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0012 LONGFELLOW DRIVE - Health
12 Longfellow Drive Centerville A= 188 -042 UPC 12534 ' N0.2153LOR TOWN OF BARNSTABLE .LOCATION f� l��Q 6"� �� 1Z SEWAGE 535 At ASSESSOR'S MAP&PARCEL i f? ®V,2 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY -f!.5—06 ice. H 1 LEACHING FACILITY:(type) /(9 tyl S size)r 12 `7 NO. OF BEDROOMS OWNER ?a.ry-O•�' PERMIT DATE: ®/k COMPLIANCE DATE: /Lyl u — Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -VCJ�.l 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 f 0 ` • r 1' J A3 4 164 �3PS TOWN OF BARNSTABLE CATION �a 'o(1S �`II06.i !1- SEWAGE# ];,LAGE Ceni e cy.& ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY W00k) I LEACHING FACILITY:(type) {��"r (size) NO.OF BEDROOMS 3 OWNER 1 r ar PERMIT DATE: 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) I Feet FURNISHED BY 1 Spe�T v� FD 1 Y° 0 L l Rik A B , � 0 A Q � rs �s /� 0�c U4�'� d C No.. v� 3 Fee tv,0_ _ '00e 6 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Di5po!gar 6p-gtemc Con5tructton Vermtt Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. IZ Lo n�,.(,.,q o..A �f��. Owner's Name,Address,and Tel.No. C e�T'b 2,ui Q e- Assessor's Map/parcel I v3 0`f°L 6-1'L-`r a 44 gq o t?q'a Installer's Name,Address,and Tel.No. C qj0&" to CnAg-t)e9 Designer's E Name,Address and Tel.No. �o• �3�x 62'7r ua/1A�3� 79(.L Type of Building: Dwelling No.of Bedrooms . 3 Lot Size 1 21 ± sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 O gpd Design flow provided 3 , L Sr gpd Plan Date j 2-15 7,00(o Number of sheets / Revision Date Title 1 Z Lo n%"e— Size of Septic Tank l s,O O Type of S.A.S. 1�3yle(.,�gs Q-J 5 Description of Soil Nature of Repairs or Alterations(Answer when applicable) ew 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig Date Z " ^ ZCOS— Application Approved b Z Date Application Disapproved by: Date for the following reasons Permit No. Date Issued VI)6 Q ._No. � �,../5� ;>! - " �',Fee �D THE COMMONWEALTH OF MASSACHUSETTS " Entered in computer: t•, PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rofication for Mi.5tJOgal ,p,5tem Congtruction permit Application for a Permit to Construct O Repair O Upgrade O Abandon O ❑Complete System ❑Individual Components Location Address or Lot No. 12. Owner's Name,Address,and Tel.No. /n` 1�`'✓t r'Q(rvT C�w C ! 1 G1 Assessor's Map/Parcel 1�($ O�•� -,f a v 1.7q Z Installer's Name,Address,and Tel.No. � '° G h �J, Designer's Name,Address and Tel.No. �eT ruiti,e. W1� ��Z u 5 79(.G. Type of Building: s T-- Dwelling No.of Bedrooms Lot Size"") t ' sq.ft. Garbage Grinder ( ) ' a , No.of Persons Other Type of Building Showers( ) Cafeteria( ) Other Fixtures t � Design Flow(min.required) "� ' gpd Design flow provided ' ' �� d gP Plan Date 12 /5 2GCc Number of sheets f Revision Date Title ,R , Size of Septic Tank 1 5 0 to Type of S.A.S. f s Y7 e(e—s 5 J;c„1� �•{ S Description of Soil _ t Nature of Repairs or Alterations(Answer when applicable) ew �li'✓U� i�v�-J-o 2 �' �-�t� 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"\ 3!Y .Date / c2.. " S- �, Application Approved by '/, 1. �� � � � Date Est to F l Application Disapproved by: Date for the following reasons `�. Permit No ` Date Issued —— —————————————— , ———————————� ———————————— THE COMMONWEALTH OF MASSACHUSETTS _ BARNSTABLE, MASSACHUSETTS Certificate of Compliance x THIS IS TO CERTIFY,that the On-site lewage Disposal System Constructed ( ) Repaired ( ) Upgraded Abandoned( )by [ ,J,c�a, OJ►yP 5 ALL at has been constructed in cc ^ance with the provisions of Title 5 and t e for Disposal System Construction Permit No. " ;J_ ted InstallerL� �t/I ��)P� Designer s #bedrooms 3 Approved design flow ?j _<5 gpd The issuance of this permit shall not a construed as a guarantee that the system will-f t b a` e igned. Date 1 �f Inspector �-----_.� —————————— - ——————————————————————————-- I ———— J lam. No. �I � Fee THE COMMONWEALTH OF MASSACHUSETTS l PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 'i!9po!5ar ,*p5tem Cottgtruction Permit Permission is hereby granted to Construct ( ) Repair ( ) . Upgrade (V) Abandon ( ) System located at i') and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty`" to comply with Title 5 and the following local provisions or special conditions. Provided: Construc Dion m t be completed within three years of the date of thi p ft)n . j Date Approved by f O Town of Barnstable F11HE � Regulatory Services Thomas F. Geiler,Director • BABNSfABLE • 9� '. Public Health Division % Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Designer: _Shay Environmental Services, Inc. Installer: CJ�nDQ'WLAeFo=, L-L-(- Address: P.O. Box 627 Address: D• DOX -7(03 East Falmouth, MA 02536 Ce_ ,,A-U A f V^vA 6Q3 2, On 12TIZIUP CAVEC A.)