HomeMy WebLinkAbout0029 MANNI CIRCLE - Health 29 MANNI CIRCLE, CENTERVILLEOmni
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No. 9 C) Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
9ppfitation for Misposal stew Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.a q All n.1.' Code i e Owner's Name,Address,and Tel.No,'I rt-L-mh r cc vc J
c evwzr�,1` ot� pp.� rr�ti. e�+er,hl--e G q
Assessors Map/Parcel !�1 r`t Co� El
Installer's Name,Address,and Tel.No. C Designer's Name,Address,and Tel.No.
�O�ln Cc t 1�(Y�th 7Tf' (} (i'"t � Rf i �vO��CS _%r I L vn 4
Type of Building: G 3 7 — csr
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) a gpd Design flow provided gpd
Plan Date '(a l/d_Z� Number of sheets . Revision Date
Title a-4 A""h,-
Size of Septic Tank (7C Type of S.A.S. 560 9 4 f C Act—bet/
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) -g"e d J,
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 Healt
Signe Date /fQ
Application Approved by r Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued Z P- 21-2
S
No. 2 y/� I O '"� t �. Fee Uv
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for Disposal stern Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.a q M n; /� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 1i Q Mrr� K C, z
Installer's Name,Address,and Tel.No. ' Designer's Name,Address,and Tel.No. , /. arc S
fj&J
J hr C� <<t{�uh - 3 Gn 'i►eer� �v�lk f�
Type of Building: - _ 3 0 - 3 7 -7 X
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) w 6 gpd Design flow provided -,-> - ' and
Plan Date lr —TT�/'$'L,>) Number of sheets ti Revision Date
Title
Size of Septic Tank / Type of S.A.S. !�>60
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �� �,�, ( T �. J_L
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 Healt
Signed / Date
Application Approved by Date - -�(.)
Application Disapproved by '(' Date
'r for the following reasons
Permit No. �, Date Issued :2 7
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal)system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by e ��((-4 s v g C )
at 7 �� G� r��n n, Ck i has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �� "47-dated (O _ Z C)
Installer �z � _- ' Designer
#bedrooms' , Approved design floe _, a e5 gpd
The issuance of this ermit shall not be construed as a guarantee that the system wi ncti n as desi ed.
Date Inspector
l
- --------------------------------------------------------------------------- - - ------------------------------------------------
-- No. O o.gw -l Fee
THE COMMONWEALTH OF MASSACHUSETTS �—
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at an Vylti hnr`
P
and s 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 completed within three years of the date of this permit, /
Date 6 - 1 Approved by ' `
TOW11 Of Barnstable
�-_fm!
Refrulatory Services
Richird V. Scaija Intel-i2j, j)iy._4!ctfjr
muss.
Public Health Divisio
ji
Thomas A'L..K'ap, Director
.lain Street,Hyannis,MA 02601
Mice: 508-M2-4&
4 4
Fax: 50
Install
at, n Fot.7R
Date: Sewage Asscssor'sj.v.j',ap\Paj-cej I G,Cl' - fi
Deslkmer:
v,
Address: Address: U-1
................... .......................
........... ............
iziq 141 A
..........
.............. .......................................
.18SI-10d; R p err�it to in.stalt a
...............
Mavml
........... ..................--—-------
Vj
dated
SYst I :djuezic iced above .1v Ms as i ta ed Substantially afxordlfly to
the d appI-WTd CIPInnocs sk:ich. as lateml j.-Gjf)cat-'
es i r1j; . i I
loll of 0.1c
box and/or septic tart k. Strip 0�._ (11 'e(pired) was inspcctee.. zirjil
d"
'IYOrAfOULid sm:-,
certily t4at th- "(:Put sys-lery" ab,.-Pvc ',vas installed -wlth, mc�jo,i- djao
ti
orcater than 110, -elocaljort of tile SAS or-ame vc-nical rtiocation of all-V c(MIP(MCM
61 the septic SYSIc-m,) but in accor(].,,mce Stale Local Ro<_ II:
V aions.
as—bu?'U by designer to R.-rHOW. "t"i oul (if re-quired" �v-a�s P i pteted i-In.cl sol s
were folli'd satjsf"Ictorv�
certl'.f�? that ftic. system refcf nc,nl above was
k_,f'tjj.L J\.AI _Ipproval icue'.s {ll applicable)
S
p
... ........
inulleF's
..............
s i gii*',r F,
PLEa�;..-F, RJE�TURN TO BARNSTABLE, PUBLIC C -.1.1
C NITLIAN 1. EAZI "ICATE
OF S6:E,-D UNTIL BOTH TIR 0 ZNI AND AS-
BUIT-i'l.—CARD A. R'E RECEIN"
......... 6 TKU, BARNST.,AJII E, �ALJII DIVI'SIoNi.
:f L
THAIN"X y0ti. ......................
Q
w�insia:fr�4 prior io backfil!. '"he
Engineers note: firritted'tc.ar,
eng::neer t�icl trot supanilse c.3jislikickin of(lie s-v tom. ite insiaii�V
y for all mata , backii1ling
w-spec:ifil::cl gzacces viith prop; cumpaction and sellim
as 5hown.on"Ic'.:Ie-sign plan.
TOWN OF BARNSTABLE A q Ia
LOCATION c)'� /-fq nh YCAC SEWAGE _a .Q-1 se ;
VILLAGE Cg�td ASSESSOR'S MAP&PA/ CEL\
INSTALLER'S NAME&PHONE NO. 5� C�1iwI2�V1 CST�� 77 4
SEPTIC TANK CAPACITY l000 qQ
LEACHING FACILITY: (type) 5—oo (size)
NO.OF BEDROOMS 3 4
OWNER
' PERMIT DATE: COMPLIANCE DATE: c
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 4 "
site or within 200 feet of leaching facility) "s Feet
Edge of-Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important` A. General Information
When filling out
forms on the ( �
computer,use 1. Inspector:
only the tab key
to move your A.Riker
cursor-do not Name of Inspector
use the return
key. R.L.C.
