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HomeMy WebLinkAbout0624 LUMBERT MILL ROAD - Health 6 .4 Lumbert Mill Road C'e! . rvi IIt A= 147-083 S M E A D No.21531,OR UPC 12534 smmdcom • UwW In USA gmi) 100mu iNmwAw�IRTW SFI a i�NocssW►m wwwsMoaw��aoo Commonwealth of Massachusetts Title 5 official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ,.�..-- Owner Owner's Name QNlog KV( �{� /)/finformation is /I/required for every — — page. City/Town State Zip Code Date of Insp ction 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. 614 Important:When filling out forms A. Inspector IWT40 ation � on the computer, use only the tab lr�l� key to move your Name of Inspector ✓— cursor-do not ���1 Q / EG use the return Company Name n key. //� `/O� /�"%e57 �1 Company Address City/Town /j State Zip Code tetra 0 U d4c_ 0 Telepho umber License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the sys 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails A,�. a. 911'a, lao Inspector't ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 1 Commonwealth of Massachusetts 91-1 Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is C»4er,V`Ile— A4 aa6?a-- required for every page. City/Town State Zip Code Date of Ospectiln C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System ses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 16.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) 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): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6j�r /�ICAI rn4w� d Property Address To.s� Owner Owner's Name /� information is / � ✓��I/L �, V/S j/!y?� /4- n required for every l-� J o�v page. City/Town State Zip Code Date Anspectfon C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments / cc) Property Address -�-� Owner /JA Owner's Name information is GQN ei,�j'llC 6� � !l; required for every O"' ap page. City/Town State Zip Code Date Insp ction C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.1Y26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Oisposal System•Page 4 of 18 Commonwealth of Massachusetts I@ Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u ii�J o beel 1A ied Property Address ` �.-- Owner Owners Name J information is wired for eve40 //SectioZ v" page. City/Town State Zip Code Date of I C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ 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 water supply 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 2000 gpd- 10,000 gpd. ❑ 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form iIa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'J Property Address J 0- Owner Owner's Name information is required for everyAfl page. City/Town State Zip Code ti if C. Inspection Summary (Cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for a//inspections: Yes o ❑ umping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ as 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. El approximation 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)] t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is �✓ l required for everyj, page. City/Town State Zip Code Date of 4spectiott D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3.3-o Description: / /57��.7�v d✓t �U rl 6 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes eNo information in this report.) Laundry system inspected? ❑ Yes �0 Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes, No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name / information i every required for every �/�'' i[l! 1 e�- �i page. City/Town State Zip Code Date of In pectin D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: ©� Was system pumped as part of the inspection? ❑ Yes 2X No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: — — t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,. % 6�-`f ,, /V,' to ct v Property Address J ode Owner Owner's Name(,' information is -- required for every '7�����/// //l7 J 9 0 page. City/Town State Zip Code Date of Inspecion D. System Information (cont.) 4. Type of stem: 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate a of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;140 ❑ cast iron PVC ❑ other(explain): — A7 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u . Property Address J Owner Owner's Name information is required for every (/ page. City/Town State Zip Code Date ofAnspediion D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet Material construction: oncrete ❑ 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) ElYes ❑ No Dimensions: `J 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? --- de-4!�,(er Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): l ✓1 ,mac'�n o /� f—� ��— _ t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6� Property Address Owner Owner's Name information is A�4 required for every a irk/ page. Cityl I own State Zip Code Date of 1 pectin D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9c! Property Address Owner Owner's Name AIA information is -I required for every _ (/ page. City/Town State Zip Code Date of In ection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): 19 AQ Of- t5insp.doc•rev.7t26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments All Property Address s Owner Owner's Nam information is Ile grequired for every _/ � 11V4 � I �a` Ji /0-)0 page. City/Town State Zip Code Date of In pectin D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 9/ 0 ZA 1-7_. . ❑ eaching pits number: -- ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: -- ---- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sevrage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments gcj Property Address ---� Owner —'�` `� Owner's Nam i information is //� required for every t� !l`(/ 4Dtof �page. City/Town State Zip Code ecti n D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ol' Iles n h Gi lit h L / ! re . 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126/2018 Tide.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts J. Title 5 Official Inspection Form Inc Subsurface Sewage Disposal System ForZC4 f for Voluntary Assessments 6d Il Property Address Del Owner — S Owner's Name information is required for every page. City/Town State Zip Code Date of Ins ection D. System Information (cont.) 13. 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.): I t5insp.doc•rev.712612018 Tide 5 Official Inspection Form:Subsurface Sev age Disposal System•Page 15 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form i �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Namn�o�wyl O S information is � lo required for every / ' O!- page. City/Town State Zip Code Date of I pectio D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmark benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the bui ng. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately 9+c 1 "all 5ef4-r c i 3 6-) 141 - 1 /'id_ - 1117 kld- t5insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �Ib Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address o Owner Owner's Name information i required for every page. City/Town State Zip Code Date of Inspe tion D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ! 0 t Estimated depth to high ground water: 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: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ;---� Checked with loca Board of Health- explain: 4ar's / Aeor `Tr--W- /-101ke ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must desc how you a ablished he high ground water elevation: _ _Oct✓144 r ty ^ 1OGcac�l V�j 309 50'. A Ago 'lie-- A 1!T --------- ova-�.------ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sev ge Oisposal System•Page 17 of 18 Commonwealth of Massachusetts �M Title 5 Official Inspection Form ��� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ad-Lp A) Property Address Tose—o k Owner Owner's Nam&JOV4144 /A information Is //V� ��!/ D required for every ,/ BOO page. City/Town State Zip Code Date of I Spectiofi E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. L�J B. Certification: Signed & Dated and 1, 2, 3, or 4 checked 2 C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 allure Criteria)and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts T Title 5 Of Inspection or Subsurface Sewage Disposal SyMem Rsar,-Nll¢ ftr V0!Unt3TV Asses.t;nnents Property Address — So�L 017Te -Y�� 9 0 4 7 ON qer Ow ner's Name information is required for every 6e,,4,xv-t 174 e-- J�page. Cy/Town 22- -6 Zip Code Date of InsIfection IV Inspection results must be submitted on this form. Inspection forms may not be altered in any I way. Please see completeness checklist at the end of the form. Important:When A. General Information Ming out foam S on the computer, use only the tab 1. Inspector key to move your cursor-do not use the return key. Name of Inspector Company Names7r E /d Company Address Od 6 Wd" uty/-roWn,/,,.,— 610 State gc�- Zip Code Telephone umber License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper fU'nction and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Seddon 16.340 of Title "10R 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails D iNeed Further Evaluation by the Local Approving Authority 7a. hspector,b Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design low of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5rr•3113 Tite50ffidal ImpecdonFom Suburface SewageDi$POW System-Page I 0f17 �Ojq �s Commonwealth of Massachusetts Title 5 OffiCial Inspection Form Subsurface Sewage Disp"I System Form -Not for Voluntary Assessments e L(.t ',1 401 / // WC Property Address ONner Ow �a/'9v lo0 information is ner's Nsme required forevefy ,Qy.�Qivi� Aj4 page. Qty/Town State Zip Code Date Inspection B. Certificaflon (cunt.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: if I emhave 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 ex0ain. t. 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 wiU 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): k a tSrs•3M 3 Title 5 Official Inspection F orm Subsurface Se"e Disposal S)stem-Page 2 of 17 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form w Not for Voluntary Assessments Ga( Z6407kl-"J 4 Property Address Om ner information is ON ne>'s Name required for every page' down State Zip Code Date of spection B. Certification (corn.) ❑ 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 mannerwhich 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 Ens•3M 3 Titla S Offidal Inspection F omt Subarface Sewage Disposal System•Page 3 of 17 �L\ Commonwealth of Massachusetts 19Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not fbrr Voluntary Assessments /� (Do2 I_C4 h / /v/ r `� Property Address Om ner so Ow ner s Name information is page required for every /Town �� �/Ile V 0� _7j �/ /16 State Zip Code Date oftsp6ction B. Certification (coat.) 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 fbrm. 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 ❑ Ey" 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 Y2 day I ow t5ns"3M3 Tile 50f6aalIspectimFarm SubsufaceSevageDisposal System-Page 4of17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v Property Address (' / �141 ad Owner information is Qlv ner's Name // II_ � required for every ce", �/ 6 4 �' //9 ��2 (, 7e2 page. arylrown State Zip Code Date of Inspection B. Certification (coat.) 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. Elld 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,OOOg pd. ❑ The system fails I have determined that one or more of the above failure criteria exist as described in 310 CM 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 systes, 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. t5m-3(13 Titie5 Official Inspection Forrrr Sutrnaface Savage Disposal System•Page 5of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��- -Z&4 �4. A,// AP Property Address 0 u ner Cw r 0 �0`7 information is ner's Nsrtte II 9uiredforevery ury!Town �2v►-t,& VI 'e Q— oZ(`7� 6L11 State ip Code Date of in pection C. Checklist 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? ❑ as 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 WA) 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? Ly' ❑ 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): Number of bedrooms (actual): ? DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �J t&rs•3M 3 TitleSOffiaal IrspectionFartrt Sulsvface Sewage Disposal System*Page6of17 N Commonwealth of Massachusetts 9 Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address so/10 P"70P1 ON ner Ow nets Nameinformation is // /�f / required for every page. Cily/Town State lip Code Date of Inspection D. System Information Description: / � � 4,C r q w Number of current residents: 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 years usage(gpd)): Detail: Sump pump? ® Yes No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: t5 ns-3M 3 Title 6Official 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 Property Address Ow ner Oar nees Name /� information is C�� ! e iT D�G 3a2 8/// `b/ requked for every _ page. Cityf row n State Zip Code Date of In lion D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ' Se QS,9�t L 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 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Cl Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(desod be): Wks•3113 Yjue 5official Inspection Form Subsulaee SevageDisposal Sysmm•Page Sof 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ohv io✓/ Oav n� Ouv ner's Name requiration is / Z/T requ�ed forevery ��' ✓� � � ✓ o'- page. Cityfrown State Zip Cade Date of Ins Lion D. System Information (cons.) Approximat�ge of all components, date installed(if known)and source of iin"f'ormation: / — Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;/40 ❑ cast iron PVC ❑ other(explain): / Distance from private water supply well or suction line: ?— feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet 7en*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 5 Dimensions: Sludge depth: 15ns-3M 3 rIIU6 5 official IrspWU0n F 0=Subsurface SevMe Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form a Not for Voluntary Assessments pAj 14�// �d Property Address sol000kj Ow ner Ow ner's Nameinfommtion is 19.2 page. Ctyllown State Zip Code Date or Inspection D. System Information (cont.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness � P— u Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle PO!2// / How were dimensions determined? /�G1 N2vtG� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): (�✓'f�l h �J� ���C�G_ �n �✓ Qrn d 4aeS ! ✓1 ejoo d r 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 tyre-3M3 Tioe5official lrepectonForm Submeace Sewage Dispreal System-Page 10d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewag e Disposal System Form -/Not for Voluntary Assessments 44 y4 b e/J- / // Property Address SO X12 010✓I ON ner ON ner's Name / � / information is requ�edfor every Cep y1t 6 -e //'I4 page. cdyrrown State Zip Code Date of IrApedtion D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: [we Comments (condition of alarm and float switches, etc.): t Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t9ns•3M3 Titl85Official Inspection Form Subswace sewage Disposal System-page 11 of 17 i' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form ,Not for Voluntary Assessments Property Address 6j C/ L CA,✓,4 S el-47 � �i L information is information Name required for every ��✓� �� 'e /�.