Loading...
HomeMy WebLinkAbout0396 LAKE ELIZABETH DRIVE - Health 396 Lake Elizabeth Drive Centerville A=227-025 `1 � Town of Barnstable °*tHE AO"`� Regulatory Services NAP- O•' Thomas F. Geiler,Director + BARNS1`AUM 9� MASS. �� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: Eco-Tech Installer: Wm E Robinson Sr Septic Address: 43 Triangle Circle Address: PO Box 1089 Sandwich Centerville On d J Wm E Robinson Sr Septs issued a permit to install a (date) (installer) Service septic system at396 Lake Eliz Dr , Centerville based on a design drawn by (address) Eco-Tech dated 06-23-05 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed-with major changes (i.e. greater than 10' 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. ZH OFg.�ss 9 DAW cyD. N COUGHANOW R y ( staller's Signature) No. 1093 �\ "/STEREO �qN/TARTAN (Designer's Signature) ) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form r ' e r COMMONWEALTH OF MASSACHUSETTS ID Ch EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECT ON r ZE on TITLE 5 ' ` ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME S ui m SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 396 Lake Elizabeth Drive � � Craiaville Owner's Name: Joanne Cox Owner's Address: 65 Arrc)whpad Rc)ad Date of Inspection: Name of Inspector:(please print) Wil 1 i am E_ • Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number:_ ism 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper functio and maintenance of on site sewage disposal systems.1 am a DEP approved system inspector pursuant to ection 15340 of Title 5(310 CMR 15.000). The system: t Passes i Conditionally Passes ' Needs Further Evaluation by the Local Approving Authority Fails � Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthvr 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 approxing 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 r Page 2 of 1 I , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 396 Lake Elizabeth Drive Craigville Owner: Joanne Cox Date of inspection: Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A. Sys in Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR - 15.303 or in 310 CM 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more stem components as described in the"Conditional Pass"section need to be replaced or repaired.The system, pon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or n,t 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,ekhibits substantial infiltration or exfritration 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 septicjtank 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 ex lain: The system required pumping more than 4 times a year due to broken or obstitKied pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is xmwvcd ND explain: Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 396 Lake Elizabeth Drive Craigville Owner: Joanne Cox Date of Inspection: . '.� `�!—0 C. urther Evaluation is Required by the Board of Health: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing ;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: — C% sspool 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 w II fail unless the Board of Health(and Public Water Supplier,if any)determines that the syst),nn,c',,'ioning in a manner that protects the public health,safety and environment: stem has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a r supply or tributary to a surface water supply. stem has a septic.tank and SAS and the SAS is within a Zone t of a public water supply. stem has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. stem has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more iron%a r supply