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0031 MEADOW FARM ROAD - Health (2)
31 Meadow Farms Road Centerville A = 189 . 118001 No. 4210 1/3 ORA P(Dncldou 10/LM ® o 0 0 J No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpYitation for Misposar �6pstem Construction Permit Application for a Permit to Construct( ) Repair(Y Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. 31 MQ4bota)Fi4-gM PO okn Owner's Name,Address,and Tel.No. d%V1t,q5 GrEZa:&s Dsrb.0ZM M•4CC01�M*4tK Assessor's Map/Parcel q 00 1 $11 Ci-o--AVC—VVE S00-n4 WA!'CES f_C. Installer's Name,Address,and Tel.No. 50Q-4`�'7—��r'1"i Designer's Name,Address,and Tel.No. Type of Building: DwellingNo.of Bedrooms A " ' / Lot Size s .ft. Garbage Grinder q g ( ) 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) �06M4 .1,_ R-ao 0 3oX 4 0A R15 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 -;to Application Approved by Date Application Disapproved by Date for the following reasons Permit No._ Date Issued �� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 21ppYication�for Disposal 6pstem Construction Vermit Application for a Permit to Construct( ) Repair(Y Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. ( h�- �F�p ,l �O�� Owner's Name,Address,and Tel.No. C%v11-L6 GrFot DED, t��4CCo�t1''A�K Assessor's Map/Parcel ( gq g O©t 19'11 a-V-1 AVC~ E SUOTk-t N14P4R5 fit;.. Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building:Dwelling No.of Bedrooms //�" 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) 1 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) 1�� 14-310 1)--R?mX 40a RIS0K 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 h'as been issued by this Board of Health Signed Date 7 Q-�c,�p(�j Application Approved by Date !Y a Application Disapproved by Date for the following reasons Permit No. O r 24-0 Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned( )by (ZA Dt u.)t r,) <ciU7MN lS-ES LLC. at 3( M G,_(7p W F-Ait M (Z(D C. u<<.C-E has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.dOII Ir-7-2-C)dated Installer (mil E LL Designer NJA #bedrooms Approved design flow A gpd The issuance of this permit shall /o,f be c )nstrued as a guarantee that the system i 'on de 'gned. Date / /Z � /S Inspector --------------------------------------------------------------------------------------------------------------------------------------- .�Noo I Fee_/&f� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( x) Upgrade( ) Abandon( ) System located at ��jq� 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 co pleted within three years of the date of this permit:•^ — A"X 3 C), 17 -S Date 'O a Approved by ul 20 15 10:57p p,1 Commonwealth of Massachusetts v: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road: rw~ Property Address ' •a Deborah&George Mac Cormack °t Owner Owner's Name / :r,• information a Centerville✓ li A 02632 7-20-15 required for every � page. Citylrown State Zip Code Date of Inspection r7 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 forth. Important:When filling out forms A. General Information on the computer, OFrti1�rS�''�i,, use only the tab 1. Inspector: c, key to move your cursor-do not James D.Sears _ JA M ES :P, use the return Name of Inspector key. CapewideEnterprises,LLC .• o_ ,o_:' l�l Company Name ? 153 Commercial Street %°'� N i, ,p�c``���.� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508477-8877 S1623 Telephone Number license Number B. Certification i certify that I have personally inspected the sewage disposal system at this address and that the i 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 l Title 5(310 CMR 15.000). The system: ® Passes i❑ Conditionally Passes El Fails ❑ Needs Further Evaluation by the Local Approving Authority i i i i 7-20-15 i spectors 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 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. l ****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 wiff perform in the future under I the same or different conditions of use. 15in3-3H3 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 1 of 17 i Jul 20 15 10:57p p.2 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah&George Mac Cormack Owner Owner's Name informrequire for Centervifle