� �oZ 6�� gpeec�f page. Wrown State Zip Code Daten D. System Information (cons.) 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.): 610'x/ f_e ✓� sa / s 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) pocate on site plan, excavation not required): If SAS not located, explain why: t5irr.-W3 Title5 Official lrepec tionFortrtSulsurfaceSew age Disposal System-Page 12 of 17 Commonwealth of Massachusetts lug Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments CJ Y Zc4 p4e,,� zl , Property Address Owner so 47 M o of infomiation is Owner's Name I T required for every 2vti�!-�✓!ir /1�'' T/� page- City/Town State Zip Code Date of Ins ction U. System information (cons.) /� / do S�lo� Type DC /�5<0 — C ��c,�.Sl�,.s ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/aitemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): oe4 CJ114 _�O, o all1-1 lqt4 C>1 7 - / - 7, Xv, _r oe�' 4c, c4t c Cesspools(cesspool must be pumped as part of inspection) pocate 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 f5ns•3M3 TiCe5Official Inspection Form Subsurface Sewage Disposal S)Wam•Page 13 of 17 Commonwealth of Massachusetts IPTitle 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address pC J! /�'/J/ fc Ow ner Owner's Name 0` 9 V%149 vJ information is `Io/ required for every P'��" vi -e /��/� oa 6 1.2 page. Cltylfown State Zip Code Date of Ins U. System Information (cost.) pection 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.): 15ns•3113 Tibe5official ImpecbOnFomt Subsuface Sewage0isposal S5613m•Page 14 of 17 Commonwealth of Massachusetts lug Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z C4 P'1'4e'-4 ZVI Property Address �G/� �� Owner Ow no's Name information is /�%jc�e ll ? / required for every Q✓' l// / " 0j& Y� z <�page. 5�ownState Zip Code Date tion D. System Information (coat.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where lic water supply enters the building. Check one of the boxes below. hand-sketch in the area below ❑ drawing attached separately w -/ovo G,Itn•. ��-�« i,N�►. /44f 14 12o>,- X P1';S-4'C- Ac� 67,0— c( 11r"V'W t5rts-3113 Title50ffidal ImpactionFartt Subsurface SeeageDisposal System,Page 15of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Zt4�6� / `// Property Address - ow ner Owner's Name �O�d v-1 fop) information is required for every Cecit �/!/� '1111 e( 6 page. City/Town State ip Code o� Date o Ins De system Information (cont.) pectron Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells �0 Estimated depth to high ground water. 11yn 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: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with al Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe ow y u established the high ground Ovate elevation: � d � ����Q.r 2. cue Sc kl�l Itif /"- Ae- PIC-k 14 ZL) /fit- f Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15t5.3f13 Tive 50fficw i specton Fam Subsurface Sewage Disposal system•Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurrace Sew//a''ge Desposaf System/Form-Not for Voluntary Assessments RoperiyAddress ON ner oTCM(9 requw fo is eY Ow nef's Name CQ� ) �``C page-edforev y2 7F- :� // /6 Page• Cdylrown State E• KePort COMPlelDnesS Checklist caae 11ce Df 2---ins ection Summary: A, B, C, D, or E checked L7 Ui.S ,� pectbn Summary D(System Failure Criteria Applicable to All Systems)completed ;/S�k em Information—Estimated depth to high 9roundwater ch of Sewage Disposal System either drawn on page 95 or attached in separate file t5ms^3rf 3 TMeSOffidW UBPeaknFaM SuCw ff=e SewageDMp-d SyMM*FBge 17 of 17 TOWN OF BARNSTABLE LOCATION / WAGE# `�`_� VILLAGE / ASSESSOR'S MAP&PARCEL s 12Z? INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type��"�?,p of S (size) NO.OF BEDROOMS OWNER o/LpxJlo�� PERMIT DATE` �. COMPLIANCE DATE/- g�/� 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 exi\within 300 feet of leaching facility Feet FURNISHED BY : . v /41- -� �rro � sue/ i d L No. �-. - ;. f Fee - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYitation for Dispo r opstem Construction 'permit Application for a Permit to Construct( ) pair( pgrade( ) Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. ///� ` Owner's Name,Address,and Tel.No. , Assessor's Map/Parcel ��� �'U� Installer's me,Address,an Tel. � D igr,,,Nameress-and Tel. Type of Building: _ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building _No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -' gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) — Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of alt . > S' Date ,"��7^. •>:. .. Application Approved by Date Application Disapproved by Date for the following reasons Permit No. r Date Issued t. Ll No. // , --+� Fee p" THE COMMONWEALTH-OF MASSACHUSETTS' Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes a 2pprication for Mispo-s'al 6pstem Construction 3permit Application for a Permit to Construct ) air( pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 114/ 02V Owner's Name,Address and Tel.No. Assessor's Map/Parcel y _ Installer' e,A dress,a d el. o ��� Designer's Na y ress,an Tel.No Type of Building: ��j Dwelling No.of Bedrooms Lot Size o<'�'/ sq.8. Garbage Grinder( ) Other Type of Building �� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)! Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o ral Sigried Date Application Approved by �, ,' Date f G Application Disapproved by Date for the following reasons Permit No. 1_-_Q / 3 Date Issued ----------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that thonsite Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by 11axr7 at n i -- as been constructed in acccorrrrd"�ance with the provisions of Title 5 andfihtffor isposal System Construction Permit No. 3�d�ted �G �S � '1 Installer,,% Designer m 0110, #bedrooms Approved design flow y gpd The issuance of this permit shall not be const ed as a guarantee that the system will function de y i e . Date /U / 1I Inspector ` �� .�,— --------------------------------------------------------------------------------------------------------------------------------------- No. �� k4 Fee UG `THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS -misposal 6pstem onstruction 3permit Permission is hereby granted to Const ct( ) Rep a' ebngra e( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be com leted within three ears of the date of this permit.71 I ! y Date �l S l ( Approved by Town of Barnstable .°EVE' Regulatory Services Thomas F. Geiler, Director • UMNSfABLE. Public Health Division pTF1639.a�A. Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Sewage Permits ' ® ^ Assessor's Map\Parcel 3 Designer: MNe-y", Installer: li Address: �(/ �Jk. �� Address: Or. �J � %��� was issued a permit to install a (date) lU// (instaal -< �PPllle� p� septic system at Z Zt LUMb(�dy► M I • based on a design drawn by f (addres') r " J " I dated (designer) 6 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 ol'ythe distribution box ancU'or septic tank. V I certify that the septic system referenced above was installed with major changes (i.e. greater than 10" lateral relocation of the SAS or anT, 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. OF MASs9� Dal (Installer's Signature) No: 1140 SANITVV AR�P� 4 (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BAR`ISTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORNI AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-264doc ;i WALTER SILVA<wjsilva25@msn.com> Deed Restriction-624 Lumbert Mill October 4, 2011 10:18:38 PM EDT 3: <oysterhomes@aol.com> Janet<jmccoole@comcast.net> 1 Attachment, 92.9 KB Hi Mike - Please let me know when you'll be starting work and estimate of when you'll finish. Thanks, Walt 508-776-7578 11-1-04-201 1 2:46 BARNSTABLE LAND COURT REGISTRY DEED RESTRICTION WHEREAS, JANET MCCOOLE of 624 Lumbert Mill Road, Centerville, MA 02632 is the owner of 624 Lumbert Mill Road,Centerville, MA 02632 (hereinafter referred to and being shown as LOT' 3 on Land Court Subdivision Plan No.37432A(sheet 2);and WHEREAS, JANET McCOOLE as the owner of said lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home located on said lot as a pre-condition to obtaining a disposable works construction permit in compliance with 310 CMR 15,000 State Environmental Cod, Title V, Minimum Requirements for the Subsurface Dispose of Sanitary Sewage;and WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, is requiring that the agreement for the restriction on the number of bedrooms in the house constructed on the lot be put on record with the Barnstable County Registry of Deeds by r ding this document. NOW, THEREFORE, JANET McCOOLE does hereby place the following permanent deed restriction on the above referenced land which restriction shall run with the land and be binding upon all successors in title: 624 Lumbert Mill Road, Centerville, MA 02632 being Lot 3 on Land Court Subdivision Plan No. 37432A (sheet 2) may have constructed upon the lot a house containing no more than three bedrooms, For title see Certificate of Title No. 123491 I (2JI l- y Lw f''DAvi q �N C p0o EVER No. 1140 STE�4 SANITAR�r l � l SJ �3x�i APPLICANAWLU ADDRESS: M (3 DESIGN FLOW: 330 gpd REVIEWED BY: DATE: N/A OK NO Le al boundaries denoted [310 CMR 15.220(4)(a)] - Street, Lot, tax parcel number and lot number noted on plan [3.10 CMR 15.220(4)(0] Locus Provided [310 CMR 15.2204 t Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for com onents) [310 CMR 15.220(4)] X Easements shown [310 CMR 15.220(4)(b)] X System located totally on lot served [310 CMR 15.405(1)(a) for r[3 ades]- i not, a variance is required [310 CMR 15.412(4. ] X cation of impervious surfaces (driveways,parking areas etc.) 0 CMR 15x cation all buildings existing and proposed 310 CMR 15.220(4)(c)] x Location and dimensions of system components and reserve areas [310 CMR 15.220(4)(e)] 7� S stem Calculations [310 CMR 15.220(4)(f)] dail flow se tic tank ca aci (re uired and provided) soil absorption system (required andprovided) whether system designed for arba e indec X North arrow [310 CMR 15.220(4)( )] Existing and proposed contours [310 CMR 15.220(4)( )] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] X Felevation?) il evaluator and BOH representative [310 CMR and M1 X date of percolation tests (performed at proper 310 CMR 15.220(4)(i)] X Percolation test results match loading rate? [310 CMR 15.2421 X Certification statement by Soil Evaluator[310 CMR 15.220(4) ')] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] x Location of every water supply,public and private, [310 CMR- 15.220(4)(k)] k Address (✓� �� ,1 l �/,hl V1 tG/ Sheet 1 of 7 within 400 feet of the proposed system location in the case of surface water supplies and gr4yel packed public water supply within 250 feet of the ro osed system location in the case within 150 feet of the proposed system location in the case k of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and d'th6fiftibsufface ufilities located [310 CMR 15.220(4)(m) (if water line cross see 310 CMR 15.211(1) 1]) Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(o)] Stamp of designer 310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5.ft. of lot line) [310 CMR 15.220(3)] X . Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2)or as ,approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? 310 CMR 15.103(4)] �( Test Holes adequate to confirm adequate groundwater separation? [310 CMR 1.5.103(3)] x Benchmark within 50-75'of system [310 CMR 15.220(4)( )] X Materials specifications noted? [various sections of 310 CMR 15.000] x System components not> 36" deep(unless Local Upgrade Approval or LUA,requested) 310 CMR 15.405(1(b) Address � � � M l LL R-0) � � " Sheet 2 of 7 jji Size OK? _[310 CMR 15.223(1)] Inlet tee located ten inches below flow line 310 CMR 15.227(6)] Outlet tee 14" or 14"+ 5"per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base[310 CMR 15.228(1)] �( Separation between inlet and outlet tees (no less than liquid depth) 310 CMR 15.227(2) Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA [310 CMS 15.405(l)(k)]. X Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (b 7/07) [310 CMR 15.228(2)] X Access to within 6 "-of grade - one port for systems<1000gpd, two fors stems>1000 gpd 310 CMR 15.228(2) All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] x > 10 ft from building foundation [310 CMR 15.211(1)) k Buoyancy calculation Required/Done 310 CMR 15.221(8)] X 14-20 Where appropriate? 310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] Required when other than single-family dwelling or flow>1000 d [310 CMR 15.223(1)(b)]. �( First compartment 200%daily flow; Second compartment 100% daily flow 310 CMR 15.224(2) and 3)] "U"pipe through or over baffle, outlet of each compartment with as baffle or approved filter[310 CMR 15.224(4)] Address klvi l'C-e. Sheet 3 of 7 Located at�leasi ten feet from any waterline? [310 CMR 15.222(2) Disposal piping at least 18"below water line (when water and sewer cross, see 310 CMR 15.211(1)[1]) x Cleanouts required/provided ? [310 CMR 15.222(8)] li Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] ]Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] X Proper pitch on all runs?(.005 within gravity-distributed trenches and beds ) 310 CMR 15.251(9) and 310 CMR 15,252(2)(c)] Sip honproblem/ le achfield below pump chamber) Endca s or vent manifold specified? Size and orientation of discharge holes specified? (not smaller than 3/8"not larger than 5/8") [310 CMR 15.251(8) and 310 k CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) X Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash.plate or baffle tee required on inlet/provided?(when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 1.5.323(3)(a)] �C Riser if deeper than 9" [310 CMR 15.232(3)(t)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum,,sum 6" [310 CMR I 5.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] X Capacity(emergency storage above working=design flow)? [310 CMR 231(2)) Pro er setb acks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20"MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep,with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [31Q.CMR 15.231(6) and (8)] Stable Corn acted Base [310 CMR 15.221(2)] Buoyancy calculations needed-?Provided? [310 CMR 15.221(8)] Address ( 2,q R4t 1l get Sheet 4 of 7 Calculations correct? 4 feet of naturally occurring material demonstrated?[310 CMR 15.240(1)] Required separation togroundwater? 310 CMR 15.212).] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or >36"deep) [310 CMR 15.241) Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] x Breakout requirements met?(No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] )( Each structure with one inspection manhole(if>2000 gpd must be tograde) 310 CMR 15.253(2)] Aggregate 1 minimum-4'maximum. 310 CMR 15.253(l)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)]. In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)] Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] , 100 feet-maximum length [310 CMR 15.251 1)(a) Minimum separation 2x effective depth or width whichever eater(3x if reserve between trenches) [310 CMR 251 1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document]1 ME minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum s aration between lines 6' 310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10' minimum. [310 CMR 15.252(2)(f)] X Bottom area used in calculations only 310 CMR 15.252(2)(i)] �( Address J� �A,-Jj A4)tl U A ;, a Sheet 5 of 7 Pressure Dosed System ? Provided pump and piping calculations as re wired. 