Company Name
P.O. Box 726
Company Address
South Yarmouth MA 02664
City/Town State Zip Code
508-776-6460 SI 4590
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:
rU
® Passes ❑ Conditionally Passes ❑ ' `ails '~
❑ Needs Further Evaluation by the Local Approving Authority - i7 Uj
03/24/2012
Inspectors Signature Date t
C E§t
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s. 29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
On inspection of septic system there were no obvious failure observed,septic tank,d-box and leach pit
were inspected .
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
_
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
o
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
I 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 flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11 f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (1f they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) f310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M y 29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/2412012
every page. City/Town State Zip Code Date of inspection
D. System Information
Description:
At time of inspection the property was no occupied full time,the property was for sale and prior to .
only a part time residence.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available Oast 2 ears usage d
2011=aa 6 PQ
g . (I Y 9 (gP )) 3 6 P 2012 �, a
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: unk.pate
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: homeowner
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined? not required
Reason for pumping: recommend pumping eve ears or as conditons
every two y
require.
Type of System:
® Septic tank, distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/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 I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. Citylrown State Zip code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed (if known) and source of information:
Certificate of compliance dated 06/20/1989
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑other(explain):
Distance from private water supply well or suction line: n/a
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
dry PVC interior with no obvious leaks
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Precast concrete septic tank with PVC tee Y's on inlet and outlet
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 9'8"x5'x5'
Sludge depth:
12°
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
N ti: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. CityTrown 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
22"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle 41'
Distance from bottom of scum to bottom of outlet tee or baffle 12"
How were dimensions determined? Sludge Judge/Measure Stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
There was no obvious failure observed at septic tank.Tank could use risers on covers .
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is Centerville MA 02632 03/24/2012
required for _
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day_
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-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
29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at invert single outlet
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.):
No evidence of failure observed on d-box inspection
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes No
❑
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 'Y 29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 6'x6'w/ 1'stone
❑ 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.):
Leach pit located in driveway with no vent but manhole to grade.The leach pit appears to be an H-
10 pit with additional concrete poured on top to provide H-20 requirements.Plastic riser used not
recommended for driveway applicationswas observed.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5ins•11/10 Title 5 Official Inspection Fom: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
M 29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. City/Town State Zip code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
I
�tj 001,�, fool
G
j+`eai
Gac@t>t�
8` 1 ; 16,
B-3
a
t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17
•' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. CityTrown State Zip Code Date of Inspection
D. System Information (cost.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: > 12feet
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: 04/12/1984Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
plan on file indicates 4'seperation for required 1978 code.
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Plan on file was designed with 4'seperation from adjusted ground water. Rear of lot was at much
lower elevation with no water observed with a 5'augur hole.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-11110 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
29 Manni Circle
Property Address
Peter Dandridge
Owner Owner's Name
information is required for Centerville MA 02632 03/24/2012
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater,
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
• COMMONWEALTH OF MASSACHUSE17S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
l�
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: A Hakli t C °{ i
Owner's Name:�E0�Jx-I
Owner's Address:
Date of Ins ection: 7,1o,
k
Name or Inspector.(please print) W i] 1 i am R_ .Robi nson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089 1:7
_Centerville. MA i Telephone Number: t5081 775-8776 ,
K) co
CERTIFICATION STATEMENT _ r" >
I certify that 1 have personally inspected the sewage disposal system at this address and that the in ation reported 7-1
below is true,accurate and complete as of the time of the inspection.The inspection was performed ed on m a
training and experience in the proper function and maintenance of on site sewage disposal systems.I m a Dke
approved system inspector pursuant to Section 15340 of Title 5(310 ChiR 15.000). The system (-n rW
i, Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: J� Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Neatthvr
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 approying
authority.
Notes and Comments �--
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/1512000 page 1
T
Page 2 of 11 ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: t Hf yit1+ Coz-cJe.
Lk
Owner. MCA I A ' IeA v-C
Date of Inspection: :z:::z
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
Cya��YJr� j
s
II. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repa' d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer es,no or not determined(Y,N,ND)in the for the following If'%at determined"please
explain. ng statement.
Th septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally f
unsound,a ibits substantial infiltration or exfritration or tank failure is imminent System will pass inspection if the
existing is replaced with a complying septic tank as approved by the Board of Health.
•A metal s ptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating at the tank is less than 20 years old is available.
ND expla'
bservation of sewage backup or break out or ldgh static water level in the distribution box due to•broken or '
obst ru ed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with'
approv of Board of Health):
broken pipe(s)are replaced ,
obstruction is removed
distribution box is leveled or replaced
ND explain:
Th, system required pumping more than 4 times a year due to broken or obsutxted pipe(s).The system will
pass i7 nsption if(with approval of the Board of Health):
r
( broken pipe(s)are replaced
obstructinn is rtamovcd
ND explain:
Page 3 of 1 I
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:6 1"6CA ,i l aj _
Owner- ' C° L_A
3 ,
Date of IuspeefI a!
C: urther 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 failin to protect public health,safety or the environment.
1. S tem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
sys em is not functioning in a manner which will protect public health,safety.and the environment:
esspool or privy is within 50 feet of a surface water
esspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Z. System ill fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is.fu ctioning in a manner that protects the public health,safety and environment:
_ The ystem has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface ater supply or tributary to a surface water supply.
_ Th system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
._ Th system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more froul a
privat water supply well— Method used to determine distance
his system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
boa teria and volatile organic compounds indicates that the well is fire from pollution from that facility and
the re
s.nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
fail c criteria are triggered.A copy of the analysis must.be attached to this form.
