HomeMy WebLinkAbout0248 MONOMOY CIRCLE - Health e •
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t TOWN OF BARNSTABLE
LOCATION Z yB Mono rnou C:rcl c. SEWAGE# Zo 117 - ZG I
VILLAGE Cc-nAcru 11CZ- ASSESSOR'S MAP&PARCEL 191 - Z 13
INSTALLER'S NAME&PHONE NO. Q . 3 E)(CqL%JaAN O�,,
SEPTIC TANK CAPACITY /SOO
LEACHING FACILITY: (type) s��� t.�c ( 21 (size) 13 ;*ZS A Z
NO.OF BEDROOMS 3
OWNER S-ic�l,cn .Dor�on
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
A► - is ' :
AZ - Zo��
A 3
.83 - Z�
Ay � yL ' a s
B'y - 38 ' O O
. o
0
TOWN OF BARNSTABL E
LOCATION ?VP �.t%' SEWAGE #
VILLAGE L°�x, `e'X v���e ASSES:(IXS MAP&LOT
INSTALLER'S NAME&PHONE NO. DeLrA Cae A WE
SEPTIC TANK CAPACITY
�T' f J LEACHING FACILITY: (type) Ze,",N (size)
NO.OF BEDROOMS 3 yy��
BUILDER OR OWNER olq
PERMTTDATE: —COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 7 Feet
Private Water Supply Well and Leaching:Facility (If any wells exist
on site or within 200 feet of leaching facility) OV4tA' Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility)
Furnished by k1w. J-q,44hJ J. 9�
�iv
�r lid
��9137
J
i \1
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4pf ration for Disposal,0pstem Const union VPrlitlt
Application for a Permit to Construct( ) Repair(✓j Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Zy$ MnOMOc4 C;rc,I G Owner's Name,Address,and Tel.No.
Sicuc..DO��Jrho•>n
Assessor's Map/Parcel I q -3L),3 Ci -e.lc.
Installer's Name,Address,and Tel.No.g k(3 6XColt4%ji0A Desi er's Name,Address,and Tel.No.
14-rcc6ct-r t.rJ Rbresictolc CM7-OLS3 L03%r_r-ly ENv;ror+ntn-1a.�
y S . a
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) D gpd Design flow provided gpd
Plan Date S(711:7 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) �S'00 iO S? • 20 .� .Q07i ' Z'SOO L�C
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 Health.
ed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. �'7 Date Issued
• rn
1
No. i' s�V l Fee
F
Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS
'-# PUBLIC HEALTH DIVISION,- TOWN OF BARNSTABLE, MASSACHUSETTS yes
2ppl cation for MWbvsa -,*pstrm Construction Vermit
Application for a Permit to Construct( ) Repair(✓}<Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Z 4$ M0n0,-10(.( C;Cc i c- Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 9 l- a f 3 s-�cu C .DOt�rY,Q t1
O L
Installer's Name,Address,and Tel.No. f3 B EX Ca\1(:,A iOA Desi neroJ\ct-iN's Name,Address,and Tel.No.
'L ENV��'omcn-10.�
i4"1"ca5crry L►J {aresic�ac �}
11'1 0653 5 . arenoo-1IN,
Type of Building:
Dwelling No.of Bedrooms ��3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons#' Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �3 0 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) /\5"00 t4 1 O 57 ' ti ZO .D Box Z-$00 L.1 C_
1
4
�y?w
Date last inspected: .
Agreement:
r
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in.
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
& ned Date 2-'8
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No.
f ? Date Issued
----------------=---------------------------------------------------------------------------------------------------------------------- '
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓< Upgraded( )
Abandoned( )by _( Q E XC.ca�JoA 1 O n
- at Zy$ 1-0 Ot1O r le)Lj C i r"CI c_ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NoPO/7 dated J /
Installer B E X Ca V0.4 O/\ Designer -bavc. a k c r ~2 V
#bedrooms \� Approved design flow ) gpd
The issuance of this permit shanot be construed as a guarantee that the systeNtn wil"`1 fu c*d a- designed.
Date 7{ ~+, / Inspector
-----------------------------------------------------------------------------------------------'---------------------------------
(.\ �}
No. / '-" Feet/
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS;
Misposal Epstein Construction j3erinit
Permission is hereby granted to Construct( ) Repair(1,*f Upgrade( ) Abandon( )
System located at T q a MQ I O rn Ot, C t P C)G.
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 b 'ompleted within three years of the date of this pe it.
