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0027 LONGBOAT DRIVE - Health
27 Longboat Drive " Centerville A= 193 - 157 I. *Pendafie,v'r a *Esselte 42101/3 0RA 10% P4 TOI1VN OF BAW$I TA LE i,—OCATION `c „ fi` ® ; SEWAGE - 'VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. L;F�r ' �`�' SEPTIC TANK CAPACITY ''��i LEACHING FACILITY: (type) 7�c� i�E�:O' (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: � 07 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 ' l �1 C � ® , : � � � .:� ryr, .� .. . , � � _, ._ p .. ,- . .. , � . „} X .. :, .; _ . _. ... ,. ._. ,:. ,. ,. � . j ;:: .... . w ..,_, . . �.: . -. � ! .. �, r- . No. . �./c-- ' t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y s pphratiou for 30igpont 6p5temc Cou0trurtton Permit Application for a Permit to Construct O Repair(e Upgrade O Abandon O ❑.Complete System L"J Individual Components Location Address or Lot No= Owner's Name,Address;and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms "� Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building• No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ���� gpd Design flow provided gpd Plan Date �'� �y�,� Number of sheets oo, Revision Date Title Size of Septic Tank --0 er.1-0 LP44 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B of Health. Signed ✓/�� Date Application Approved by ate Application Disapproved by: Date for the following reasons Permit No. Date Issued No. f � t/ ';. -j1L i Fee 1 4� - . Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS —eYs PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTSYes ZIpphratiou for �Bts;po5a[ *potem Con.4iuctiou Permit 8 Application for a Permit to Construct.O Repair(/< Upgrade O Abandon O O.Complete System LJ Individual Components Location Address or Lot No= -e_1C7 ��pJ(� Q$�a Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: 3 Dwelling No.of Bedrooms 1 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow(min.required) ��p gpd Design flow provided .�� gpd .Plan Date Number of sheets � Revision Date Title Size of Septic Tank0,M941, Type of S.A.S. t ti Description of Soil s Nature of Repairs or Alterations(Answer when applicable) - r` Date last inspected: Agreement:-l 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 thCBo &fHealth.Signed � 4Date Application Approved by . Date w j J - Application Disapproved by: / Z;pDate forrthe following reasons �. Permit No. «Date Issued — —. ——————.—————— - T ——— ———-— THE COMMONWEALTH OF MASSACHUSETTS R� BARNSTABLE,MASSACHUSETTS ` CertificaWbf Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( ) Abandoned( )by ' ab 7 ,C'p y� p,(J'/y��p, Ge�`�T h been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. t%, •� r dated / 7 //J//)/7 Installer�?�/J1 d ef�p�`!//t' Designer ,,ej/% ,v l #bedrooms Approved e ' n flow , `„ ,Jo gpd The issuance of this pe shalYnot onstrued as a guarantee that the systeiMlinclion Z desi ed.1716 Date Inspector ———————— ../ �———————————————————— ———————————-- No. \t� - Fee VHE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 'Wi5 pogal *pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair (jr-1 Upgrade ( ) Abandon ( ) System located a � ca` y C � r ; . e _ and as described ii1the 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. - Provided: Construction st be lompleted within three years of the date of this permit Date Approved. y A / a,- :k t , `'L Town Of Barnstable' •p�fHE..T. .. o A ��•. �:� Regulatory Services Thomas F. Geiler,Director • �N.S{'t4BEE, s a Public Health Division rFp , � Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644- Fax: 509-790-6304 Installer &Designer Certification Form Date: Designer: Installer: 1 ` J Address: . �� � �� Address: � vas issued a permit to install a (date) (installer) septic system at based on a design drawn by (address) "b dated Zoo (designer) I:certify that the septic system referen e4 above was installed substantially according to T1e design, which may include minor proved"ch ges ch as lateral relocation of the 1i,stribution box and/or septic tank. r. p I certify`ythat the septic system referen above was installed vnth"�aajor,changes (i.;e, greater than 10' lateral relocation;of the SAS or any vertical relocation of any componeuat of the septt system)but in accordance with State&Local,Reg1Aations. Plan revisiork or certified as-biiiltby designer to follow. 'OMgs �DAVID. : (Installer's Signature) � '; '•� � o 1-066 � sgNJTAgi (D er s Signature) (Affix 'is Sfaip Here) PLEASE kZE11W TO BAR' N�S' 'ABLE PUBLIC HEALTH DIVISION.. CERTMF TE OF. CONLPLIANCE Wffit 'N: ; SSUED N L:BOTH=T$I 3FORM A 1` A5= BUILT CARD ARE RECEIVED BY BaNSTABL]E PUBLIC:RE DIirIS OI lid. . TIIAANK YOIT. Q:Health/Sep ic/Designer Certificafion Forr, 'x ; Town of Barnstable P# Lr Department of Regulatory Services Public Health Division Date 200 Mr `Street,Hyannis MA 02601al> -' Date Scheduled J �_ G line Fee Pd. Soil Suitability assessment for Sewage isposal Performed By: V t '"/ i ( 'Witnessed By: f LOCATION&GENERAL INFORMATION Location Address 7 � . Owner's Name Z✓. C,<— LoT 11 1191 � 1 Address Assessor's Map/Parcel 9 �'�� Engineer's Namage24 j�'io,�?