%QC, eQ7, was issued a permit to install a (date) (installer) 12 septic system at �.e� Q. based on a design drawn by address) Shay Environmental Services, Inc. dated c - I a(' (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. 4 IN OF M,4ST moo`' CARMENE. I staller's Sig tore) 0 SHAY 4 No. 1181 •p o RQ►8TSµ� MAWSANI R\PN esigner's ignature) (Affix Desi p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 'own of Barnstable P# 1 Department of.Regulatory Services 1 ° /e� /1� /? • � = Public Health Division Date 200 Main Street,Hy nnis MA 6 1 Time Fee Pd. Date Scheduled �� V� i so' uitabili ssessment for _W4 D' osal' - C� N\ CLVWitnessed ey: Performed By: LOCATION & GENERAL INFORMATION c Owner's Name ot)-c- Location Address i �,�e i L.A i Address i �� �©l�� � � Engineer's Name c7 Assessor's Map/Parcel: 1 '/ _._._ -_ 2C� NEW CONSTRUE 1 ION REPAIR /`I/�� i Telephone# ?J� `� ,1 1�Q Land Use �Q 1 Slopes(%) sZ` i Surface Stones QJ �_ft Drinking Water Well �ft Distances from: Open Water Body—Tft Possible Wet Area ft Drain a Wa 'P ft Property Line ft Other g Y SKETCH:($treet name,dimensions of lo4 exact locations of test holes&pert tests,locate wetlands in proximity to holes) rn I - I � I , i ,l r J I Depth to Bedtoek t Parent material'logic) Depth �' rah (� n D/��, Weeping from Pit Face.-...- Depth to Groundwajer. Standing Water in Hole �t I o�s , I 73�Estimated Seasonal High Groundwater 1 l �s'crn�n ATION FOR SEASONAL HIGH WATER TABLE Dt� j MWA���Val__ Method Used: `,�„�la. Depth tq sall mettles: �Depth dbgerved standingin obs.hole: �, {p, Groundwater��dJusdutentDepth to;weeping from side of obs.hole: A�,factor Ad.Gro }a Index Well# i� Reading Date t) O Index Well level ° PERCOLATION TESL' Daft: Observation .a1. 1 i Time at Hole# =T�-- �� Time at 6" Depth of Perc aM,ti � 'Time(911•6") Start Pre-soak Time.@ End Pre-soak N�P! Rate Min./Inch Additional Testing Needed(Y/N) Site Suitability Ass0sment: Site Passed Site Failed: Observation Hole Data To Be Completed on Back original: Public HeM Division ercola'ion testis to be conducted within 100' of wetland,'you must first.notify the - ***If p prior to beginning- Barnstable C44servation Division at least one(1)week DEEP OBSERVATION HOLE LOG Hole# L Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Strucre,Stones,Boulders. ten ravel l .31 - Ia M -Sd�c1 ._ • cj cc�e 1 t_ex)S..e DEEP OBSERVATION HOLE LOG. Hole# - I-Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) t i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structui'e,`Stones,Boulders. nsislgencz aravel) i t I ' Flood Insurance Rate Map: / Above 500 year flood boundary No— Yes . __✓-- Wlthin 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Nafittaffy Oceurrin Pervious Materla. Does at least fo r feet of naturally occurring pervious material exist in all areas observed throughout the area proposed Or the soil absorption system? Y4 D „ �j� If not,what-is the depth of naturally occurring pervious material? /'►��"" Certification I certify that on, l 1 (date)I have passed the soil evaluator examination approved by the Department of�nvi ental t 'on and that the above analysis was performed by nAe consistent with . the required tral g,ex se a d x eri ce described in 310 CMR 15.017.' Signature Date a l ab QASENTICIPERCt.ORM.DOC Town of Barnstable OF INE Tp� do Regulatory Services saMSrnB Thomas F. Geiler, Director 9� `�. •�� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 November 27, 2006 Mr. Milton Parrott 12 Longfellow Drive Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located at 12 Longfellow Drive, Centerville, MA was last inspected October 30th 2006 by, James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The system is in the high groundwater zone. System automatically fails in the Town of Barnstable. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health w TOWN OF BARNSTABLE OCATION SEWAGE# v VILLAGE Q ASSESSOR'S MAP&PARCEL ®y3— INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) —,2 (size) NO.OF BEDROOMS OWNER /'�✓��/� PERMIT DATE: 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 - . ,u 13 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 12 LonQfellow Drive Centerville MA 02632 Owner's Name: Milton Parrott Owner's Address: Date of Inspection: October 30 2006 /�� Name of Inspector: (Please Print)James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 Telephone Number: (508)862-9400 `J 63 CERTIFICATION STATEMENT �-� I certify that I have personally inspected the sewage disposal system at this address and that the inforrpation rcj;rted below is true,accurate and complete as of the time of the inspection. The inspection was performe' sed