Date /c �� Approved by
Town of Barnstable
Regulatory Services
.�. Richard V. Scali,Interim Director
BAM►► & Public Health Division
639• ���
� Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: 11 Sewage Permit# 2.ot-1 - Z61 Assessor's Map\Parcel 19) - Z13
Designer: Env.rornanim1 Installer: Ri, j3 EACAVo-i10JS
Address: 2— C 4ddress: 1 y Ty=S-r rt-y c.rQ
>> F-o czsi ofa 1�-
On $-$- s 4 B Ex ca►V 0A i o✓� was issued a permit to install a
(date) (installer)
septic system at Z4$ mono rmo" Ci rc c— based on a design drawn by
(address) p
�Lw dated O
(designer)
✓ I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructe ""'�`° ' _ ce with the terms
of the IAA approval letters(if applicable) �,r ss9c
moo`' DAVID yGN
• o D.
PQ FLAHERTY,JR. N
(Installer's Signa e) No. 1211
ISTE�171, R�O
SgNITA'tbRtPN
e igner's gnature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Rev 8-14-13.doc
a
Town of Barnstable P#
Department of Regulatory Services
Public Health Division DateMAIM
8
%659. 200 Main Street,Hyannis MA 02601
IIIRt�
Date Scheduled / Time r 7 M Fee Pd. S " o
S iSuitability
S abili sses ment for Sewa a Disposal
Performed By: 1 1KA1 94 Witnessed By:
LOCATION&GENOIAL INFORMATION /� �/��Location Address/� y� �/ /`��_� Owner's Name o ftl0n,Al vim/
a�8 / la/ om J G�(i�e, C&tt. Address j/VW
Assessor's Map/Parcel: `q, - 213
Engineer's Name
NEW CONSTRUCTION REPAIR Telephone#
Land Use Slopes(%) 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)
®-TO
Parent material(geologic /L( r V t/ �'/Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
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 It.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_
PERCOLATION TEST Date �Ime / 1
Observation
Hole# Time at 9"
Depth of Perc Time at 6"
Start Pre-soak Time(a3 Time(9"-6') Aj
./�'
End Pre-soak
Rate Min./Inch
Site Suitability Assessment: Sitc Passed Site Failed: Additional Testing Needed(Y/k)
Original:Public Health Division Observation Hole Data To Be Completed on Back--------
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPnC\PERCFORM.DOC
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
-l i Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
0 �7 �) onsisten %Gravel
14
12 e3
r
i
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
Lit
s 2ys
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
Flood Insurance Rate May:
Above 500 year flood boundary No L Yes_
Within 500 year boundary No_ Yes
Within 100 year flood boundary No—9 Yes
Depth of Naturally Occurrine Pervious Material
Does at least four feet of naturally occurring pervio material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring perFous material?
Certification L
I certify that on �j Z (date)I have passed the soil evaluator examination approved by the
Department of En 'o ntat Protection and that the above analysis was performed by me consistent with
the required tr ' ,expertis and ri ce d cri in 310 CMR 15.0017.
Signature Date f� /
Q:\SEPTIC\PERCFORM.DOC
L 1
Town of Barnstable Barnstal'e
~ ` Regulatory Services Department ;edcaC-1
�A5fABU itN
9 1639. �� Public Health Division m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4987 6179
July 31, 2017
DOWMAN, ALICE E
248 MONOMOY CIRCLE
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 248 Monomoy Circle, Centerville, MA was inspected on
06/13/2017 by James D. Sears, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Leaching facility with standing liquid level at or above the invert pipe (per
Town Code 360-20 h).
You are ordered to repair or replace the septic system within two (2) years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
XOF THE BOARD OF HEALTH
ean, R.S., CHO
Agent of the-Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\248 Monomoy Circle
Centerville.doc
Town of Barnstable
�xxsras�,
E 596L. Regulatory Services Department
Public Health Division
200 Main Street,Hyannis MA-02601
Office: 508-862-4644 Richard Scali Director
FAX: 508-790-6304 Thomas A McKean,CHO
Feb 6, 2007
Rev. 5111116 .
DEADLINES T.O'REPAIR FAILED.SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000) _
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA.
❑Discharge or ponding of effluent to the surface of the ground
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe
❑Backupof sewage into the house due to an overloaded or clogged SAS or cesspool
g gg P
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
. cgim
�iessip
e
❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
o Leaching pit or cesspool with high liquid level,<12"below inlet (per Town Code
§360-9.1)
Leaching facility with standing liquid level at or above the invert pipe (per Town
ode §360-20 h)
OTHER
Repair deadline:
WSEPTIMDEADLINES TO REPAIR FAILED SYSTEMS.doc
Jun 1,3 2017 22:21 HP Fax page 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form r-
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �11
I`Q
c�
248 Monomoy Circle
Property Address '..
