The URL can be used to link to this page

Home My WebLink About0006 LIETRIM CIRCLE - Health 6 Lietrim Circle Centerville P A 169 051 t Commonwealth of Massachusetts /0- Ob/ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 6 Lietrim Circle Property Address N Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ►►pHUItnH�p�� on the computer, �``�`\�.SNOFMgS Nz use only the tab 1. Inspector: .�```y��' key to move your p � ••.yam cursor-do not =mac JAMES use the return James D.Sears = m key. Name of Inspector :0 Capewide Enterprises, LLC ; �•.,c� o :� Q Company Name ��i��' T I F` •' �`� 153 Commercial Street Company Address PfewA Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-18-16 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions bes co d ttons at the time of inspection and under the conditions of use p Y p at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page'1 of 17 �.o �S Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °,M s 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank D Box and two chambers. 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. 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r f , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in awspW is less than 6" below invert or available volume is less than I/.day flow 8111ellItip' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 _. .. .. .. .. . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City(rown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and two chambers. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No 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 ears usage d 2014-128,000Gal g ( y g (gp )) 2015-86,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 6-5-15 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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): 1 5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2010 Permit 2010-016 Were sewage odors detected when arriving at the site? ❑ Yes ® No 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.): Pipeing House to tank cast iron. Other pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 20" 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. Precast H - 10 3" Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8° Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank at 20" below grade w/both covers at 1'. Inlet baffle, outlet tee. No sign of leakage or over loading. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): D Box is 16"x16"-3' below grade w/cover at 18". Box is clean, and solid, w/two lines out. No sign of loading or solid carry over. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): Leaching is two 500 Gal. Dry well chambers- 13'x25'x2'. Chambers are 3' below grade w/cover at 1'. Chambers are dry w/clean wall's like new. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately g,t AC K TP 13-/ 2 6-V R��R /-9- 1)- u o -y z �Ia;6, 3 0 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells o D� Estimated depth to high ground water: 12 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: 12-17-09 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: T.H. on design plan 12-17-09 no G,W.at 12'. Bottom of chambers at 5'-6" below grade. Bottom of chambers at 6'-6"above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 6 Lietrim Circle Property Address Strefanie Ruge Owner Owner's Name information is required for every Centerville MA 02632 3-18-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ' f i No. 02 t� I d ' b I IJ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Zisposal 6psteut Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.x1 ic-+r;m C:,rc 1c Owner's Name,Address,and Tel.No. Ce 4u.nUC Assessor'sMap/Parcel 1(,et ✓ e1 S'1 �4`r/G sV' ^^�' �' �� Installer's Name,Address,and Tel.No. Sp¢,-77G•GN6 U Designer's Name,Address,and Tel.No. Box 7 1a S: 41,,jt, W 4 ea6G`l 14% RT CAA Saod,,•:cf-. . McA Type of Building: Dwelling No.of Bedrooms Lot Size , a sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 6. C) gpd Design flow provided 3 Ll q gpd Plan Date 1.164 y9 f�_! Number of sheets Revision Date Title Size of Septic Tank EGG 0!, 1 C— Type of S.A.S. ),- 5'6 D ✓a 11S' Description of Soil CSC to✓St Nature of Repairs or Alterations(Answer when applicable) ' 1 hii rC S. 4.S�. �,� A e`, D- a6 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 C _ Application Approved by — — Date Application Disapproved by Date for the following reasons Permit No. 010 8 f Date Issued I _10 - - y`. • .,, I � �,,. ..ate? No.t' t� 6 �d ' d1 � / � Fee I - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes i PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE, MASSACHUSETTS., 2ppliLation for Misposar OpBtr tt tottstrttttlott J)ermit Application for a Permit to Construct( ) Repair�Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. C it fr�Yv% C're-Ic Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /(, CG„atnfllt:e S� GJr y� a ellS�z��,Q D• ?4 J)C✓' of-re Installer's Name,Address,and Tel.No. Sod,-776-04 U Designer's Name,Address,and Tel.No. F A �: Sc,..ie y tnc kIC- Rb 131,4 _nl, S. I4A c GG�I IliI Rs G4 Sar.aw«< �t�.4 a Type of Building: Dwelling No.of Bedrooms 9 Lot Size a oZ sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) )X Q gpd Design flow provided 3 y Q Y gpd Plan Date a 12c,6 Number of sheets Revision Date Title Size of Septic Tank &-j 0 a a llC, Type of S.A.S. nor Sd pr�S Description of Soil CC a"Sc r, Nature of Repairs or Alterations(Answer when applicable) (< A r.,i 0- d 6 Y 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 C,_�) Application Approved by - ( Date - /C! -/0 Application Disapproved by Date for the following reasons n Permit No. a 0 0— 0 Date Issued � �� -/0 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired X Upgraded Abandoned( )by . L, C, at 0 I„ Lel e,--4 (',Vc)C Ce.,)-d,v-'k has been constructed in accordance a with the provisions of Title 5 and the for Disposal System Construction Permit No. Q 0/0 O/b dated 1 `� Installer x_ L. C• Designer 1-4. S #bedrooms 11,)O Approved design flow )ra O gpd The issuance of thi permit shall not be construed as a guarantee that the system will fu ctio'n as designed. Date ? / �J�� Inspector �C, No. ------I-----�-0f-�-------•------- ----•- -------__-------_.-------------- ---_----_-_--=---Fee {-C�(> :- ._, . - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS MiSposal *pstem Construction permit . Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at ►} L;6�,i✓t (.rc �'t,. <i�,i7 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 c mpleted within three years of the date of this permit. Date�� Approved by 5 Town of Barnstable Regulatory Services Thomas F. Geiler,Director � scRrisrAs�, . MASS. Public Health Division ''j�o► ''�� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 'L _,5 i 0 / Designer: Installer: �. �• Address: 1722 Address: F.0, �o x 7; 5�'' vleh- G 2 )`3 s. Y�sMG ►� r M� On /9 o?0/0 Ip t- (f- 4.,eik,, was issued a permit to install a (date) // /J (installer) septic system at G`/ J-/ ("� 6�411VI based on a design drawn by / (address) dated 1' 2 /01q ao6 (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. VSN OF h4gss9cy DAVID D. (Installers Signature) FLAHERTY, JR. N No. 1211 q O FGISTER� Sq N I TARS�`� /Y esigner's ignature (Affix Design '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 DTVISION. THANK YOU. Q:Health/Septic/Designer Certification Form P� 1 1 , Town of Barnstable P# 7 g Department of Regulatory Services Public Health Division, Date 7 /� VUE .63y 200 Main Street,Hyannis MA 02601 Date Scheduled - Time Fee Pd. f �� Soil Suitability Assessment for Sewage Disposal av�L ` , � /� Performed By: �-' `' '— S l4�-va-�y(yitnessed By: _E74-WM A) �o LOCATION& GENERAL INFORMATION Location Addres3�/_�� / /y� _ Owner's Name CO �-'I Address &,,I/ / �l t1L C-40 l/� Assessor's Map/Parcel: !�9 ._-�S Engineer's Name �S NEW CONSTRUCTION REPAIR ! Telephone# — G Land Use S ICE. Slopes(Y6) Surface Stones2 6 Distances from: Open Water Body wr�Ut Possible Wet Area_41k—ft Drinking Water Well AWft Drainage Way _--ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proxirr ity to holes) / IL e l� ,Q . >° C G Parent material(geologic) Vj' {, wO Depth to Bedrock Depth to Groundwater. Standing Water in Hole: A1�4- . Weeping from Pit Face Estimated Seasonal High Groundwater ! �2- V,�/dcr�/i1v,C✓ �urvst y�ey¢ DETERMUNATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth ed standing in obs.hole: in. Depth to soil mo in. Depth to weeping side of obs.hole: a in, Groundwater Adjustm ft. Index Well# Reading Date: Index Well,level Adi,factor Adj.Grout ter level PERCOLATION TEST bate) t ,inme ,t,&w1 Observation Hole# ��" Time at 9 Depth of Perc Time at 6" Staff Pre-soak Time @ / Time(V-6") - End Pre-soak / 2¢ Rate Min./Inch G 2 L Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) A 6 Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***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:\SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# 17,¢ Depth from Soil Ho rizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,%Gravell AV n Z,shJ �1a C% DEEP OBSERVATION HOLE LOG —:,747 Hole# -x ¢73 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) 17 /o fj 7.s�2 ss Cc�r� • Z8'' �" G �'�n o� Z'5�7.