3. �Othe
f -
3
T r
Page 4 of i
-OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
ty Address: # -Prope ' k �
Owner: �'�C
C :� 1
Date of Inspe tort n:
D. ' stem Failure Criteria applicable to all systems:
You m st indicate"yes"or"no"to each of the following for all inspections:
Yes
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ Static liquid level in the distribution box above-outlet invert due to an overloaded or clogged SAS or
cesspool
iquid depth in cesspool is less.than V below invert or available volume is less than%day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within t GO.feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone I 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 Katrr
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds
Indicates that the well is free,from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.1 have determined that one or more ofthe 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. tArge Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd.`.
You st indicate either"ycs"or"no"to each of the following:
(The fo Iowing criteria apply to large systems in addition to the criteria above)
yes no
e system is within 400 feet of a surface drinking water supply
e 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)Ora mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant ihrcat,or answered
"yes"in Se tion D above the large system has failed.The owner or operator of fury large system considered a
significant hreat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.T s stem owner should contact the appropriate regional office of the Department.
4
Page5ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 6)o C ilo" ,;'ec-(
n.
Owner: tL
Date of Inspect on:
Check if the following have been done.You must indicate`Yes"or"no"as to each of the following:
Ye� No
V„ Pumping information was provided by the owner,occupant,or Board of Health
1L Were any of the system components pumped out in the previous two weeks?
J _ Has the system received normal flows in'the previous two week period? i
_ 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 MIA)
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?
_ t/ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location '• _ •• .�
of the Soil Absorption System(SAS)on the site has been determined based on.
Yes n•/o/
/ Existing information.For example,a plan at the Board of Health.
f
_ Determined in the Geld(if any of the failure criteria related to PartC is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)J
5
F'
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
~
Owner:
Date of Inspection: i It— 6 N
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): i Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 11 of bedrooms): ='
Number of current residents: f
Does residence have a garbage grinder(yes or no): t -0
Is laundry on a separate sewage system(yes or no):,L[if yes separate inspection required)
Laundry system inspected(yes or no):4:!:�'
Seasonal use:(yes or no).�-
Water meter readings,if available(last 2 years usage(gpd))'. `?-?-ct-c
Sump pump(yes or no):_ sJ r ti= {Y _ 5Z 5
Last date oCoccupancy.
'
COMMERCIAIANDUST L
Type of establishment:
Design flow(based on 310 MR 15.203): rpd
Basis of design flow(sea persons/sgft,etc.):
Grease trap present(ye r no):_
Industrial waste holdi g tank present(yes or no):_
Non-sanitary waste scharged to the Title 5 system(yes or no):—
Water meter read' s,if available:
Last date of occu ancy/use:
OTHER(des4be):
GENERAL INFOR1►iATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped:__gallons—Now was quantity pumped determined?
Reason for pumping:
TYP,F SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool -
Overflow cesspool
Pr9y .
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Altemative technology.Attach a co of the current operation and maintenance contract to be
gY PY P (
obtained from system owner)
_Tight tank `Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): « v
6
1'agc 7 of 1 I
OFFICIAL INSPECTION FORAI—NOT FOR VOLUNTARY ASSMNIENTS
SUBSUR ACE SEIVAGE DISPOSAL SYSTEM INSPECTION FORDI
PART C
SYSTEM INFORMATION(continued)
Pruptrty Address: I ~� r
Owner: (,L{� ti_ xtt'cCk,�
Date of lnsp cc tlon—�fp•--Oe
BUILDING SENYLI .ucate un site plan)
Depth below grade.
Materials of coust�rtion:_cast itun _40('VC_uglet(explain):
Distance 6om pr}valc water supply'well or suction line:_
Comments(oil(bilditioll of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:Zootatc on site plan)
L•
Depth below grade: j d
Material of construction:_(uncrcic metal fiberglass I)ulycdtylcnc
_uthct(cxplain)
If tank is metal list age. Is age cunfirmcd-bp a Cenif►tale o(Curapliar►ce (pcs or nu):_(altach a Cupp ul CCr11fICatC) e .•
Dimensions:
Sludge depth:_ 3
Distance from top of sludge lu bullum of outet lee of baflle: �•%� i
Sewn thickness:
Distance front tup of scum to lop of uutict Ice or baflle:�br
Distance horn buitunl of scum lu button uruutict tee or battle:
I tow►ecre dimensions Jetclmincd:
Cummenis(un pumping recummcndatiuns,inlet and outiN tee or battle cunditi�n, slruclwal intcgli►p, liquid lcvcla
as related to oullel utvell,evidence of leakage,etc.):
n E.
1.IREASE TRAP:—(locate un site plan)
Depth below grade:
Material of eonsuvctio :_ml(lcle inclal fiberglass__pulycthy1cnc__other
(explain): `—
Dirnmsions:
IScunl thickness:
Distance from toy.of scum to lull of outlet let or baffle:_
Distance from bollum of scum to butlum of uullct let or baflie:
Date of last pul(tping:
Conuncnis(oil pumping rccul►►mct►datiuns,ililct and out►ct tcc or balilt cvl►ditw.t.$%Imituat Wit pIty,liquid ICVCk
as related to outlet inserl,ct•idcncc of Icaka&C,ele):
7
)'age 8 of I I
OFFICIAL INSPECTION DORM—NOT FOR VOLUNTARY ASSESSNILN'I'S
SU[ISUIVACE SEWAGE � _
DISPOSAL SYSTLNI INSPLCTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: —'—x^
Owner:
Dille of losptcl on:
TIGHT or HOLDING TAN (:`(tank must be puutped at tiuu of inspection)(lucate on site I)ian)
Dcplh below grade; !
l.taterial of const union:j_cmtcrete ttttetal`fiberglass mlyc1hylelle olhcr(explain).
