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0255 MONOMOY CIRCLE - Health
s � 255 M O'n,toy,Circle 21'6.;, S M E A D No.2-153LOR UPC 12534 smead.com • Made in USA Sx FMLMWTMLM SFI DE '� SR CERTIHED SDURUNG NNYNESHPROGQANLONfs r TOWN OF BARNSITABLE LOCATION Or S !?3 n n 0 rl SEWAGE#��l�' �b$ 4- VILLAGE 3 eyn,ee-,,'JIP ASSESSOR'S MAP.&PARCEL �I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 15 C b LEACHING FACILITY:(type) r9- SCFZ) (size) /3 k z,� _ NO.OF BEDROOMS OWNER fit�C PERMIT DATE: (e COMPLIANCE DATE: (o 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 Qom. aSS cM���n�o c,rz(e Of(/ I ��- 37 ' 1 II -- d 0� Fee C, / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippliLatlon for Disposal 6pstem Construttion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. a.�s$ Mono thoy e�rLjc, Owner's Name,Address,and Tel.No. Mgrygpt_ - AN 4c jeQ& 2.$'S Vhorrr►a Cam;tcA - ct rT&et./,H e, Assessor's Map/Parcel q — 2.w Y Installer's Name,Address,and Tel.No. '�/� G Designer's Name,Address,and Tel.No. ktj CwZe Nu_ k�4Sct,2,7 (P$ 2g .8 — li g`oS — ?moo Type of Building: Dwelling No.of Bedrooms 3 Lot Size 3Q,Oag) sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3-3 C gpd Design flow provided gpd Plan Date 10 —31 Number of sheets Z, Revision Date Title Size of Septic Tank r y `Mc, Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /�/@,(,� �� iCQ Date last inspected: Agreement: The undersigned agrees to ensure the construction LCodeand ce of the afore described on-site sewage disposal system in accordance with the provisions of Title 5, f the Enviro ental t to place the system in operation until a Certificate of Compliance has been issued by this Boar a (Si Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Z ��V Date Issued No. 2 1 l0 _ . t©� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplication for Vsposal bpstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) Uromplete System ❑Individual Components Location Address or Lot No. ZS� mono fhocJ Gd r f(L Owner's Name,Address,and Tel.No. Mgryq m ac jeod GGn,rc C— %.C_ 2-S S- Yl,onop• y Assessor's Map/Parcel Ott — Installer's Name,Address,and Tel.No. 't q/� C.�t C Designer's`1$e,Address,and Tel.No. k11 C42e@t}; T-Vu. l",%b5cf,�;wry &a h:�� ��c.d-�r �1-C Q-owc— Iq Wti- Type of Building: Dwelling No.of Bedrooms 3 Lot Size 3Z,Opp sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 O gpd Design flow provided 3 � gpd Plan Date 1 0 —31 — 16 Number of sheets Z. Revision Date Title Size of Septic Tank Type of S.A.S. Z� Description of Soil L ec Nature of Repairs or Alterations(Answer when applicable) /k L41 1 P6,c. ►r� G ![ Date last inspected: Agreement: The undersigned agrees to ensure the construction maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 I f the Enviro ental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar �a Sign Date Application Approved by Date I ) Application Disapproved by Date for the following reasons Permit No. 0966 Date Issued / --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(V}/ Repaired( ) Upgraded( ) Abandoned( )by i C_ �. I/ cn=..5 at 2TE' A,, G; C. has been constructed in accordance with the provi lOns of itle 5 and he for Disposal System Construction Permit No.�(�—qLP, dated 16 Installer Designer h k cei (.- Se-Q.c- a �.(_C.L #bedrooms - Approved desiignn flow A 3-3Q gpd The issuance o this p rsmit shall not be construed as a guarantee that the system '11 iun�for as designed Date ! ��) �� Inspector1 r �v --------------------------------------------------------------------------------------------------------------------------------------- No. ' 0 Fee THECOMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE,MASSACHUSETTS Misposa[ bpstem Construction Permit Permission is hereby granted to Construct( ) Repair(Y Upgrade( ) Abandon( ) System located at Z5 `7 YIAQwV MA p%4 , (e— 45fU) _trg=!/1 LL[ = and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. / Date - p(�p Approved by �. Town of Barnstable Regulatory.Services Richard V.Scab,Interim Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508- Installer&Designer Certification Form Date: t 1 1 I Sewage Permit# 1-01 b—qc� Assessor's Map\Parcel Designer: Installer: Yoe dil i brdb 30c Q 4W, 50t�'� Address: I11 i7t,r u(' Address: l✓.F�I,�,�,,,,Nl�oa��C� iN1 a�5�.�s �tl(s ►1/1,� �•t�y�' On L* s l l i6r r b -� a . (+ as issued a permit to install a (date) �q (installer) . septic system at Z 5 5 t l o rJ u�rw Ll C�r�� based on a design drawn by •''-- ,, (address) S' "H C�+ 1 dated t lkd1� (designer) I certify that the septic system referenced above was installed substantially according the design,which may include minor approved changes such as lateral relocation of tl distribution box and/or septic tank. Strip out (if required) was inspected and the soi were found satisfactory. I certify that the septic system referenced above was installed with major changes (i. greater than 10' lateral relocation of the SAS or any vertical relocation of any compone of the septic system)but in accordance with State&Local Regulations. Plan revision certified as-built by designer to follow. Strip out(if required)was inspected and the soi were found satisfactory. I certify that the system referenced above was constructed in compliance with the tern of the RA approval letters(if applicable) { f(94 Y C t L 1/J�jr9� 1��- (In al Signature) (DesigtON Signature) (Affix Design�s tamp e) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICAT OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND A; BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISIOi THANK YOU. QASepticMesigner Certification Form Rev 8-14-13.doc Town of Barnstable P# Department of Regulatory Services 1 DAM r" F Public Health Division Date 1.011311/0 >a� • � re39. 