� of Y ✓Yo � e DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. o Gra veil DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consiste Flood Insurance Rate May: Above 500 year flood boundary No— Yes-NAz�� Within 500 year houndary No_ Yes - Within 100 year flood boundary No,, Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio s material exist in all areas observed throughout the- area proposed for the soil absorption system? ti If not,what is the depth of naturally occurring rvious material? - Certification a ,, I certify that on (date)I have passed the soil evaluator examination approved by the. Department of Environmental Protection and that the above analysis was performed by me consistent with . the required tra' ' pertise nd x ie described in 310 CMR 15.017. \ Signature Date Q:\SEPTIC�PERCFORM.DOC ((O COMMONWEALTH OF MASSACHUSETTS y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z DEPARTMENT OF ENVIRONMENTAL PROTECTION � p E DEC 15 2004 l OWN OF BF,.tNSTABLE TITLE 5 f;E:.'.TH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 ,�j C)' tS�1 Owner's Name: PATRICIA GRUTCHFIELD Owner's Address: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Date of Inspection: 11/22/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title ( 10 CMR 15.000). The system: X Passes _ Conditionally s — Needs Furthe v ation by the Local Approving Authority Fails Inspector's Signature: Date: 11/22/04 The system inspector shall submit a y 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 sha submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copie sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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 Tncnantinn Fnrm F,/1 S/,?Mfl 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Owner: PATRICIA CRUTCHFIELD Date of Inspection: 11/22/04 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 PASSED TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN 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 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. n/a 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: 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 ND explain: n/a I Page Yof 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Owner: PATRICIA GRUTCHFIELD Date of Inspection: 11/22/04 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 safe r p p o the environment. safety 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 aseptic 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 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Owner: PATRICIA GRUTCHFIELD Date of Inspection: 11/22/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: 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'h 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 SYSTEM WAS PUMPED IN.1ANi1ARV 2003 PER 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 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.] NO (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 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 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—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Owner: PATRICIA GRUTCHFIELD Date of Inspection: 11/22/04 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 any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Pago 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Owner: PATRICIA GRUTCHFIELD Date of Inspection: 11/22/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):220 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)): We o ([/�Uv) s `�o b) Sump pump(yes or no): NO 1 Last date of occupancy: n/a V S gza)D COMMERCIALANDUSTRIAL Type of establishment: n/a V Design flow(based on 310 CMR 15.203): n/a gpd gp Basis of design flow(seats/persons/sqft,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 Title 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 Source of information: SYSTEM WAS PUMPED IN JANUARY 2003 PER OWNER Was system pumped as part of the inspection(yes or no): YES If yes,volume pumped: 1000gallons--How was quantity pumped determined?n/a Reason for pumping: MAINTENANCE 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,date installed(if known)and source of information: 