Alice Dowman Estate 'ti
Owner Owner's Name 'X
information is I'5
required for every Centerville MA 02632 6-13-17 V!
page. CitylTown State tip 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:Whenfill A. General Information on the
out fort �j�jy �aL��� �►tt►►uuuip��
u only the tab ��.�P��.1N DF QS�����i
1. Inspector:
key to move your ��Z� ''• +''y
cursor•do not �' �'
James D.Sears =A: JAMES `•N
use the return Name of Inspector
key.
Ca wide Enterprises
c+
�y Company Name lo" TIF •O Qo
i ! '' •.. l
153 Commercial Street i���iF 5 fNSP�-L6g,,N�
Company Address
' Mashpee MA 02649
I Clty/rown State Zip Code
508-477-8877 S1623 l
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-13-17
8p'ector's 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 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 insp
ection 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.doc.rev.8118 Tide 5 official Inspection Forth:Subsurface Sewage cispoear system•Page 1 of 17
- - �a Vj
Jun 13 2017 22:21 HP Fax page 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
isrequiredfore very Centerville MA 02632 6-13-17
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:
Failed system. The system is a 1000 Gal Tank and pit
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):
t6lns.eoc-rev.6/16 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
L
Jun 13 2017 22:21 HP Fax page 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
k1Wj-
248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
inforrequIredfo is Centerville MA 02632 6-13-17
required far every
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cant.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpsialarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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
16.303(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.doc•rev.6116 Title 5 official inspection FoFmi Subsirface Sewage Disposal System•Page 3 of 17
Jun 13 2017 22:21 HP Fax page 4
SN Commonwealth of Massachusetts
Title 5 official Inspection Form
ZVELMN
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°Y 248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owners Name
information is required for every Centerville MA 02632 6-13-17
page. Cltyffown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning In a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
�• This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
Nr9 ❑ ❑ or clogged SAS or cesspool
® ❑ Liquid depth in is less than 6" below invert or available volume is less
than Y2 day flow ,L,9ACNN6
t5lne.doe•rev,6l16 Title 5 Official l,ispection Forth:Subsurface Sewage Disposal System•Page 4 of 17
L
Jun 13 2017 22:21 HP Fax page 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
information is required for every Centerville MA 02632 6-13-17
page. City[rown 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 pprn,
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
t5ine.doc rev.WS Tale 5 Official Inspection Form:Subaurfece Sewage Disposal System•Page 5 of 17
Jun 13 2017 22:22 HP Fax page 6
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
information is required for every Centerville MA 02632 6-13-17
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? (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 CM 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): NA Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
t5ins.doc-rev.6116 Tllle 5 Official InspecJon Forth:SubsuRace Sewage Disposal System-Page 6 of 17
Jun 13 2017 2222 HP Fax page 7
�LN Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owners Name
information Is Centerville
required for every MA 02632 6-13-17
page. Cityfrown State Zip CDde Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank and pit,
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 2015-49,000Gais
Detail:
2016-48,000Gals
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
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.doc-rev.6/16 Title 5 Official Inspect.on Form Subsurface Sewage Disposal System•page 7 of 17
i
i Jun 13 2017 22:22 HP Fax page 8
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
248 Monomoy Circle
Property Address _
Alice Dowman Estate
Owner Owner's Name
information is required for every Centerville MA 02632 6-13-17
page. CityiTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancyluse: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t&ne.00c•rev.6116 Title 5 Official Inspection Form:Subsurface sewage oisposel system•page 6 of 17
Jun 13 2017 22:23 HP Fax page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
y 248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
information is required for every Centerville MA 02632 6-13-17
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:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan).
41"
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage,etc.):
Pipeing is 4" PVC SCH-40
Septic Tank(locate on site plan):
Depth below grade: 31
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth: 2
15ins.doc-rev.6116 Tale 5 Official Inspection Form:Subairfece Sewage Disposal System-Page 9 of 17
Jun .13 2017 22:23 HP Fax page 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
". 248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
information is required for every Centerville MA 02632 6-13-17
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
28"
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 12
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-TapeSludge 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.):
Tank at working level. Tank show's sign's of being over loaded in the past. Tank and inlet cover
at 31" below grade w/outlet cover at 8". Old wall type inlet baffle. Outlet baffle.
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
t5insAoc-rev.6116 Title 5 Official InWectlon Form:Subsurfax Sewage Disposal System-Pape 10 of 17
Jun .13 2017 22:23 HP Fax page 11
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
information is
r wired for every Centerville MA 02632 6-13-17
page. Cityrrown 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
l6ins doc-rev.6116 Title 5 Official Inspection Form:Subsurface sewage oisposai system-page 11 of 17
Jun 13 2017 22:23 HP Fax page 12
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
kvl�ztzj 248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
information f is
required
uired for every Centerville MA 02632 6-13-17
page. City/TDwn 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 No Box
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins.doc-rev.6116 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System-Page 12 of 17
Jun ,13 2017 22:24 HP Fax 'page 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Monomoy Circle _
Property Address
Alice Dowman Estate
Owner Owner's Name
iequiredifo is Centerville MA 02632 6-13-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont,)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativelalternative 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 a 1000 Gal. Precast pit. Pit at 3' below grade. Pit is full to cover. Need to replace
system.