well" Method used to determine distance "This s stem passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria d volatile organic compounds indicates that the well is free from pollution from that facility and - the presen a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crite is are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 396 Lake Elizabeth Drive Craigville Owner: Joanne Cox Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _✓/ackup 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 logged SAS or cesspool _ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or esspool ✓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 I of a.public well. .Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private%%ater 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 lice 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 I triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more ofthe 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 large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd- You must indicat either"yes"or"no"to each of the following: (The following c iteria apply to large systems in addition to the criteria above) yes no _ the s stem is within 400 feet of a surface drinking water supply _ the ystem 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 Zo a 11 of a public water supply well If you have swered"yes"to any question in Section E du system is considered a significant threat,err answered "yes"in Se ion D above the large system has failed.The owner or operates of arty large system considered a significant t eat 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 l 1. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 396 Lake Elizabeth Drive raigvi e Owner: Joanne Cox Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o _ PP mping information was provided by the owner,occupant,or Board of Health _ ►i Were an of the system components pumped u ' / Y Y p p p out m the previous two weeks? j Has the system received normal flows in the previous two week period? V Have large volumes of water been introduced to the system recently or as part of this inspection 1/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? 71e 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 C1v1R 15.302(3)(b)) A,,l S �� 5 Page 6 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 396 Lake Elizabeth Drive Craigville Owner: Joanne Cox Date of Inspection: z —O FLOW CONDITIONS RESIDENTIAI. Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CAR 15.203(for example: 110 gpd x R o bedrooms): L 0 Number of current residents: _ Does residence have a garbage grinder(yes or no) Is laundryon a separate sewage system es or no): (�[ifyes separate inspection required] P g. Y (Y � . Laundry system inspected(yes or no): , Seasonal use:(yes or no) �'S Water meter readings,if vailable(last 2 years usage(gpd)): 2004 — 14,000 Sump pump(yes or no):.A-U 2003 — 13, 000 Last date of occupancy: COMMERCIAIANDUSTRIAL Type of esta�tshment: Design flowAbased on 310 CMR 15.203): gpd Basis of de ign flow(seats/persons/sgft,etc.): Grease tra present(yes or no):_ Industrial'waste holding tank present(yes or no):_ Non-s itary waste discharged to the Title 5 system(yes or no):_ Wate meter readings,if available: Last ate of occupancy/use: OTHER(describe): GENERAL INFORMATION l Pumping Records Source of information: i7v •. A—/ Was system pumped as part of the' spection(yes or no): A - U If yes,volume pumped:__gal ons--How was quantity pumped determined? Reason for pumping: TYPleptic F SYSTEM distribution box soil absorption 'system rP _Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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 