MA 02632 7-20-15 required for 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 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: The system is a 1500 Gal-Tank D Box and three 500 Gal. chambers, 1 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. I Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not j determined,"please explain. e 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 exMiration or tank failure is imminent. System will pass j 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 ❑ NO(Explain below): I t5ins•31Q 1-i6e 5 Offldal Inspection Forrm Subsurface Sewage Di i p g Sposaf System Page 2 or 17 I Jul 20 1510:57p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah &George Mac Cormack _ Owner Owners Name information required for every Centerville MA 02632 7-20-15 page. CityfTown state Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes foont.): ❑ 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 it system wi11 pass inspection if(with approval of the Board of Health): I ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): - i I 1 C) Further Evaluation is Required by the Board of Health: i ❑ 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 wfthfn 50 feet of a bordering vegetated wetland or a salt marsh I t5ins•3113 Title 5 Ofriidal Inspection Form:Subsurface Se%ege Disposal System•Page 3 of 17 Jul20 1510:58p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 31 Meadow Farm Road Property Address Deborah&George Mac Cormack Owner Owner's Name information is Centenrifle MA 02632 7-20-15 required for every page. Cityffown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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 Eras a septic tank and SAS and the SAS is less thart 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system asses if the well water analysis, performed at a DEP certified laboratory, for fecal Ys P Y 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 Wm. ! I 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 ❑ ® 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 %day flow t5ins-3113 Title 5 Official Inspection Form Subsurface Sewage Disposal system-Page 4 or 17 j Jul20 15 10:58p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah &George Mac Cormack Owner Owners Name informationis required for every Centerville MA 02632 7-20-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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 j 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 fairs. The j system owner should contact the Board of Health to determine what will be necessary to correct the failure. i 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 ei her"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 fleet 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•3r13 Title 5 Official tnspod ion Form:Subsurface Sewage Disposal System•Pape 5 of 17 1 I r Ju120 1510:"p p,g Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah &George Mac Cormack Owner Owner's Name information is required for every Centerville MA 02632 7-20-15 page. CityrTown 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 ❑ Z Were any of the system components pumped out in the previous two weeks? ED ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ 0 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 I 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)1310 CMR 15.302(5)) i D. System Information j Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 1 i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ! 1 1 Jul20 15 10:59p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah & George Mac Cormack Owner Owner's Name information a Centerville MA 02632 7-20-15 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and three 500 Gal.chambers. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes 0 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 0 No 2013-186,000Gal it Water meter readings, if available (last 2 years usage(gpd)): 2014-219,00OGaI's Detail: Ii it Sump Pum ? ❑ Yes No P Last date of occupancy-. Present Date 1 i 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.): I Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No i I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: t5ins-3113 Title 5 Official InspWiun Form:Subsurface Sewage Disposal System•Page 7 of 17 �I I Jul20 15 10:59p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a t 31 Meadow Farm Road Property Address Deborah &George Mac Cormack Owner Owner's Name information is required for every Centerville MA 02632 7-20-15 page_ Citylrown State Zip Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 08113 Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? i 1 Reason for pumping: - Type of System: I ® Septic tank, distribution box, soil absorption system i ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Q Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract { ❑ Tight tank.Attach a copy of the DEP approval. i i ❑ Other(describe): 1.5ins•3113 Tille 6 Official Inspection Form:Sub wdaoe Sewage Disposal Systam•Page 6 of 17 Jul 20 15 10:59p p,g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road Property Address _Deborah & George Mac Cormack Owner Owner's Name information is CertterviNe MA 02632 7-20-15 required for every page. Cityffown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 2001 -Permit # 2001 -517 New D Box 7-2015. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 26" Depth below grade: feet I Material of construction: I ❑ cast iron ®40 PVC ❑other(explain): 1 Distance from private water supply well or suction line: I feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC 5CH 40. i I Septic Tank(locate on site Ian): Depth below grade: feet Material of construction: I ®concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain) i 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 1500 Gal. Precast H-10 1 Dimensions. i Sludge depth: 2" t5ins•3113 Title 5 Official ingncGon Form:Subsurface Sewage Disposal System•Page 9 of 17 Jul20 1511:00p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah & George Mac Cormack Owner Owner's Name information is Centerville MA 02632 7-20-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Distance from top of scum to top of outlet tee or baffle t3' Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge 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 Tank at working level.Tank and covers at 16"below grade. Two inlet tees, out let tee. No sign of leak age or over loading. i i i i I Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): { I I 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 1 Date of last pumping: Dime I Mina•3113 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System.Page 10 of 17 I! I i Jul 20 15 11:00p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah & George Mac Cormack Owner Owners Name information is required for every Centerville MA 02632 7-20-15 page. Cityrrown State Zip Code Date of Inspection U. 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 Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: f ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): i Dimensions: i I Capacity: galions Design Flow: gallons per day � ; Alarm present: ❑ Yes ❑ No i Alarm level: Alarm in working order: ❑ Yes ❑ No i i Date of last pumping: Date i Comments(condition of alarm and float switches, etc.): I i i I 3 Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No i 151ro-3113 Titla 5 Official Inspection Form:Subsurface Sewage Disposal Systom-Pago 11 of 17 i Jul 20 15 11:00p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah &George Mac Cormack Owner Owner's Name information is required for every Centerville MA 02632 7-20-15 page, Cityrrown Stale 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.): D Box is new 7-2015. Box is H-20-20"below grade w12 lines out. Steel cover at grade in black top drive. i Pump Chamber(locate on site plan); i Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i i i i If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): i F I If SAS not located, explain why: j I 1151ns•W73 Title 5 official Inspection Form.Subsurface Sewage Disposal System-Page 12 of 17 i Jul 20 1511:01 p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 31 Meadow Farm Road Property Address Deborah & George Mac Cormack Owner Owners Name information is required for every Centerville MA 02632 7-20-45 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): , Leaching is three 