on training and experience in the proper function and maintenance of on site sewage disposal systems. am a DEP. u approved system inspector.pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system; co N ► ' Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ✓ Fail Inspector's Signature: Date: November 1 2006. , The system inspector shall sub it 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the.conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Lonvfellow Drive Centerville MA Owner: Milton Parrott Date of Inspection: October 30 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken;settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Longfellow Drive Centerville MA Owner: Milton Parrott Date of Inspection: October 30 2006 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 CN M 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 I Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Lonefellow.Drive Centerville MA Owner: Milton Parrott Date of Inspection: October 30 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ 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 '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high groundwater elevation: ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have detennined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following.criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 12 Longfellow Drive Centerville MA Owner: Milton Parrott Date of Inspection: October 30 2006 Check if the following have been done: You must indicate" es"or"no"as to each of the followin Yes No Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No Existing information. For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 i Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 Longfellow Drive Centerville MA Owner: Milton Parrott Date of Inspection: October 30 2006 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unknown Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system Single cesspool ✓ Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: A leach 12it was installed on 916188- er in o on f3h, Were sewage odors detected when arriving at the site(yes or no): No 6 I Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SU BSURFACE SEWAGE DISP OSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Longfellow Drive Centerville MA Owner: Milton Parrott Date of Inspection: October 30 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank) Depth below grade: 9" Material of construction: concrete —metal _fiberglass _polyethylene ✓ other(explain) Cesspool block If tank is metal list age. Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: S'W x 4.S'T x 7.S'bottom to grade Sludge depth: " Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Measuring stick Commnents(on pumping recotmmendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The cesspool had 6"of li uid on the bottom. An outlet tee was resent. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: —concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Lonzfellow Drive Centerville MA Owner: Milton Parrott Date of Inspection: October 30 2006 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above 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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or.no): Alarns in working order(yes or no) Conn ments(note condition of pump chamber,condition of_pumps and appurtenances,etc.): 8 i i Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Longfellow Drive Centerville AM Owner: Milton Parrott Date of Inspection: October 30 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 overflow nit-4'x 6'1600 gal) leaching chambers,number: leaching galleries,number: leaching trenches,number,length:; leaching fields,number, dimensions: overflow cesspool,number: Innovative/alternative.system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The Pit was dry, The scum line was 2'a rom the bottom. The cover was 26"below ade. The bottom to rade was 6.7' CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow(yes or no)': Continents (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,.signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 i ;�. Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ 12 Longfellow Drive Centerville MA Owner: Milton Parrott Date of Inspection: October 30 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A B 13 /S 10 I ! 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Longfellow Drive Centerville MA Owner: Milton Parrott Date of Inspection: October 30 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 8.5 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: ✓ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:. Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the'high ground water elevation: The botto✓n o the cess ool to rade was 7.5. 1 hand au Bred down below bottom o the it to round water which was 8.5'below rade. Usin Ca e Cod Commission technical data the hi h round water ad'ustment or this site MIW 29 Zone C 9/06 was 3.2. The system is in the hLzh gyroundwater. This report has been prepared only for the septic system and components described herein. This septic system was inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION w f TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /,2 Owner's Name: Owner's Address: !a r� Date of Inspection: sl2 to/0 4, F , s�idx�✓ 5' ' Name of Inspector: (please print) Company Name: J�Ur2�i�+s L.SP.rie%.5�tr�' Q�ivST j f Mailing Address: 7e K eN-1,> S �E✓ �` - c�..�r?�ry%/ Telephone Number: Co V -7 11-0-2-9'y 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 myZ, training and experience in the proper function and maintenance of on site sewage disposal systems.I an�a DEP approved system inspector pursuant to Section 15.340.of Title 5(310 CMR 15.000). The system: 4�-fasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: �-X 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: Inspection Summary: Check A,B,C D or E/ALWAYS complete all of Section D A. System Passes: !/ 1 have not found any information which indicates that any of the failure criteria described in 310 CUR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /� ze Owner.Date of of Inspection: ,fl- -4 4 C- C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: , ; lot Owner. P Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for aII 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 AtStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ,,cesspool v1_I luid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ref times pumped AM 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 meter supply. r/,y portion of a cesspool or privy is within a Zone 1 of a public well t/_any portion of a cesspool or privy is within 50 feet of a private water supply well. ,_/ Airy 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.] Jk/0 (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 _ 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: I;- D Owner. Date of Inspection: L W e to(- Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes _ _ 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? L/Have large volumes of water been introduced to the system recently or as part of this inspection? 4 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? v — Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no s� 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 unac_ceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Z Owner. Yiu•�tsrn �a-•u Date of Inspection: 1—/2 fie%C, FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): S DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): — -;7f�zrb � E Number of current residents: f? � ��` � s o/f Does residence have a garbage grinder(yes or no):& Is laundry on a separate sewage system(yes or no):2& [if yes separate inspection required] Laundry system inspected(yes or no):AU Seasonal use:(yes or no):_V b Water meter readings,if available(last 2 years usage(gpd)): ac�cv Sump pump(yes or no):_/0 Last date of occupancy: IV—o c, COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgketc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records I Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system l 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: Were sewage odors detected when arriving at the site(yes or no):f�1 Q Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1.2 Owner: Date of Inspection:_ / (p BUILDING SEWER(locate on site plan) Depth below grade: 3C, '( Materials of construction: t iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:Oocate on site plan) Depth below grade: Material of constriction:_concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRA4 fli cafe on site plan) Depth below grade:_ Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /-I vul 4 /Jy1a Owner: Date of Inspection: 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:&�(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER: !(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: oZ n4t& Owner: Date of Inspection: t�--L& /n(o SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number._ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_L_ -X( 3 r� 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.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Z Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: 1Cey�f3 Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:N, .