310 CMR 15:220 4 r)] Pressure dosing required on all systems>2000gpd or alternative systems undfW4+ernedial approval [310 CMR 15.254(2) and I/A Remedial Use Annrrvnll If used in gravelless system - make sure jet is directed as not to scour soil interface [Guidance Document]. Inspections once per year(systems<2000 gpd)or quarterly (>2000 d Crnnrl to note on plan [310 CMR 15.254(2)(d)] Construction in fill -Did the plan specify that the fill shall meet the s eciflcation of 310 CMR 15:255(3)? x Im ervious barrier and/or retaining wall ? [Guidance Document] >4f Impervious barrier installation must be supervised by desi ner [310 CMR 15.255(2)(b)] X Retaining wall must be designed by Registered Professional En ineer [310 CMR 15.255(2)(a)] X Side slo e not exceed CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document X At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [3I0 CMR 15.255 (2)(e)] u Check DEP A royal letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour.soil interface �( , Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for 2erpetual maintenance a eement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a coy of a maintenance P.Are the variances listed on the plan ? [310 CMR 15.220 (`I)( )] X RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] >C New construction or increased flow proposed - [Refer to 310 CMR 15.414] X Address Sheet 6 of 7 Is the system in a Designated Nitrogen Sensitive Area(Zone 11 fo a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR-15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well,? [310 CMR 15.214(2)] w Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] x Pumping to septic tank? [ 310 CMR 15.229 Shared System [310 CMR 15.290 Address �'(J`1 Lqw, j i MA � Sheet 7 of 7 .Gown.of BAmstable. Departinent of Regulatory Services A 7/ . Date �►eLr. Publlic Health Division ems? ib39• tee$ 200 Main Street:Hyannis MA 02601 '`lFn►M't� ` �O ',Time Fee Pd. AV v Date Scheduled La' hl i . i oil' bSuitability Assessmie�t fob age Disposal � l �r Witnessed B Performed By �� ! y. i LOCATION & GENERAL'INFORMATION Location Address'. �L{ ()(t� r /A l t& Kbi Owner's Name(fa ejf, C ��, li�'J�Ti✓( �y I I Address j,1G-J+Jt. Assessor's Map/P4rcel: (l.(?I 3 Engineer's Name DO�Y)Ae-1 I �( I. 2�Z� NEW CONSiRUt�TION REPAIR ` Telephone# Land Use 9 � + -�p Slopes(40) •v�' �A� -o Surface Stones 'v ft Possible Wee Area �"'O ft Drinking Water Well ft Distances from: Open Water Body i brainage Way L ® ft. Property Line � (�- ft Other• ft i SKETCH:(street name,dimcnsiods':4lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) • I . I • 190.00 "4._---Jam--- __� . poQ`- ------- 10 100, < So I- U,1 i zZ Z ----- --- I N - I @ems v 1O • v.o OPrLWI.Y \\ � I I Parent material(gccilogic) u&A &KWask ' Depth to gedtoek ��� .-•----- ' a/+ Depth to Groundwatdr. Standing Water in Hole: i Weeping from Pit Face Estimated Seasonal Righ Groundwater DtTERIVIINATION FOR SEASONAL HIGH WATER TA19L Method Used: I in. Depth td SON ttlottlP : ln. Depth Observed standing in obs.hole: I in, ©roundwater Adjustment h Depth toiweeping from side of obs.hole: t A A&01!,,,,._ ' AdJ,.GroundwaterLevel.,,�,e, Index Well#� Reading Date: Index Well lev4I -- df• PERCOLATION x'EST • Date Time•_. Observation Tithe at 9" .:- -- 1Lole# i 33 Time at 6" Depth of Pere 05 -- Start Pre-soak Time-9 Time I End Pre-soak ! ' Rate MinJInch 1 Site Failed; _ Additional Testing Needed(YIN) Site Suitabiiity AssessmenC Site Passed ; Original•.Public lialth Division Observation Hole Data To Be Completed on sack-- I• - ***If percola�itin test is to be conducted within 100' of wetland,.-You must first notify the Barnstable C44servation Division at least one (1)we6k prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon SoffTexture Soil Color Soil ' Other :Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel 33'°-l�l » G Pew DEEP OBSERVATION HOLE"`LOG Hole# Depth from Soil Horizon Soii li xture Soil Color Soil Other Surface(in.) (USDA) (Munsell). Mottling (Structure,Stones,Boulders. Consistenc %Gravel) 71 DEEP OBSERVATION HOLE LOG Hole# N A Depth from' Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistency. Gravel) F t , Flood Insurance Rate Map: y Above 500 year flood bound No— Yes Y boundary Within 500 year boundary No x Yes Within 100 year flood boundary No - Yes Depth.of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? rl If not,what is the depth of naturally occurring per ions material? Certification I certify that on 2ni (date)I have passed the soil evaluator examination approved by the Department of Enviro al Protection and that the above analysis was performed by me consistent with the requirecJ.7L- i ' g,expertise and experience described in a10 CMR 15.017. gg A V Signature J Date QASEPT10PERCFORM.DOC Postal7 U.S.. CERTIFIED MAILT. Qf-CEI PT IT' (Domestic • Provided) Ln 0For delivery information visit our website at WWW.USPS.COMO N - ru Postage $ Certified Fee �r v rl O Retum Recelpt Fee Postmark p (Endorsement Required) VA � Here O Restricted Delivery Fee O (Endorsement Required) r`- Total Postage&Fees $ W— r..,r-q aMs Janet McCooLe- 624 Lumberts Mill Road Centerville, MA 02632� 1 I Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece~� is A record of delivery kept by the Postal Service for two years, Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Maile or Priority Maile. ■ Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the address. addressee's authorized agent.Advise the clerk or mark the mailpiece w?tio endorsement"Restricted Delivery". s If a postmark on the Certified Mail receipt is desired,please present the artil, cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 Town of Barnstable Barnstable Regulatory Services Department AHmedcaC'P IIARNSfABLE, + 1639."Ass. Public Health Division ArED MAy a' 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7011 0470 0001 4525 7659 September 12, 2011 Ms Janet McCoole 624 Lumbert Mill Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 624 Lumberts Mill Rd., Centerville, MA was last inspected on 8/22/2011,by Patrick O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • System is in hydraulic Failure You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\624 Lumberts Mill Rd.,Cent..doc 'Dz6, / e - AV) Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 624 Lumberts Mill Road Property Address Janet McCooL e. Owner Owner's Name information is required for Centerville MA 02632 ' August 22,2011 every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the �I computer,use 1. Inspector: only the tab key { J to move your Patrick M. O'Connell cursor-do no; Name of Inspector use the return r key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 rensn Cityrrown State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 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 ? Y-` =t August 22, 2011 Job# 11-13t ector's ignature Date k..-1 r--�- M The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or .