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.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Jun 13 2017 22:24 HP Fax page 14
Commonwealth of Massachusetts,
Title 5 Official
a Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
information is Centerville
required for eve MA 02632 6-13-17
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.):
i 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,):
tSlns.doc-rev,6/16 Title 5 Officlal Inspection Form:Subsurface Sewage Disposal System-Papa f4 of 17
Jun 13 2017 22:24 HP Fax page 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
246 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
information is
required for every Centerville MA 02632 6-13-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
� no
01.
/3 y_s
A 4-: r.
4-s
t6ins.doc•rev.6116 Tide 5 Ofridal Inspection Form:Subsurtace Sew ego Disposal System-Page 15 of 17
Jun .13 2017 22:24 HP Fax page 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
information is Centerville
required for eve MA 02632 6-13-17
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to igh ground water: 50'+
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: Dare
❑ 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:
USGS Well level.
You must describe how you established the high ground water elevation:
G.W. at 50'+ per USGS Well.
Before filing this Inspection Report, please see Report Completeness Checklist on next page,
t5ins.doe-rev.&16 The 5 Official Inspectim Form:Subsurface Sewage Disposal System-Page 16 of 17
Jun 13 2017 22,25 HP Fax page 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
248 Monomoy Circle
Property Address
Alice Dowman Estate
Owner Owner's Name
information is required for every Centerville MA 02632 6-13-17
page. ClryrTown State Zip Coda Date of Inspedion
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
15ins.doc•rev.6/16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17
i
N ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:....>..:�'t• ?--t------ OF......................... . . _.........-..-.-------_-.-----------------
Apphration -for Bi-q uiittl Works C omitrurtiou Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
--------�---�D---�--- ......................
Locationess — r Lot No.
W -------•••--
Owner Address
.............................................. -------------------------------------------
Installer Address
UType of Buildirg Size Lot............................Sq. feet
Dwellings No. of Bedrooms..--_--_..__ _____________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons_-___-_----_-____----___.-_ Showers ( ) — Cafeteria ( )
A' Other fixtures ------------------------------------------------------
W Design Flow_________________��`'`_4R_-------------gallons per person per day. Total daily flow-------------------------------------------.gallons.
P4 Septic Tarrk—Liquid capacitvfw .gallons Length---------------- Width................ Diameter_...-.-_--_-__ Depth.-.-----_._.--.
xDisposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area.......-------------sq. ft.
Seepage Pit No..................... Diameter____________________ Depth below inlet.................... Total leaching area.----_.__---____sq. it.
z Other Distribution box ( ) Dosing tank ( ) 0.�6, 1�9 C /,k _ —/— -a Z — > --c—
Percolation Test Results Performed by.......................................................................... Date_-------------------------------------..
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water....-.--.-_---.-----.-..
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
Description of Soil------- - --�--------�--------------`��
x r v
r,
x ----------------------------' --- . -----...--- --------------------------------------------- -----------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------...................-.------------------
•-------------------------------- ---------------------------------------------------------------------------------------------------------------•---.---------------•---------•------------------•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The undersigned Wther agrees not to place the system in
operation until a Certificate of Compliance has been issued by the of alth.
Application Approved By._.. ... _ .____.. __.
----- ----------------------- ,S
Date
Application Disapproved for the following reasons:.................... ---------------------------------...-----------------------------------•-•----•-•-••-------
•----•---------------------------------------------------------------------------------•----------------------------------------•--------._...---------------------------------------------------------
Date
PermitNo........................................................ Issued........................................................
Date
nimJ
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_..f-- -------.OF............................:..........
AVV irtttion -for Di.gpu,ittl Works Tonstrurtion Vrrnift .
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
..
Location-Address —— or Lot No.
W ! Owner - Address
----------------------•.---.- ....•-•-------- ---------•-•---------------•- ..-- - `<. ..---
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_____________ ____________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building -_------------------------- No. of persons._.-_....._-_-_-________-.__ Showers ( ) — Cafeteria ( )
dOther fixture---:,L-------- ---•------------•---------••----------- ------•---------------------------
W Design Flow..................- __...._._._.gallons per person per day. Total daily flow.....-- __.__.___gallons.
