESHWT® - NONE OBS. 144" Assumed ADJUSTED H2O Elev. NONE OBS. - 144" Assumed ± i � ' 104X1 DENOTES PROPOSED i ASPHALT i �' ' SPOT GRADE 66 ' DRIVEWAY ' ,� ; DENOTES EXISTING gyp• .' �` X 104.46 SPOT GRADE I PL r PROPERTY LINE i � �\ i �� 96' i i I 171.53' 90--- PROPOSED CONTOUR - - - - - -97 EXISTING CONTOUR KN0 T T Y pI �� ® DEEP TEST HOLE c 2-18 DIAM. ACCESS MANHOLES NE LA ATE PERCOLATION TES LOCATION (40 FOOT RIGHT OF 6 FOOT STOCKADE FENCE tT WAY)' #&ETP OT P LAN r V DIT�,� F� T OF PROPOSED SEPTIC SYSTEM UPGRADE 7 --•-c` SET DEEPER THAN a IMa+Es BELOW FINISHED PREPARED FOR • :_ •, GRADE SHALL BE RAISED To WIM 6' OF STEEL REINFORCED PRECAST CONCRETE FIMSHED GRADE' PLAN VIEW INSTALL AW-TITE GAS BAFFLES OR EQUALS MR. P A U L W E B S T E R . 3-24• RE'ABLE 0DVE7tS ' AT #214 KNOTTY PINE LANE 3 min. c1sarance F mh Y -I-fret to aati t ,.,�,, 1r KET C E N T E RV I L L E, MA oun Er Design Calculations s• -r F r PREPARED BY: I 4'-0' min. Number of Bedrooms: 3 Equivalent to 330 Gal./Doy (330 Gal./Day Min. per Title V) °"'"' ua�b ��' Garbage Grinder: No �� "RNEW E ,SHA Y 7 Leaching Capacity Proposed: 330 Gal./Day Minimum--(Min. Per Title V) R N E. Septic Tank : - 2 x 330 Gal./Doy - 660 USE EXIST. 1,000 GAL. Septic Tank. 0 20 40 50 " H ENVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch s•-0" 4 -10• Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons P.O. BOX 627 CROSS SECTION END-SECTION Sidewal► Area: 0.74 gal./sq. ft. x 78 sq. ft. = 58 gallons �F �� �• Prodding: = 331.80 gallons =3 GISTE4 EAST FALMOUTH, MA 02536 �NITAR"� TEL/FAX 508-539-7966 TYPICAL 1000 GALLON SEPTIC TANK Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1«=20' NOT TO SCALE TO BE USED,WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE SCALE: 1 a=20' DRAWN BY: CES DATE: AUGUST 31, 2004 ON THE ENDS. NO STONE UNDER. PROJECT#SD622 FILENAME: SD622PP.DWG SHEET 1 'OF 1