- has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is required for Centerville MA 02632 August 22, 201;1 every page. City/Town State Zip Code Date of Inspection, B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D f A) System Passes: ❑ 1 have not found any informatioIh which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 dMR 15.304 exist. Any failure criteria not evaluated ate indicated below. Comments: f f 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)i 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): i i 15ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal system-Page 2 of 17 I I II i Commonwealth of Massachusetts 9-7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is Centerville MA 02632 August 22, 20111 required for — every page. City(rown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution boz. System will pass inspection if(with approval of Board of Health): . broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain kelow): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): I I i ❑ 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 Ulelow): i I i i 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. i 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal'System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 624 Lumberts Mill Road i Property Address Janet McCook Owner Owner's Name information is Centerville MA 02632 August 22 20111 required for every 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 a1public 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: I i i 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 El ® 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 Ian overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i I I ' Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is Centerville MA 02632 August 22 201'i1 required for State Zip Code Date of Inspection every page. CityRbwn B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to Iclogged 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.] i ❑ ® 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 El Elthe 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. i i t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is Centerville MA 02632 August 22, 20111 required for every page. Citylrown State Zip Code Date of Inspections 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) i ❑ ® 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 interio�of the tank inspected for the condition of the baffles or tees, material of constr l ction, 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)] I i I D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f I I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is required for Centerville MA 02632 _ August 22, 20111 every page. City/Town State Zip Code Date of Inspection D. System Information i Description: I I Unknown Number of current residents: Does residence have a garbage grinder? Yes ❑ No i Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No i i Seasonaluse? d Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp )): i Detail: i - I Sump pump? El Yes ® No Last date of occupancy: C tirrently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: I i Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): I Grease trap present? ❑ Yes ❑ No i Industrial waste holding tank present? ❑ Yes ❑ No i' Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - 15ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposil System•Page 7 of 17 i i J Commonwealth of Massachusetts Title 5 Official Inspect,ion Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is required for Centerville MA 02632 August 22, 2011 every page. Citylrown State Zip Code Date of Inspection,) D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): j i I I I I i General Information Pumping Records: Source of information: Tank pumped one year ago. I Was system pumped as part of the inspection? ❑ Yes ®' No If yes, volume pumped: - gallons How was quantity pumped determined? I Reason for pumping: Type of System: i i ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool i ❑ 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 I ❑ Tight tank. Attach a copy of the DEP approval. I ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts I W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments j 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is Centerville MA 02632 August 22, 2011 required for every page. City/Town State Zip Code Date of Inspections D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Unknown I I Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 3' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): I Distance from private water supply well or suction line: feet I Comments (on condition of joints, venting, evidence of leakage, etc.): I j i j Septic Tank (locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I I i I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 3 — l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal)System•Page 9 of 17 I i i i I, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is Centerville MA 02632 August 22, 20111 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 2 Scum thickness 6 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12 � 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.): Liquid level was found at bottom of outlet invert, baffles were intact. i I I f Grease Trap (locate on site plan): j Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ I ther(explain): I i Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle — i i Distance from bottom of scum to bottom of outlet tee or baffle -- Date of last pumping: Date t5ins•1 Ill 0 - Title 5 Official Inspection Form:Subsurface Sewage Disposal(System•Page 10 of 17 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wH 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is Centerville MA 02632 August 22, 20111 required for every 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.): i i i Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan'): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain).- Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 624 Lumberts Mill Road _ Property Address Janet McCook Owner Owner's Name information is Centerville MA 02632 August 22, 20111 required for every page. City/Town State Zip Code Date of Inspection, D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): i I i Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is required for Centerville MA 02632 August 22, 2011 every page. City/Town State Zip Code Date of Inspection: D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit. ❑ 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.): Liquid level was found at top of pit, pit is in hydraulic failure. i i 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is Centerville MA 02632 August 22, 20111 required for every page. Cityrrown State Zip Code Date of Inspection;. D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: — Dimensions Depth of solids i Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i !Sins•11110 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 624 Lumberts Mill Road Property Address Janet McCook -- ---- - ------._..._..-- ---- —--- -------'------ Owner Owner's Name - - -------�------- requir atifo is Centerville MA 02632 August 22, 20'11 required for -----------------------....-_...------.._.__.......--.................. ---------- ------------- —9 I every 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 ❑ drawinq attached seoara.tely 15 Back 12 rCjiuy,';1,A ' 64 64 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is required for g I,Centerville MA 02632 August 22 20'11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: N/A 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: i ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: i You must describe how you established the high ground water elevation: i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 624 Lumberts Mill Road Property Address Janet McCook Owner Owner's Name information is required for Centerville MA 02632 August 22, 201 - every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i i i 1 I i ( i I _ 1 i I i 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF............�.4 �n_ ....................----._........_.....------ Appliration -for Ui,ipuiitt1 Works Tomitrurtion Vrrm t Application is hereby mall`ffora�P Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal Sys at: � Z Local' .-Address or J O n�e " �l� Address fWl -'�__.l..........6 --......--••-•-----......-•----•---•..........................................................•--- Installer Address Q Type of Building Size Lot... ----Sq. feet Dwelling—No. of Bedrooms-------------- _----:--•__-----__---__-Expansion Attic Garbage Grinder �4 pa, Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtures ---------------------------------------------••------------------------------- ...........:.......................................................... w Design Flow............:�70........................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacit/40 -gallons Length______________ Width................ Diameter__._-_-.-.--__ Depth---------------- x Disposal Trench—No. .................... Width...._._............ Total Length-------------------- Total leaching area............._......sq. ft. Seepage Pit No--------_ Diameter_CtX Depth below inlet.................... Total leaching area------------------sc ft. >� Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed bY.......................................................................... Date--------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.--------............... (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_._-.-----.----_-_-__-- P4 ---------------------- ----------------------------------------------------------------------------......................................................... 0 Description of Soil----- -------------------------------------------------------------------------------------•---.---------.--------------------------------------------------------- x -------- !/Lc ----------------------------------------------------------- w U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------_ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha n issued( the d of health. �J`/A� R Signed... . ............................ ------- -------Date Application Approved BY iie -:_�..------------------•--•----••---••-•--•--•-•----•---•----------------•--------- -------------------- -------------- Date Application Disapproved forfollowing reasons----------------------------------------------------------------------- -------_-----------Da.t.e.............. ....-•••-•-------•--•--••-•-----•-•-•-------••------•---•••------------•-•--•-••-•----------••••-••----------------------------------------------------------------------------------------------------- Date PermitNo.. --=3. 1--•---------•-•------------------- Issued........................................................ Date r 5./ �`�1• mac,. k. a,.. - r��.�,7�N .. .. .. - v.�a '�lr No.... r THE COMMONWEALTH OF MASSACH USETTS a � tom'" ...M;�,�y„�....---/"_',••,,�..,,�!^' t ` BOARD 'OF .HEALTH .. O F r�irtt i�rn Jor t u tt14 �axk ( > t� r�trfiAY� rrutit ?. ,b ,Application is,hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage`Disposal Sys tetrir at; Location_Address or Lot No. owner Address Installer je, Address Q Type of Building Size Lot._._ ___Sq feet Dwelling�No. of Bedrooms`-°____________________________________ _____Expansion Attic ( ) Garbage Grinder'( u) pOther=Type ofj Building______________________________ No. of".persons, x--a----------- Showers ( ) - Cafeteria ( ) Dest n " Other 'fiktures ----- -- --- ----- ---------`---- . .-... of 1 k W •glow -:`_ /, allons per person per day. Total daily flow------------------ gallons WSeptic Tan � L�qt•', cap tcitvr�" �`tllons Length Wldth Diameter = Depth................ x Disposal Trench IrTo77 --------------___ Width__ Total"Length Total leaching 1re1___ sq. ft. �- Total-leaching area _----•_- _� Seepage:.Pit No �.------------Diameter_.l� ._. Depth below i et-_._... � g . _-.sq. ft. z Other Distribution box (x ) Dosing Yank / --- -----••- - -- -- De th to pro e- ----- ILI PercolationPest piTt oRi cults --minutes tes pedr.in ; Depth of;. l eat`Pit P Date water y LZ, Test Pit No. 2..............._minutes per inch, Depth of Test Pit.................... Depth to ground water -_ ___ -. a --------- --- --------------------------- ........................................ . , •....--- Description'of Soil _.. --------------------------- --------=------------ - - r! it.•- -•-•---- !_G� .! ? 1---- ----------------••---,_ } U.- y- � --•--•---------r-•-------- -------- ---•c:-------- - ^b x _________________ __________ ________ ..__. .___.__..___._. ........_...........................,_ __ ---------------------------------------. Nature of Pe cars or Alterations-Answer when applicable-__.__: . U P` - --------------- --------- -------- --- ---- ----------------------------------------------- --------- ----------------- ------------------------------------------------ Agreement The undersigned agrees to install the aforedescribed .Individual Sewage Disposal`System in accordance with '< the provisions of Article XI ofjthe State Sanitary.Code_—The undersigned further agrees not to place the system in r ` operation until a Certificat,of,Corngliance•Iias-bee,;�,assu,d,,,by the board of health. '�4 ' Signed ------ ------ ................ ..�:.-1. } APPlicatiori Approved By Date rt v. Date .A lication, Disapproved or s.• PPPP f 1e.following reasons: v .._•___.._.__y______________• :_- a .' ` Date PermitNo. d ----•-.---------------------------- Is {ied ------------------------------------ Date tr r ru y, h m K 71 'P` t +a 1'•t+'�92 ='5 4':i ... .�^.> a"�.. i` :..I {�a j THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .Zoi l.A;' rfp"�i.4 .......................................... r T-rdi irate �rf�"T` MvIittrtr-r THIS IS TO CERTIFY,'That the.,Individual::Sewa e Disposal System constructed or Repaired by ........... 1 r eaa,.��' ------. -- --' ............................................ - -----•-------------- --- .. �-- 1 Installer ------------ 4sG j /C'1 CG L C has been installed in accordance'with the provisions of Article XI of The State Sanitary Code as described in the application for Dtspossal Works`'Construction PermitfNo.___ d��_� _ ..... dated --_-, �! __.7 THE ISSUANCE OF THIS CEPtT4F;CATE`SHALL,,N4V"tONSTRUE AS A GUARANTEE TFIAT.TIME f' . ,: SYSTEM WILL FUNCTION SATISFACTORY. DATE.:: w `° -------------------------- Inspector . = #� THE C04MONVIFEALTH OF MASSACHUSETTS F R BOA 'D OF`�HEALTH .> _ _,[...__._ .. ....... .... .. ..------ -?.e ..................... /'"' '•' o F. � NO ` >A� FEE __ � _. r 7. Permission is hereby granted `..t�r�r_ _. e� ,.f "" ---`--------------------------- -------- `$ IS ... to Construct O or Repair ( ) an Individual Sewage Disposal System at No.............................?G " ,_ .:......4 'f_' 4.,' )4,e_. __..� ` ---�-e� 't' G�� � R f. .T•, ,�_ - Street _ ,as,show o tthe application for Disposal Works Construct}ozi Permit No.-._.._ '- �_ Dated....,5 '__ ..__._..._ r PP B x j c ` >v Board of IIealtlb -_h t DATE = -r * a' w z, FORM 128.$, HOBBS &•WARRrEN. INC.. 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C'CJ.t//?C7P"A-f .7'�.3 7"N!@ S'O ♦ 6r *Srr 3 , R „ r , % P t t a �'� ' THE 7"b/1/RJ O4 ' T. BGeE t ar A - 7•i�V '� .�r n I � rEt ('tk xy r�t.'R•�.Jr.k y ram ' f _ x 4 k, R ;a af"r S�$r'T r S y , r d 7. .�f c t ,,I ^ P r r, R 'i�f r'M,� .- �'£3� 5 A pig �,V , d i, i -i , of t�1'k u ,_�I s"o SFr ��< 7 _ s"��sS iX CGV/L "�E.V�r/A/Et@iC!!;S : aJ � F N F 4 Sfti r a L q.c/&) SC/AP%O' C,s ' ei ° # 4',_` ry w� x't'r , i .� 4 '.. eta A�j(E�. '�`^"a x�'., .r' r�O "" .�/1�OC_ r�/ /�A.�i•J'+'. F ,�.:;k�7/9TL�"':, r � 1 .. d�E r ,,. " • i...