WSeptic TCLtik—Liquid capacity---------..gallons Length................ Width-.-_--._---_-- Diameter................ Depth--_-____------.
x Disposal Trench—No.___________________• Width-------------------- Total Length-------------------- Total leaching area-.------_.--.---__-_sq. ft.
Seepage Pit No..................... Diameter----------_......... Depth below inl j�j--.-.-._ ____.__ Total leaching area._-_-._.____--_-_-sq. ft.
z Other Distribution box ( ) Dosing tank ( ) {V ��'�2? -"> ._�G`-?- --_
Percolation Test Results Performed bY------------- ..................................................... Date---------_-----------_---- --------
Test Pit No. I_______.-•_.._-_minutes per inch Depth of Test Pit.................... Depth to ground water..---___.___..___ --.-.
r14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
0 -- --•-T !/ --- .
Descri tion of Si oil___ d - '�,r�r� `-'� `
------------
------ ------�t-'-•---,,---." ", '1�--------- -------------------------------------------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------•----------------------••--••-------------------------------•---••-----•-------••----------------•-•---•--------•--.._..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article YI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
C.._ /
Date .---�-
Application Approved BY = =`:._...... ?' j 5
-------------
Application Disapproved for the following reasons:..................../../...................................................
.................Date..............
..--••-•••••-•••••••-•----------------------•-------•---•••---------•--•••-•-•-----•--••-••••--------••---------------------------------------•••-•••--`---•••.......---------•••-••--••-------------•-
Date
PermitNo......................................................... Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
�i... 1..........OF..... .......................................................
(11prrtif irttte of Tomplittnrr ��
THIS I TO C I'IFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by............... •---.. �....�j------- ... -- ............... 7................. .......... ...... . .-------------•-------------------
Install$r
at = ---.------ /�d���� 1��� - ----- ------=--------------------- ------ = ..................................... ------
has been installed in accordance with the provisio�Ar II le XI of The State Sanitary Code as escril4d iYLthe
application for Disposal Works Construction Permit No--- _.__-_3 `? _
---------- ------------- dated----�-__.._.-------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT,BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------ ........................................... Inspector------ . us
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No......................... FEE...
�i�a g ttl rrxk� n �cstrurtion prrmit
erssio 1 -------•---------Pmi hereby granted r . - --...
to Construct ( ) or Repr4ir ( ) an Individua Se a his oral S s m
atNo -G 4 -----.--• 01 .. . �� f �-----------------------------------------
Street _ J-
as shown on the application for Disposal rks Construction Per it� .....................
r1___: _..� .t,� � ... ...--• --•----••••-.
Board of Health
DATE----------------------------------------------------- ..........................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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Commonwcotth of Massachusetts �,r ocT
ExecLdive Office of Environmentol Affoirs
Department of
Environmental Protection F
William F.Weld
Gcwmor
Trudy Coxo '
:ecr.t.y,eou .
David 13. Struhs
Comml.elona -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 248 Mon'Rmoy Circle, Centerville Address of Owner:
Date of Inspection: October 19, 1996• (If different)
Name of Inspector: Robert W. Saben
Company Name, Address and Teleplione Number: Barnstable County Systems Inspectors
25 Mid—Tech Drive
West Yarmouth, MA 02673
CERTIFICATION STAM%117NT (508) 778-0101
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspeclor :
s Signature: Date: October 19, 1996
.,(J�
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approvinG autltoritl.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
X 1 have. not found any information which indicates that the system violates any of the failure criteria as defined in 310 Cn{R
Any failure criteria not evaluated are indicated below.
n] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, u1x>n completion of the re t,lacrment nr n t.yr,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", f yplain why not)
_ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or e\fdiration, or tank failure- is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
Onn.VIntnr Street • Poston,t.lnssnchusntts 0210l1 • FAX(G17) 55G-10,19 • Tolnphone (G17) 292.55M
�. rnnr.l m.t•rt1•L•I r•.Iv,
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2.48 Monamo.y Road, Centerville
Owner: Mary .Foley
Date of Inspection: October 19, 1996
B) SYSTEM CONDITIONALLY PASSES (continued)
_ Seware.backup or breakout or high static water level observed in the distribution box is due to broken .x obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year duc to broken or obstructed pipe(s). The sys em will pass
inspection if(vi►h approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
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 fai inr, to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING 114 A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within So feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (,AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES-THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND TH
E'N:Al1RON'sIENT-
_ The S%,gem IIit ) septic mnk and soil absorption system and is within 103 feel to a sur(ziu watet upp:, of
surface wales supply.
The system h.r a septic tank and soil absorption system and is �sithin a Zone I of a public seater supply .:ell.
_ The sl strm ha' a septic rani:and soil absorption system and is within 50 feet of a private %v.lter supply vrll.