Uuncnsions:
Capacil)'— ( ralluns
Ucsign Glow. ) gallons/day
Alarm present(),es ur no)
Alarm Icvcl: A ann in wurkiu urdcr
Date of last pumping: 6 ().Cs or rw):
Cununcros(condition ofttalarm and (lual switches.c►c.).
DISTRIBUTION BOX: �Vfprescut must be opcned)(locate on site plan)
Depth or liquid level above outlet invut:
Cununcros(note if box is level and
di;lrU Huleaks a itrtu or oul ofbox,etc.):
u outlets c4 ual an •evid
ence of;ulrJs car�us•cr,any cvrdcrrce of
1'Ut►11'CIIAI\LBCII:`(local on site plan)
Pumps in working ordcr()'es i nu):_
Alarms in working ordcr(Yc or no):_
Contntcnls(rsotc condition of punyt cltainbcr,condition of pumps and apputicnan(cs,CIE.).
s
Page 9ofII
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:�� i_��' c i wm i t
Owner:
Date of Iuspec ion'y��s o— ` v
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type ,
aching 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:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): _
-
f
CESSPOOLS: ( sspool must be pumped as part of inspettion)(locate on site plan)
Number and configur lion:
Depth—top of liqui to inlet invert:
Depth of solids lay r:
Depth of scum lay r.
Dimensions of ce spool:
Materials of con ction:
Indication of gr"dwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (lo,ate on site plan)
Malcrials of construction:
Dimensions: i
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I I r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ' Act.-N n 3 i G�JE.
Owner: �(✓ �T�( ;� 3 ��G
Date of Inspection: —/a
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
1 a
J
j
i
el r
- E
F
Wage 1 l of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:` (-I i 1C 1+�� i--
CjC,
Owner. b)Ai ,C(CX
Date of Inspection: 7—10- «6
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must descri4e how,you established the high ground water elevation:
0
11
Town of Barnstable
�pTHE Tp� ,
Regulatory Services
eaxxsrnsie Thomas F. Geiler,Director
y� 3 0 8. `eg
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 568-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report .the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved at a particular property would . be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEP"IICTisclaimer Private Septic lnspections.DOC
I�
29 MANNI CIRCLE
CENTERVILLE , MA 02632
MAP 169 PARCEL 123 LOT 53
PREPAU E0R
MR: JAMES MACURDY
29 MANNI CIRCLE
CENTERVILLE MA 02632
BULM
MR. & MRS . PETER DANDRIDGE
2 NORWOOD RD .
MILTON , MA 02186
HILLIARD HILLER, JR.
41 MAPLE AVE
CENTERVILLE , MA 02601
508-`l-78- 1472
e T
SUBSURI'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property a 9
owner' s name �, �irlcvQ o y
Date of Inspection. y1/3195-
PART A
CHECKLIST
Check if the following have been done:
_V Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period . Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
t/ '1'1ie facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
[/ All system components, excluding the SAS , have been located on the
site.
t/ The septic tank manholes were. uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of-
sludge, depth of scum.
!/ The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
_ The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
3 number of bedrooms
number of current residents
NO garbage grinder, yes or no
YES laundry connected to system, yes or no
Ala seasonal use, yes or no
If nonresidential , calculated flow:
Water meter readings, if available:
0
Last date of occupancy
GENERAL INFORMATION
PUinpi.►ig records and source of information:
IVo System pumped as part of inspection, yes or no
.if yes, volume pumped
Reason for pumping :
Type of system
Septic tank/distribution box/soil absorption system
Single cesspool
_ Overflow cesspool
-- Privy
_ Shared system (yes or no) (if yes, attach previous inspection
records, if any)
other (explain) -___________
----- ---
ApprOX-Lilat:e age of -till components. Date installed, if known. Source of
information:
��'S
/No Sewage odors detected when arriving at the site, yes or no
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:-_/—
(locate on site plan)
depth below grade:
material of construction: _concrete metal FRP other(explain)
dimensions:
_LO 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
IV" distance from bottom of scum to bottom of outlet tee or baffle
Comments:
( r-ecommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
L
n:1 STJ :I BUTTON BOX:
(locate on site plan)
!7 _ depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal , evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
L fF!/_e:C. �lGd ��__/�G�T �'LO�/!G T
PUMP CHAMBER:_ __
( locate un site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
VCC0111111C11d-It ioils for 111a111Le1jance or repairs, etc. )
i
1V
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
/moo 617G 1a/2-
Type
leaching pits and number
leaching chambers and number —
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
CESSPOOLS ( 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
mliter:i.als of construction
i-ndication of groundwater
inflow (cesspool . must be pumped as
part of inspection) _
Comments:
(note condition of soil- , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs, etc. )
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B .
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
ay
s
I _
I
DEPTH TO GROUNDWATER
depth to"groundwater
method of determination or approximation:
-- /� �JX X T 6/>.�% T
f
WATER DETERMINATION FOR: 29 MANNI CIRCLE
CENTERVILLE
The water table for the adjacent lot (31 Manni Circle -
see next sheet ), was determined to be at 17 ' . Per the
Barnstable GIS the elevation of the ground at the leaching
pit is 30 ' . The bottom of the pit is 8 ' below grade (per
engineer 's drawing) at elevation 22 ' . Adding the USGS
correction 4 .4 ' (MIW-29 ZONE D) to the 17 ' gives a maximum
high watertable at 21 .4 ' . The bottom of the leaching pit is
out of the theoretical maximum high water table by . 6 ' (22 '-
21 .4 ' ) .
The test pit was dug down 12 ' and did not encounter any
water .
