HomeMy WebLinkAbout0050 MEADOW FARM ROAD - Health (2) 50 Meadow Farms Road
Centerville
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Commonwealth of Massachusetts
f N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information Is Centerville
required for MA 02632 April 6, 2011
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 214
(eq_2computer,use 1. Inspector:
only the tab key
to move your Darren M. Meyer
cursor-do not Name of Inspector
use the return
key. n/a
Company Name
rQ PO Box 981
Company Address
East Sandwich MA 02537
ranea CityTTown State Zip Code
781-424-6748 S13920
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
:7- ` --a
Inspector's Signature Date •. � .,.,.„
The system inspector shall subnacopf 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 systern'„or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall suhinit tlie;
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.
v{
t5ins•09/08 I
Title 50rficlal'lnspection Form:Subsurface Sewage Disposa ystem•Page 1 o 17
Commonwealth of Massachusetts
w Title 5 official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information Is Centerville
re uired for MA 02632 Aril 6, 2011
every page. City(rown State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. lf"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 exfltration 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•09/08 T tle 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
ha
" 50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information is Centerville MA 02632 April 6
required for p �il , 2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cant.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning In a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t51ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
VUTitle 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
information Is required for pril Centerville MA 02632 A 6,2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cons.)
2. System will fail unless the Board of Health(and Public Water Supplier, If any)
determines that the system Is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•09/08 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
f Title 5 official Inspection Form
h
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information Is Centerville
squired for MA 02632 April 6,2011
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
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 Wealth 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•09108 Title 5 Official Inspection Form:Subsurface Sewege Disposal System•page 5 or 17
f
4
Commonwealth of Massachusetts
Title 5 official Inspection ForM
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"e 50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Informrequired
Is Centerville MA 02632 Aril 6, 2011
required for _ p.
( o C t !T wn State 2i every page. Y p 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:
g
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR:15.302(5)1
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x #of bedrooms): 550
t5lns•09/08 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
Q
50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information Is Centerville MA 02632 April 6 required far p �il , 2011
every page. Cltylrown State Zip Code Date of Inspection
D. System Information
Description:
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(last 2 years usage(gpd)): 2009: 164 gpd
Detail: 2010: 479 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information is Centerville MA 02632 Aril 6, 2011
required for p
every page. Cltyrrown State Zlp Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: pate
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the UA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5fns•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title i�• t e 5 Official r Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information Is Centerville MA 02632 Aril 6, 2011
required for p
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
System installed 2003, system Is 8 years old.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
No signs of leakage.
Septic Tank(locate on site plan):
Depth below grade: 12 inches
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
• years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: typical 1,500G tank
Sludge depth: 0-1 inches
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 9 of 17
Commonwealth of Massachusetts
4 Title 5 official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
Jet 50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information Is required for Centerville MA 02632 April 6, 2011
every page. City/Town 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 33 inches
Scum thickness 0 inches
Distance from top of scum to top of outlet tee or baffle 0 inches
Distance from bottom of scum to bottom of outlet tee or baffle 0 inches
How were dimensions determined? tapes and rods
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level equal to outlet pipe, structural integrity is sound, no sign of leakage, no sign of hydraulic
failure, PVC tees with baffle is in place.
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
151ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of.Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
information is April Centerville MA 02632 A 6 2011
required for p � ,
every page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ 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
t5lns•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
4 w Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F
r 50 Meadow Farm Road
Property Address
Seminara
Owner Owners Name
required information IsCenterville MA 02632 April 6, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert n/a
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 level, riser in place to within 12", no sign of solids carry-over, no sign of leakage, no sign of
hydraulic failure or overflow.