500 Gal.Dry well chambers w/47 stone, Chambers are a below grade. Chambers are wet.Wall's clean like new. No sign of over loading or solid carry over. I I i i I i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): i Number and configuration Depth—top of liquid to inlet invert s Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ NoI i 151ns.31113 Title 5 Official Inspedion Forth:Subsurface Sewage Disposal Sysldn•Page 13 of 17 i i i i i 1 i Jul 20 15 1 1:01 p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah &George Mac Cormack _ Owner owner's Name reformation is required for every Centerville MA 02632 7-20-15 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 f Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): - 1 i I I {I I I i I� I I . i i i t,ains-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 t I i Jul 20 1511:01 p p.15 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road Property Address — Deborah &George Mac Commack Owner Cwner's Name information is required for every Centerviife MA 02632 7-20-15 page. Cityrrown state Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks- Locate ail wells within 100 feet Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below F\ R-3 - 3 � o /3-1 30 I / / I i I i 4 i t5ns•3I13 Title 5 0lrxim Irupoction Forth:Subsurface Sowsgo Dksporal Systom-Page 15 0117 f! P i I Jul 20 15 11:02p p.16 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah &George Mac Cormack Owner Owner's Name information s Centemille MA 02632 7-20-15 required for every page. City/Town State. Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Nam' Estimated depth to high ground water: 1 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: 7-11-00 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) a ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design Plan 7-11-00 no G.W. at 12'+. Bottom of chamber's at 5'-6" below grade. Bottom of chamber's at 6-IT'above T.H. Depth. i _ I i `t 1 Before filing this Inspection Report,please see Report Completeness Checklist on next page. i t5ins•3113 Title 5 Official Inspection Form:Substdaw Sewage Disposal System•Page 16 of 17 f Jul20 15 11:02p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Meadow Farm Road Property Address Deborah &George Mac Cormack Owner Owner's Name information required for every Centerviffe AAA 02632 7-20-15 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 1 i 1 i I i i i i �i f t t I I i, it I I 15tns•3113 Tina 5 O Tidal Inspection Forty:SubsWece Sewage Disposal System•Page 17 d 17 1 j: z TOWN OF BARNSTABLE cc, LOCATION 31 MEfi Dow `,q P-M RD, SEWAGE # 20,5 1 -$l q VILLAGE CP/t N� Ili ASSESSOR'S MAP & LOTl8? /18-6 L INSTALLER'S NAME&PHONE NO. 111 . M� IVTY�E 508 -,365-g4n2 SEPTIC TANK CAPACITY 6-00 (5/9G LEACHING FACILITY: (type 4 D,2Y�ECt s (41ze) NO.OF BEDROOMS BUILDER OR OWNER d,ONS i PERMUDATE: S-6 -d COMPLIANCE DATE: O Z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N�'g' Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) N�R Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) �l>� Feet Furnished by r r r DW E�-L UIJDE�2 'Cot.�sTRvGTI�� g A _ I I °I Z t Z - 5 4 z 3= q = za` 3 Si34`d `� g - I =13 ' Z = 2r ' . r » No.Roy G �=:/ y, Fee� « THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: )/ es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0ppYication for Mie;pogar *pftem Construction Permit Application for a Permit to Construct(�)Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components A ocatio Address or L t No. �l Owner's Name,Address and Tel.No.sse r� a ve) l !s Q Ins a's at s-en o. r l�A Designer's Name,Address and Tel.No. \�A� 06 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 .0 gallons per day. Calc slated daily flow gallons. Plan Date ( Number of sheets Revision Date Title Size of Septic Tank CAN i M, Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) .,l a aA.02 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 provisiona of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i u ' b h' of e . : c C �� 4ak/ ZSigned Date f Application Approve Date "' C Application Disapproved for the following reasons Permit No. ;,::?014P Date Issued ��' � �t�-�',. � t i .:*,a.rai*r•.:.ia 1 � .. �.,,ura.