Sin)and source of information: Were sewage odors detected when arriving at the site(yes or no): - 6 Paw 7 of I I r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORII'IATION (continued) Property Address: 396 Lake Elizabeth Drive Craigvil e Owner:_Joanne Cox Dale of Inspcctlon: —� "� BUILDING SEWER locate on site plan) Dcpt't below grade: Materials of const lion:_cast iron _40 PVC_other(explain): Distance Goin priv to water supply well or suction lute: Comments(on c sdition of jousts,venting,cvidcncc of Icakagc,eic.): SEPTIC TANK:Z(locate on site plan) Depth below grade: Material or'construr _otlscr(explain) — -- tion:_concrete metal fiberglass___polyethylene If tank is metal list age: Is age confinned•by a Certificate of Compliance(yes or no):—(attach a copy of certificate) �,c Dimensions:, � )lj �. Sludge depth: Distance fromm top of sludge to bottom of outlet Ice or banlc:3 O Scum Ihickncss: _ s Distance from top of scull,to top of outlet Ice or baffle: _ t Distance [join bottom of scum to bottom of sru let t e or baffle: V _ 'low were dimensions determined: - I -t-d A,A, Comments(on pumping recommendations, inlet and outlet tee or baffle c ondition,sUuctwal integrity,liquid levels as related to outlet invert,eviders�c f cakage,etc.): GREASE TRAP:_(loca n site plan) _ Depth below grade:_ Material of construction: concrete metal fiberglass�}solyethylene�otlser (explain): _ Dimensions: Scurn thickness: Distance from top of um to lop of outlet tee or baffle: Distance Gom bottoi of scum to bottom of outlet tee or baffle: Dale of last pumpin Conunents(on pu ping recommendations,inlet and outlet(cc or baffle conditio:s,structural integrity,liquid levels as related to outic invert,cvidcncc of leakage,etc.)-. 7 Page 8 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address:396 Lake Elizabeth Drive raigvi e Owner: Joanne Cox Date of Inspectlon: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:—c ncrete_metal_fiberglass_polyethylene otlter(explaut): Dimensions: Capacity: allons Design Flow; gallons/day Alarm present(yes or jAAl : Alarm level: , in working order(yes or no): Date of last pumping: Conunents(condition of al n and float switches,etc.): DISTRIBUTION BOX (tf present must be opcncd)(Iocatc on site plan) Depth of liquid level above outlet invcrt: Comments(note if box is level and distri wn to outlets equal,any evidence of solids carryover,any evidence of - leakage into or out of box,Nc.): d , PUMP CHAMBER: (locate om Re plan) Pumps in working order(yes or n Alarms in working order(yes o no :— Comments(note condition of ump chamber,condition of pumps and appurtenances, etc.): r. Page 9 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 396 Lake Elizabeth Drive raigvi e Owner: Joanne Cox Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation*not required) If SAS not located explain why: Type _ _�l�aching pits,number:_ rr//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,dam soil,condition of vegetation, etc.): CESSPOOLS: (cesspo 'mu r6e pumped asp of inspection)(locate on site plan) J Number and configuration: U _ Depth—top of liquid to inlet' v rt: Depth of solids layer: v Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes/br no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): _ PRIVY: (locate 4itc plan) Materials of cons tion: Dimensions: Depth of solids: Comments(n a condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 1 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 396 Lake Elizabeth Drive Craigville Owner: Joanne Cox Date of Inspection: 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. _�_ 5 r - a li i r 10 i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 