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:
t51ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 12 of 17
Commonwealth of Massachusetts
_ Title 5 official inspection Form
's Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information Is Centerville MA 02632 Aril 6, 2011
required for p
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ 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.):
4- 50OG concrete chambers w/4 ft stone around, chambers 34" below grade. Vegetation normal,
soils normal, probed and augered into stone, no apparent signs of full hydraulic failure
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t51ns•08/08 11tle 5 Official Inspection Force;Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
's Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information Is April Centerville MA 02632 A 6 2011
required for p � ,
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cons.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts a usetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'rV 50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
information Is Centerville MA 02632 Aril 6, 2011
required for _�
every page. Cityfrown 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
�Alk
sit
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
h
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V
50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
Information Is Centerville MA 02632 Aril 6, 2011
required for p
every page. City/Town State Zip Code Date of Inspection
D. System Information (cons.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallowwells
Estimated depth to high ground water: 132'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date 2003
Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Based on elevations listed on design plans, system is not within adjusted groundwater
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
. Tide 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Y '
" 50 Meadow Farm Road
Property Address
Seminara
Owner Owner's Name
information is Centerville MA 02632 Aril 6 2011
required for p ,
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t51ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Roma, Paul
From: Stanton, David
Sent: Friday, April 14, 2006 10:54 AM
To: Roma, Paul
Subject: 50 Meadow Farm
Paul,
I am all set with the septic for 50 Meadow Farm, so I can sign off on the CO. 24 Meadow Farm I'm still waiting for a
letter, which the contractor is working on.
David
1
-,,f6I'OWN OF BARNSTABLE \
LOCATION M2aW662 FQflM FJ, I I SEWAGE #
VILLAGE 0,,oe2ieryrl Ie ASSESSOR'S MAP &LOT/8 09-8
INSTALLER'S NAME&PHONE NO. l I �- M c J n re J 407
SEPTIC TANK CAPACITY I SOU GaJ5
LEACHING FACILITY: (type)(4)6ao(5d, r-rC&6+-D4Ld�ize) /3` X K Z
NO.OF BEDROOMS
BUILDER OR OWNER ,L-- MIYILLal, 0-,:345-f•
PER MTTDATE: COMPLIANCE DATE: 0-
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility n �- Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
h C'fr Feet
Edge of Wetland and Leaching Facility(If any wetlands exist Z S ,
within 300 feet of leaching facility) Feet
Furtiished by e �^�
�6' ri r
Z= Z3'3°' ri.seY
e-xI 54- 3=
riser
h 5e-r
41 .
r
kK)l
No. Fee
y
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
application for ;0iopooal bpoteln Construction Permit
Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. wn s Name ss and Tel.No.
Assessor's Map/Parcel 8 ^ o (:--) A n O
�(� Designer's Name,Address and Tel.No.rn
N i T � � �
Type of Building:
Dwelling No.of Bedrooms 5- Lot Size ZZsq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow f l o gallons per day. Calculated daily flow Ssd gallons.
Plan Date 6-Z 7"C / Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil '��
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental C de a nce tie s i operation until a Certifi-
cate of Compliance has been y t1i oard o ea h. - �� ��� 30 -®
Signed Date
Application Approved by ® Date
Application Disapproved fof Ve following reasons
Permit No. &LZ2t 74 f2 Y Date Issued
s,P
No. s ... Fee
OW
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLE, MASSACHUS1 TTS
2pphiation for ig o�arr ip tenY Cottgtruction Permit
Application for a Permit to Construe O Repair( )Upgrade( )Abandon( ) [ Complete System 0 Individual Components
Location Address or Lot No. lw�eis,Name d. s and Tel.No. •;'1 �
�f %1��1i' 4VI
Assessor's Map/Parcel �t, .ff��.ILL' a 4
DO ., �I t styli A'•��.Y l{�c�(dC9�
stalle n'5g5" Designer's Name,Address and Tel.No.
Type of Building: ` .
DwellingNo.of Bedrooms 4 S L"ot Size 2sq.ft. Gazbage,,Gnnder( )
Other Type of Building No.of Persons Showers'( ) 6afeteria( )
Other Fixtures J s
Design Flow f/o gallons per day. Calculated daily flow gallons.