1977 PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Owner: PATRICIA GRUTCHFIELD Date of Inspection: 11/22/04 BUILDING SEWER(locate on site plan) Depth below grade:20" Materials of construction:_cast iron _40 PVC Xother(explain): ORANGEBURG 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: 14" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 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: I" 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: 17" 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 NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S 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 recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 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: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Owner: PATRICIA GRUTCHFIELD Date of Inspection: 11/22/04 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) 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 R Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Owner: PATRICIA GRUTCHFIELD Date of Inspection: 11/22/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GALLON 6'X6' LEACH PIT leaching pits, number: 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 HAD 5' OF LIQUID IN IT AT TIME OF INSPECTION.STAIN LINES INDICATE THE PIT HAS 6" OF EFFECTIVE LEACHING LEFT IN IT.BOTTOM IS AT 8 FT. 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: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Owner: PATRICIA GRUTCHFIELD Date of Inspection: 11/22/04 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 ppblic water supply enters the building. A 0 Ali 21 � 6k 2-0Ab 2u 2q f�G Zq in Pape 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 LIETRIM CIRCLE CENTERVILLE,MA 02632 Owner: PATRICIA GRUTCHFIELD Date of Inspection: 11/22/04 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 database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. 11 TOWN OF BARNSTABLE LOCATION to �,°C��Ii� t�'vcJ� SEWAGE# (9/6 VILLAGE ASSESSOR'S MAP&PARCEL S /G INSTALLER'S NAME&PHONE NO. R.L.C. SU$- 7,21-6 q6G SEPTIC TANK CAPACITY i GGO jlc„Lr 9 0 LEACHING FACILITY:(type) Z X.:& t4 /7r-',rc 1-k (size) f 3wy�!SC�' d NO.OF BEDROOMS OWNER 5 s PERMIT DATE: COMPLIANCE DATE: , v 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 �. �,� Nr0 TOWN OFBA�R�NSTABLE LOCATION �P VI I �� \o� A�' SEWAGE # VILLAGESQ 1 D , ASSESSOR'S MAP.& LOT S INSTALLER'S NAME&PHONE�NO. SEPTIC TANK CAPACITY V U LEACHING FACILITY: (type) CfAJ lug (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: C MPLIANCE 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)! 1 f � Feet Furnished by �J u2 "�/ �1J o Q 24� A-L 2V POA �ZO Z� NOTE: ELEVATION DATUM: GISf(NGVD) CEN TER VI LLE LOCUS LLJ_..I KITCHEN a BEDROOM y =moo �t-- co �I II N S LIE�IM U I� 45 SSB. PARCELLOT 3D: LIVINGROOM BEDROOM CIR ROB 28 `SO' 169/050 M 46 GAS O F N qp 04 EXIST. FLOOR PLAN LOCUS MAP i p SEW — — _ � — — AY — � LOCUS INFORMATION _ 1 PLAN REF: 223 139 TITLE REF: 20952/168 W I I PARCEL ID: MAP 169 PAR. 51 I J I I O' ZONED: RC-WP STATE ZONE II WATER 2 FLOOD ZONE: C„ I � � N —� „i i $3 �� COMMUNITY PANEL: 250001-0015-C DATED:08/19/85 20.4' 12. �,... �t� SEPTIC SYSTEM 66 7. �:::•o REPAIR PLAN I I 2—BED. 0,oQ- N opt` — r � LOCATED AT: DWELLING 7 4' #6 LI ETR I M CIRCLE I T.O.F. EL.= ' 1 CENTERVILLE MA. �� o 47.76' i JA TGAL w 33 ;;;;,,,' ; PTO REMAK) / LOT 29 PREPARED FOR -3 F"� & / i PARCEL ID: G R E G O R Y B. 8c -- VSN, �� 169/046 OHW PUMP, CR LEpCNP / Oo SUZANNE D. MILLER 28.2 \ 46 BpNO��E 5 �� DECEMBER 29, 2009 � �_ZH OF MAS 9 OF�L9Sgg0 EDWARD yGm \ A. �=+ STONE LOT 34 Op �2 U �l No.2 9 ¢ S` PARCEL ID: f S8S0. 169/051 l-l00 r rE��`� s GAS eR 00 F AREA=18,622 S.F.t Sq.v TA0' LOT 35 PARCEL ID: r ^� LOT 28 E. A. S. 169/052 ^00 PARCEL ID: SURVEY, INC. 1,gj a,�o 169/045 141 ROUTE 6A GRAPHIC SCALE �6, �,'� SALT POND BUILDING 20 0 10 20 40 so ► = P.O. BOX 1729 SANDWICH, MA. 02563 m,G 1 LOT 27 ( IN FEET ) PARCEL 41): BUS: 508)888-3619 FAX:(508)888-2496 1 inch = 20 ft. 169/044 SHEET 1 OF 2 J 1213 r TG4 OP"FOUNDATION ELEV. 47.76' 2" LAYER OF 4" SCHEDULE 40 P.V.C. PROFILE OF MIN. PITCH 1/8" PER FOOT SEWAGE DISPOSAL SYSTEM DOUBLE WASHED D STONE 10' MINIMUM-� (NOT TO SCALE) OR FILTER FABRIC 10' EXISTING TO REMAIN EL= 47.0' _ EL= 47.0' 6" MAX."