The sy>tPni I::., a septic tan', and soil absorption system and is Icss than 100 feet but 50 feet or more fro n a private ssatcr
supply swell, unless a well seater analysis for eoliform bacteria and volatile organic compounds indicates that the sell is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm-
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as definMJ in 310 CMF IS.103. The basis
for this dctcrmin.i6on it identified below. The I'loard of Health should be rnntietrd to determine what will Iw nr•estmy to corwrt
the failure.
Backup of sewage into facility or system component due to an 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 c logged SAS or
cesspool.
(revised 811s/9s1 2
SUBSURFACE SEIWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 248 Monamoy Road, Centerville
Owner. Mary Foley
Date of Inspection: October 19, 1996
DI SYSTEM FAILS (continued):
_. 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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
._ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 1 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 So 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 •upply well with nc,
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of wel; water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to publi- health and safer•
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 to et of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (RNIPA) or a mapp•d Zone II of a
public walrr supply welh
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater t eatment program
requirements of 3 1 A CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOPUM
PART B
CHECKLIST
Property Address: 248 Monamoy Road, Centerville
Owner: Mary Foley
Date of Inspection: October 19, 1996
Check ;(the (ollowing have been done:
X Pumping information wa, requested of the owner, occupant, and Board of Health.
X None of the system components have been pumped for it least two weeks and the system has been receiving normal flow rites
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
N/A As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow
X The site was inspected for signs of breakout.
X All system components, excluding the Soil Absorption System, have been located on the site.
X 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.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive. methods.
X The facility own,-, find nccupants, if(Wferrnt frnm owner) were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 8/15/95) 4
t ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 248 Monamoy Road, Centerville
Owner: Mary Foley
Date of Inspection: October 19, 1996
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms: 3
Number of current residents: 1
Garbage grinder (yes or no):Yes
Laundry connected to system (yes or no): Yes
Seasonal use (yes or no): No
Water meter readings, if available:
Last date of occupancy: Current
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_rralions/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_ .
Non-sanitary waste discharSed to the Title 5 system: (yes or no)_
Water meter readings, ;f available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
12/15/94 — Property owner
System pumped as par, of inspection: (yes or no)_
If yes, volumr pumped, gallons
Reason for pumping:
TYPE OF SYSTEM
X Septic tank/distribution boyJsoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (cvplain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: 1975; .Property Owner
Permit #75/325
Sewage odors detected when arriving at the site: (yes or no) No
(revised 9/15/951 5
SUBSURFACE SEWAGE DTSPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 248 Monamoy Road, Centerville
Owner: Mary Foley
Date of Inspection: October 19, 1996
SEPTIC TANK:X
(locate on site plan)
Depth below grade:
30"
Material of construction: X concrete metal_FRP other(explain)
Dimensions: 8 x 5 x 4.5
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 2'2��
Scum thickness: 1n 11"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 1'7"
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etr l Condition of tank is good Liquid level at bottom of outlet
invert. , No evidence of leakage.
GREASr TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
L)i!tancc from hottom n� «t��, t� hnttnn, of outlet tee or battle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of Icak,lcr, v10
6
(revised tt/1S/95)
SUBSURFACE SnVAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 248 Monamoy Road, Centerville
Owner: Mary Foley
Date of inspection: October. 19, 1996
TIGHT OR HOLDING TANK: '
(locate on site plan)
Depth below grade:
material of construction: _concrete_metal_rRP—other(explain)
Dimensions:
Capacity. Sallons
Design (low: gallons/day
Alarm level:
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX-_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if and clisuibu;i;,i: ;, eju..!. r•,idence of solids carr,•o:•er, ev;dence of leakage into or out of bnY, etc.)
PUMP CHAMBER:_
(locate on site plan) '
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
J 7
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 248 Monamoy Road, Centerville
Owner: Mary Foley '
Date of Inspection: October 19, 1996
SOIL ABSORPTION SYSTEM (SAS):X
(locate on site plan, if possible; excavation not required, but may be approximated by non•intrusive methods)
If not determined to be present, explain:
t.
Type:
leaching pits, number. 1
leaching chambers, number:_
leaching galleries, 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,etc.)
Normal vegetation. No signs of hydraulic failure. Coarse material and medium sandy
soil:
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:
Materials of construction:
Indication of groundw.1tei.
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of rnn:truetion: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8115195) B
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 248 Monamoy Road, Centerville
Owner. Mary Foley
Date of Inspection: October 19, 1996
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
r 6" fib i�
pi dy8 ii
Fe' )ZoF
Doge LNN�
DEPTI I TO GROUNDWATER
Depth to rroundwater: > 12 feet
method of determination or approximation: USGS Map, elevation over SO feet.