�i� NEW CONSTRUCTION REPAIR Telephone'# Land Use � �0 mopes(%) Surface Stones Distances from: Open Water Body ft "Possible Wet Area Lft Drinking Water Well ft ' i Drainage Way ft Property Line ft Other It w SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Parent material(geologic) d"`^^'�`t Depth to Bedrock Depth to Groundwater. Standing Watei in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater IZA- t DETERNIINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to soil mottles: Depth to weeping from side of obs.hole: , in, Groundwater Adjustment tt. Index Well# Reading Date: Index Well level `Adj.factor, a. Adj.Groundwater Level,Re PERCOLATIONTEST Datta Thee Observation •' Hole# Time at 9" Depth of Pere _ f, Time at 6'. Start Pre=soak Time @ Tuna(9"-6') End Pre-soakIM Rate MinJinch ti JSite Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) a Original: Public Health Division, . r 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:ISEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Other Depth from Soil Horizon Soil Texture .Soil Color Soil r Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. / Consistencv.%Gravel) c F4_� 7 IPWD DEEP OBSERVATION HOLE LOG _.,Hole.# Depth from Soil Horizon Soil Texture Soil Color Soil i� l Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) b' 17 PXC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon.- Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi t n I Flood Insurance Rate May: _ s �t• Above 500 year flood boundary No_ Yes ._ a Within 500 year boundary No Yes ' Within 100 year flood boundary No F Death of Naturally Occurring Pervious Material GUdt1 Does at least four feet of naturally occurring pervious rial exist in all areas observed throughout the area proposed for the soil absorption system? ; If not,what is the depth of naturally occurring pervious material? IJ I Certification JA) i I certify that on (date)I have passed the soil evaluator examination approved by the Department of Enviotection and that the above analysis was perfWaDya consistent with . the requi ed training,e e ' e n experience described in 310 CMR 15.017. 7 Signa e Date /0d/ Q:\S.EPTICIPERCFORM.DOC TOWN OF BARNSTABLE kx'-wi-ION L �'� 0-4 7 SEWAGE :t �'TLLAGE L��'� ASSESSOR'S MA.a& LOT NAME&PHONE NO. SEPTIC TANK CAPACITY 51 If// c— S770A' LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER !� C PERMTTDATE: 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 READ �` a TOWN OF BARNSTABLE LOCATIONA✓ �'' ,5 c"•�3 'b A' SEWAGE# VILLAGE C Z si✓T ASSESSOR'S MAP & LOT Hq3TALLIMS NAME&PHONE NO. SEPTIC TANK CAPACTTy 7. o c— c7on., LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER / C'A PERMITDATE: CZb4PE4ANM 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) r Feet Furnished by i 331 Q 3 -C 7s 0-736 i COMMONWEALTH OF MASSACHUSETTS b2 Title 5 Official Inspection orm Not for Voluntary Assessments W C /�J rev Subsurface Sewage Disposal System Form a_7� Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Property Informatio : MAP 193-PARC 157 - 27 LONG BOAT DRIVE - CENTERVILLE MA, 02632- ll Property Address LIDBECK, ULF Owner's Name 27 LONG BOAT DRIVE Owner's Address CENTERVILLE MA 02632 City/Town State Zip Code AUGUST 1, 2007 Date 2. Inspector: JAMES D. SEARS Name of Inspector A & B CANCO Company Name 350 MAIN STREET Company Address WEST YARMOUTH MA 02673 Cityrrown State Zip Code 508-775-2800 Telephone 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The System: ® Passes F1 Conditionally Passes ® Fails�a: ® Needs Further Evaluation by the Loc pproving Authority Inspe Signature: Date: r'n The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or P) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd r 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage DisposalY System Form D. Certification (cont.) 27 LONG BOAT DRIVE Owners Address CENTERVILLE MA 02632 City/Town State Zip Code LIDBECK, ULF Owners Name AUGUST 1, 2007 Date of inspection Inspection Summary: Check A, B, C, D or E/always complete all of Section D A) System Passes: N/A I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: N/A ❑ One or more system components as described in the"Conditional Pass"section need to be replaced.or Repaired. The system, upon completion of the replacement or repair,.as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ® The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved,by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of compliance indicating that the tank is less than 20 years old is available. ND Explain: Title 5 Official Inspection Form:Subsurface Sewage Disposal System P g P Y Page 2 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 27 LONG BOAT DRIVE Owner's Address CENTERVILLE MA 02632 City/Town State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection B) System Conditionally Passes (cont.): 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): El