(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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l� Owner: Date of Inspection: (o SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet,Locate where public water supply enters the building. Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 02 wtia�t Owner: G�ruva Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells �-7 Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 2 7• Y i 7, a No_. F$s THE COMMONWEALTH OF MASSACHusETTS BOARD',OF ;HEALTH Ij r r�u ..wwri f nx' t,�pr>�s 1 lark Cnnns tun le nt�t Application is hereby made'for a Pertrut m Construct ( ) of Repair ( an Individual Sewage Disposal System at Z:6eatIon Address or ut':No. Owner Address Installer Address .._. Type of Buddutg Site Lot Sq. feet Dwt=llt_77ng No of Bedrooms _Expansion Attic ( ) C>arbage Grinder p, C?ther Type of Biulding j K Not a persons fi Showers ( ) Cafeteria''( Design Flow J .gallons:Per perso ow_ ..' ------•. Sons. n per day Total Septic Tack Llgwd capacity gallons Length _-.: Width ___... Diameter....__-.......Depth_------------ Disposal Tr�ch No -:- .. Width.._... .• Total Length_ - ...Total leaching area.----.-_._.......sq. ft. ---_ Seepage Pit No Diameter.__ .... Depth below inlet_ __ / Total leaching area--------_.-sq. ft. Other Distnbuhon;boa ( ) Dosing tank ( ) on:.,Test:Results;:: Performed by---.- ----•_-- ...... - Date—_`. _Y: e. Test Pit No ,1 -- �' minutes..per inch. Depth`of Test Pit .. Depth to ground water unutes;per inch Depth of Test Pit........ :Depth to..ground;water__ Descrtptioa`of Sol ....._- ,, - --- -- " Nate o€ + aars: Alterations An77 swer when applicable_ �- �Q !)l►v' � r s � txM rtnderslgned agrees to install the aforedesrtbed ividual Sewage Disposal Systemm accordance`.vinth e,farortszvns of iITL>?. 5 of tlae State Sanitary Code The undersigned'further agrees not to place the system m � koperat3on until a Certificate of Compliance has issued by a board of healtlu " — —' — aF[x*^. 57.�rie.'[� t •;.-� a� v r r th ? s Application Dlsappra+ied.jot tf�e'#oltouring reusos�.s �� � �`�' < � ` � � � � hate k Permit N6 �5-- Issued_ K 4 BOARD OR "H1=ALA W - t't sb T t t - ' c, s ISI Yr tti tn. -n I clrks Canstniction Permit �o ''— — d a N w THE ISSUANCE OF`THIS 'CERTIRCATE SHAL1 NO"f'BE CONS?RtfED AS A GUA D i1;WILL FUNCTION SATISFACTORY ° t � aT THE M � w f y S> t --•-----•- ....-- -----�-�'-------•---------�.__.___._. Inspector. _.�----T=- No.... Fzs... C7.......-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q w.VU........oF......... ... Appliration for Disposal Works Tonstrnrtion 11rrntit Application is hereby made for a Permit to Construct ( ) or Repair ('--<an Individual Sewage Disposal System at: ............� .......PLO................ ........... .._.a ..... ....._..._..... - ........:..._ ,t _1 cation_Address ���-por•Lot No. .._.........%.11GU�`�Cr1...V......19.� - � -•--•-•--------------- ........................ _4)6-L..._..................................................... Owner Address a, .... ! :�:.- A-----��q;!ZXZ1-----•---------•--- ----------------------------1- -+i a,�+n.?„5........................................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--__-_-.............................___Expansion Attic ( ) Garbage Grinder ( ) p,, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures .---•--••-------•••-----••.......................•----.---••-------••-------••-----•--•- .............................................................. W Design Flow.........J______________________________gallons per person per day. Total daily flow............ .................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.._............_.... Diameter:_..._.. ..._. Depth below inlet.......q.1....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------- -------------•-------....._.....------------------•---------_.... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... .....-•---------------------------------•-----•---•----•-•-•---•--...-----------------....-•--------........................................................-- O Description of Soil........................................................................................................................................................................ W U Nature of Fepairs or Alterations—Answer when 'applicable------A-�1-i.........Q V-Ir.--....... .._. �Y"'.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions-of iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by e board of health Signed..:- ! ---•---- ----.-11- •�--•`'-'-•- Date Application Approved By------------- \D.. .............................. ..............37_-ate:`:: Date Application Disapproved for the following reasons:_..