Plan Date -6" Z 7" / Number of sheets Revision Date
Title .S/�c� Ste"7�cJAc7F"" ' /J�•4�...�
Size of Septic Tank . Type of S.A.S. .7•/Z�.c3'Z��
Description of Soil Ag
Nature of Repairs or Alterations(Answer when applicable)
i
Date last inspected: i f
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 C eat6 n�l�ce t�9je s 1 i operation until ®i-
rate of Compliance has been"6d t i oard o '
(=•
Signed 0 Date
/
Application Approved by /1 / '� / � Date
Application Disapproved for Ke following reasons •'
Permit No. 7 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE MASSACHUSETTS
Certificate of (Compliance
t", b Q ,"5�,,.I�j
THIS IS TO C ,that the On-site Se age Dis osal Sy to Constructed QC)Repaired ( )Upgraded( )
Abandoned( )by--� 0
at has nstructed in accordance
with the pr vi i ns of T'�je�5 eyfor D' p aIS ism-
Construction Permit N
Installer ,I 1 1 �°'� ME Designer,
The issuance of this permit shall not_be construed as a guarantee that the,s sst"e�m`{ �11,uihction as desi ned.
Date � � 3 g Inspector ---��j 1 l
No. —�--------------------------Fee
-?/7//
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Miopooal 6potem Conotruction Permit
Permission is hereby jpranted Cons ct7 U g ade( }� d
�Yirk
System located at .9 n
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.
nmustbecdm Provided:Cons et� � let d within three years of the date of
Date: �� Approved b f 1 l
, u PP Y J ,
TOWN OF BARNSTABLE
LOCATION da4i Fam 9L L-64 g SEWAGE #
ASSESSOR'S MAP & LOT/B WW9 -4"
INSTALLER'S NAME&PHONE NO. �-
SEPTIC TANK CAPACITY
LEACHING FACII.ITY: (type) o
NO.OF BEDROOMS
BUILDER OR OWNER�vylJn rd- aYIEL �r^�•
PERMrr DATE:aLxa, G !L� COMPLIANCE DATE: • 31y Z�G�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility h �- Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Q- Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
Feet
within 300 feet of leaching facility)
Furnished by Cry
it
ii
rider
Z
7X1.5
F 3=
t-'ov�Gl
4 = 4Z �sQr
a
A
q : 31'6"
5 - 41 '
Town of Barnstable P#
Department of Health,Safety,and Environmental Services
oFtME Public Health Division Date
367 Main Street,Hyannis MA 02601
lEv n�� Date Scheduled �L 11 7-0oo Time rM Fee Pd. D /_
Soil Suitability Assessment for Sewage Disposal
Performed By: D4N IEL A. OTA LA , ?LS , SE Witnessed By: 100NNA kj 0ZA0Dj
LOCATION& GENERAL INFORMATION;
Lo lion Address 4 5U 0 O (r^ Owner's Name EuLLE(Q Fr}I�
oT $
Pu0_6'2 (-'+4►RR5 Address �EALTy T2us I
CcNrrE R d►u-6 13UNSI-A lUE MA
Assessor's Map/Parcel: I J Engineer's Name 17o-JN CAPE W61NGEAh*(
P-76 N o F' 1&9 f l t g/ b U'4
NEW CONSTRUCTION REPAIR Telephone# (SOe)3(oZ- *54 1
Land Use \ ACA N T Slopes(%) 0_5 Surface Stones —
Distances from: Open Water Body — ft Possible Wet Area — ft Drinking Water Well -- It
Drainage Way — ft Property Line SKETGN ft Other ft
SKETCH:(Street name,dimensions of lot,exact 1 ations of!et holes&perc tests,locate wetlands in proximity to holes)
g$� � Le T �
A r9
00
q
h
A(ZEA
�`b
w t
a
s
Parent material(geologic)6LACIAL c)--FwAs4 Depth to Bedrock 7 20a(
Depth to Groundwater: Standing Water in Hole: — Weeping from Pit Face
Estimated Seasonal High Groundwater NIA No GZo jWDwATE'9 EDON D
b l ER1VDNATTOlrt PO1t;SEASONA H T V.... `Ai L
Method Used.
Depth Observed standing in obs.hole: 1`9 A 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
'EI2COLArIC)►NTPST I)atc fi TIBze I;IL7 m
... ... ----�
Observation
Hole# 4 i Ti" 2 Time at 9"
U tt
Depth of Pere G S a _ Time at 6"
Start Pre-soak Time @ �'•00 0:00 Time(9"-6")
End Pre-soak 6 30 °J`40 94 o a �{ O--
Rate Min./Inch _� L In G,bD In 60 f0
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back j
Copy: Applicant
I.