broken pipe(s)are replaced obstruction is removed ® distribution box is leveled or replaced ND Explain: ® The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ® broken pipe(s)are replaced obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health:.N/A ® 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 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 27 LONG BOAT DRIVE Owner's Address CENTERVILLE MA 02632 Cityrrown State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection C) Further evaluation is required by the Board of Health (cont.): NIA 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 l 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ® The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ® The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well** Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less.that 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3.Other: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments �w Subsurface Sewage Disposal System Form B. Certification (cont.) 27 LONG BOAT DRIVE Owner's Address CENTERVILLE MA 02632 City/Town State Zip Code LIDBECK, ULF Owners Name AUGUST.1, 2007 Date of inspection D) System Failure Criteria Applicable to All Systems: ./ You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 0 ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® 0 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 pit is less than 6" below invert or available volume is less than day flow ® 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 0 0 Any portion of the SAS,cesspool or privy is below high ground surface water elevation. ® N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. FN—/A--1 Any portion of a cesspool or privy is within a Zone 1 of a public well. ® N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® N/A 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.] YES No The system is a cesspool serving a facility with a design flow of 2000 gpd—10,000 gpd. Yes No 0 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 27 LONG BOAT DRIVE Property Address CENTERVILLE MA 02632 Cityrrown State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection E) N/A-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 El ® 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 27 LONG BOAT DRIVE Property Address CENTERVILLE MA 02632 Cityfrown State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection 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? 0 ® Were all system components, including 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: 0 ® Existing information. For example, a plan at the Board of Health. 0 ® 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)]. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form Not for Voluntary Assessments " Subsurface Sewage Disposal System Form D. System Information 27 LONG BOAT DRIVE Property Address CENTERVILLE MA 02632 City/Town State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes [2] No Is laundry on a separate sewage system?[if yes separate inspection is required] ® Yes ® No Laundry system inspected? © Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): N/A Sump pump? ® Yes ®✓ No Last date of occupancy: PRESENT Commercial/Industrial Flow Conditions: N/A 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: Last date of occupancy/use: Date Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Do System Information (cont.) 27 LONG BOAT DRIVE Property Address CENTERVILLE MA 02632 Cityfrown State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection General Information Pumping Records: Source of Information: N/A Was system pumped as part of the inspection? ® Yes [21 No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank,distribution box, soil absorption system Single cesspool ® Overflow cesspool ❑ Privy Shared system (yes or no)(if yes, attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank.Attach a copy of the DEP approval. Other(describe): Approximate age of all components, date installed (if known)and source of information: 1978—PERMIT#78-287 Were sewage odors detected when arriving at the site? ® Yes No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 COMMONWEALTH OF MASSACHUSETTS W Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form De System Information (cont.) 27 LONG BOAT DRIVE Property Address CENTERVILLE MA 02632 Cityrrown State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection Building Sewer(locate on site plan): Depth below grade: 6" feet Material of construction: ® cast iron 40 PVC ❑ other(explain) Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): GOOD Septic Tank(locate on site plan): ✓ Depth below grade: 6" feet Material of construction: 0 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-GALLON PRE CAST Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle 22" Scum Thickness 4" Distance from top of scum to top of outlet tee or baffle OVER Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? PROB—TAPE—SLUDGE