-----•-------•---------------•---•-------------------------------------------•------=----•-••---......_---••- ....-•-•---••-•..............................•--•------•-----...----••--------------------•-•---------------------...--•-------•-----•-------•--•-----••---------------•-•------•----•-•••-------....... Date Permit No. :... ....................... -. Issued_...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. .............................. Appliratinn for Disposal Works Tonstrnr#inn 1hrnti# Application is hereby made for a Permit to Construct ( ) or Repair (—)•r an Individual Sewage Disposal System at: .•_ "bc' . _•.___...._•----------------------------- ------------- `L�bcation-Address -- or Lot No. ................. �..,-_................. ..... ---__-----------............... Owner (�`q Address Installer Address Type of Building Size Lot............................Sq. feet �-. Dwelling—No. of Bedrooms........ ________________________________Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Other fixtures . W Design Flow........>__'`,..........................gallons per person per day. Total daily flow........`_:�_ .T:1.................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No........------------ Diameter...... .. _..... Depth below inlet....... ...... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................................................,__....... Date........................................ 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit..........-......... Depth to ground water ---------------------- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-._--................... 0 Rr' .........................................•................................................................-•-._....••-•-•••-••-•.._.. Description of Soil......-.......................................................................................................-................................ Wf U -_.-_----•------------------- ---------------------- -------... --------------------------•------------------•------------------------•.---••--••---•_--------••-•-- W UNature of Repairs or Alterations—Answer when applicable____--_ ........oufle Y._....--•.4�C_-_•--n c-'-'-••. -----•-----A _'_ `-_------------CJl1-/�:--•------"-y'(,:----• ,J :1 r-."X a-�.,'.:._ �^�!'.5� �151 1--- .____._. . .-•--•-• ......... ......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLP: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ...... ' _ `5'= ' - - ' Date Application Approved By------------ -. \7 �_��. ff. . -•........................... ------------ = _5z.'£sue Date Application Disapproved for the following reasons-------------------------------=------------------------------------- ........................................... ..........................................................................---_........................................................................................................................... Date Permit No. S CK G -••• Issued.---------•----••••......----•-- --- ---••- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OR HEALTH .......... TG c��°�C {n.. ��`` ......................... Tnrtifirate of Tontplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by...................... l...rl►, c1- �'r -�. H -e l - ... -•_- r Installer at..........................V:::-N t=.�ll�.,C. r„s S 1<at-a--- .7�C . has been installed in accordance with the provisions of 111TL ' 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No - �s.-_.y�z!___..... dated----- ________________________________---------- . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Q_ DATE ..............�..........-•-••-••----••-•----•--•-_: Inspector...._.............=.............................` ..................•-----•----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......cn.�A6r.� OF............. . .� .c.1 :.. ^-� FEE...:/�............. Disposal Marks 01111nstrnrtion Permit Permission is hereby granted !`�.� !<<!�'� '.{.._ 1 . fit`' '"• %f^ :_----------------- r ............................ to Construct ( ) or Repair ( ) an Individual Sewage,Disposal System atNo...................... = ... e( .....I = --•...... ......:. ...----•-•------------....------.....................----...•-- __,_.__a•�., ._y - Street as shown on the application for Disposal Works Construction Permit �1 Dated......................................... .. ••-•----•-----•-•--------• _. � ----------•-•--••--••---------------------•---.__--• - DATE............&-------g ��----------•----------------------------- � Board of Health TOWN OF BARNSTABLE lode LOCATION SEWAGE # �J�._y159 VILL�iGE�^ � 1T �_ ASSF,SSOR'S . MAP & LOB' 1 ©y INSTALLER'S NAME & PHONE NO. 6 LAW sEPTiC TANK CAPACITY eXN 6-1-A _C sPEG\- LEACHING FACILITY:(type)�-PR2� cy4ST NO. OF BEDROOMS PRIVATE NVELL OR IILIC�IVAr BUILDER.OR OWNER_ �'To�. DATE PERMIT ISSUED:. DATE COMPLIANCE ISSUED! VARIANCE GRANTED: Yes_ No ���. � � ��l���� �-.o �� ..s� .x�-r 7.1�� .�' �„ t 1� �.,, �� ,SWITC�1bs7riYdt-,=-� _- r,i►'Air' r -: - - VENT PIPE (O Least 24 Inches tall *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. Schedule 40 PVC w/Charcoal Odor Filter3-24• DIAM. ACCESS MANHOLES ��� - e y 10' min. from Existing Foundation house to septic tank to' -e• � ' '"'=�.. Septic tank coven must be ZX6 cover must be ESTABLISHED VEGETATIVE COVER - within 6 In. of finished grade In. of finished grade d•, • ^. �,.� '. N-TOP OF FOUNDATION = ELEV. 100.00 p � �• Grade over Septic Tank-100.10 Grade ever D-Box - 99.50 ad. over SAS - 99.50 r• 'y; +' 4, ',•,...n•' , .� •v.• ♦' !", BACKFILL WITH CLEAN SAND 'v! ' •} '�``. •-. S - 0.02 :.,.:5 •...,,.. .i ,•4 ft ry !a i' .v,'+ n t a ^!', v 12 LOngfe110Widr" ~t. 6 HOLE H-20 I ! t."••..^( .+ ,.''d i' ^'� . t "„♦," ` 't." t..�•L ,r (NATIVE OR PER( SAND) ^ 1 ` •,c•', ,v '+• Q. 'rt,'l.Y:,h;'9 � �' , ':1+ ;�1, "�''��1�. ,�1rt'�,;•'•t'�' INLET -� 1 9, / ,,.�. +L"Iirokr M1 -� ST. BOX 3' Maztmum C a;,{.v• .� tt. �;„�r t... r' , r I S- q r b f 1, , , , .�,,•?. .:4:..!'"... ♦ '1.' + INLET L ` \ •i OU - P 12 10' NEW 0.01 or Greater (2 TOTAL) 4'PVC(CAPPED) I ECTION PORT TO BE 1:'•t • • :. •1n .'?'. fir' t; •'`"tiT' - 011- t - NEV PIPE O t•� .•. ,"+:' ••R '7r •!' ',' ':.• ••. ..♦'. .h: 1,500 GAL INSTALLED AND TO BE WITHIN 6.OF GRADE TOP of UNIT ELEVATION 9e o ti ,;' ,. ;,�' r;, }, :�!„ i;;;,, �;'`ti. t pp THE ACCESS COVERS FOR THE PT1C TANK, 00 !o to 25 s- 0.01" er r` • a, .,"' .: ..t,'•a '. • ,•. v I'; �.e8 �- •ab -- FRDM EXIST, FOUNDATION rn SEPTIC TANK !� P root ;5,5 ^a. ,1:,.ir4;•.,, :•.• '•.; •T';.�.•'.j •';' y,p;;,t.; •;�.•♦;,! ;,;• ,4 ,:'n t, DISTRIBUTION BOX AND LEACHING COMPONENT r �n►p x, �t 's, m ao Y" d I• 9 4 .` t , .--.�'; SHALL BE RAISED k.. II ON loft O. N a; ls' J INV. ELEVATION - 97.93 :1 •,":'',r:•t'''\': :•L;r..:r.Y..•b' ii• ''`;'r" ''L�" -1't4:�'Fi ''Tws7't?Z-7 D♦7, .� TO WITHIN 6" OF 1 I H-10 "' FINISHED GRADE. CONCRETE FULL f�UNDAT101Y j I f� lti, ,1 t� r (. a! e>, j ;r INSTALL TUF-Tl _ � � I� � M t. '�'� T+. STEEL REINFORCED PRECAST CONCRETE ON ALL OUTLET TEE ENDS FFLES OR EQUALS SYSTEM PROFILE j 6 In.of 3/4"-1 1/2" IR ^ Bottom of SA Et.�.- 97.00 _ VIEW eom oeted stone _ I BOTTOM ELEVATION 97.00 .,� PLAN Not to Scale P c 4 ROWS OF 4 UNITS AT 6.23'/UNIT+ 2 END CAPS- 26.00' ; ♦ ° C > o m 3-24•REMOVABLE COVERS \ ••4, ..,-- - j 11 H-20 UNITS I �36d61.'igRn-IFi,(}°fPy,',Il.`1�bCNlIT'.!!r?-.ni/prtlD7.Ino-r. ;�+'"� 3i MIN ABOVE BaTTOM OF 4" s' 34" _. A 4• GENERAL NOTES Bottom of Test Hole 1 Elev.- 86.00 TEST PIT OR GROUND WATER 6 In.of 3/4'-1 1/2• j EFF. WIDTH 1,8.83' \EXISTING SUITABLE MATERIAL 3 min. clearance 1 :' tr IILET•1• '• compacted stone c ADJ. GROUNDWATER Elev.- 92.00 INLET 6 min.T L_mM.filet to ouWt e'mtn. NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE w d 10•mti L9M7*vei it OUTLET �, 1. Contractor is responsible for Digsafe notification, Verification of Utilities " T Note: Remove soil down to mod land layer & replace with Note: Certification of Fill Material Required. ADJ. MSHGW EL,: - 02.00 s' -T - �£ _ � ,'s' -7• and protection of all underground utilities and pipes. (elev. 94.00) & replace with dean coarse sand w/perc. :! 4'-0•min. 2. The septic tank a distri ution box shall be set Before and After Placement b Solve Analyses SOIL ABSORPTION SYSTEM (SECTION) � r, � rate less than or equal to 2 min./In. before & after placement y �, e.oaft ?• Liquid depth level on 6 of 3�4 -1 1p2 Stone. INFILTATR❑R HIGH CAPACITY (H-20 LOADING)/ GEORGE ❑'BRIEN . 3. Backfill should"be clean sand or gravel with no .� stones over 3 in size. NOTE: PLUMBING TO RAISED AND RE-CONFIGURED BY A LICENSED PLUMBER (OR EQUIVALENT) •�.� ,;. "�+ 1.. •; . , "', 1 4. This system is subject to inspection during installation NOTE: PLUMBING PERMIT REQUIRED TO RAISE PLUMBING NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" 10'-0' s'-6• by Carmen E. Shay - Environmental Services, Inc. CROSS SECTION AND-SECTION 5. The contractor shall install this system in accordance with Title V of the Massachusetts state code, the approved plan and Local Regulations. TYPICAL (H-10 LOADING) 1500 GALLON SEPTIC TANK 6. If, during installation the contractor encounters any NOT TO SCALE soil conditions or site conditions that are different from those shown on the soil log or in our design May Substitute with 1500 gallon H-10 Polyethylene Tank-George O'Brien Co installation must halt & immediate notification be made to Carmen E. Shay - Environmental -Services, Inc. P E R C 0 LAT I 0 N TEST 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. Date of Percolation Test: 12/15/06 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. Test Performed By. CARMEN E. SHAY, R.S., C.S.E. 