(revised 8/15/9S)
TOP OF FOUNDATION COVERS TO BE WATERTIGHT AND- SEPTIC SYSTEM PROFILE
BROUGHT TO WITHIN 6" OF FINAL GRADE snot to SCa►e) Flaherty Environmental Services
EL. 56.0' EL. 54.0' INSP. PORT W I 3 OF GRADE CLEAN SAND P.O. BOX 81
2" of j" to 4" DOUBLE WASHED EL. 54.0' Yarmouth Port, MA 02675
4" CAST IRON or EQUIVALENT PEASTONr-OR GEOTEXTILE 1
MIN. PITCH 1/4" PER FOOT FILTER FABRIC 774.994.1166
4" SCHEDULE 40 PVC PIPE
4"SCHEDULE 40 PVC PIPE
'• FLOW LINE VENT (IF REQUIRED)
, (first 2'to be%ve0, °'.
20' 1.5%
—�- 5' 1% °' EL.52.1'f
MM
A.
L. 53.5' 14" —� ®•� p Q;A
°0000. 00ho 000 0000EL,51.5' 0°0°000 ° 000 �� 00°o0o°ocEL.51.7 —� 0 0 0 0 o C� O'C� po 0 0 o cEL. 51.03' °o°o° o 0°0°0°0° p 0 p o°0°o°0°c
. . o °00000000000 � ��• 000000 0 2.0'
10'MIN. (2.5%) o 0 0 0 0 0 0 o p�p®p p��p'p� p p p 0000°o°oc—
�-- GAS BAFFLE H_20 EL. 51.0' 0000°00000 00°0°0 0 0 0 0
D-BOX o 0 000000 000 oc
::;•a, ) °00°0000° 0°°°°° ^ .. .od' .e ; O 0 00 0 O
• 6"CRUSHED STONE OR SOIL ABSORPTION SYSTEM
•g' •'•°' �' °' MECHANICALLY COMPACTED (2) 500 GALLON H-20 CHAMBERS
(DATUM: ASSUMED) -�--� 3„ 1„ WITH 4'STONE AROUND IN A
5.5'
1500 GALLON SEPTIC TANK
4 to 1Y DOUBLE WASHED STONE 12,83'X 25'X 2' CONFIGURATION
(PROPOSED) EL. 43.5'
BOTTOM OF TEST HOLE EL. 43.5' LOCATIONMAP
USGS ADJUSTMENT: N/A
GROUNDWATER ELEV: N/A
N TH
\ DRIV S�00-\ fy,
A O Q.,\ Y TH-1 54
\ LOCUS W
O 00 GARAGE �2
00 i�
13.8
0
w;.s.. .•...: NTS
EXISTING
3 BR O ;�'
D ADDN,
WELLING P2.2 S° LOT 63 tHpF�ygs
t.
o ,.. 15,000 SFf
10' J:;:*. it �O P 293
0
0 H iY, R.
Lp 38.4' 121
O
BENCHMARK: Q1STE
TOP OF FNDN NIT R1I+
EL. 56.0'
54 o.
SHED ti0 DATE.-81712017 R /SED:
CONTINUE SEWER LINE THROUGH EXISTING
TANK TO PROPOSED TANK TO PREVENT h�
DESTABILIZING ADDMON.ABANDON EXIST/NG ��'
TANK BYF/LLING IT WITH SAND OR BYANY
ACCEPTABLEMETHODSPER310CMR15..000 SITE AND SEWAGE PLAN
AND THE BARNSTABLE HEALTH DIVISION.
FOR
8 & 8 EXCAVATION, INC,/
STEPHEN DONOVAN
248 MONOMOY CIRCLE
SCALE : 1 " = 30' CENTERMLE, MA
REP PB 272 PG 58 SH 2 PAGE 1 OF2
................................................................................................................................................................................................................................................................................................................................................................................................. ............................................................
GENERAL NOTES DESIGN CALCULATIONS SYSTEM DETAIL Flaherty Environmental Services
P. 0. Box 81
1. ALL PRECAST COMPONENTS TO BE H-10 Yarmouth Pod, MA 02675
RATED UNLESS OTHERWISE SPECIFIED. NUMBER OFACTUAL BEDROOMS 3 774.994.9 166
DISTRIBUTION BOX(ES)AND ANY
COMPONENTS WITH ANY ANTICIPATED GARBAGE DISPOSAL UNIT NO
VEHICULAR TRAFFIC TO BE H-20 RATED.
2. THE DESIGN OF THIS SYSTEM DOES NOT TOTAL ESTIMATED FLOW a
110 GAL/BR/DAYX 3 BR 330
ALLOW FOR THE USE OFA GARBAGE ( ) —GAL./DAY 5 REMOVAL
GRINDER.