200 Main Street,Hyannis MA 02601 —1 AIEt)Hilt[� F.► . 41A f V Date Scheduled U I :. Time i ' Fee Pd._ �T+ Soil Suitability Assessment for Sew e D'sposal 'w' Performed-BY Witnessed By:_17 %/� LOCATION&.GENERAL EVORMATIONc L� Location Address Owner's Name R- 4 ( Address 2 5 s ✓hnNv.—u`1 r C►^ Ctut�-t(•t. � o 6sZ. Assessor's Map/Parcel: Iq/ Zl Engineer's Name y�v r-1— NEW CONSTRUCTION [ REPAIR Telephone 116 Land Use ftti5 ll �� Slopes(96) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way A Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands fn proximity to holes) Gono'es- Parent material(geologic) Cjv AJPrSl- Depth to Bedrock Depth to Groundwater. Standing Water in Hole: wo) J.8 Weeping from Pit Nce Estimated Seasonal High Groundwater DETERMINATION FOR SEASONALMIGH WATER TABLE Method Used: Depth Observed standing in obs,hole: In, Depth to soil mottles: Itl. Depth to weeping from side of obs.hole: ____ ln, Oroundwater Adjustment . Index Well-# Reading Date: index Well level „ Adjr_tltetor— Adj.Groundwater Level„p, PERCOLATION TEST Dille 221 (drtme sEf_ Observation �b Hole# Time at 9 11 K Depth of Pero Time at 6" Start Pre-soak Time @ R 'limo(V-6") End Pro-soakI !l RateMin./Inch Site Suitability Assessment: Site Passed SIto Failed: Additional Testing Needed(YIN) 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 Consefvation Division at least one(1)week prior to beginning. Q:\SEPTICU'BRCFORM.DOC ���� US DEEP.OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture Sdil Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. Consistency,%'(]rival) • �•o-►a id R 3/ �o M C�J SP a 719 J&M DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. 'Causlatency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones,Boulders.. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. t Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes ... ,- Within 100 year flood boundary No., Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervl us mtitorial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring per ious material? :..:: Certification I certify that 6 C�14o1rtrr3=0- (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 a experience described in�10 CMR 15.017. Datb • Signature ' Q:\!kEVnC\PBRCPORM.DOC Town of Barnstable Barnstable . � Regulatory Services Department AN-Amedcae i IARNSCABLE, ' '"�: ��� Public Health Division DjiAA 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# 7012 1010 0000 2847 8896 - September 20, 2016 Margaret Macleod 255 Monomoy Circle Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 255 Monomoy Circle, Centerville, MA was inspected on 09/01/2016 by James Ford, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Needs Further Evaluation by the Local Approving Authority" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit shows signs of past failure, scum line up to top. If you disagree, you may appeal to the Board of Health. 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. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health r r m Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\255 Monomoy Circle Centerville.doc ,Q,Q�� Town of Barnstable anarrsrnsr.e, . 6� ,.� 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. 5/11/16 DEADLINES TO 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. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool 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). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ 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 Code §360-20 h) OTHER . 6P f1-4 A 41te, Repair deadline: bi V QASEPTIMEADLINES TO REPAI FAILED SYSTEMS.doc p q' t ov �v Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cr, rf 255 Monomoy Circle 0 Property Address 1-a Estate of Margret McCloud Owner Owner's Name information is required for every Centerville t/ MA 02632 9/1/2016 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:When A filling out forms . General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not ,James Ford use the return Name of Inspector key. Ford Septic Services, LLC Company Name P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 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 Furt Evaluation by the Local Approving Authority 9/14/16 Inspec 's Signature Date The em inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hea h or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ��M a 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owners Name information is required for every Centerville MA 02632 9/1/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N. ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owner's Name information is required for every Centerville MA 02632 9/1/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken-or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N 0 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 [Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts H u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owners Name information is required for every Centerville MA 02632 9/1/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of 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: The septic tank is under the addition in the back yard and only the outlet cover is accessable. The house is empty and the leach pit had 4'of water and shows signs of past failure 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 1Y2 day flow 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ., 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owners Name information is Centerville required for every MA 02632 9/1/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a •''t 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owner's Name information is required for every Centerville MA 02632 9/1/2016 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 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 15ins•3/13 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 w.