The owner put in a pool in his backyard which is
approximately 5 ' lower than the front ,yard where the septic
system is and dug down 8 ' and says that he did not encounter
any water .
WATER TABLE DETERMINATION FOR: 31 MANNI CIRCLE
CENTERVILLE
The Barnstable drawing entitled ''Observed Water Table
June 1992'' shows a water table contour of 25 ' running through
the site . The Barnstable GIS shows a 31 ' contour running
through the location of the leaching pit .
The engineered drawing showing the test pit (dug on June
13, 1988 ) shows that the test pit was dug 2 ' down gradient
from the actual pit and went down 12 ' without finding
groundwater . This puts the actual groundwater down below
1!' (: 31-14=17) in the same month as the interpolated lines on
the "Observed Water Table June 1992" drawing which shows 25 ' .
Applying the USGS correction (MIW-19 ZONE D) 4 .4 ' to the
17 ' gives a maximum groundwater elevation of 21 .4 ' . The
bottom of the pit is nine feet deep (per the engineer 's
drawing) . Subtracting 21 .4 ' from the 31 ' gives 0 . 6 feet . the
bottom of the pit is not in the maximum high water table .
G
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances . If "not determined" , explain why not)
Backup of sewage into facility?
N Discharge or ponding of effluent to the surface of the ground or
surface waters?
IV Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the last year?
number of times pumped
A/ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is .any portion of the SAS, cesspool or privy:
/V below the li.igh groundwater elevation?
�✓ within 50 feet of a surface water?
____L✓ within. 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
IV_ within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
__.L✓ within '50 feet of a private water supply well?
__�✓ less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysi
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
SUDSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORE
PART D
CERTIFICATION
Name of Inspector
Company Name
Company Address /
Certification Statement
T certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manntenance of on-site sewage disposal systems.
Clieck one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
31.0 CMR 15 . 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
11�1vi_' deter-mined that the sy:.t:em fails to protect public health and
the environment as defined in 310 CMR 1.5. 303 . The basis for this
determination is provided in the FAILURE CRI`fERIA section of this
forill.
Inspector ' s Signature
Date '
Original to system owner-
Copies to:
Buyer ( if applicable)
Approving authority
TOWN OF BARNS LABLE
LOCATION 11������� �\(��� SEWAGE # �=;Qj-����
VILLAGE �4'��.�.�-�.��.t4' ASSESSOR°S MAP & LOT
INSTALLER'S NAME PHONE NO. (�X�\�--+- 5 �{1` t� ) 1.1C^�Z ��
SEPTIC TANK CAPACITY
LEACHING FACILITY:(eype) AA (size) �o 6L
NO. OF BEDROOMS PRIVATE WELL OI(PUBLIC W�TERJ�
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED;
VARIANCE GRANTED: Yes No (/J
M
1.- n�i
f
KEY NUMBER <10172 >
NAME <MAC URDY, JAMES K > B-C 1 B-C 2
B-C 3 B-C 4
STREET 29 MANNI CIRCLE
CITY CENTERVILLE ST MA ZIP 02632-270$ REF 1 REF 2
PHONE ( ) - REF 3 REF 4
METER NO. < 10228> DATE READING CONS
STREET <MANNI CIR NO. 29> 12/31/94 210 65
CITY CEN J L53 ' ST LOC 06/30/94 145 33
PHONE ( ) - 12/31/93 112 42
06/30/93 70 40
ROUTE `NUMBER 32 12/31/92 30 30
SERVICE DATE 09/15/89 0 0
METER DATE 07/02/92 0 0
CAPACITY 7 0 0
STYLE T10
SIZE 1 RATE SCHEDULE
KEY PIT PLASTIC X
NOTE RR 'LEFT SIDE ADDITIONAL CONS 0
ALTERNATE MIN 0
---'7
N ............ � --- FEs.......J..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...OF.........................................................................................
Aly iration for Diiijimial Work;, C ouritx union Urrutt#
Application is hereby made for a Permit to Construct (t/for Repair ( ) an Individual Sewage Disposal
System at: ,
.................��;,��/...................................................... ----------------------....:......:...........--------------........--------------.....-----....---
` Lot No.
` '.... ...j-�.......!...1...-------------------------------------- .................... ...................................................
Ow.
nc r address
•..... -•--..._...
Installer Address
Type of Building Size Lot._:KL��___..Sq. feet
Dwelling— No. of Bedroonts......._.._�...........................Expansion Attic ( ) Garbage Grinder (X/b
p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Pt Other fixtures .......................... .
W Design Flow............`— ........................gallons per person )V day. Total daily flow........� ......................gallons.
S(•I,lic T;tnl; (.i,luid capacit✓ �.gallolls 1'ength.- D_ p�v ��Idth_ ./.--- ... Diameter...---•--•--.... Depth................
Disposal 'french-- No. ................ ... Width.................... "Total Length.................... Total leaching area....................sq. ft.
'tccp:wv 1'iC No.......-�.... ...... I)i;uncicr....... �..... Depth below inlet....I......... Total leaching area.. >....sq. ft.
7, Other Distribution box (t,,� Dosing tank
p ./._........
I'crcolation Test Results Performed by...... OT..(h�_.... Q/ `�t�1....... Date........1..........r..... .�}�
Test Pit No. I................millutes per Inch Depth of Test Pit../Z........... Depth to ground water..���...........
CL. `best Pit No. 2._..2...._ minutes per inch Depth of Test Pit...l0�...__.__. Depth to ground water....1 lQ._.........
........:.. .....
. ...............
I escriptloll of Soll.... � ..Z.r....................... ..........SVr�. '1 ........_.....
............................`'..... G...... .. . ..:
w ... .. .. ................. ..... ....... ..4 �-4 ----._............._...............------------......................---.......