+ "' ,. .. .OS. . .. Fee/ , THE COMM'ONWEALTH.OF MASSACHUSETTS _ . _ Entered in computer: I' es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for Mi!ppaar *pgtem Construction Permit Application for a Permit to Construct( )Rpair( )Upgrade( )Abandon( ) )Complete System ❑Individual Components Locatio Address or L t No. 3/ Owner's Name,Address and Tel.No. n DQ IQ • i Asses ' a vleb� [. ON Ins a 's d � ,T Designer's Naive,Address an�o.`1 w� J Type of Building: ` Dwelling No.of Bedrooms !Lot Size sq.ft. Garbage Grinder( ) Other Type of Building f No.of Persons Showers( ) Cafeteria( ) _ Other Fixtures Design Flow0 gallons per day. Call daily flow gallons. Plan Date 5n In I Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 714 If: 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 provisio of Title 5 of the Environmental Code and not to place the system in operati Lqn until a Certifi- cate of Compliance has been i u b Bo d of e 1 , �. a" dh /1UZ Signed Date Applicatioi%Approve Date �"' Application Disapproved for the following reasons Permit No.s:i'0-0/ - Date Issued Y•. i --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS wn a Certificate of Compliance THIS IS TO C ,that the On-sit S wa a D' osal System Constructed(X)Repaired( )Upgraded( ) Abandoned( )by at LOT _ s been constructed in accordance E, with the pr o. T' e 5 and t�fDisosalSystemC `nstruction o ` dated :>h `•5 2�4 Installers �° Designer '�' The issuance of this permit shall not be construed as a guarantee that the syrem will nction a d ig ed. Date 2N I Id 3 Inspector r� --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi0po0al 6potem conotruction Permit Permission is hereby granted to Construct(x)Repair )U grade( )Abandon System located at 7� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. { Provided:Constru t on must be completed within three years of the date Of M7. ' Date: J4;:7N- Approved by ,V Town of Barnstable P# Department of Health,Safety,and Environmental Services t Public Health Division Date -1 -11 00 367 Main Street,Hyannis MA 02601 a►nxsrABM rF639.&� Date ScheduledCVq/. Time M Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: �AN1Et. A- O,)ALA Witnessed By: Mo"NA M I OAR403>I LOCATION A GENERAL IIVFORIVIATION Location Address Owner's Name f=VU_GV1_ �-�°tfLi`^5 ,rn r Address P4ArUTY 7607T, AAA Assessor's Map/Parcel: fw`-f" a 1: 1$q/1 tf6/out Engineer's Name Ewa [�4i'E C,n>G�r/EEjt NEW CONSTRUCTION (/REPAIR Telephone# SO T H 5'1 Land Use V A%-.A,^J r- Slopes(%) 0' S Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) h�. 5-�► L N y3, ?H2 L 0 - 5 Parent material(geologic) &LAC*%A1- OeTjW pts t Depth to Bedrock 2� Depth to Groundwater: Standing Water in Hole: N Weeping from Pit Face Estimated Seasonal High Groundwater D TI R I TIOT . ' tt St;ASbNA �? 2'fA in, Method Used: ..: _: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well#_ .Reading Date:.--..,—.- Index Well level.. Adj.factor Adj.Groundwater Level PERCOLATIOI�i TEST Aatc � TimetAM Observation -� , T )I Hole# Time at 9" Depth of Perc Pe Go GZ Time at 6" Start Pre-soak Time @ p0`•00 Time(9"-6") End Pre-soak -7 y`J ay �"` In a'M,SA% ' Rate Min./Inch G2 L 2 Site Suitability Assessment: Site Passed_ Site Failed: Additional Testing Needed(Y/N) N Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant ,t _ _ DEEP OBSERVATION HOLE LOG Holy 1. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel Z..Sy&/& 'jG 1L1LN G1 M/G 5AOb 2.517/1' oclu75 4�L,5 T4N%' .............. .�...... ......... .......... ......................... ......... ......... ......... ............... ..... ......... -........... -....... .. ...... ................................................................................................................................................................................................................................... :;DEEP OBSERVATION HOLE LOG Hole#;.... '?- . . . ....:... . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel 2 - L� A I—S to 11-413 LA-"3L T3 L5 . 2-yy 10•/v b,rotwl 36�l50 L \ Mk/C 4AND t00/6 +ru 1-lI DEEP OBSERVATIOlY H LE LOG Hole# Depth 11 from Soil Hcozon Soil Texture Soil I.Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel 0 ' ... ., .DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soii Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel Flood Insurance Rate Map: / Above 500 year flood boundary No_ Yes Within 500 year boundary No_ 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? If not,what is the depth of naturally occurring pervious material? �— r Certification I certify that on NOV �� (date)I have passed the soil evaluator examination approved b the PP Y Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature c < 1 Date 7L, w (1,+-if 3 ) TOWN OF BARNSTABLE Ec Op J/7/0 ' LOCATION MEH/Dycy L=AP-M 2D, SEWAGE # 2C�/ -$lI VILLAGE C �eN� 11d ASSESSOR'S MAP & LOT182 18 INSTALLER'S NAME&PHONE NO. M, @• M'.1-1,TY6'E 568 -385-1402 SEPTIC TANK CAPACITY SUo Gi�G LEACHING FACILITY: (type �00��L l�2Yw�CL 5 (size) tee � o NO. OF BEDROOMS 4 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 'G 1' y Z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility IJ R Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) NL� Feet Edge of Wetland and Leaching Facility (If any wetlands exist A) if- Feet within 300 feet of leaching facility) Furnished by Nl. G°- cTY�E D(xyELL UlJD�R Coos?�2UG?IvN 5 4 z 3= J; 4 = 28` 3 g- Z - Zl ` 3 = 3� — -----=----- — -- GF NEP A'P_Iv^'vN (�".:WJGIJ; 3e -- --- -------- v CFc:E`_rf¢� _,,.2'+``,� _.�?-;r.: NOVU c _JS. ap ✓- ��;>� r '+..-�r.r.:.F ,_G.,�,�. - - N_c 2 Y -C'2rE4 :r T-r- 4.�10 ?62,: n' 4e^.3�SST�EZd'n'+�y.Y'� . '�P..FIXtrt } TOP YFFf, �:�?I� -- - \� '. I• I ec rx' _d(' EZ'- - --- _ _----- - 2s�,•-sg - i " -r - -------- c --- '* i ..,,�m�~ --. v ' •,.< ------i a,te k. ,ax T i---1--c - — -- ea A♦ \ \mil- E -X 3 - - .- � _t--�-- ---_- 5'_+0E I j I I i G I DECK ---------—1C� < I i el GR MAST ER vAT I i ,A..T.-cr 1,I <T .1 rN � UNETTE F MASTER BEDROOM 17 Ur L`NALK[IIN CLJSFT ` - J S— -�..i.',� z• I ,T � � I ' ,1. — EsI.c HAL I ?�•`+E -- T1 _-- _- __ f i "dew 9_ _ls:z_.� tE -�,;R �FJ` F_ IM - T3 A_ Ar\l Er;YEIR r GtiCH' 1 u 2.2 : t I t, �.. S.ta'E'y]EE� .:e :p:•. ePr.:e EY� R"4„ NINPOW SCHEPJLE !I Oil 2'i:1 GK_5S RE I _ -- Q i, r.,- --r+- �� i1:Pefi4E i � _ _— -- -___.- ..- -_---, 5 4F 1._5 6 - C..: .. `� i> \ _._-��.•..[. vizm V2. c 5AC<F._ry tom_ I - J Y -r J2 Y S ✓r R e Ilnc. c¢ FED- • L—I 2 »5 �65 0,a.. `YF .,AUK-: \� 4_. t UM i �I 'r 11:;c'_-�F� ____—'__—._ 's'-53:.5- -_.__.._._--_-__ -_-_.-_-__.15'C__ - '_-'�__ - --._-. >„•4.— __._- _g6'_' _5,5. sf KEYWAr ' I IS0 WAILI DE"f AIL NET TO SCALE j 244Ere.P'.E. �uH `a BEPROOMI#2 JJ,q�K n G� ct BEDROGf #' r - L Y 264 -f � P }' HOME OFFICE 1 k--jL r I I / c Z �' , i ' I i i a ,. .. �J9,:E:-;E,:S a�at .•.;0es: -- ..T kr I �' _ } �,...� �e� �� f � � t -� �� , N � .� n � � � � �� � � , v �� �, � � , � i � E/' 5 � z � �� /a� � � � � � � � 1 � � � �� � � � o _ � 1 °� 1 � _ Z 1 , � � � �, 1 � � _ ° F t � C� � \ . �� � �,� G� ���� �,O p � � � i � f � . 4� _ i � ��rrrr � S� s a ��: �-. t i i. � i f Ik _ �� �.� f� s �� F I ' TEST HOLE LOG DATE: Z000 97�i dT� SOIL EVALUATOR: WITNESS: s'c—C 2�I1�'iz•.5� vim"/lX. PERC RATE: Z�+���/�✓c•� at Z p` o �'2•0 �~ O SZ•v LrJ/GroZ/,cG y. �oyiz V/3 y� /o x yes 6 4 5• Q` Z/ foA�ZSTr �►.�5� ' Z/s, S3 Q� S n�.o Sr9N O moo" 3y, s o DESIGN DATA If DAILY FLOW: (y)BDRMS.z 110 GPD=�7� GPD SEPTIC TANK:y GPD z 200%=,5S o GPD 4 USE:/So o GALLON PRECAST SEPTIC TANK Zg s 7S LEACHING FACELrr USE:_-63) SX Z --- Soo �O.�yygJ6Gc,5 -- e i N CAPACITY: SIDEWALL:_593i< Z 'XO,2j1.¢ a BOTTOM: .._/3_ C33,Sx a7 =:32Z.3 �8 TOTAL: Ste' O vf� OF Q MB m j v 3 79 ..�P��H OFDA BRAMAN yGN CIVIL A _ No. 68 E � NOTES: oFEss�ONAI��G� 1. ALL PIPE TO BE 4"DIA.SCII 40 PVC. - �0 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2•LAYER OF 3/8•PEASTONE OVER SAX .eD 3/4•-1 1/2•WASHED STONE ALL .5- ' AROUND / 3 TOP OF FOUND. y y o ca v ' a0 �O. Z o �� J7�f��2 y o 0 SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR TO ANY EXCAVATION OR CONSTRUCTION. 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR 1&00:TITLE V. 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE ; DETERMINATION. 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. DATE: ,�9192. 9/ 2�a/ SCALE: �SNu��c� a 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY -- REQUIRED INSPECTIONS. p'# FI WELLER & ASSOCIATES FALMOUTH ROAD CENTERVILLE, MA. 02632EL: (508)775-0735 FAX: (508)775.0754 I !I I APPROVED BY: