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HomeMy WebLinkAbout0050 LUMBERT MILL ROAD - Health 50 .umbert Mill Road Centerville F/R A = 168 102 openefa m 1521/3 ORA 100/0 P2 TOWN OF B STABLE LOCATION r SEWAGE # VI)tr AGE_ ASSESSOR'S MAP& LOT AL O INSTALLER'S NAME&PHONE NO. jSEPTIC TANK CAPACITY ,� LEACHING FACILrrY: (type) ��� � UP� (size) � ?;5:A9r f NO.OF BEDROOMS BUILDER OR OWNER �t7CI�� PERMrr DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 �o —3®' o Commonwealth of Massachusetts ( [61 oZi W Title 5 Official Inspection orm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Lumbert Mill Rd L Property Address Jared Dwyer Owner Owner's Name information is -, required for every Centerville Ma 02632 4-28-15 page. City/Town State Zip Code Date of Inspeckn Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information I filling out forms on the computer, !� use only the tab 1. Inspector: key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. Excavation Company � Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification 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 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority JeO 4-28-15 7Insp or's Signature Date e system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future \nder " the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pa 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required.for every Centerville Ma 02632 4-28-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail: 2013-45,000gallons 2014-47,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1'8" Depth below grade: 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.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): 1'2" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 4" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 4 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass El polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '< 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in working order no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM ,•�'" 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: infiltrators37.25'x10'x10" ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "T 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. Cityrrown State Zip Code Date of Inspection D. System. Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �4 &-� e' O bi- a t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water Z Check cellar ® Shallow wells Estimated depth to high ground water: No Gw 144" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed. 1-25-04 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: Plan on file. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Lumbert Mill Rd Property Address Jared Dwyer Owner Owner's Name information is required for every Centerville Ma 02632 4-28-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z DEPARTMENT OF ENVIRONMENTAL PROTECTION W Fd FED 05ARN TITLEs. TAB`EOFFICIAL INSPECTION FORM—NOTA Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 L10 -- Owner's Name: ALYNN SOUZA Owner's Address: 50 LUMBERT MILL RD CENTERVILLE 02632 OT ' Date of Inspection: 1/20/05 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the in ection.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 Tit ,5,s(310 CMR 15.000). The system: Passes >f g _ Conditionally P,��'sses _ Needs Further) u"luation by the Local Approving Authority X Fails Inspector's Signature: Date: 1/20/05 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 SYSTEM FAILED TITLE V INSPECTION. STAIN LINES INDICATE LIQUID LEVEL HAS BEEN OVER PIPE IN THE LEACH PIT. THE PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING. ****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. Titla S Imnactinn Fnrm F/1 VM00 1 Page 2 of`11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 L10 Owner: ALYNN SOUZA Date of Inspection: 1/20/05 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: SYSTEM FAILED TITLE V INSPECTION.STAIN LINES INDICATE LIQUID LEVEL HAS BEEN OVER PIPE IN THE LEACH PIT. THE PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to.broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed I ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 L10 Owner: ALYNN SOUZA Date of Inspection: 1/20/05 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Z Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 LIO Owner: ALYNN SOUZA Date of Inspection: 1/20/05 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT IN THE.LAST YEAR. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] YES (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. a .Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 L10 Owner: ALYNN SOUZA Date of Inspection: 1/20/05 Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A). X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems`? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable).[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 L10 Owner: ALYNN SOUZA Date of Inspection: 1/20/05 FLOW CONDITIONS RESIDENTIAL 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):NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: 12/15/04 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitarywaste discharged to the Title 5 system(yes or no): NO g Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YEAR Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1977 PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 L10 Owner: ALYNN SOUZA Date of Inspection: 1/20/05 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle:34" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING EVERY TWO YEARS FOR MAINTENANCE GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 .Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 L10 Owner: ALYNN SOUZA Date of Inspection: 1/20/05 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): STRUCTURALLY SOUND PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 LIO Owner: ALYNN SOUZA Date of Inspection: 1/20/05 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 6'X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACING-STAIN LINES IN THE PIT INDICATE THE LIQUID LEVEL HAS BEEN OVER PIPE-AT TIME OF INSPECTION THERE WAS 1' OF WATER IN IT CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 L10 Owner: ALYNN SOUZA Date of Inspection: 1/20/05 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. inr LJ 0 PA �� to ,Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE 02632 M162 P102 Ll0 Owner: ALYNN SOUZA Date of Inspection: 1/20/05 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED ON SITE-NO WATER AT 12' No. C)b", O q a- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Miopooal 6potem Conelruction Permit Application for a Permit to Construct( )Repair )Upgrade( )Abandon( ) ❑Complete SysteIndividual Components 'Location Address or Lot No. So (iv)iaslc-� (1v 1 1—> Owner's Name,Address and Tel.No. Assessor's Map/Parcel i. 0 Installer's Name,Address,and Tel.No. \ Designer's Name,Address and Tel.No. Szu CS Type of Building: e(��� (�y�(J Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder(lj/)!�•- Other Type of Building No. of Persons 3 Showers( ) Cafeteria( ) Other Fixturessn.- s• =i bc�° F��n f n�� � Design.Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date — Title Size of Septic Tank Type o S.A.S. _-S_ Description of Soil l D X'3 ' ` � Nature of Repairs or Alterations(Answer when applicable) Q (C4 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 Certifi- cate of Compliance has b igned. 2nqn�. Date FS Application Approved Date �$ Application Disapproved for the following reasons Permit No. �v'� �— Date Issued Y No. Fee a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes c `PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS' t b ritatI. for i o aY pqteiit Cottetructiott Permit Application fora Permit to Construct( )Repair)Upgrade( )Abandon( ) ❑Complete SystemA�dividual Components Location Address or No. 5O uw)V-40r 0, 1 Owner's Name,Address and Tel.Nta ja P L Assessor'sMap/Parcel l t917 10 � l�C Installer's Name,Add ss,and Tel.No. Designer's Name,Address and Tel.No. a, Type;of Building: a3 _ Dwelling No.of Bedrooms Lot Size s .ft. Garbage Grinder 0) )14- Other Type of Building �'--- No.of Persons Showers( ) Cafeteria( ) Other Fixtures 22 C- T - #c� C�— f` �r/> , ccss�� Design.Flow J gallons per day. Calculated daily flow' 2, ?,l gallons. Plan Date 1 S ��I,S Number of sheets Revision Date Title -S�ZD O�r1 �P 0-ktC. � C �Ycc Size of Septic Tank �CKt S�t 14t:..:bo Cc\ Type of��S A.S. 5" r 01P()-rQ_ A--rvyc 5 "y f S Description of Soil Nature of Repairs or Alterations(Answer when applicable) ! (CN r *..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 Certifi- cate of Compliance has heen issued-by B: and of Heal igned Date—�—^i— Application Approved Date I Application Disapproved for the following reasons Permit No. S `� �-- Date Issued i4-- )o 71 — THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Colt phatire THIS IS TO CERTT that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded(✓)'� Abandoned( )by at S© L�oA'a: k6L,\� GA l A�P has been constructed in accordance with the ps ons of Title 5 and the for Disposal System Construction Permit No. dated Installer M— Designer The issuance of this o e t shall not be construed as a guarantee that tht syste, w Ili nct, as designed. Date o��Cao Inspector .� -- No. S —O-/"3' Fee Q o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Migo of *pgtem Cow trUction Permit Permission is hereby granted to Construct LIVk Repair( )Upgrade( bandon(System located at 5—o EX,-7-- and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constr c ion m st be completed within three years of the da e of this a it. Date: o Approved b --' i s r TOWN OF BAARNSTABLE I LOCATION e±&1( SEWAGE# VILLAGE ASSESSOR'S MAP&LOT ' l� INSTALLER'S NAME&PHONE NO. s SEPTIC TANK CAPACITY LEACHING FACILITY: (type) o � U (size) c��L��:/3 K NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 i IA- -020 � to moo' f • Town of Barnstable �pINE r Regulatory Services Thomas F. Geiler, Director + BARNSTABLE, MASS. s639- Public Health Division �� A'ED1A0�A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: AA 5 Designer: � ,� �n 0 e �,j(';5. Installer: Address: (o a� Address: S T-"f ��- �- On a� Z5 5 was issued a permit to install a date) installer) septic stem at C-��'" 1 p Y � �''t � based on a design drawn by (address) GS dated 2 Z� esigner) I-- ,7,&'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. nstaller's e) AR E SHAYin No. 1181 e gner's Signature) (Affix Oe ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIMS N. 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 Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: efL&&55 /G /*MtF BUSINESS LOCATION: 5­0 AI:D. MAILINGADDRESS: Mail To: TELEPHONE NUMBER: - c/24— �J--y f Board of Health Town of Barnstable CONTACTPERSON: i¢�y D/}-LC- �T�'N���vs P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: 7�/- ;5--3/^ 6r3 `7 Hyannis, MA 02601 TYPEOFBUSINESS: /'FmQDCG/ NG- Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(forgasoline orcoolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS 43 dP _ to F0 n O COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 50 LUMBERT MILL RD CENTERVILLE, MA 02632 M162 P102 L10 Name of Owner MARY FOLEY Address of Owner: 14 SULLIVAN DR RANDOLPH MA.02638 Date of Inspection: 6/15/00 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 608-664-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes _ Conditionally Passes _ Needs Further Evalu io By the Local Approving Authority Fails Inspector's Signature: Date:6/27/00 The System Inspector shall sul1lit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My Inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE, MA 02632 M162 P102 L10 Name of Owner MARY FOLEY Date of Inspection: 6/15/00 INSPECTION SUMMARY: Check A, B, C, Or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the Inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced nLa The system required pumping more than four 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 r { revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 60 LUMBERT MILL RD CENTERVILLE, MA 02632 M162 P102 L10 Name of Owner MARY.FOLEY Date of Inspection: 6/16/00 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 the public health,safety and the environment. S IN ACCORDANCE WITH 310 CMR 1) SYSTEM IN A MANNER WHICH WILL PROTECTT EEPUBLIC HEAL O A HEALTH AND SAFETY ET AND THEENVIRONMENT: NOT HE SYSTEM IS Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance n&(approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE, MA 02632 M162 P102 L10 Name of Owner MARY FOLEY Date of Inspection: 6/16/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: _ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, _ X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water ana"s for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYS TEM FAILS: You must indicat e either"Yes" or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system Is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. i ' revised 9/2/98 Page 4 of 111 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 LUMBERT MILL RD CENTERVILLE, MA 02632 M162 P102 L10 Name of Owner: MARY FOLEY Date of Inspection: 6/16/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or hoard of Health. _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined.Note if they are not -vailable with N/A. _ The facility or dwelling was inspected for signs of sewage back-up X _ The system does not receive non-sanitary,or Industrial waste flow. _ The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on Me site. pened,and the interior of the septic tank was inspected for condition of baffles or tees,material of g _ The septic tank manholes were uncovered,o th of scum.The size end location of the Soil Absorption System on the site has been construction,dimensions,depth of liquid,depth of sludge,dep determined based on: X _ Existing information,For example,Plan at B4O,H, _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)J X _ The facility owner(and occupants,if different from owner)were provided witlo information on the proper maintenance of SubSurface Disposal Systems. revised 9l2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 50 LUMBERT MILL RD CENTERVILLE, MA 02632 M162 P102 L10 Name of Owner MARY FOLEY Date of Inspection: 6/15100 FLOW CONDITIONS RFCIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:0 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: nla COMM ERCIALIIND I¢TRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a. Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped nla gallons Reason for pumping:nla TYPEO F SYSTEM X Septic tank/distribution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous inspection records,if any) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1977 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE, MA 02632 M162 P102 L10 Name of Owner MARY FOLEY Date of Inspection: 6/16/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast iron _ 40 Pvc X other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) THERE IS TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_i Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10"" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED Comments: condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, (recommendation for pumping, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEA RS GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle nla Date of last pumping: n/a Comments: condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, (recommendation for pumping, etc.) n/a Page 7 of 11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60 LUMBERT MILL RD CENTERVILLE, MA 02632 M162 P1O2 L10 Name of Owner MARY FOLEY Date of Inspection: 6/16/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nla Material of construction: _concrete_ metal_Fiberglass _Polyethylene ;her _ Explain: nla , Dimensions: nla Capacity: nla gallons Design flow: nla gallons/day Alarm present: NO Alarm level:NIA Alarm in working order:NO Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc. nla PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nla Pain B iif'i 1 revised 9/2/98 SUBSURFACE SEWAGE DISPOSALART C SYSTEM INSPECTION FORM SYSTEM INFORMATION(continued) Property Address: 50 L MBEYRT MILL RD CENTERVILLE, MA 02632 M162 P10 2 L10 FOL Name of Owner Date of Inspection: 6/16/00 SOIL ABSORPTION SYSTEM(SAS): X approximated by non-intrusive methods) (locate on site plan,if possible;excavation not required,location may be If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (nla)n/a overflow cesspool,number: (n/a)n/a Alternative system: nla Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damn soi,,t ondition of vegetation,etc. THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO 13E F'lNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n1a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of pondir, condition of vegetation,etc. nla PRIVY: (locate on site plan) Materials of construction: nla Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condii;+on of vegetation,etc.) nla Page 9 of 11 revised 9l2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE, MA 02632 M162 P102 L10 Name of Owner MARY FOLEY Date of Inspection: 6116100 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) L �--A L___" I3 a P4 1� � age Page 10 of 11 revised 9/2198 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 LUMBERT MILL RD CENTERVILLE, MA 02632 M162 P102 L10 Name of Owner MARY FOLEY Date of Inspection: 6/16/00 NRCS Report name: nla- Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET Page 11 revised 9/2198 LOCATION EWAGE PERMIT NO.: 1-0 /d ��✓� a7' ,�'II,/l dew VILLAGE INS! LER'S NAME & ADDRESS PO r AI X B U1'LDE R OR OWNER DATE" . PERM.IT ISSUED DATE COMPLIANCE ISSUED ti_ Y rj ,ti 7.7 No.......... ....... ...../...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H A TH . ...... . .. L...-- ...OF........Z.. .. ................................. 114 X�_ Appliration -for Ui_npoottl Works Tomitrortioo rrot� Application is hereby'made for a Permit to Construct ()(') or Repair ( ) an Individual Sewage Disposal System at: 4Uk # . ��s �D . �� Loon•A ss or Lot Np. , o ner Address Installer Address U Type of Building Size Lot_ ®_d.. q. feet Dwelling—No. of Bedrooms____________________ ________--.--_-Expansion Attic ( ) Garbage Grinder Wi? aOther—Type of Building C.. .. No. of persons............................ Showers ( ) — Cafeteria add......-----•• ( ) Otherfixtures ------------------------------------------ .......................................................................................................... Design Flow--------------r_...........................gallons per person per day. Total daily flow---------;L --- --_-----_--.--.-.--...gallons. 9 Septic Tank I Liquid capacity/ -_gallons Length---------------- Width................ Diameter........_.__--- Depth_.-------.....- x Disposal Trench—No. ..................... Width___.*4iiik __. Total Length--_-__-__--_.._---.- Total leaching area--------------------sq. ft. Seepage Pit No.......I...........Diameter../i:Oepth below inlet_ _.-.. ..... Total leaching area..--.__-.-..__--sq. ft. /S-7Other Distribution box ( ) Dosi ( ) 3— aPercolation Test Results Performed by.......................................................................... Date------------. ............ ---------._.. Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water....----.-.--.-----..-.. f=, Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water.-.-..-.--------_---.... ----------------------- - -- --- --------• f--------- ----- Descripti of Soil '"_f.-.. i!-�! -----��: 1 x ----- --------------- W -,----- ._...2 ----- -----------------------•--------------- UNature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the syste in operation until a Certificate of Compliance has been issu by oa of healt . Sign e � ..... ........•............. Dat Application Approved By....... :/ =----- ---• •• . •-----•-•-------------••-- ----- Date Application Disapproved for the following reasons--------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH ...........OF.:......./ ..... ........... trertif ira#.e Of. Tompfiaurr THIS S TV ER, That d'vi ual Sewage Disposal System constructed ( or Repaired- by.. --- r--.... -- - / " /7�4-'-t nst r J. - --- 11 at--- a Y --T��-- -- !has been installed in accordance with the provisions of Ar �.�' XI of the State Sanitary C de "des�rrij�ed in the 1 application for Disposal Works Construction Permit No.................................... dated------------------------------:._..___.._........ : . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE.,, SYSTEM WILL FUNCTION SATISFACTORY. DATE 3 ? Inspector - --- ---------------------------- -------- THE COMMONWEALTH OF MASSACHUSETTS , BOARD S.F GL3-H I � �:. .:• •• - '� r . ... ..of. ................{��� ...:..... No.......................... FEE. ,� W.. t5 Al )<trf l[1k� rr t Permission hereb ranted_____ y g ------ -- ------..•-•-- to Cons ( l or Rep ' ( ) n In vdf 1 e sp 1 tem/�� " atj . ......1�:� Gt#�.aff�:. lA�.+ '/- _-- '.a------•-•--- Street 7 as shown on the application for Disposal Works Construction Pe<o ated.......................................... / S' v�-� Board of Health; ✓ / / `: DATE . ---------- ------------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS G No.......... ' Ficiz.....................:........ THE COMMONWEALTH OF MASSACHUSETTS `BOARD O,:F 3HA H D �...... ..OF........ ApVtiratiun -fur UiiVuutt1 Works Totw1rurtiun Puntit Application,is hereby`made for a Permit to Construct` (() or Repair ( } an Individual Sewage Disposal System at: '� I. on ss h 5+G or Lot N -J� = . G`. .. 1-----...--••--... ------.�.. �'........_fv _RW.-! `. .. O ner Address W � Installer Address Type of Building Size Lot. it$p_Q__ . " Sq. feet U Dwelling—No. of Bedroom................�-_---_--.__-_-__-Expansion Attic ( ) Garbage Grinder Other—Type of Building .______ No. of persons____________________________ Showers Cafeteria i < Other fixtures .-- •------------------•----------------------------------------------------------------------------- * Design Flow..1...._._.._-:..............10 ...............gallons per person per day. Total daily flow----------------------------------------....gallons. WSeptic Tank-¢ Liquid capacity _-gallons Length________________ Width----------------- Diameter................ Depth.-.---_--.-.---- xDisposal Trench—No. .................... Width___.____._.. _ Total Length--_____-_-:--:::--.: Total leaching area....................sq. ft. Seepage Pit No..__...`..._.___... Diameter_./OD epth.below inlet_ ______ ________ Total leachin �p area._:_-_...._______sc ft. Z Other Distribution box ( ) Dosi ank ( ) d " /' c�" S- 7 1 aPercolation Test Results Performed bY................ -----------•--•--•-----•-••---••--•---.................. Date_-__-_---•----------•----------•------- 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------------_----__..-. a ---------------------- ------- . Descriptio of Soil � Wes.... !�` `` u ( __ -�- .. --- - ----- - v -------------- `�' -�-----(La Q....... ' �-•------------------------------------------------ -------------------- ------------ -------- -------------------------w V 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 Article \I of the State Sanitary Code—The unde igned further agrees not to place the syster4 in operation until a Certificate of Compliance has bee iss by oa of healt Sign .....` ------ ----- -` ---_*7.. Da Application Approved BY f' ......................... -- `'... Date Application Disapproved for the following reasons:........................................................................................................-•------ -•---•••----•-•-•---•---------------•-- -----•--•-------------------•-....------•------•-••--•-----------••-----••--------•.......-•--------..--•-•----•----------------•-------•----------------.----- Date PermitNo......................................................... Date i .-��.��`7 2��4�a au �' � d'�•,,�•��,.�,�, + I t. .e a „r .y�:.. ... f � r r ..{. J°.. c a. i` 2',�1,. 5, it Ilk - 72 .•�" (�fn� } t•> } �Ix t F iu. q�� -+.., tib• , `, < .x dl�4t '8 J � .. �a 4 0 # fr t ) a7` i ,'i.F •, a , n � a4 Ri" � r � 4 1 ( '`Ja °rC ws, ' S f r,#a 'fir r n r� ^ ,4. �i 7-Y�''f' "'i'n• r: k,, i f 10- 6� 'CI .�,' 1° r•�# r 1ri = ' t .. `f• ^`t �'y +... .y Y t� ,.�.�} + �� ,_ y N �a 5 +,f dr. '� 1- ,,,. fit. -, 'ti.,. r • - < � w7�'4 S r' + -.a '' ' ., ' x +R �. T r �. y- <4 • + [ +°` , ; ° S ` �( I 3x � �,S yy�lA'I ��Se f` kn � i I ;j�' .,I o ''�` 1 Y•}. �'�� 05. /y� ��BB.FP ss q.$ •�'t� e uy.�.arr �� ��s-''a°• ..tH i Y _ r:, � 5 , I,c s ,. i"* �;° A +I�r,'� + � ��/p / �r.4 4�N '6�,! A ye w vq, v. ro a. ...^ ` c •F w i•'iJ\ Y` 4 w - , \ `�, F ,c i^ ,`� OR �� '•a^" r ? yf "•% 4f �'r,.y.C•. ''`r c .` �` { .•0 ¢ �� �` a: 4 _.✓�s "•AE;: 'In, ��♦ ws 0 M,Q i4�n�sS as � r `. r t' a. n r } �... .n # g" W'' I ,' � � /' i F,,ic4 "4 Q� '".; 3. - ;� ,x,t r ^ .e y:��, • * '� .,. . t r �� Q i;, 9 i �i#t 'S�y,r�''1 i , t +fd!1 'ij 0r � �� ��. �j �' 1yr �' �'.• ` � :t`' g4 4e t �`�... r . Ak.,`ICI .,t. ` �� #` �s #if�s�(a r �'%. P. " fi„ `.'�' •.J. J V` - ♦�` ,doa a.IJr- Sc x ,jJ-�"EF,E y, ,k^ •[� .t, ,: •�1^\ \ / .' e'` ��5�• .J COf �r 1 .�a,, f •l.d "6,'d .is 2 iqq7� Y i' x ,A } d .•! /l,. H r 4 fit:`. 6 ., • t .B l rA E A 'b p/gyp s 4 S,7 tq�1 h �Ft-r '�a.�' °r ,. �' ����1�.7✓ ��� ���Y} /c.t .�' J ' S + Yr:. - J T Y'� a `'r LEGEND ' - M ELEVATION , C O; t CERTIFIED PLOT !PL l,STING ,, SPOT EL _-- _ - - x # "h � ,ZXISTINQ' `_CONTOUR' 0 t d f f FINISHED SPOT ELEVATION - �,� y. L.a� #/e w-.,��` k•'/Vt '; FINISHED CONTOUR w �� — ,--- — J r IN `^ tag PROVED = BOARD OF HEALTH � ' ` ► --- -=— SCALE: DATE , DATE AGENT -- - e>yy. Tee�9 .DREDGE' ENGINEERING CO. ING' CLIENT _ 1, CERTIFY THAT THE PROPOSED, s EGISTERE� REGISTERED �°O 3 y BUILDING SHOWN ON THIS PC AN ` e JOB NO.. "rr "CIVIL• . LAND p.R CONFORMS TO THE ZONING LAWS ENGINEERS SURVEYORS DR,BY -� OF. BARNST,ABLE , MASS: a. . BY CH.S �, ) G` 'N0. MAIN ST 712 MAIN ,`` O �YARMOUTH, MISS. HYANNIS., MASS. SHEET OF DATE REG. LAND SURVEYOR 20 FT. MIN. /O FT MIN. moo. o CONCRETE 4" PVC PIPE CLEAN SAND Je-�° MIN PITCH - c COVERS 1/811 PER FT CONCRETE A 10 COVER t ,> LIQUID LEVEL ° 4" CAST i ii 1 i {, LAYER IRS PIP °,a OF 1/8"- 3/8`. E /OGv �j t ! • • • '. WASHED STONE ' MIN PITCH- SEPTIC TANK DIST PER FT. BOX ° , . • . . . . °, e: • • WECTIVE: . ° °° 3/4 - 1 1/2° o . fH. • • o . WASHED STONE lot i • • e: • • PRECAST 'SEEPAGE n i . • 0" . . . • . • ° PIT OR EQUIV. INVERT ELEVATIONS I 6 FT �DIA. INVERT AT jaU LOINS ` rf } €c 10 FT. DIA. I C (SEE TABULATION) INLET SEPTIC TANK "p �=�F c - N , GROUND WATER TABLE OUTLET -SEPTIC TANK —FTFT 41' SECTION aOF INLET DISTRIBUTION BOX FT SEWAGE DISPOSAL SYSTEM OUTLET DISTRIBUTION BOX FT. of O INLET SEEPAGE PIT FT. v TABULATION ,,� cP,� DIMENSION A 3 T.F �, DESIGN ..r%:TLEM%'IA DIMENSION B C FT. NUMBER OF :BEDROOMS Y, DIMENSION �, FT M, G>,RBAGE DISPOSAL UNIT TOTAL ESTIMATED FLOW boo GAL/DAY SOIL LOG SOIL TEST NUMBER OF SEEPAGE PITS ELEVATION DATE OF SOIL TEST SIDE LEACHING PER PITL_SQ. FT RESULTS WITNESSED BY _ BOTTOM LEACHING PER PIT SO. FT. 'PERCOLATION RATE ' MIN/INCH 1 TOTAL LEACHING AREA SO. FT. RESERVE LEACHING AREA 2_6'6 SQ. FT -"'c, Of blgss c i e f r f r '. ')O �rY � ���o it ROBERTBRUCE G�, ,. ., bm a. Vie•.; .f; r r ' " • ' eLaktocE y _ ' DIODE ENGINEERING CO ]C. - 1. • i 33 NO. MAIN ST. 7M MAIN 0 YARMOUTH 16lSSw HYANNIS JOB No.- 77005— 'SHEET�OF VENT (0 Least 24 inches Schedulle 40 PVC w/Chorcool Odor)Filter J, wa 10' min. from 'NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. 2-18' DIAM. ACCESS MANHOLES f�� 01 Existing Foundation [house to septic tank D-Box cover must be • -. Septic tank coven must be in 8 in. of finished grade SECTION A -A T.O.F. elev. 100.00 - •:sj.r�'` .�: �.' �' �yw•... « within 6 ,n, of finished grads ` Grad. over septic Took - 99.00 Grade over o-Box - 90.00 ads aver SAS - 99.DO PROFILE VIEW OF ADDITION TO LEACHING SYSTEM . rpe f 3' of 1/8" - 1/2' Washed Peaston ��� �;�• i M 3/4" to 1 1/2 ' Washed Crushed Stone S 0.02 3 HOLE Tap land - Qw. -95.25 INLET (H-10) GIST. BOX J' Maxi Cover t �, 10' S-0 04 Top of SAS - Elev. -94.75 4• PVC (CAPPED) INSPECTION PORT TO BE r T ry � �i4 • INSTALLED AND TO BE WTHIN 6'OF GRADE 1 o +_ EXIST. PIPE N x15T. 1,000 GA 0.010' per foot 2' Effective Depth r 3 +•p r--• FROM FOUNDATION SEPTIC TANK 65• ,`I IV THE ACCESS COVERS FOR THE SEPTIC TANK. ►R'" '"'"'• 'I 'r H-1D p rM 20 i DISTRIBUTION BOX AND LEACHING COMPONENT 1 If onDW. r? ,"' '� ^' r.;%z. TT Tom.-''.�'• SET DEEPER THAN 6 INCHES BELOW FINISHED CONCRETE FULL FOUNOA ?y A A O 0.83' } e•.a • r GRADE SHALL BE RAISED TO WITHIN 6' OF Ci4 d 1y _ v '16 r" STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. n A 5 Units e 6.25' = 30' > j h I INSTALL TUF-TiTE GAS BAFFLES OR EQUALS �`. i + SYSTEM PROFILE d I, 3'L� l 3' PLAN VIEW AJ Not to Scale 4' -t 4, I 31.25' 3-24" RE ERs MOVABLE Cov ^+ a J f2.5=--I > 37,25' ` ` 67 -paW oAo t}a.p S Can�anv m20D4 N fi.TIQ " > i0' Effective Length 6 M.ot 3/+"-1 1/2' Effective width ;. .' .,...•,.•. :,." .. .• :•. . .' ;" •, a• ., �.: .'. SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES compacted atone o _ 3 min, deorance 1 f�41tAfD_➢1_ICit11Q1J�_I:li�L�7.�_m INLET 6" min.T-12' 7± inlet to outlet 8• min. I Ir �NL[T•,'•' INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE ❑'BRIEN -- Liqui level ounEr 1. Contractor is responsible for Digsafe notification 10'mM (OR EQUIVALENT) Not to Scale 5' -7" I- r T 5' -7' 2 and protection of all underground utilities and pipes. 1 . The septic tank and distri ution box shall be set NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" ;' E 4'-0' min. level on 6" of 3/4"-1 1/2" stone. 1 c oe.sew. • Liquid depth 3. Backfill should be clean sand or gravel with no 's stones over 3" in size. NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE ,` I 4. This system is subject to inspection during installation •, n.'