JUDGE Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 27 LONG BOAT DRIVE Property Address . CENTERVILLE MA 02632 Cityrrown State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection 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 & COVERS AT 6", TANK FULL OVER OUTLET TEE. Grease Trap (locate on site plan): N/A Depth below grade: feet Material of construction: ❑ concrete ® metal ❑ fiberglass ® polyethylene other(explain) Dimensions: Scum Thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass, ❑ polyethylene other(explain) Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 27 LONG BOAT DRIVE. Property Address P CENTERVILLE MA 02632 Cityrrown State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection Tight or Holding Tank(cont.) N/A 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 a copy of current pumping contract(required). Is copy attached? ❑ Yes No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert OVER 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 LOCATED ON SITE. Pump Chamber(locate on site plan): N/A Pumps in working order: ® Yes No Alarms in working order: Yes No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments " Subsurface Sewage Disposal System Form D. System Information (cont.) 27 LONG BOAT DRIVE Property Address CENTERVILLE MA 02632 Cityrrown State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection 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: Type: ® leaching pits number: 1 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 (1) 1000-GALLON PRE CAST PIT. PIT & COVER AT 2' BELOW GRADE. PIT FULL TO COVER, LEACHING NOT WORKING, NEED TO REPLACE LEACHING. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Q1 y0� Subsurface Sewage Disposal System Form D. System Information (cont.) 27 LONG BOAT DRIVE Property Address CENTERVILLE MA 02632 City/Town State Zip Code LIDBECK, ULF Owners Name AUGUST 1, 2007 Date of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Privy (locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 l r COMMONWEALTH OF MASSACHUSETTS o Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 27 LONG BOAT DRIVE Property Address CENTERVILLE MA 02632 City/Town State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection Sketch of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmags or benchmarks. Locate all wells within 100 feet. Locate where public waters ipply enters the building. ' o Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 I . COMMONWEALTH OF MASSACHUSETTS j d Title 5 Official Inspection Form !, Not for Voluntary Assessments Subsurface Sewage Disposal System Form I D. System Information (cont.) 27 LONG BOAT DRIVE Property Address CENTERVILLE MA 02632 City/Town State Zip Code LIDBECK, ULF Owner's Name AUGUST 1, 2007 Date of inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to NO ground water: 12'+ Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: Checked with local excavators,installers—(attach documentation) Accessed USGS database—explain: You must describe how you established the high ground water elevation: LOT &AREA HIGH, 12'+ NO GROUND WATER. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 O.CAV-ION 4 2-7 SEWAGE PERMIT N0. IN ?8 s LLAGE a INSTA LLER'S NAME & ADDRESS �C n an n�JCJ"�0 B U It D E R OR OWNER 9 DATE PERMIT ISSUED 4_30 ir DAT E COMPLIANCE ISSUED . y_ � v-7oc— ,Al • .sF �t <..� s (qj No....................... .............................. THE COMMONWEALTH OF MASSACHUSETTS 80AR® ®F F-i LTH ............. .........OF.... ............ ......................................••----•- Appliration for Bisp sFal Works Toustrnrtiun ramit Application is hereby made for a Permit to Construct (L-�' or Repair ( ) an Individual Sewage Disposal System at: --...... ..._ ..... --... ...................... ...... --•--•--•----•-- -- r��ryycati n-A dres Lot o. • •�- _swat I� iCs �IJS _�d= 0 ... !Viv`G .........................Owner ,.,,.Address /A s i9 ................... Installer Address UType of Building Size Lot-. ......Sq. feet �1?�Dwelling—No. of Bedrooms_ . - ........................Expansion Attic (4j Garbage Grinder (A.A7 aOther—Type of Building ...... No. of persons...._ ......... Showers (d2) — Cafeteria ("'!p dOther fixtures -------••-•-•----•----•-•--•---•---•------------------•-=-•••••--•••-----••••••---....._.....................••••-•--•••....-••--•••-._.........._.. W Design Flow.........� ...............................gallons per person per day. Total daily flow............ __73_0_................gallons. WSeptic Tank—Liquid capacitylOX..gallons Length.......:........ Width................ Diameter................ Depth................ x Disposal Trench—N ....... Widt otal Length.. -•- Total leaching area.-•••••••-•-•`•---•_.sq:ft. Seepage Pit No......�_______.. Diameter.....V......... Depth belo inlet._.__..._..._. Total leaching area_ 0� ft. Other Distribution b ox (/ ) Dosing tank �� Percolation Test Results Performed by____._-.. a __.