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':i':�L.i, ; of the State Sanitary Code— The ul signed further agrees not to piacc the systeru in
oper:uiou until a Certificate of Compliance leas been issued i )oard of licalthh.
.....---- .. //
igrrc l............. �4?/.......................-- .... ...........................
Application Approved 13Y. . .._ :........................ D
. ...
Date
Application Disapproved for the following rensons:................................................................................................................
--- •----------------------------------------------------------•.._...------•---------•------....--•----•-----•-••----------------:.... Dite
Pernhit No.......� . ._....... ............... Issued----......) {
Date
THE COMMONWEALTH OF MASSACHUSETTS
�— BOAR _....OF HEALTH
bJJ ........................I �
Ta ifiratr IRf T.> ulpliatirr
TFTIS.LS 7'0 CER7'iFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by /M1 N_..............
``++ _ /Installer
at........�.4 Sl.-...._....��. _..._.�_..._...................... �.<<,. ......._............_......_._..........
i,ocil ithstaile(i in accor(lancc with the provisions of T.—lT%,r j of The State Sanitary Code as described in the
�.Y l.4)... �:'. .. ....appliruinn for i)i=.i�osal Works Construction I'crmit No--- _--.... dated......--��..l...___---•-- -- - �,..._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
c.
DATI................................(� � � ............ Inspector................ ... .... -- ..................................................
THE COMMONWEALTH OF MASSACHUSETTS
-- BOARD OF HEALTH
.........................................OF............................... ....................................................
-- .
t\. :..............----...._ FEE....'__.........•--••••
I` D41ijui-nal Warta, Tntuitr uffatt Frrinit
r,<
ermissirnt i _.hereby granted..............................................
Y r
f n,
to Construct (✓) or Repair lndividua Scwag� Disposal System
9 v `I,
No l 1 G a n .. ( -L. .................
St,ect
as shown on the application for Disposal \'orla Construction Permit .' �'�`� .__. Dated.. r O •�:( .........
Board of llcalthi
K \_ i
DA1 �............... . z --- l
Rl
74 o I
8z •v
ZI-—L17
_ - /ate /�i 3 �Gz^ ' Jn.S/ '•; /vS/ -! <7.D
iLLcx/ ��
I
P717-,,,�/
v '• blgRT �y c.
U
( M + y
1 n� ssic E'�
c TOWN OF BARNS';ABLE
LOCATION j jf))I �k ��(Z� SEWAGE #
VILLAGE 4`�l� ��9'f13
�t-����� ASSESSORS MAP 6i LOT
INSTALLER'S NAME & PHONE NO. ��
SEPTIC TANK CAPACITY (COO C,Pf is
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER 1- 0
DATE PERMIT ISSUE
DATE COLIPLIANCE ISSUED: c
VARIANCE GRANTED: Yes No
r
d,`t3 q
C
e
I
ASSESSORS MAP NO: =�� 9�y91t i 3 � •�+ �
F�
PARCEL NO.: _ f ;
N 4 ..........`.....
.. C
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------.....I. ..........................OF.....................................
Applira#ion for Biiipn,ial Workii Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct (,,-<or Repair ( ) an Individual Sewage Disposal
System at:
00
tion-Address o Lot No.
F� ...-•..... '`�l.......-- -•--•- ... ....
?,... Owner ................•-----------•---Address
Installer Address
Type of Building Size Lot._"Z-lo-. ......Sq. feet
V Dwelling—No. of Bedrooms........... ...........................Expansion Attic ( ) Garbage Grinder (r/b
aOther—Type of Building ............................ No. of persons........................_... Showers ( ) — Cafeteria ( )
Other fixtures ----------------------------------------
W Design Flow.............:.�.................... gallons per person Sr day. Total daily flow--------5.��3_.....................gallons.
WSeptic Tank—Liquid'capacit/Mngallons Length__- _-1(r.... Width.Y./ _. Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........t.......... Diameter....... Depth below inlet... ............. Total leaching area.. ....sq. ft.
z Other Distribution box (64 Dosing tankl� / / �} /_
'-' Percolation Test Results Performed by....... �`/ T..1�`i--.....�� 1-....... Date........
Test Pit No. 1---�Z_.......minutes per inch Depth of Test Pit..lZ......._... Depth to ground water._A-ZQ-________-.
fq Test Pit No. 2................minutes per inch Depth of Test Pit...lQ........... Depth to ground water_._.�.KO...........
••---•--•-•-- ----------•----•-----------•------------•-••---•.......................•------.......------------...........--•------
O Description of Soil....4- .......... ....•------------------�------...S0'� 5X: 1L
---------------------------
UW ---------------------------------------- ---•--••--••-•----------•--•••---------- �----4. -4 ------------------------------------------------------------------------.......
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 iiTl r of the State Sanitary Code—The d signed further agrees not to place the system in
operation until a Certificate of Compliance has been issued oard of health.
ApplicationApproved By........... ........................................................................... ........ i......... _
Date
Application Disapproved for the following reasons:................................................................................................................
--•-••-••-••-•••----•--•--•--•-•••---••••-•...-•---•-•--•••--•••-•-•-......---•••----••-••••-•----••----•---•----------------------------------------------------------------------------••---•--•-----
Permit No......... ------- '— Issued......... -�- �.�../E�...---
Date
�T
THE COMMONWEALTH OF MASSACHUSETTS
77;;
BOAR�F HEALTH
`�R w�.... ..................................
Trtgfsratr of Toutphaurr
Till S TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( }
tU -F h'?fYN(V
er
at....... 5 •--•-1___!........................5..�-_..--•jj���11MTT�r
c�n11 1C�, �' -has been installed in accordance with the provisions of L l 1 Z 7 of The State SanitaryCode as described in the
----•-. dated--------
THE application for Disposal Works Construction Permit �o._ � �-----
ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............................. a' .............. inspector................ .a-�..................................................