DEEP OBSERVATION;HOLE LOG Hole#. }
.. _. _.
Depth from Soil Horizon Soii Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel
0-6 A lam S" 5 y2 ` 2.
-4g Sc a 2.5 VZ �/�
4 Z- 132 CI M/C 5"'d �?,S yg -7/4
DEEP OBSERVATXON HOLE LOB Hale# �>
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
II Consistency,%Gravel
0- 9 I.OQm Sand �.S 4/2
g-31- 2.S -14'
3;L Cl MCI hand a-5 la 7/
DEEP;OBSERVATION HOIE LOG Hole#
..::::
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel
: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)
Flood Insurance Rate Man:
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? _I CS
If not,what is the depth of naturally occurring pervious material? NI R .
Certification
I certify that on N 0 qs (date)I have passed the soil evaluator examination approved by the
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 r Date (�OD
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��\\ TEST HOLE LOG
DATE: JULY 11, 2000 P-9801
SOIL EVALUATOR: D. OJALA, CSE
8.37 WITNESS: D. MIORANDI
PERC RATE: <2 MIN.IIN.
X� o r
._Via- y`..'� _ 1 38,0 0„ 20 o„
42Z t ��P S►� ^�•,N / V 3 Ap - LOAMY SAND Ap = LOAMY SAND
8 2.5YR4/2 2.5YR4/3
vj If It I
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3&`\ 2.5YR7/6 „ 6,0 36"2.5YR7/6
� �--, -�-- � // 3¢D as 3
"' \\ 8 • ��� , � 34- c MEDIUM SAND ( C MBDIUM SAND
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3L✓�� -�_� � \� 3Z
3o Z�0 132" Z8'0 132"
Z8
\ / \ NO WATER ENCOUNTERED
—(17 i� ,� .. \ �/ \ DESIGN DATA
DAILY FLOW: (5) BDRMS. x 110 GPD = 550 GPD
SEPTIC TANK: 550 GPD x 200% = 1100 GPD
USE: 1500 GALLON PRECAST SEPTIC TANK
LEACHING FACILITY:
USE: (4) 5' x 8.51 500 GAL. PRECAST DRYWELLS
LINED w/4' OF DOUBLE WASHED STONE
V f � Q CAPACITY:
SIDEWALL: 110 x 2 x 0.74 = 162.8
BOTTOM: 13 x 42 x 0.74 = 404.0
TOTAL: 566.8 GPD
^U If
AI
OF Mq�
'E.&1EVEN CIVIL
`�.• ,� RUMBA No.32686C j
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Py' 0 -29-o1
LOCATION MAP
NOTES:
1. ALL PIPE TO BE 4" DIA. SCH 40 PVC.
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.
Ij 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
*4"-lW' DOUBLE WASIIED STONE
---------____-- ALL AROUND
TOi OF FOUND.
35.25 35.00 34.87
f
SEPTIC SYSTEM PROFILE of TEs�4ar
Z7,o
SITE -- SEWAGE PLAN
GENERAL NOTES
FOR
jLOT 8 MEADOW FARM RD. , CENTERVILLE, MA 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION
w5 ASSESSORS MAP 189 PARCEL 118-8 OF ALL UTILITIES, ABOVE AND UNDERGROUND, PRIOR ;
TO ANY EXCAVATION OR CONSTRUCTION.
PREPARED FOR 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH
310 CMR 15. 00: TITLE V.
SEMINARA CONST . CO" . 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE '
DETERMINATION.
DATE: AUGUST 27 , 2001 SCALE: 1" = 40'
4. ALL DISTURBED AREAS TO LOANED AND SEEDED.
5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY
REQUIRED INSPECTIONS.
WELLER & ASSOCIATES
1645 FALMOUTH RD. - SUITE 4C P.O. BOX 417
CENTERVILLE , MA 02632
TEL: (508)775-0735 FAX: (508) 775-0754 APPROVED BY: _ _ `