Loading...
HomeMy WebLinkAbout0131 LIETRIM CIRCLE - Health 131 Lietrim Circle Centerville A= 169—038 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..'' 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is required for every Centerville MA 02632 February 13, 2013 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 on the computer, use only the tab 1. Inspector: v key to move your cursor-do not David D. Coughanowr, R.S. use the return Name of Inspector key. Environmental Company N Company Name 43 Triangle Circle Company Address m� Sandwich MA 02563 CitylTown State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification �l J I certify that I have personally inspected the sewage disposal system at this acfd ass and that the information reported below is true, accurate and complete as of the time of the':in pection.Thle inspection was performed based on my training and experience in the proper function and; aintenance of or Bite sewage disposal systems. I am a DEP approved system inspector pursuant t Section45.34 f Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ F�ils rti ❑ Needs Further Evaluation by the Local Approving Authority 4� - � February 13, 2013 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 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. PI &urfacezl ► 13 t5ins•11/10 Title 5 Official Inspection Formwage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13, 2013 required for every ry 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. C c 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): l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13, 2013 required for every ry page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13 2013 required for every rY 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. I . ❑ 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 cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i f 11�D IN Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13, 2013 required for every ry page. Cityrrown 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 m 9 9 q PP 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 11 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. l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13 2013 required for every ry 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 CM 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 gpd t5ins•11/10 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 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is required for every Centerville MA 02633 February 13, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 330 gpd leaching provided Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 38 gpd 9 ( Y 9 (gpd)): Detail: 2011, 2012 Sump pump? ❑ Yes ❑ No Last date of occupancy: 2 months agoDate 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•11/10 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 GSM ,a''y 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02633 February 13 2013 required for every rY page. City/Town 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: 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): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is rY Centerville MA 02632 February 13 2013 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 5+ years. Certificate of Compliance issued 4/20/2007. (permit#2007-154). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 0.5 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: 8.5 x 5 x 6- 1000 gallon tank Sludge depth: 2 in t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "r 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13 2013 required for every ry 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 32 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time, but maintenance pumping is recommended within and every 2-4 years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is required for every Centerville MA 02632 February 13, 2013 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 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M se'°r 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13, 2013 required for every � page. City/Town 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 at outlet invert 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 appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. Few solids in sump. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner. No staining above the normal operating level was observed. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts W Title Official t e 5 0 c a Inspection Form p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13 2013 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13, 2013 required for every ry page. Cityrrown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 ' fn .o n onwealth of Massachusetts: Tale 5 Official t� Ins econ Forrri 1� Subsurface Sewaje Dispos°al Syst- Form :Not far Voluntary Assessments t 131 Lietrim Circle property%Ad'dre"ss Albert E�,:&ewsfer Owner Qwner 6 Name lnformatlon is Ubteru1116 MA 02632 Fetirua. 93,,2013 required`for every ry- _ page; _ Gity/Town ; State Zip Code Date 6 Inspection D.' System nformation (,co.nt.) Sketeh i f owage Disposal System Provrtle a view of the sewage disposal system, including lies. at least two pecrrianent:reference land marks.or`benchmarkS, Locate�all wells wtthm 100 feet Locate "public,water` up'ply ente`[s_the bi%ifdrng...Check'one of the boxes=below: .hand=sketch in the area below drawing attacii`ed separately 3o ; 2I N1l ;C 151ns"•11110 Titlo'S':OfflCfal lnspeclien Form,-5ubsuiface'Se"wage DisposahS�stem?PageaS ai 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13 2013 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ 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: 4/19/2007 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: Approved design plan on file with the Board of Health shows bottom of system to be 5.5 feet above the bottom of a test pit in which no groundwater or groundwater motting was observed. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Lietrim Circle Property Address Albert E. Brewster Owner Owner's Name information is Centerville MA 02632 February 13 2013 required for every rY page. Cityrrown 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable P# Department of Regulatory Services BARNMBt.& : Public Health Division Date KAS& � tti39. �e� 200 Main Street,Hyannis MA 02601 pJEO �h f Date Scheduled �� � Time : Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: V;;9.0Aa I d4c, ^7-0V� Witnessed By: LOCATION& GENERAL INFORMATION Location Address 3 L �� ` C i t e 12 C di ?t Owner's Name A t Z fe,,zs—,C K Address I�J i f.�e�(Li sue. C r'c).,C �.0 ' '\ EKStif fr�s tiL Assessor's Map/Parcel: (owl a 3 ff Engineer's Name me jZ0+ � NEW CONSTRUCTION REPAIR Telephone# $0it"422 Vole Land Use Slopes(95) Surface Stones Distances from: Open Water Body t't Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Parent material(geologic) meld S.n�9 Depth to Bedrock Depth to Groundwater: Standing Water in Hole: [/A Weeping from Pit Nee. [A 4 Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLV`_ � Method Used: Depth Observed standing in obs.hole: _ in, Depth to Soil mottles: ►n'. Depth to weeping from side of obs.hole: in, Groundwater Adjustment Index Well# Reading Date: Index Well level— Adj,factor-�� Adj,Groundwater'Level PERCOLATION TEST Date — � Observation Hole# _ Tlme at 9" .�......-...e ...,...�..�. r Depth of Perc Time at 6' _— Start Pre-soak Time @ i f 0 Time(9"-G') End Pre-soak Rate Min./Inch A Site Suitability Assessment: Site Passed Site Failed:_ Additibnal Testing Needed(Y/N) 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:XSEPTICIPERCFORM.DOC i DEEP.OBSERVATION HOLE LOG Hole# / Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Cansisteng,%Grivin As Ps d lz C MV--b Sft*14) 1,a st Ik S' O DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi enc S y x % ravel t? • 5�i �oAn~ a��Z DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency, I Flood Insurance Rate Man: LtU" Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No- Yes_;_�.._ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the t area proposed for the soil absorption system? y, If not,what is the depth of naturally occurring pervious material? Certification 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 trai •ng,expertise and experience described in 310 CMR 15.017. Signature !