3. MUNICIPAL WATER IS AVAILABLE. REQUIRED SEPTIC TANK CAPACITY 660 GAL.
4. ALL CONSTRUCTION TO CONFORM WITH SIZE OF SEPTIC TANK 1500 GAL. (PROPOSED)
310 CMR 15.000 AND ALL OTHER
APPLICABLE LOCAL, STATE AND FEDERAL SOIL CLASSIFICATION 1
CODES AND REGULATIONS.
5. INSTALLER/CONTRACTOR TO REVIEW& DESIGN PERCOLATION RATE <2 M/NAINCH
VERIFY ALL ELEVATIONS AND DETAILS EFFLUENT LOADING RATE 0.74 GAL./DAY/FT7 O O 12,83'
AND REPORT ANY DISCREPANCIES TO —
DESIGNER PRIOR TO CONSTRUCTION OR
ASSUME ALL RESPONSIBILITY. LEACHING AREA
6 (2)x x 12. ; 12.83)(2) = 151 SF
. INSTALLER/CONTRACTOR IS
25.0' 2.83' =320 SF
RESPONSIBLE FOR MAINTAINING SAFE 471 SFx 0.74 =348 GPD
WORK AREA, VERIFYING ALL UTILITIES
AND NOTIFYING "DIG SAFE" USE(2)500 GALLON H 20 CHAMBERS WITH 4'STONE 25'
(1-888-344-7233) 72 HOURS PRIOR TO /NA 12.83'X25'CONF/GURATIONASDIAGRAMMED
CONSTRUCTION.
Z ANY CHANGES TO OR DEVIATIONS FROM RESERVE LEACHING CAPACITY N/A
THIS PLAN MUST BE APPROVED IN
WRITING BY FLAHERTY ENVIRONMENTAL
SERVICES AND LOCAL BOARD OF
HEALTH.
8. FINISH COVER OVER COMPONENTS IS
NOT TO EXCEED 3'PER 310 CMR 15.000 (NTS)
UNLESS SHOWN PER PLAN.
9. ALL ABANDONED SEPTIC SYSTEM
COMPONENTS TO BE PUMPED DRY AND SOIL EVAL UA TION
FILLED WITH CLEAN SAND OR REMOVED TESTHOLE1 P#15459 TEST HOLE#2 P#15459
AND REPLACED WITH CLEAN SAND. Evaluator- David D.Flaherty Jr.,RS,REHS Evaluator David D.F/ahe*Jr.,RS,REHS �1C� �F�S .
10.ALL COMPONENTS TO BE PROVIDED SE#2755 SE#2755 yG
WITH WATERTIGHT ACCESS PORTS BOH Witness Tim O'Connell,RS BOH Witness: Tim O'Connell,RS v,
Date: August 5,2017 Date: August 5,2017 0
WITHIN 6"OF FINISH GRADE. F {
I I.ALL SEPTIC TANKS, DISTRIBUTION TH-1 ELEV.54.0' TH-1 ELEV.54.0' ° 1
BOXES AND PIPING TO BE INSTALLED �Ols TE�``�
D"-12" F/LUA 0"-12" F/LUA �Nt$ �®
WATERTIGHT. Ls 10YR 212 LS 10YR 2/2 s
12.NO KNOWN WETLANDS OR WELLS
WITHIN 100 FEET OF PROPOSED
LEACHING. 12"-34" B LS IOYR 516 12"-34" B Ls 10YR 516
13.THIS IS NOT A CERTIFIED PLOT PLAN
AND UNDER NO CIRCUMSTANCES IS THIS
PLAN TO BE USED FOR ZONING OR 52"EL.49.7' I certify that on November 12,2002,l have passed SITE AND SEWAGE PLAN
BUILDING PURPOSES. DERC the exam/nation approved by the Department or FOR
Environmental Protection and that the above analysis
14.LOT IS SHOWN AS ASSESSOR'S MAP 191 has been performed by me consistant with the B & B EXCAVATION, INC./
LOT 213. 34"-126" C MS 2.5Y 615 34"-120" C MS 2.5Y 6/5 required training,expertise,and experience described STEPHEN DONOVAN
15.LOCUS PROPERTY IS NOT LOCATED j In 310 CMR 15.018(2)."
WITHIN AN AQUIFER PROTECTION G.W.ELEV.NIA G.W.ELEV.NIA 248 MONOMOY CIRCLE
DISTRICT(ZONE II). CENTERVILLE, MA
BOTTOM TH-1 ELEV. 43.5' BOTTOM TH-2 ELEV. 44.0'
PAGE 2 OF2
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