THE COMMONWEALTH OF MASSACHUSETTS
�---- BOARD OF HEALTH
S. ...-
Cxl�s w Lis z. ---7 �?
�r ......................... FEE---..... �...........
hapvoa ork.5 Tonstrudion rruttt
Permissioni ereby granted........-----•----•-•---......................................................................................................................
to Construct or Repair ( ) fn Individua 1
ewa Disposal System
St:eet L n'
as shown on the application for Disposal Works Construction Permit _._ ._. Dated... .. .........
_
-- mil'?�, --�
�y - Board of Health' s-
FORM 1255 HOBBS & WARREN. INC.. PULISHERS j
1
� t
�L h- /
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.........................................OF..........................I........... ...................................
Appliratinn for Disposal loorks Tonstrnrtiun rnmit
Application is hereby made for a Permit to Construct k- ) or Repair ( ) an Individual Sewage Disposal
System at:
.................................................................... •.........--••••••----••••--......-••---..
.__,._. ....•••......------------------------------------------ Lot No.
................... - ............................................. ..........--......................................................................................
�j^�� Owner Address
W ,—F
Ins ta:':er Address /G��V
Type of Building Size -------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder k16
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ------------------------•--••----••••••----.•••-
WDesign Flow._.......�.........................gallons per person der day. Total daily flow._.... '- �.__._..._...•..........gallons.
R: Septic Tank—Liquid capacity _n.gallons Length Lylj -_.___. Width hc...... Diameter---------------- Depth................
W Disposal Trench—.\To_ ____________________ Width_;.. ___._.-___-_-- Total Length..__....___...._.__ Total leaching area---------_..._......sq. ft.
x
Seepage Pit No..._._.............. Diameter..... ..._..... Depth below inlet.�............. Total leaching area.��..... ft.
Z Other Distribution box Dosing .tan& )
Percolation Test Results Performed by....................T._...................... ���..:�__..!-.._._.._. Date...... ..._____.f'..__.__..
Test Pit No. 1_,,.._...._..minutes per inch Depth of Test Pit2�Z............ Depth to ground water_x A .............
Gc, Test Pit No. 2................minutes per inch Depth of Test Pit.ZG.-........... Depth to ground waten. -_-_--..-___-
p� f� ----------------------------------------------------------------------------------------------
Description of Soil,c .__:-..Z "�J''�I :>....
..................... -----------------------------------------------------------------------------------------
x 2 -/ C.. i tn/ cl c./� -��/l-'
/ -
--------------..` ._._
V Nature of Repairs or Alterations—Answer when applicable...._...........................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of L1i'LEE 41 of the State Sanitary Code—The u er' ned 'further agrees not to place the system in
operation until a Certificate of Compliance has been issued b rd of health.
Application Approved By......;::2•--............G .f
Date
Application Disapproved for the following reasons----------------•----•-•-----------•----------•---------•-----------------------------------------------••••••...
•--------------------------------•------------------------------------------------...------••------------.._........-•-------------------------------•--------------------------------------•••-•••--•-•.
l l Date
Permit No.... ............................................ Issued ( .................f f
.....---
Date
` r
Vo
y . ,o
07
® 7�,
� 7 Sly/ r-2FkCCX4714A/ / 4_72=�-
. faZ •I : 8Z •o
AAA L*A7:-- d\/41L-4 nZ,5r
a
T.
r AA .a v
104
�✓ a
o MMT,
�v MOR/W Ham/ 3Y / jcJ
,� B 23417 -
t!�
—N Ames Way ° 98 —— EXISTING CONTOUR
c N x 100.98 EXISTING SPOT GRADE
® 6� NI PROPOSED WATER SVC.
a
° �o�P —
Pts p°t �a UGW— UNDERGROUND WIRES
h
doh °jc N TEST PIT
e01 G �� BENCHMARK
Rd F °
j °m°` LEGEND
0 a
a LOCUS `O
Cl o
Route 28 a
�5
c � 0 Q
Westminster Rd G° �, 0
e
F, � tr1 co
TCALErt MANNI
LOo UoSSMAP Ix � 30.45
3 .74 .
EXISTING S.A.S. x 30.78 CIRCLE'
PUMPED, FILLED W/SAND
AND ABANDONED
1.21
PK SET
EXISTING SEPTIC TANK 31.10 30.33
(TO REMAIN) 30.79 BENCHMARK
TOP OF TANK, EL.=29.57t MAG NAIL SET
INV.(OUT)=28.24f 30,70 EL.=JO.33-
\ 30.08
�: ,.•. : 1.11
1 4. 1�05:: 29.7
#- 30,13
30.2
8� \ 31 hyd•
/
-
�, Q / x 30.8VENT x
T :1 .' L' ` 30.53
N 3i:OQ `::. 0.85 L w
TP .2`31;12't....;..;.. .: 31.26
Off• �\ 8 �10, . 31.y1 . . x 3 .00
29,18 � 31, 4
0
x0.61 y 28.4
GARAGE X 30.06
(slob)/ EXISTING
x 27,19 HOUSE(#29)
T.O.
x 25,82 (cellar)
DECK
x 27.03
O \
\ PATIO
\ w
,-2-6 — w -X 2 6.0 4
� o
� o
POOL Lo
edge �� LOT 53
°f 0/0, t 21,000 SF z
bo
� oft i
reCO o� �i
PETER T. ti� PARCEL ID: 169-123
M CIVILEE N PROPOSED SEPTIC SYSTEM UPGRADE PLAN
No. 351009 29 MANNI CIRCLE, CENTERVILLE, MA
GIsl
Prepared for: JTC Constractors, 1 Buttercup Ln, S. Yarmouth,. MA. 02664
OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO.