� g u Date Q:ISEPTlCVERCFORM.DOC No. . 9007— t 5q < r , Fee I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes RpPlicatton for � gponl *pgtern Congtructton Verna Application for a Permit to Construct( ) Repair Wi Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3/ Li err"rn ecee a Owner's Name,Address,and Tel.No. AL bvwr 13Yew.S-mQ ('ewTt��,Glc mot as'.I a. 131 LT e'r f i v1'1 ej e-c.1C A"`t� $_10 yL__�I21gi ee-nTERVi1ie , 94<+ Assessor's Map/parcel !(o 02w3>r Installer's Name,Address,and Tel.No. 6N-4, 4k Er/1'E,CRrjeg Designer's Name,Address and Tel.No. C-,7 tj¢ � Lc,UKKS PC•430x -zG3 /La.-co-osiFYlr/ sr. Ce<-�rERvi1/N mjq ezb 2 7 �✓�sr�7Af{ Off✓ Type of Building: Dwelling No.of Bedrooms Lot Size �yl�ao+- sq.ft. Garbage Grinder ( ) Other Type of Building 5'%n%t e JC4 4 No.of Persons 'Z Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 30 gpd Design flow provided gpd Plan Date 4-1$'too'7 Number of sheets ( Revision Date Title l 3 t L i-_XrCVv- Size of Septic Tank 1000 qA t e&;stii••, Type of S.A.S. (2) Soo G Ai, Description of Soil 9_a� 4+ Nat e o Repairs or Alterations(Answer when a plicable) C00 0 Cl p,( TVN,-cl. 0—i3iD A S'®o 5m . L.-C- /r S7oc 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 F 101th. 't Signed Date "['� l'100-7 Application Approved by _ Date Lr (� 7 Application Disapproved by: Date for the following reasons Permit No. Date Issued q - 19-07 No. ,,. Fee F �; • THE,COMMONWEALTH OF MASSACHUSETTS, Entered in computer: PUBLIC HEALTHIDIVISION .'TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIPPYication for -Mi5pogaf 6p.5tem Con5tructiou Vermit Application for a Permit to Construct( ) Repair(%4/Upgrade( ) Abandon( ) ❑ Complete System 0Individual Components Location Address or Lot No. 134 L e rr,'✓., C(lrae Owner's Name,Address,and Tel.No. lot err i3,rewSTE rb 6e ree"ile nsA ez4;z 131 Lierr;m Circje, Assessor's Map/P CenrE�ur, t , w 3i p2� arcel Installer's Name,Address,and Tel.No. �'dp�,,c4 G,k,1r6e P,1,XS Designer's Name,Address and Tel.No. '.'7 W`;`Kf , P.a.Sox ?�3 it u•. �rvs��,<id+ S� Cehrt11viIle rN�! oza72 lor�sr ?A(r o�/� Type of Building: Dwelling No.of Bedrooms 611. Lot Size Zyl�a0{= sq.ft. Garbage Grinder ( ) Other Type of Building �'����< .(a w a No.of Persons• 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 O gpd Design flow provided gpd Plan Date -1`�'Zao"] Number of sheets Revision Date Title 13 1 L e t J,✓►,► Size of Septic Tank Joao qi ra 1 Type of S.A.S._ (2) Sao C1 F1L L`G- Description of Soil 0-4 AA^ Natu e o Repairs or Alterations(Answer when applicable) )o 3 T;rt (030 Cl a( Tya^'4— q1D � Spo y L, G- µ.) S7�..� Ilk, t' f Date last inspected: 7- 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 opera tion-until,a Caitficate of Compliance has been issued by this Board of Health. a Signed Date 11' �'7 Application Approved by Date t 1 /61 cq>7 Application Disapproved by: Date -for the following reasons Permit No. P-" 7 — 1 5 ` Date Issued q — ,D }, THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE-,,,MASSACHUSETTS = Certificate ofNeompliante THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( vl/Upgraded ( ) ih Abandoned( )by C F+¢,&J,& E n1�p t ,S ei (,L C at 173 1 Lieu;vv, G.i r Or— has been constructed in accordance ' with the provisions of Title 5 and the for Disposal System Construction Permit No. 2007— 1 S L/ dated Installer CtA. J., (.LC Designer #bedrooms 5k Approved design flow gpd The issuance of this permit shall not beAnstru d as a guarantee that the systemill function as_LeliG—n�d-e-. Date °'!