................::� 6" MAX.: F .. EL= 47.3 6 MAX.' 6" MAX. ., .,.,,., ...;:,....,, ADD ADD .................,.. .,.....,.,...,".,...,. ., .,..,....,..,. INVERT CLEAN SAND FILL . .............. RISER RISER CONC. � 9 MIN./ EXISTING PIPE EL= 45.76 RISER & LEVEL EL= 44.0 ��, PER 310 CMR 15.255 2.5 36" MAX. COVER FOR 2' � s=o.os 10' S= .025 9' s=.01 EL= 44.8 EXIST. EXIST. FLOW LINE EXIST. INVERT INVERT 110" 14" INVERT INVERT INVERT EL=45.26' EL=44.68' MIN. EL=44.51 EL= 44.26' 6" SUMP EL=44.09' " ° °° ° °° O O o o� ° °° 4' ADD SUMP 24 0 � ° cQ O 000 0 DOD O (co 'p 4P BAFFLE 6" BASE OF COMPACTED SAND MECHANICALLY ° ° °° °04' 000 EL=42.0 & TEE PROP. DB3 DISTRIBUTION A' 4.0' 8 5' 4.0' TYP. EXISTING BOX 3/4" TO 1-1/2" ( ) 25' 1 ,000 GALLON TANK DOUBLE WASHED STONE 2-500 GAL. (H-10) DRY WELLS (4'-10" X 8'-6" X 2'-9") (TO REMAIN) SOIL ABSORBTION (TRENCH FORMATION) C° SYSTEM (S.A.S.) 12.83' X 25' I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPARTMENT OF BOTTOM OF TEST HOLE #2 ELEV.= 35.3' GENERAL NOTES ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR 15.017 TO CONDUCT (N 0 GROUND WATER) SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS DESCRIBED IN 310 CMR 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY DESIGN DATA: FOR SUBSURFACE DISPOSAL OF SEWERAGE. SOIL EVALUATION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, 2. AT LEAST ONE ACCESS PORT OVER TANK TEES SHALL BE ARE ACCURA AND IN ACCORDANU WITH 310 CMR 15.100 THROUGH 15.107. ACCESSIBLE WITHIN 6" OF FINISH GRADE, WITH ANY REMAINING ACCESS PORTS BROUGHT TO WITHIN 12" OF FINISH GRADE. NUMBER OF BEDROOMS.........__2/DESIG.2/DESIGN 3 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE - GARBAGE DISPOSAL...... NO CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE EDWARD A. 9TONE, CERTIFIED SOIL EVALUATOR UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEN THEY TOTAL ESTIMATED FLOW MUST WITHSTAND H-20 LOADING. (110 GAL./BR./DAY X �L BR.) 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION TEST PIT RESULTS: P #12797 330GPD X 200% = 660 GAL OF ALL UTILITIES PRIOR TO ANY EXCAVATION. USE EXIST. 1000 GAL. SEPTIC TANK 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SOIL TEST DATE: DECEMBER 17, 2009 OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. INSTALL: 2-500 GAL. DRY WELLS W 4' CRUSHED STONE 6. FINISH GRADE SHALL HAVE A MINIMUM OF 2% GRADE B.O.H. AGENT: DAVE STANTON ( / OVER THE S.A.S. AND DISTRIBUTION Box. SOIL EVALUATOR: EDWARD A. STONE ON THE SIDES, 4' ON THE ENDS) AND BACKFILL 7. SEPTIC TANK SANITARY TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6' ABOVE BACKHOE: REID ELLIS WITH CLEAN SAND FILL PER 310 CMR 15.255 THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND LOCATED DIRECTLY UNDER THE CLEANOUT MANHOLES. SOIL CLASSIFICATION................ 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN TH#1 EL.=47.4 DESIGN PERCOLATION RATE......92- N,/LN. 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT ELEVATION OF THE OUTLET PIPE. ELEV. DEPTH (IN.) HORIZON TEXTURE COLOR MOTTLING OTHER EFFLUENT LOADING RATE......... GA�DAY 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES. 46.9 0-6" REQUIRED LEACHING CAPACITY.....330 FILL -- - 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS �, LEACHING CAPACITY PROVIDED.....349 GAL/DAY BAFFLE, 4 INCHES IN DIAMETER AND CONTRUCTED OF 4" PVC. 46.6 6-10 A LOAMY SAND 10YR4 3 11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND 44.9 10-30" B LOAMY SAND 7.5YR5 6 SIDEWALL:(12.83, + 25 )x2x(2 SIDES)(.74)= 112 GAL/DAY FIRST TWO FEET OUT OF THE DISTRIBUTION BOX SHALL 35.4 30-144" C COARSE SAND 2.5Y.7 1 BOTTOM: (12.83' x 25')(.74)= 237 GAL/DAY BE LEVEL. 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION NO GROUNDWATER ENCOUNTERED TOTAL= 349 GAL/DAY TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW AND APPROVAL.--, 349 GPD PROVIDED - 330 GPD REQUIRED = 19 GPD RESERVE TH#2 EL.=47.3 ��ZNOFMASS9 CONSTRUCTION NOTES: ELEV. DEPTH IN. HORIZON TEXTURE COLOR MOTTLING OTHER o�� DAV c ��jNOFht4 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND 46.8 0-6" FILL SEPTIC SYSTEM DETAIL PAGE ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING 46.5 6-10" A LOAMY SAND 10YR4, 3 F RJR o`'� ED WARD yG�� #6 LIETRIM CIRCLE WORK ON THE SITE. 2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE 45.0 10-28" B LOAMY SAND _7.5YR5/61 o. ST N CENTERVILLE, MA. 1 WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT 35.3 28-144" 1 C ICOARSE SAND 2.5Y7 1 ' c�sTe�``� No 2 D DECEMBER 29, 2009 IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. Sa 3. ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING NO GROUNDWATER ENCOUNTERED `yl RR J TAPE OR A COMPARABLE MEANS. ` SHEET 2 OF 2 J# 1213 •r 1 •'