396 Lake Elizabeth Drive Craigville Owner. ' Joanne Cox Date of Inspection: ^l"-p . SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground waters L� 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must de cribe h you eslabliised the high grouncJ,water elevation: i a i 11 TOWN OF/BARNSTABLE /� LOCATION 'r:5 L� L k✓ t Al b% SEWAGE # �� 6%ryC/ VILLAGE / ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) "� (size) NO.OF BEDROOMS / BUILDER OR OWNERS Cam ' PERMITDATE: 4 � ?G V CO LIANCE DATE: �f,�girPGl Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Lea ng Facility Feet Private Water Supply Welland Leaching Facility (If an wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any well ds exist within 300 feet of leaching facility) Feet Furnished by 14 ,1 � 3 mr A- 3 ® tj- r� . Y • s No. " _ _ - Fep 0 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Miqual *potent Com5truction 3permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 7 81 —8 9 3—7 2 0 3 396 LAke Eliz Dr, Centerville Joanne Cox Assessor'sMap/Parce 227/25 65 Arrowhead Rd, Weston, MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco—Tech 43 Triangle Cir PO Box 1089, Centerville Sandwich, MA Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder(nc) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 septic system to plans of Eco—Tech, ETE-2032. 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 E vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi oar f I+ealth. Sig � Date _CJ Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ---."" �: S100.00 No. 5. .Y »�" �. Fee THE COMMONWEALTH OF MASSACHUSETTS -. Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Ztpprication:for Migpo!5ar '*pgtem (Construction permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 7 81—8 9 3—7 2 0 3 396 Lake Eliz l�r, Centerville Joanne Cox Assessor'sMap/Farcel 65 •Arrowhea RCi 1J125to1� l�RA 22T/25 ► , Installer's Name;Address,and Tel.No. 7 7 5 8.7 7! Designer's Name,Address and Tel.No 3 6.4—0 8 94, Wm E Robinson Sr Septic Eco-Tech 43 Triangle Cir PO Box ,1089, Centerville Sandwich, MA Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder(nq Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons.. Plan Date Number of sheets Revision Date- Title - Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re airs or Alterations(Answer when applicable) Install a new Title 5 septic sy tem to plans of Eco-tech, E— 03 . 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 E -vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by thi .'oar f Health. o - Sign, Date P r Application Approved by Date Application Disapproved for the following reasons i Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS Cox BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired ( X)Upgraded( ) Abandoned( )by Wm E Robinson Sr Septic Service at 396 Lake E iza et Drive, Centerville has been constructed!! in ac o dance with the provisions of Title 5 and the for Disposal System Construction Permit No. Sc dated +, 1 Installer o Designer C +ram� The issuance of this pCer�mfit sh 1 not be construed as a guarantee that the ys s'ste rlll i 1 urn tion as d ned. Date 1 I�j �7 Inspector No. A'O 7 C -- 4100 0 00 Cox THE COMMONWEALTH OF MASSACHUSETTS " PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS - li5pont *pe;tem Construction hermit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 396 Lake Elizabeth Drive, Centerville 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: Constr ction musl be completed within three years of the date of this �'t Date:__— / U Approved by —_ t t 9/1o/Ud Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, 'D�y D C �,tl 1-N6 