/ �© Inspector -------------------------------------------- NO. 9-d v7 Fee l THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 0igoal,*pgtem Con6truction Permit Permission is hereby granted to Construct ( ) Repair ( to ) Upgrade ( ) Abandon ( ) System located at 1 31 4.;g r✓;m G;t c (`�,,,-�t,r:,��r- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. p Provided: Construction must be completed within three years of the date of this permit. Date �-�� C1 Approved by �— z 04/26/2007 07:28 5084775313 ENGINEERING WORKS PAGE 01 Town of Barnstable Regulatory Services i $ Thomas F. Geller,Director ss. Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862A644 Fax: 508-790-6304 Instoff. Designer Certification y Date: � -�l sewage permit# Assessor's MapTarcel f c q_316 Designer: e,?:o f, "ar4 c, Installer: VF,'12e-Z t) Lowe W,0 Address: Z W Cmssf re td aril Address: 1 a 1 13Yac 7�° On 1-I y' Zoe wkh A_ k-�W_Ivo was issued a permit to install a (date) (installer) septic system at ! ''� C` ' ' )-e based on a design drawn by (address) dated (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 (Le, 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. 4� y + PETER 14mWiert Si WENTEE CIVIL ,Q No.35109 O (Designer's Signature) (Affix De0o p Here) rLE E UTJ1RN O Bev TABL , ,XUBLIC HEALTH DIVI W CERTIFIiC OF �nMt►t NCE �yI L NOT RX ' 6SUED UNTIL BOTH Vila FORM AND ARE RECEIVED BY UM BARNSTAB E PUBLIC HEALTH DIVISION THANK XW Q_ Certification Form 3-260+I46c >3 / � TOWN OF BARNSTABLE LOCATION Li 1 , ��,.T,� 1 fv\ �� SEWAGE# . VILLAGE � 1 �lfL ASSESSOR'S MAP&PARCEL 22(�N &PHONE NO. SEPTIC TANK CAPACITY G.. LEACHING FACILITY:(type) V-N c._ -r (size) NO.OF BEDROOMS ��� ATE: � C COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �- � 1 zl lH 4D 1 LPL /TOWN OF BARNSTABLE LOCATION Z3I ��t ri^i/� �'<.�r�i SEWAGE # J0077•-16 VILLAG ASSESSOR'S MAP & LOT !G4 `38 INSTALLER'S NAME&PHONE NO. e.P4 c-1'CC. Eire 90z i- %,Z E SEPTIC TANK CAPACITY l000 rY LEACHING FACILrrY: (type) Cab !-/-/0 Sd 0 L C (size) 13•a Y 3 NO. OF BEDROOMS BUILDER OR OWNER Ql�C/2 812611 PERMIT DATE: - COMPLIANCE DATE: -' — Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Ne !U 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 B 1}3 ag A-4 ��•� 3 f 3t • �� t, Q�X39 _ LEGEND Oe-,6&n Wy ,L23 52.9°44'00"W �, ,�.�f. l/ 99 Q o R°Semary `a Z 36 / X)0.03, / 78 PROPOSED CONTOUR K ou cap' �o m a / 79 PROPOSED SPOT GRADE 4 k 9 99 4) ' . ..... ` EXISTING CONTOUR07 °� 102.76 x EXISTING SPOT GRADE 71 333 t i PIT? TEST mac GARDEN � ta Rd W EXISTING WATER SERVICE `fp7 ` Route 28 LOCUS >f G EXISTING GAS SERVICE EXISTING S.A.S. f_,_..........�1 72 k TO BE PUMPED & { I.... ._—m _...... ._ .�, -___, �._ I sc9 FILLED WITH SAND 67 OGW OVERHEAD WIRES ..................._. ......, . .......... A�3 :1 °........... ...._ BENCHMARK LOCUS MAP N.T.S. I--23 0' EXISTING SEPTIC TANK r - S. T PROP. TOP OF TANK EL.=99.17 GRDEN ...�_.,. I'•; I N INV.(OUT)=97.84t ! rJ si O I GENERAL NOTES: W 39 �`� BENCHMARK: ((]� � r N 7 x gg 19 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 7p GCS ' BULKHEAD CORNER BOARD OF HEALTH AND THE DESIGN ENGINEER. In (n 0J9 ' ELEV. I00.00' 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 2 �5 �� a� CTI (A55UMED DATUM) OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE In - / 9� ® LOCAL RULES AND REGULATIONS. (� yf / 79 UI 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR j TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE ;NO. 131 /� I �_ DESIGN ENGINEER. / 151Y /'' / 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING / ! FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN k 70 / Fes,' ENGINEER BEFORE CONSTRUCTION CONTINUES. Ippo T.O.F. - 100.74' 5, ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 0 700� I 9 7. WATER SUPPLY PROVIDED BY TOWN WATER. _, { _......, 76 8. THERE ARE NO ABUTTING WELLS LOCATED WITHIN 150' OF THE S.A.S. ° 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED ^• z TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. ] 3 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING ;g r CONSTRUCTION. j 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS i IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). a 12. CONTRACTOR SHALL EVALUATE STUCTURAL INTEGRITY OF EXISTING APN 169"3V �aSs SEPTIC TANK PRIOR TO CONSTRUCTION. C9 _ � 9�y 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY 16,475±SF o PETER T. AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. MCENTEE O VJ CIVIL !