••�• .;, 'J by Carmen E. Shay - Environmental Services, Inc. 6'-0" +' -10' 5. The contractor shall install this system in accordance CROSS SECTION END-SECTION with Title V of the Massachusetts state code, the approved plan and Local Regulations. 6. If, during installation the contractor encounters any TYPICAL 1000 GALLON SEPTIC TANK soil conditions or site conditions that are different NO? TO SCALE from those shown on installation h e soil log o must halt & immediate notification designr in our be made to Carmen E. Shay - Environmental Services, Inc. 7. No vehicle or heavy machinery shall drive over the PERCOLATION TEST septic system unless noted as H-20 septic components. 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. Date of Percolation Test: JANUARY 20, 2005 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes. Test Performed By. CARMEN E. SHAY- R.S., C.S.E. 10. All solid piping, tees & fittings shall be 4" diameter Results Witnessed By. WAIVER (per Barnstable BOH) Schedule 40 NSF PVC pipes with water tight joints. Excavator: SHAY ENVIRONMENTAL SERVICES, INC. 11. SITE and Surrounding Properties are Connected CD Percolation Rate: Less Than 2 min./inch ® 42" BELOW GRADE. to Municipal Water. PLO Test Hole \` \\ No. 1 DEPTH SOILS ELEV. NO.TE: 0 99.00 THE PROPERTY LINES ARE APPROXIMATE AND COMPILED FROM THE PLAN BY BAXTER & NYE, INC. \ \ � Loamy San I I t \I \\ 1O YR 3/2 ENTITLED "PLAN OF LAND IN CENTERVILLE, MA " I 1 0"-6" As 198-50 DATED NOVEMBER 10, 1976, PLAN BOOK 309, PAGE 5 Loamy Sand AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN IT SHOULD BE USED FOR NO PURPOSE OTHER THAN IOYR 5/6 THE SEPTIC SYSTEM INSTALLATION. 96.67 I 1 \ Mod I I Sand PROJECT BENCH MARK i i \ 2.5 Y 7/6 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE TOP OF FOUNDATION I 1 \� •� \� FROM THE EXISTING SEPTIC SYSTEM TO BE DISPOSED �� i ; �\ I �-, �\ 40'-so" c, sa.00 OF AS PER BOARD OF HEALTH SPECIFICATIONS. ELEV. = 100.00 (Assumed) - I Coarse - Sand 2.5 Y 6/6 EXISTING LEACH PIT TO BE PUMPED DRY & \ FILLED WITH CLEAN FILL MATERIAL. LOT #3 I �\ �i --�\ LI 60"-144" C1 87.00 23,650 Square Feet ASSESSORS MAP - 168 PARCEL - -02 ' I ZONING - RESIDENTIAL r--------, Perc 1 FLOOD ZONE C Depth#to Perc: 42" to 60" I f Perc Rate=<2 min./inch Groundwatc- THERE ARE NO WETLANDS LOCATED WITHIN A 200' RADIUS 3 i I I "!-t .`, ervcd . ;�. I I I I BOTTOM OF TEST HOLE Elev. = 144" 32' r. r" Failed I I I OF THE PROPERTY i.l I I I I ADJUSTED H2O Elev. No Adjustment Required. " r Leach Pit D-Bo w: I EXISTING :�' • 37.26' I\ I+ 1i --`9� AL.OUTLET PIPES FROM THE /I 3 9EDROOM w,• DISTRIBUTION BOX SMALL BE LEGEND HOUSE EXIST. 1000 gal. r,. I \ I i � SET LEVEL FOR AT LEAST 2 FT, I` CONCRETE COVER Septic Tank ;,) i I I 24 �=�' ---- #50 ,4' ;s: ! i I 50' i" KNOD(OUTS"ET 2 DENOTES PROPOSED 12• 04LET SPOT GRADE DEN PATIO TEST HOLE #1�M Cf � �O _,�,•_ X 104.46 SPOTOTGRADEES ISTING J 4' - SCH. 40 Te L75' \ ELEV.= 99.00 , PLAN SECTION CROSS-SECTION 4" PVC �' PL PROPERTY LINE rQ�' �W o. VENT , 3 HOLE DISTRIBUTION BOX - H-10 LOADING -ERL�-- PROPOSED CONTOUR NOT TO SCALE 97- - - - - -97 EXISTING CONTOUR DEEP TEST HOLE & Design Calculations PERCOLATION TEST LOCATION Number of Bedrooms:3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) Garbage Grinder: No FENCE ,' OQ Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) �Q• Septic Tank - 2 x 330 Gal./Day = 660 USE EXIST 1,000 GAL. Septic Tank. SOIL ABSORPTION AREA: Using percolation rate of <2 min./linch { PRIVATE DRINKING WATER WELL Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. 273.8 gallons Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. 58 gallons REVISIONS Providing: = 331.80 gallons Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, NO. DATE: DEFINITION TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE `Fe ON THE ENDS. NO STONE UNDER. 1 PREPARED FOR : PROPOSED I SUBSURFACE SEWAGE DISPOSAL SYSTEM OF ALYNN SOUZA #50 LUMBERT MILL ROAD # 50 LUMBERT MILL ROAD CENTERVILLE, MA U PREPARED BY: ,0 20 40 50 CENTERVILLE MA 02632 I Cti OF EN9 GN CARNEY E. ,SHA Y S �' VIRONMENTAL SERVICES, INC. �ChT OF 1.�� 11 P.O. BOX 627 }_ �Y) GiSTE EAST FALMOUTH, MA 02536 S'4NITAR\Pa O TEL/FAX 508-539-7966 i SCALE: 1 "=20' DRAWN BY: CES DATE: JAN. 25, 2004 r= PROJECT#SD-684 FILENAME: SD684PP.DWG SHEET 1 OF 1