__ _ / minutes per inch Depth of Test Pit.................... Depth to ground water--_-_-___________--___ . t_N � Test Pit No. 1._..__o�..._._ - f�, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... a' ..........o•------ • ---------- _---------------- --•...................................................................................... O Description of Soil..... r'L000c� 1 c.� ----------------------�� --••-•••••• --• •••.....---------��---------------------------------------•--•-••-••-•.... ----------------------------------- /'� ------- ''g / ' -----------------•--------------------------------•------------------------------------••••------•••- U Nature of Repairs.or Alterations—Answer when applicable............................................................................................... ----------------•----...-•--------------------------------------...------------------•-------•••-.....---._.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITx LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system operation until a Certificate of Compliance has been issued by the board of health. • Sign '.... •--•• -..... ................................... ............Date•-•---•----..•---- Application Approved By....... ... ... _ -_.. .. -------•----- ---4 ....... Date Application Disapproved for the following reasons---------------------------------•------------------------.....----------------------------------------••--•-•••- ...-•-••....................•••••-----•-•..........•••••••••......••••-••••---•-•-•-•---••...••••----•-•-I-•••--•••-•---•-••--------•------••----••••••••••-•---••-•-----•••---••-•---------••••---•---•- Date PermitNo......................................................... Issued_.-- ~a...................................... Date No....... ........ FElIc.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD O=F LTH ............. ... ............ ft...... �.. ..................................................... Apptiration for DiApwial Workti Tongtrurtion Vrrntit .,Application is 'hereby 'bLde for a Permit to Construct an Individual Sewage Disposal .- or Repair System at: —2, ... ............................. ................................................................................ ... Acatio.-411ress-p r t JAv ............. ----------_----------------.......... .................................................................................................. Owner Address V _5 �cq .......................................11C------------------------------------------ ............. ................................................................................ Installer Address4 Type of Building Size Lcft!� .......Sq. feet U Dwelling—No. of Bedrooms.'.........................................Expahsign Attic fc,) Garbage Grinder aOther—Type of Building-s./9' .fff...'�....... No. of persons..!!�.......... Showers Cafeteria Otherfixtures ..................................................................................................................................................... Design Flow........Z/6�...........................gallons per person per day. Total daily flow..___..__& 6' W .....*...*....__.______________gallons. ................gallons. 9 Septic Tank—Liquid*capacit/ . kallon�s , - Le�Ln 11h................ Width,....... Diameter._.-............ Depth............... ",;o. ....... Wid Disposal Trench—-L t I-------- ......... Total Length........ ......... Total leaching area____________ sq. f t. Seepage Pit No.....I------------- Diameter____ ___________t Depth belq�V inlet___.__________.......... Total leaching ar;��? q. ft. Z Other Distribution box Dosing ta)6 10 A10. /7 IT 141 -- P .1.. Percolation Test Results, Performed by........ Ar Xawd... QA4x A. .. *, 1- Date.JO /t.A Test Pit No. I.... .V......-,-minutes per inch,.,Depth of Test Pit_____________________ Depth to ground water_:______.__._____._..._. 44 Test Pit No. 2.................minutes per inch. Depth of Test Pit .............. Depth to ground water________________________ ......................... .................�!.�..................................................................... 0 Description of Soil.... .................................................................................... ......... ........ WZ-Z��..........��w .................................. -----------7......... ................... ........................... ...............................d................................................. J ..,---------------------------------------- .............................................................................................................................................................. U Nature of Repairs or Alterations—Answer when applicable_�------------- ---------------------------------------...................................... ----------------------------------............................................................................................... Agreement: 'The undersigned agrees to irlstall the aforedescribed Individual Sewage Disposal System in accordance with 'I T T-Zj 5 of r the provisions of L the Sanitary Coq,;eThe undersigned further agrees not to place the system in operation until a Certificate of Compliance has been sued by the board of health. Sig d........ Date ozw ................ .... ...... el"'(00P ....... .......... Application Approved By____. ..... .. ..... ...J16...00.0... Date Application Disapproved for the foilpwing reasons:................................................................................................................. ....................................................................................................................................................................................................... ns Date PermitNo......................................................... Issued.---------..._..--------------- - ------------ Date THE COMMONWEALTH OF MASSACHUSETTS BOA.RD/)DF HEA1,TH .......7.Zoum............oF..... .................. . ............. ............................................ .............. T I T��� -91 Trrfiftratr of Tantphatta A—, WS SL ER FY That the Individual Sewage Disposal System constructed or Repairedby.... .. . ...... ... ... . .......A...............0.... at... ... -k� to ............... ........................................................................... d-i has been installed in accordance with the provisions of 4 of The State Sanitary C4 as describen the application for Disposal-Works Construction Permit No.____`_._____-----EZ............ dated__...F7.J.40_.11---?V............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W17a ,,.M , LL ,FUNCTIQN SATISFACTORY., r 0 DATE................................................................................ Inspector..# ................44a--k..................... ................. ....I..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH k7, ............ '!'.:-.-OF.................................t................................... ............. ..................... O ................ FEE........................ trtu in "amit Permiss* . ................... .............................. !pne��re�b� grante -------- ................1�,777........................... d to Cons or Repair an I i sposal -1 IC rag y UP ................ .......al ...... ....... .. 1 6�� ............... .. ....... Street as shown on the application for Disposal Works Constru•ction Permit ;1 ... .... Dated.............................................. ..................................................... F Board of Health 7�— .. ...... DATE...... ..................................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1 A:�? A zn s ¢ fv -7 L9�� �.ld_Q. H-L-7 � H �o a a' r�O g r � •�''' 1 2, — — — — i�^i�f1s� 7 Z. 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The first two feet out of the d-box to the leaching shall be level. �"" �► F11,1' +� �It't� 4) This plan is not to be utilized for property line d_ �-� p p p y determination nor any other LuAwk � { � L "U purpose other than the proposed system installation. kD lot l AQ Ib j� 5) All septic components must meet Title V specifications. 2� Lb" 6) Parking shall not be constructed over H10 septic components. LOCATION MAP �` � ' �� � 1b` ! ! t � 7) The property is bounded by property corners and property lines. 104 8) The property owner shall review design considerations to approve of total b :_.. ..,,,.__ 94 design flow and number of bedrooms to be considered for design. Receipt of w �1�1�' C I payment for the plan and installation based on the plan shall be deemed y^ approval design Pp of the g flow by the owner. I /O R CSC) 9) The existing leaching or cesspools shall be pumped and filled with material �06 JID per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean washed sand per Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends routed if SEPTIC SYSTEM DESIGN g \ \ applicable. \ ` FLOW ESTIMATE MATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. `-� Y�_1_677k_1 .2 8DQ. 12)The installer is to take caution in excavation around the gas line if applicable. 2 BEDROOMS AT GAL/DAY/BEDROOM -2f O<DGAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. �\ "96 SEPTIC TANK 7A � 1 2ZD GAL/DAY x 2 DAYS - GAL oz� \�� USE 10Q0 GALLON SEPTIC TANK C��,.l�Ttlr•l,�����,� SOIL _-ABSORPTION. SYSTEM--- ., __- \ 2 T 1 ( Wfm 9 N&05D 00r to/ F,wD vwi ` 13 SIDE AREA: 2 X 2-X, 29' qDAVID r, 8 ,... BOTTOM AREA: z 211 e IZ- 167 MASON " ._.. Ib M�� SEPTIC SYSTEM SECT ION -.�, "� ' 01 �. 3: - , 76,EI rW11- y:.,.. \. M ♦...ir 1 AS-..N.:i!.rv�hb:3.w. � ' ....1 i�i� �� z . } PIN A D u1s. D-BOX �i7il()/C7C OGAL '`� i t-----1 SEPTIC TANK ,.. �--- °° K , CROSS SECTION NOT TO SCALE ':eP1_(0r of -TC51 HDLF .a f.. .�J........��...._� i S I TE AND SEWAGE PLAN FILTER FABRIC LOCATION : -bwtfbOvcr r 1 PREPARED F 0 R : ---a l,,.j ---4.25' 10' 4.25' —I SCALE : *® DAV I D B . MASON�� DATE: Id 1 on DBC ENVIRONMENTAL DESIGNS z H EAST SANDWICH . MA w «� T DATE HEALTH AGENT W ( 508 ) 833- 2177 Z