w2 ,hereby certify that the engineered plan signed by me dated GC 2;3 v 5' ,concerning the property located at 3qC �� Cl;z+ e+6 r meets all of the. following criteria: • This failed system is connected to a residential dwelling only. There.are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: I A) Top of Ground Surface Elevation(using GIS information) l �� B) G.W.Elevation CC-'5 +adjustment for high G.W. O"q DIFFERENCE BETWEEN A and B Z •C SIGNED : � DATE: ( Z3 I NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. I gASeptic\p=ex=V.doc 17'-3„ wrD � 37-0 1/2'• rEw woR "� 4'-6"— © © © 12'-3.� m © Q 56R gELIXATE h�M� © 2 1� BEDROOM COWENSOR ExTEN51Pv EUSE 4 © ROtATE F' ISLAIO }f�M1 IUD n / 17 11 K'wcdmEl6at RERIOcniED — — C� REUSE • �iN SHELVES �BE^N/90�'E NDOw E45TIrKi TALL 166E lass z6 6 IRDD 4 D � cABn�Ts � 6aR iV HELVES _ � PRE-FWOAx © OEx �O i Hnw�01 iHRLUpglli ?'t V 29,bB�rwg 4 12'7" 11' " H cEw HEw PR6nw5HED OAK 6066 E FLOORING THRg1G4OU( tow BAY 2866 IK1Tw DN 2 �ore—En Dux+G O O 5w. RaoM u u O u sEAr - v m _ CCATE SUPPLY 7 BEW.WA �� /JT ini SHELVES PAL.ETUP,NpIRS s O 1.2'.0" 2'41 Qlj O 5 yD' saR �R OQOQ�� W O O PAYrt D READB A � �1 E RISERS U //�y Y BEDRouM eEn,v� T-0,. _ 7•-0" E srrc roots C� a MERT ze-o 1n" UP �D O � M 11 O L^J O x n Proposed 2nd floor plan 0 0 iew aoR O dsTOP.M ® ZLE NUIIG L WNItON Thy w ASPHALT 5HNGEL5 4 Pro o5ed First Floor DN 15B FELT PAPER A5PHALT SHINGEL5 ICE&WATER 5HELD 15N FELT PAPER 5/8"EXTERIOR SHEATHNG vent NEW BATH 2"x&'CLNG.J5T5.16"O.C. ICE&WATER 5HELD 2"X&"RAFTEP516"O.C. P..30 FBP.GLS.IN5UL. tx3 5TRAP 16"O.C. 5/8"E%TEP,IOR 5HEATHNG U2"SHEETROCK 2"%8"RAFTERS 16"O.C. 12 32'3" q vcnc baffle (2)13/4 x 71/2 cu LVL Header (2)13/4 x 117/8 " y \ DRIP EDGE W.C.5HNGLE5 LVL Header I"X 10"FA5CIA TYVEK HOUSEWP.AF` NEW 'b r CJ late CONr.5OFFIT VENT 1/2"CDX 5HEATHIZ N W p i 5"WK.ALUM.GUTTER 2'x4"x&&"5TUD516O.C. EXTENSION � a Q v R-13 FBRGL5.INSUL. ILI Simpson 1/2"5HEETRCCY, 1z1 z.0n<ae�.,.�P. '� hurricane cie U W21-11re 6'00 EXISTING ROOM M II A I c N III WC.5HIJGLES IIIIIIIIIIIIIIIIIIIII TYVEK HOUSEWRAP 1/2"PT.SHEANNIG 1/2"CDX 5HEATHING R-30 F13RGL5 INSUL. 2"x4"n88"5TUD5 16"O.C. 2x10 J015T5 0160f, 3/4"T&G CDX R-13 FfWGL5.IN5UL. 3/4"T&G.CDX SHEATHING • 'BRalvn i6 8c _ GLUED&NAILED I/2"5HEE7P.CCK GLUED 4'-0" -. III III =III III=i vD. 111=III=III-III111. � REVISIONS =1I=III -1Ti-IT1=1Tj_ITI= plate III=1 —II 1. Y'A rll n, H 5/12/06 c—ting floor j019i5 - z/'coNc.PIERS1 EXISTING 7/28/06 48 F25 OOT BSMNT. I I I I I I I I I I I I I I I I I I I I I EXISTING FIRST FLOOR �o I I I I I I I I �20lnrcrRla,acr,I6.0I I I I I I I I I I � ❑ t SECTION I I I I 1 2nIDGaMURa�icn IIIIIIIIIIIIIIIIIIIII 2aDG.NoRa,F°� 2 SECTION _ 1 IIIIIIIIIIIIIIIIIIIII Q 2n10 Lwo rmf Lcc fKL, /� 2 � ROOF FRAME A. — _ _ 0 / NEW 5ECOND FLOOR \ / ur�Msru� 2nw EXTENDEDEXIS er \ NEW SECOND FLOOP. CMMNEY — — — — — — — R \ Q o � / 00 ° a �w LLUo �. o vy � 7 CD S O � 3 w V RIG T ELEVATION W � o0 W r 00 FP.ONT ELEVATION_ H F w / — — — — — — — — —,o — / TMYY11h1 \ 2 \ v O 121 o a V V M \ - - - - — � � - - - - / \-- - - - - - - - - - M �G u p Y Y o anr� REVISIONS For�a� 5/12/06 7/28/06 - NEW REAR ELEVATION EXTEN5ON E� FT ELEVATION 00 A 3 SOIL TEST LOG' DESIGN CALCULATIONS DATE OF TEST: MAY 9. 