— 100.00, �. No. 35109 PROPOSED SEPTIC SYSTEM UPGRADE �. N31°1 OWE t �£GISAE�``° �• BHA, _ �hW livo'---- HYr £sS,O, �e�c�� 131 LIETRIM CIRCLE, CENTERVILLE, VA . ...._......... ... - PAVEMENTx Prepared for: Albert Brewster, 131 Lietrirn Circle, Centerville, MA 02632 99 98 EDGE 01� 9) r n P 4� 96 l 67 V�v ! Engineering by: Surveying by: SCALE DRAWN JOB. NO. LIETRIM CIRCLE EngineedngWorkr HOOD SURVEY GROUP 1"=20' P.T.M. 139-07 r 12 West Crossfield Rood 18 Route 6A Forestdale, MA 02644 Sandwich, MA 02563 DATE d CHECKED SHEET NO. (508) 477-5313 (508) 888-1090 4/18/07 • P.T.M. 1 Of 2 • NOTE: TO PREVENT BREAKOUT, THE PROPOSED • T.O.F F.G. EL: 99.5t FINISH GRADE SHALL NOT BE < EL:97.0 FOR A DISTANCE OF 15' AROUND THE (EXISTING) PERIMETER OF THE S.A.S. EXISTING F.G. EL: 99.7%P(EXISTING) � F.G. EL: 99.8tt MAINTAIN 2% MIN SLOPE OVER S.A.S. 4' SCH 40 PVC PERFORATED PIPE WITH SCREW CAP SET TO WITHIN 3" OF FINISH INSTALL RISERS OVER INLET & OUTLET INSTALL RISER OVER D-BOX TO 2-500 GALLON LEACHING CHAMBERS GRADE TO SERVE AS INSPECTION PORT. TO WITHIN 6" OF FINISH GRADE WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL SIDES <: INSTALL RISER OVER CHAMBER L =37' L=4, SHOWN ON PLAN AND SET COVER WITHIN 6" OF FINISH GRADE ^ 4" SCH 40 PVC 4" SCH 40 PVC to" ^ f-2" LAYER OF 1/8" TO 1/2" ta^ ® S= 1% (MIN.) kli�k = = 1% (MIN.) (OR APPROVED FILTER FABRIC) DOUBLE WASHED STONE EXISTING aa" VEL INV.=97.50INV.=97.33 2' EFF. DEPTH LEVEL 3/4"-1 1/2" ' EXISTING 0-BOX !EF DOUBLE WASHED FIFLE INV.=97.84f !E !4# STONE EXISTING 1000 GALLON SEPTIC TANK (SEE NOTE 12-SHEET 1) INV.=96.50 TOP CONC. ELEV.=97.3 —BREAKOUT ELEV.=97.0 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING INV. ELEV.=96.50 ®®a®® PIPE INVERTS PRIOR TO CONSTRUCTION. ®®tea®®B®e®® ®®®aaa®®ea® 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.=94.50 2 x 8.5' = 17.0' 3' GRADE ON A MECHANICALLY COMPACTED SIX 3' INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 23.0' 3) INSTALL INLET & OUTLET TEES AS REQUIRED. LEACHING SYSTEM SECTION 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE. NO G.W. ENCOUNTERED T BOTTOM OF TP EL: 89.0 (TP-1) SEPTIC SYSTEM PROFILE N.T.S. (3) 5" DIA.OUTLETS 15.5" "I 1-- 1 " 2" DESIGN CRITERIA : 12" NUMBER OF BEDROOMS: 2 BEDROOMS [,*D 'L 15.5" 8 O r; a„ SOIL TYPE: CLASS I DESIGN PERCOLATION RATE: 5 MIN./IN. T ' 2" SOIL LOG DAILY FLOW: 220 G.P.D. / H-10 LOADING j' i /// 1, f, ,�,� � / � DESIGN FLOW: 330 G.P.D D—BOX i *&001 ® '�•Ol '�' DATE: MARCH 29, 2D07 {P-11,723) GARBAGE GRINDER: NO N.T.B W21A/•dN1 LEACHING AREA REQUIRED: (330 = 445.9 S.F. SOIL EVALUATOR: VERONICA WARDEN C.S.E. ) f WITNESS: DONALD DESMARAIS - HEALTH AGENT .74 EXISTING SEPTIC TANK:ISI p EX T NG 1000 GALLON CAPACITY (ESTIMATED) ®®®® ® ®®®® / , ` Elev. TP— 1 Depth Elev. TP-2 Depth a W ®®®®®®®®®®® �/ / ''/ 99.0 0" 99.0 0" USE 2-500 GALLON LEACHING CHAMBERS IN SERIES N ®�®®®®®®®® FILL FILL SIDEWALL AREA: 2(13.2' + 23.0') X 2 = 144.8 S.F. ,. 98.6 5" 98.3 7" 102" Ab SANDY LOAM Ab SANDY LOAM BOTTOM AREA: 13.2' x 23.0' = 303.6 S.F. 2.5YR 2.5/2 2.5YR 2.5/2 0 2 98.a 7" 98.2 Bw 9" TOTAL AREA: 448.4 S.F. eW SANDY LOAM SANDY LOAM 10YR 3/1 10YR 3/1 4• KNOCKOUT 97.7 15" 97.6 16" DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. � 20" DIA. COVER C 26" C L " KNOCKOUT0 4" KNOCKOUT 62" V W a 38" PROPOSED SEPTIC SYSTEM UPGRADE PROP. s.A. CENTERVILLE MA 4" KNOCKOUT I MED. SAND MED. SAND 131 LIETRIM CIRCLE, , 11 10YR 4/6 10YR 4/6 Prepared for: Albert Brewster, 131 Lietrim Circle, Centerville, MA 02632 Engineering by: Surveying by: SCALE DRAWN JOB. NO. 500 GALLON CAPACITY, H-10 LOADING 89.0 120" 89.0 120" EngineedngWorb HOOD SURVEY GROUP N.T.S. P.T.M. 139-07 CHAMBERS S.A.S. LAYOUT NO GROUNDWATER OBSERVED 12 West Crossfield Road 18 Route 6A Forestdale, MA 02644 Sandwich, MA 02563 DATE CHECKED SHEET NO. NJA PERC RATE <2 MIN/IN. ("C" HORIZON - TP 1) (508) 477-5313 (508) 888-1090 4/18/07 P.T.M. 2 Of 2 r s