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes. Results Witnessed By. Donald Desmarais/Roger Roberts 10. All solid piping, tees & fittings shall be 4" diameter O EXCAVATOR: Shay Environmental Services, Inc. Schedule 40 NSF PVC pipes with water tight joints. �O Percolation Rate: <2 MPI ® 36" 11. MUNICIPAL WATER IS AVAILABLE TO THE SITE and Surrounding Properties. Of Qi Test Hole Test Hole p Lt i No. 1 No. 1 Z I DEPTH SOILS ELEV. DEPTH SOILS ELEV. 0 0 97.00 0 98.00 THERROPERTY LINES ARE APPROXIMATE AND 88-__ EpGE OF i Loamy Sand loamy Sand COMPILED FROM THE PLAN BY ED KEL:LOG, C.E. Cf?1A O I 10'A 3/2 10 YR 3/2 ENTITLED " SUBDIVISION PLAN OF LAND IN CENTERVILLE, MA" RRY B w 0"- 12" Ae 95.50 0-- 12" Ae 97.0o PLAN LC 24614-C Q loamy Loamy AND I NOT INTENDED TO BE A SURVEY PLOT.'PLAN W Sand Sand IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 10 YR 5/6 10 YR 5/e THE SEPTIC SYSTEM INSTALLATION. 6"- 36" Be 94.00 6"- 36" Be 95.00 Medium Medium Sand Sand NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE 2.5 Y 7/4 2.6 Y 7/4 FROM THE EXISTING CESSPOOLS TO BE DISPOSED 9Q 36"- 120 Ct 36"- 120 c, OF AS PER BOARD OF HEALTH SPECIFICATIONS. EXISTING CESSPOOLS TO BE PUMPED DRY & N/F WALCOTT AMES FILLED IN PLACE ASSESSORS MAP - 188, PACEL 042 ` ZONING - RESIDENTIAL pGCEss ROAD �/� Perc #1 BOG �' Depth to Perc: 36" to 54" CRANBERRY Perc Rate= 2 MPI - _ �/ Groundwater Observed -- 120" ® TP1 _ -�- -� No Observed ESHWT - WETLANDS ARE LOCATED WITHIN A 200' RADIUS ADJUSTED H2O Elev. = 4' per MIW-29 ZONE D OF THE PROPERTY AS SHOWN - -'-' - _ 5 1 43+ Level 8.7 for OCT.-06 ' 2 ADJ H2O ELEV, 92.00 ALL OUTLET PIPES FROM THE 48•88 g� DISTRIBUTION BOX SHALL BE 12" CONCRETE COVER SET LEVEL FOR AT LEAST 2 FT. LEGEND 97. 33 ,/ �' _ '.. 6 - 5" OUTLET �; ',rr. a,• a,+, 2• E D R ' _ / KNOCKOUTS - LOT #6 f �j II DENOTES PROPOSED L y 15.5" OUTLET �) t 12" INLET SXD 12,000 Square Feet t/- �/' 6. 8" �,' SPOT GRADE �''', .,i,,.;..�t;, 2 DENOTES EXISTING 15 5" X 104.46 SPOT GRADE 1,75" SHED -' PLAN-SECTION CROSS SECTION--- ------- JPL PROPERTY LINE 6 HOLE DISTRIBUTION BOX - H2O PROPOSED CONTOUR •- NOT TO SCALE Failed Failed LOT ##62 97- - - - - -97 EXISTING CONTOUR PROJECT BENCH MARK Cesspool Cesspool TOP OF FOUNDATION �� p co - Design Calculations = _ DEEP TEST HOLE & ELEV. = 100.00 (Assumed) �'- -- � ------- \�`�� PERCOLATION TEST LOCATION Number of Bedrooms: 3 Equivalent to 330 Gol.%Day (330 Gal./Day Min. per Title V) N/F SUN REALTY CO. 98P �� p�6 Garbage Grinder: No �\ Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) FENCE _ i Septic Tank : - 2 x 330 Gal./Day - 660 USE NEW 1,500 GAL. Septic Tank. IV TEST HOLE #1 i SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch EXISTING (CRAWL , PRIVATE DRINKING WATER WELL ELEV.= 97.00 - i - Bottom Area: 0.74 gal/sq. ft. x 468 sq. ft. - 346.32 gallons 0 0 3 BEDROOM SPACE) , _ - 40 POLYETHYLENE LINER FROM ELEV. O Sidewall Area: NOT USED _ - 96.00 to 92.25 AND TO EXTEND p NEW ROUSE --- �� / Providing: = 363.25 gallons REVISIONS 1500 I. (FULL FOUNDATION --\ 10' BEYOND SAS & FND AS SHOWN Septic nk #f2 Use: 4 ROWS OF 4- HIGH CAPACITY CHAMBER UNITS WITH NO NO. DATE: DEFINITION �\ STONE FOR AN SAS HAVING THE DIMENSIONS: 12,83' x 26.0' --- #1 12/22/06 H- I Caps Ins ea oa ��� Bottom Area: (General Use Approval for 4.50 SF/LF of INFITRATOR of Kick 4 S o I I 4 UNITS + 2 END CAPS per ROW = 26.0 FT TEST HOLE #2 - " 4 ROWS x 26.0 x 4.72 SF/LF = 466.00 -- ELEV.= 98.00 - -- � -- `9 -- -- 1 8 DESIGN FLOW PROVIDED: 0.74(468 S.F.) = 346.32 GPD 12.93 D Box H ; 100.00' PROPOSED DRIVEWAY; - PREPARED FO Rfoo---- --- SUBSURFACE SEWAGE DISPOSAL SYSTEM -----------+.-------- ------ -------- 100 -------------L'� I \------------ OF L OAT -.,L O W z�1?I VE MR . M I LTO N PARROT # 12 LONGFELLOW DRIVE Note: Remove soil down to el. 94.00 & replace with (40 FOOT RIGHT OF WAY) 68 COMMONWEALTH AVE. CENTERVI LLE, MA clean coarse sand w/perc. rate less than or or equal to 2 min./in. before & after placement (5 FOOT STRIPOUT ALL AROUND AS SHOWN) CONCORD, MA 01742 &- PREPARED BY: F Mq q`` N CARMEN E. SHA Y 0 20 40 50 ;{ ENVIRONMENTAL SERVICES, INC. P.O. BOX 627 VARIANCES REQUESTED: ,! �" ;,'- S�NtTAR ' � EAST FALMOUTH, MA 02536 SCALE: 1 =20 "� . 1 . Request a Variance to install an SAS 11 From a Full Foundation. a 40 mil Polyethylene Liner Has been Proposed. TEL/FAX 508-539-7966 SCALE: 1 "=20' DRAWN BY: CES DATE: DEC. 15, 2006 PROJECT#SD-996 FILENAME: SD996PP.DWG SHEET 1 OF 1