2005 SOIL EVALUATOR: DAVID D. COUGHANOWR. RS DESIGN FLOW: 4 BEDROOMS X 110 GPD - 440 GPD WITNESSED REOUIREMENT WAIVED NO VARIANCES SOUGHT GROUNDWATER ENCOUNTERED AT 156 in SEPTIC TANK: 440 GPD X 2 DAYS - 880 GALLONS TEST PIT I PARENT MATERIAL-: PROGLACIAL OUTWASH INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) ELEVATION - 21.25 +_ PERC AT 76 in : 2 MIN/INCH IN C SOILS DISTRIBUTION BOX: USE 3 OUTLET H-20 D-BOX. DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOIL ABSORBTION SYSTEM: A 33.5 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 2125 Abot - (33.5 x 12.5 ) - 418.75 sf 0-22 FILL Asdw - ( 33.5 + 33.5 + 12.5 + .12.5 ) x 2 - 184.0 sf Atot - 602.75 sf 22-26 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE Vt 0.74 x 602.75 - 446.03 GPD 26-60 B LOAMY SAND 10 YR 3/4 NONE LOOSE USE A 33.5 ft x 12.5 ft x 2 ft GALLERY. Vt - 446.03 GPD > 440 GPD REQUIRED 16.25 60-156 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 8.25 GROUNDWATER ADJUSTMENT LEACHING GALLERY CONSTRUCTION DETAIL 500 GALLON DRYWELL OBSERVED GW 8.25 WIGGINS CONCRETE SOO DMMIOM AND DETAIL INDEX WELL MIW-29 GALLON PRECAST DRYWELL ZONE C EOUIVAILENTNIT OR GIBE H-ZO C�IJT READING DATE APRIL. 2005 STONE READING 6.4 s -s X a'-io-X r-io WTALL OW naPECTION ADJUSTMENT 0.9 2 ft EFF. DEPTH RISER S F/WL GRADE ADJUSTED GW 9.15 33.5 f t AND/�DICATE LOCATION ON AS-Bl.<T PLAN u'. O O O O O O o f 34 v o0 in 000Qo�oa ��NOTES o4.0 8.5' 8.5, 8.5' O" 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN 33.5 ft 10216 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM, 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. 5) EXISTING CESSPOOL TO BE PUMPED. COLLAPSED. AND REMOVED. REMOVE CONTAMINATED SOILS AND REPLACE WITH CLEAN MEDIUM SAND PER TITLE 5 SEWAGE DISPOSAL SYSTEM PLAN 6) ALL STONE TO BE DOUBLE WASHED AND FREE' OF IRON. FINES AND DUST IN PLACE 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE'-PITCHING DOWN -TO SERVE EXISTING DWELLING 8) ECO-TECH ENVIRONMENTAL RECOMMENDS AND APPLIANCES. AND BIANNUAL PUMPING HOFI THE SEPTIC, TANK NSTALLATION OF OW FLOW FIXTURES JOANNE AND DOUGLAS COX 9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING, DO NOT 396 LAKE ELIZABETH DRIVE CENTERVILLE. MA PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. 10) INSTALLER TO OBTAIN DISPOSAL WORKS_ PERMIT BEFORE STARTING WORK. ECO-TECH ENVIRONMENTAL 11) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL 43 TRIANGLE CIRCLE SANDWICH MA 02563 STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE HAS, BEEN PLACED TO MINIMIZE UNEVEN SETTLING ETE-2032 JUNE 23. 2005 2/2 — PLAN REFERENCE r CONTOURS , , - L- e,:3 PLAN BOOK 118 PAGE 3 EXISTING - - - - - - - 50 NASSESSOR'S MAP: 227 MINIMAL GRADING PROPOSEDLOT: 25Jo z oo� <uO m vawW h v, C> LL VENUE �_n CENTERVILLE. MA 0 LOCUS MAP w 33.5 ft X 12.5 ft X ,2 ft NOT TO SCALE 0 o N LEACHING GALLERY Lu `� - USE H-20 UNITS 30 32 34 N }- 28 �' Z O 3 VENT PIPE 22 24 26 /� 36 0. w Q z 18 126.71 f i 6 N 41 20 / LEGEND GE D z rN G AR - 280 s �- W 1500 GALLON 0 I^? m o SEPTIC TANK O O O 3 v / / H-10 UNIT m 17.8 �, 2 -P 1 USE J o � ` � m o H-20 a-BOX o N Q = M M „ 15-P -� m TEST PIT HILL ' o > \ r O - X 38 0O LL _ m 3 � , �o m EXISTING V zw m �� 9 v �T CESSPOOL O c R •`-p cn � Z-1 U) �Nm N o �p Z O C) 1 UTILITY POLE $ O '' TREE � � INE -NUMBER REFERS TO DIAMETER rea M ~ IN INCHES. LETTER DENOTES TYPE mWATER WAT R �._ RETAINING O-OAK M-MAPLE P-PINE r. is-P N LINE ALL GAS L W I RIVEW PY 38 ao N Z Y ST pNE ' _ 36 19 � LL m Q 32 34 c <m z ~ 7p fi 26 28 30 SEWAGE DISPOSAL SYSTEM PLAN o LL 126.5524 $ -TO SERVE EXISTING DWELLING ow C JOANNE & DOUGLAS COX L m BENCH MARK cn PLAN ��cA��H 0FI�Ssy 396 LAKE ELIZABETH DRIVE CENTERVILLE. MA ELOEVOATIONTE21.0 GATE 'SCALE: 1 in - 20 ft o��a DDID cyG� (� O ELEVATION GIS DATUM " COUGHANOWR E"O-TECH ENVIRONMENTAL 0 43 TRIANGLE CIRCLE SANDWICH MA 0256 w T00111�az No. 1093 H M w i �S 508 364-0894 ~ T qN tiPN ETE-2032 JUNE 23, 2005 A 1/2 THS PLAN IS TO BE CONSIDERED A DRAFT PLAN UNLESS IT BEARS THE STAMP AND SIGNATURE OF THE DESIGN ENGINEER ORIGINAL PLANS INTENDED FOR SUBMITTAL TO THE BOARD OF HEALTH WILL BE SIGNED IN BLUE AND STAMED N RED. .