„yr11. r .a a, fit. x .'� ;a-. , F< rf'� a '7.e s� r•' r 'y f�xr 2 r c a s"',r A, uq t i` `f 11._ " r ,c m Y a rR f r r . �� 4.44'+r t r"`F,� '{I 7: i�} t - r +4x. r rk �. n 1 d` r - r. a E .r. ` it tr^`" 4x �.R�s��S ` . ,�,, r... c� ,M k s �7 ..,j yr •{P t .. t 4 tr�>.1 r9'` w t a p , Z^jf , r �:V,w '�,,IV.t ;P ad• . 1 ,.°9 s �`+ ... ,r ^�,Pi r r _ � LO>CAT ION , S7, PE R M I T N0. `EVIL AGE I Ile INSTALLER'S NAME & ADDRESS re /,o -14s % B UI'LDE R OR OWNER DATE PERMIT ISSUED J�, - 1�- 77 DATE COMPLIANCE ISSUED CT- 6z 9C BARNSTABLE COUNTY HEALTH DEPARTMENT J• (d..�-� B p�ggy�NST�p BLE MARS. qp,R 2 0.3 TRL[PM®HR! « 362-2511 Ext, 331 Date: April14., 1977 To: Tam-.-Ho Farms, Inc. Box.-905 Hyannis, Mass. 02601. On the basis of a sanitary survey and a laboratory examination on the sample Of water taken from a ..WPA... .. . . . .. . .. .. .... . .. .. . . . . . .. . . . . . . .. ... .... . . .. .. . located on the premises of..Ta, Y.Ho.Farms..Inc. ... ... . . .... . ..0.... . .. • . . .9. ... 0 located at.."3y.Lambert.M3.LL Road,,-Barnstable... . .. ... ...... ... ... ... .. ..... .. on.... . .. ..Air L a3e,.1.974'. . .. ... . ...••this supply is approved for domestic purposes at the time the examination was made. If you wish further information regarding this supply, please contact us at the County Court House, Barnstable, Massachusetts (Tel: 362-2511 Ext. 331) and we will be glad to assist you in any way possible. -- - Signed... �.� .. . .. . .. PuMs"E ealth Sani.�t an 3/21/77 500 y 33 OSTERVILLE » ' 34 / 775 O 35 w Q ft t i o 37 0 W 38 o ��FXQ5TING LEACHING Q 110 ' ' (NOTE 10) m LOCUS 0-o ' i 624 LUMBERT v~i MILL ROAD ROUTE 28 O ' rasp ports , 0 i I 7 CD ,' / 5 fr LOCUS MAP ° \� / LOCUS INFORMATION 35----- TH-1 LOT TITLE REF: LCP 84115 ® PARCEL ID: M:147 L: 083 T ' AREA = 1 7 SO sf + EX1ST. I 000G IN ZONE II ZONING: "RC" GW DISTRICT "GP" ' FLOOD ZONE: "C" ' SEPTIC TANK COMMUNITY PANEL: 250001-0015—C DATED:08/19/85 SEPTIC SYSTEM 36//// � cv REPAIR PLAN LOCATED AT: 3 624 LUMBERT MILL RD. ' \l C CENTERVILLE, MA �C FND PREPARED FOR JANET McC00LE 3B'' \ SEPTEMBER 22, 2011 SCALE: 1"=20' 40 OF MASs9c D 3R EN 0 0. 11 0 o 'PECI EEO SANITAR�a� 7 00 ft \ MEYER & SONS, INC. M�J pA�eMeIVT P.O. BOX 981 -40/ BENCH MARK EAST SANDWICH, MA. 02537 M/l CORNER OF \ WOODEN STEP (508)362-2922 0/� ELEVATION = 40.14 DBARNSTABLE GIS DATUM SHEET 1 OF 2 71337 REVISED-09/23/2011 F _ t NOTE: TO PREVENT BREAKOUT, THE PROPOSED - NOTE: •MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISHFOR AI DISTANCE SHALL CE OF NOT TABE < E :3 14 DESIGN CRITERIA PERIMETER OF THE S.A.S.SEPTIC TANK PROPOSED D-BO NUMBER OF BEDROOMS: 3 BEDROOMS X PROPOSED S.A.S. T.O.F. EL.=40.80 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN/IN OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. DAILY FLOW: 110 G.P.D./BEDROOM DESIGN FLOW: 330 G.P.D. • F.G. EL.=39.0-36.Ot F.G. EL.=39.0t • F.G. EL: 38.0f F.G. EL: 37.0-35.0 (MAX.) GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) g I PROPOSED SEPTIC TANK: 330gpd x 200% = 660 GPD L = 15't 9" MIN COVER/ +, " VENT USE EXISTING 1,000 GALLON SEPTIC TANK 36" MAX COVER L = 10' TEE L = 10'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) ®"S=1% (PVC) ® S=1% (MIN.) 0 S=1% (MIN.) t 4`scH40 PVC 4`scH40 PVC s LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F. 10" 14• 6 11.2" TO DISTRIBUTION BOX: 4 OUTLETS (MINIMUM) \INIV.=35.701 �.u4wo INV.=35.45 INVERT LEVEE PRIMARY S.A.S. GAS BAFFLE PROPOSED INV.=34.30 4 ROWS OF 4 UNITS AT 6.25'/UNIT = 25'/Row USE 4 ROWS OF 4-16" 16006D ADS (H20) BIODIFFUSER UNITS-NO STONE INV.=34.50 INV.=32.75 SOIL ABSORPTION SYSTEM (PROFILE) BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF OF BIODIFFUSER) aim EXISTING 1.000 GALLON SEPTIC TANK �y20) (BIODIFFUSERS) 16 UNITS x 6.25 LF x 4.73 SF/LF = 473 SF DESIGN FLOW PROVIDED: 0.74(470 GPD/SF) = 350.02 GPD > 330 GPD req'd EXISTING SEWER OUTLET RESTORE VEGETATIVE COVER BACKFILL WITH CLEAN PERC SAND 75" NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING TO TOP OF CHAMBERS PIPE INVERTS PRIOR TO CONSTRUCTION ?'•,:.":.:',' " 2) D-BOX SHALL BE SET LEVEL AND TRUE TO - BREAKOUT=TOP ELEV.=33.14 GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.= 32.75 INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 31.81 310 CMR 15.221(2) EXISTING SUITABLE 3) REPLACE EXISTING 1,000 GALLON SEPTIC T.P. XCAVATION OR G.W. 2.83' MATERIAL 5' MIN. ABOVE BOTTOM OF � _ TANK WITH 1500 GALLON SEPTIC TANK EFFECTIVE WIDTH = 4 x l 2.83' = 11.32 f~ 76" IF FAILED, DAMAGED, OR UNDERSIZED. . 4) INSTALL INLET & OUTLET TEES W/ (8.06' PROVIDED) USE 4 ROWS OF 4-16" HIGH CAPACITY PROFILE BOTTOM OF TESTHOLE EL.=23.75-=- ADS 160OBD SIODIFFUSER UNITS-NO STONE GAS BAFFLE AS REQUIRED _ SEPTIC SYSTEM PROFILE GENERAL NOTES: N.T.S. TYPICAL SECTION �- 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL "Ts 11.2" 16" BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS SOIL LOG P#: 13416 POA OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: DATE: SEPTEMBER 20, 2011 34" � 310 CMR 15.405 (B): 1)) A 0.86 FT. VARIANCECE FROM 310CMR1 5.221(7) TO ALLOW LEACHING SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE #1614 SECTION END CAP TO BE 3.86 FT (MAX) BELOW GRADE VS REQ'D 3 FT. (H20/VENT PROVIDED) WITNESS: DONALD DESMARAIS, BARNST. BOH 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR ADS 1600BD (H-20) BIODIFFUSER UNIT TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. ��� �F �/q J' Elev. TP-1 Depth i Elev. TP-2 Depth 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING Q 35.75 0" 36.50 0" FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN DA s A LOAMY SAND A LOAMY SAND MODEL 1600 BD ENGINEER BEFORE CONSTRUCTION CONTINUES. r^ 10YR 4/1 tOYR 4/1 LENGTH 76" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. EYER 35.08 8" 35.83 8" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF " No. 1140 B LOAMY SAND B LOAMY SAND EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 1OYR 6/8 IOYR 6/8 SIDE WALL HEIGHT 11.2"THE SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. Isi 33.00 C1 33" 33.75 C1 33" OVERALL HEIGHT 16" 7. WATER SUPPLY PROVIDED BY TOWN WATER. C1 i 4640 TRUEMAN BLl/D a 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED OVERALL WIDTH 34 4640HILLI TD, MA BLVD TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. " �t MEDIUM SAND MEDIUM SAND 13.6 CFL • 43026 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 6 2.5Y 7/3 2.5Y 7/3 CAPACITY 01(101.7 GAL) ADVANCED DRAINAGE SYSiEMs, INC. THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. VA : 10. EXISTING LEACH PIT TO BE PUMPED, REMOVED, AND FILLED W/ CLEAN MED. SAND PERC 0 31.50 VA VA PROPOSED SEPTIC SYSTEM SITE PLAN 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION ; 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 23.75 144' t 24.50 144" 624 LUMBER MILL R D., C E N T E RV I L L E, _.MA 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING Prepared for: McCoole 14. ALL PIPE TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPEC. OTHERWISE) PERC RATE <2 MIN%IN. (*Cl" HORIZON) Surveying b 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW NO GROUNDWATER OBSERVED Engineering by: Y 9 Y SCALE DRAWN JOB. N0. Meyer&Sons,Inc. MacDougall Survey NTS D.M.M. FOR THE USE OF A GARBAGE GRINDER I, Darren M. Meyer, R.S., CSE, hereby certify that 1 am currently lapproved by MAOEP pursuant to 310 CMR 15.017 pOBOX98f 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING to conduct soil evaluations and that the above analysis has been performed by me consistent with the 419-1086 DATE CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October, 1999. EAST SANDWICH,MA 02537 (508) 1 122 508-362-2922 09/ / D.M.M. 2 of 2 REVISED-09/23/2011