Z� COSTA, MIRANDA M Engineering Works, Inc. 1"=20- P.T.M. 195-20
29 MANNI CIRCLE 12 West Crossfield Road, Forestdale, MA 02644 DATE
CHECKED SHEET N0.
CENTERVILLE, MA 02632 (508) 477-5313 6/17/20 P.T.M. 1 Of 2
r
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL.26.0
FOR A DISTANCE OF 15' AROUND THE
EXISTING SEPTIC TANK PROPOSED D-BOX PERIMETER OF THE S.A.S.
PROVIDE RISERS WITH COVERS OVER INLET & INSTALL RISER & COVER PROPOSED S.A.S.
OUTLET MANHOLES SET TO 6" OG FINISH GRADE. SET TO 6" OF GRADE INSTALL RISER & COVER OVER ONE CHAMBER AND
T.O.F=31.8t SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT
F.G. EL.=31.1 t F.G. EL.=30.5t F.G. EL.=31.Of F'G' L 09.0± VENT
MAINTAIN 2% SLOPE POVER S.A.S.
L = 36' L = 5'
p S=1% (MIN.)
4"SCH40 PVC 4"SCH40 PVC 2" LAYER OF 1/8" TO 1/2-
6"
DOUBLE WASHED STONE
to"I as $ as (OR APPROVED FILTER FABRIC)
ta" s 2' EFF. aaaaaaMR
EXISTING 48" LIQUID DEPTH aaaaaaa --3/4" TO 1-1/2" DOUBLE
LEVEL ADD GAS PROPOSED L4' 4.8' 4' WASHED STONE
BAFFLE INV.=27.52 _ INV.=27.35
INV.=28.24t DUTL EFFECTIVE WIDTH = 12.8'
(VERIFY) 3 OUTLETS INV.=25.50
EXISTING SEPTIC TANK H-20 2-500 GALLON LEACHING CHAMBERS
SURROUNDED WITH STONE AS SHOWN
H-20 RATED
TOP CONC. ELEV.= 26.6f
NOTES: BREAKOUT ELEV.= 26.00
INV. ELEV.= 25.50 ease
1. . CONTRACTOR SHALL VERIFY ALL EXISTING PIPES & eases
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INVERTS EXITING HOUSE, PRIOR TO INSTALLATION. aeaaaaaaaaa
2 D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE BOTTOM ELEV.= 23.50
) 4' 2 x 8.5' = 17.0' 4'
ON A MECHANICALLY COMPACTED SIX INCH CRUSHED 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0'
STONE BASE, AS SPECIFIED 310 CMR 15.221(2). PERVIOUS MATERIAL
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' (MIN.) ABOVE G.W.
LEACHING SYSTEM SECTION
4) A GAS BAFFLE SHALL BE INSTALLED ON OUTLET TEE BOTTOM OF TEST PIT, EL.=18.5 =
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL.
SEPTIC SYSTEM PROFILE
GENERAL NOTES:
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER. RH
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DECK
LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW:
-310 CMR 15.405(1)(b):
1) A 3' variance to the 3' maximum cover requirement, for up to
6' of max. cover. S.A.S. shall be H-20 and vented.
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER. EXISTINGf29 HOUSE 2 ) GARAGE
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ENGINEER BEFORE CONSTRUCTION CONTINUES.
5. ALL ELEVATIONS BASED ON AN ASSIGNED DATUM. 10
22 8'
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF I Uj 1
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. N i O
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. LO
8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 1 \O 1 N
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
DIRECTED BY THE APPROVING AUTHORITIES. SEPTIC LAYOUT 12'8'--�
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
CONSTRUCTION.
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS SOIL LOG
IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). DATE: JUNE 12, 2020 (REF#TPT-20-110)
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE SOIL EVALUATOR: PETER McENTEE PE(SE#1542)
INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. WITNESS: DONALD DESMARAIS R.S..HEALTH AGENT
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND ELEV. TP-1 DEPTH ELEV. TP-2 DEPTH
NOT CONSIDERED TO BE A PROPERTY LINE SURVEY.
14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC 30.2 0 30.0 0
SYSTEM COMPONENTS NOT SHOWN ON THE PLAN FILL FILL
27.0 A 38" 27.3 A 32"
LOAMY SAND LOAMY SAND
26.4 B 10YR 4/2 46" 26.3 B 10YR 4/2 44"
DESIGN CRITERIA _
LOAMY SAND PERC LOAMY SAND
NUMBER OF BEDROOMS: 3 BEDROOMS 10YR 5/8 40"/68" IOYR 5/8
SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) 24.4 C 70" 24.8 C 62"
DESIGN PERCOLATION RATE: 5 MIN/IN
DAILY FLOW: 330 GPD MED. SAND MED. SAND
DESIGN FLOW: 330 GPD 2.5Y 6/6 2.5Y 6/6
GARBAGE GRINDER: NO-not allowed with design
LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF 18.7 138" 18.5 138"
.74 GPD/SF PERC RATE: 5 MIN/IN. "B" HORIZON
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY NO GROUNDWATER ENCOUNTERED
PROPOSED D-BOX: 1 INLET, 1 OUTLET (MINIMUM), H-20 RATED
USE 2-500 GALLON LEACHING CHAMBERS IN SERIES . PROPOSED SEPTIC SYSTEM UPGRADE PLAN
SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 29 MANNI CIRCLE, CENTERVILLE, MA
SIDEWALL. AREA:. 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: JTC Constractors, 1 Buttercup Ln,. S.. Yarmouth,. MA- 02.664-
BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO.
TOTAL AREA:.............................................................. 471.2 S.F. Engineering Works, Inc. N.T.S. P.T.M. 195-20
DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
(508) 477-5313 6/17/20 P.T.M. 1 2 Of 2