�,••'`t 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owners Name information is required for every Centerville MA 02632 9/1/2016 page. Cityrrown 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? (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)): Detail: unavailable 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 255 Monomoy Circle Property Address Estate of Mar ret McCloud Owner Owner's Name information is required for every Centerville MA 02632 9/1/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown 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): (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owners Name information is — required for every Centerville MA 02632 9/1/2016 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 -3/12/75 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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.): Septic Tank (locate on site plan): Depth below grade: 18" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene El 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. Sludge depth: 8 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `�M A,•'r 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owner's Name information is required for every Centerville MA 02632 9/1/2016 page. City/Town State Zi Code P Date of Inspection Da System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 14 Scum thickness 12 Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 10 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): There were tee's present. The tank is under the addition in the back yard and only the outlet cover is accessable. The tank needs to be pumped. A riser was installed. Grease Trap (locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 El polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 255 Monomoy Circle Property Address Estate of Mar ret McCloud Owner Owners Name information is required for every Centerville MA 02632 9/1/2016 page. CitylTown 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 9 ❑ polyethylene El other(explain): N/a Dimensions: i Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 255 Monomoy Circle Property Address Estate of Margret McCloud Owner information is Owner's Name required for every Centerville MA 02632 9/1/2016 page. Cityfrown State ZipCode 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 none Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, an evidence of leakage into or out of box, etc.): y 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: !Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts "MOM Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owners Name information is required for every Centerville MA 02632 9/1/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1- 1000 gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit had 4' of water and the scum line was up to the top. It shows signs of past failure. A camera was used. 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 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owners Name information is required for every Centerville MA 02632 9/1/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ ,••° 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owners Name information is required for every Centerville MA 02632 9/1/2016 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 I I A 9 o a I o ?3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^A.A •'•• 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owners Name information is required for every Centerville MA 02632 9/1/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20'+/- feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Topo and water contours map. ' ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w,e •'•y 255 Monomoy Circle Property Address Estate of Margret McCloud Owner Owners Name information is required for every Centerville MA 02632 9/1/2016 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 P. 1 • Communication Result Report ( Sep, 14. 2016 10: 50AM Fax Header) Date/Time : Sep. 14. 2016 10:46AM File Page No, Mode Destination Pg (s) Result Not Sent ---------------------------------------------------------------------------------------------------- 0543 Memory TX 5087718079 P. 17 OK ---------------------------------------------------------------------------------------------------- Reason for error E. 1) Hang uP or 1 i n e f a i 1 E. 2) Busy E. 3) No answer E. 4) No facsimile connection E. 5) Exceeded max. E—mail size IQN Commolnvealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Farm.Nol for Vohmtary Assessmems 255 Mortom Chcie Prppatywddmaa Owa,er Estate of Morprel McCloud Irdorwa0en k rra.,er s Hasa — r.pu,ed fbr ssarr Cenlervllle MA 02832 dtNrow, _ 9!1(Z016 skis aueod° baeedlon '— Inspection results must be submitted on this form.Inspection forms may not be altered In any way.Please see completeness chawst al the end of the form. t"'0°"°Inc°"°" A.General Information storm ova romp on ere nre°oSO tel,, use war ffi 1. Inspedm: keY b more yqa aasw.ao not James Ford nee the rehnn say. Name or hape�r __ Ford Sep1In Services LLC tumsa"r maim . P.O.Box 48 Cwnpanr xdeness Oslervsle MA 02655 ;;Zatyrtwm sudo zro�ea -9400 512482 Tdaphpme ndwher Uemsa Homier B.CertifiCa m I cert6y that I have personally inspected the sewage disposal system at this address and that the Informa8on report tru reported belay is e,accurate and.,q*In as of One time of the Inspection The Inspection was performed based an my training and experience In the proper function and maintenance of on site sewage disposal systems.I am a DEP appmwd system Inspector pursuant to Section MUD of TIU9 5(310 CMR 1 G000).The system; ❑ Passes ❑cood01ona0y Passes E]Fa0s ®Needs Furi e�Evshialion by the Local Approving AuOnoray t,'ImnM The am inspector shall submit a copy of this inspection reW to the Approving Authority(Board of Hen h or DEP)within 30 days of completing this Inspection.If the system is a shared system or has a design flow,of 10,000 gpd or greater,the heivoclin and the system owner shall submit the repol to the approprtate regional office of One DEP.The original should be send to the system owner and copies sent to One buyer,0 appllca le,and the approving aulhcrly. —This report only desc lbas torMitlons at the time of inspection and under Iha eornd'diom of use at that time.This Inspection does not address have the system will perform in the future under the same Or different conditions of use. en,w r°eSeaae n,oaan rwssravw..9,,,p,asAu'Sn°va•hw,dr - No(1)..... f FlzE...... ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD qF HE L .. G `G� ..-----.OF...... ....��.. .....----------------------------------------=-------------------- Appliratinn -for Bi�voiial Marko Tonotrnrtion Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ------ ---------------------------------- r N 5. ----------- Lot'on-Address • a1 Lo. LG --- . .. L�' O ner Address ay � ----------------- -_--_---------- Cal ---------------------_------•-_--- Installer Address UType of Building Size Lot................ .------_-_-Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------_------------ Showers ( ) — Cafeteria ( ) Pa Other fixtures ------------------------------ W Design Flow...........................................gallons per person per day. Total daily flow--------.-----------------------------------gallons. Septic Tank—Liquid capacity7/&_°v__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 p�area---_-..---.---.._-sq. ft. z Other Distribution box ( ) Dosing tank ( ) 6j - ®- 16-- -74-- Percolation Test Results Performed by--------------------------------------------------------------------------- Date------.---------------------------- a Test Pit No. 1................minutes per Inch Depth of "Pest Pit.................... Depth to ground water.------..----.-.-_.-__.- �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth ground ground wat{e,;__.._________��__.__. fYi ................ P' z ._._ . .......�, Description of Soil �_// --------------.2---- ' ?"_ d �fi'`�`� a e xd 1 f ------------------------------------------••-------•--•-----------------------------------------------------------q---'-'---- �-''---�"`•"�'.�' � -----••----- U Nature of Repairs or Alterations—Answer when applica.ble..-----------------------------•-.--_--_----_-------._-_-__---___-------_--.-------------------- -------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of-Compliance has been issued by t) boarA of health. Sied ••.G = --•-------------•-•---------•-•-••-----•--------- .... Gal � "Date Application Approved By---- ----- Date Application Disapproved for the following reasons:...... -------------------------------------------•----------........----------------------------••. ---------------------------------------------•--------- ................................................................................................................................................ Pate PermitNo......................................................... Issued.----� --- ..................................... __ Dat--------------------------------" LOWVTN / � air5 W�,G,E PE M1�10. 4 ev VILLAGE — — — — — — -- — — IN A ,a - E -5 U&NA 6, ADDRESS 5 D R S E ADDRESS D�►TE PERKA T ISSUED '- - -e Lz,- — D O.TE COMPLI &1`10E ISSUED � 1 -. �✓ I � �� 'I c � K JW FEIc....../�............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � �..........OF....... {. . 110 ApV irtttinn -for Di,gVuDttl Works Tonstrurtinn Vrrmit Application is hereby made:for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ s --------------------- ---•------------"-------------------....-.......•.!-............................................. Loca' n-Address Lot No. ----------. - _:_.. : r--------- � _.._...._..-• •••••--•------------. - u/ r ----------------- t' ne Address W Installer Address d Type of Building Size Lot---- feet U Dwelling'—No. of Bedrooms______________________________ _____________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ___________________________ No. of persons..____________-__--_--__-.__ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------------ --------------------------- W Design Flow. __________________________________gallons per person per day. Total daily flow-------------.______:-_______-____--.--..._.gallons. WSeptic Tank—Liquid capacity�..1d-a__gallons Length________________ Width_............... Diameter................ Depth..__---_-._---- x Disposal Trench.—No_____________________ Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No----_'_--------------- Diameter.................... Depth below inlet__.________.________ Total leac iiig<�r e�a.___.._..__.____._sq. it. z Other Distribution box ( ) Dosing tank ( ) 6�' �' /G" 76'� ` Percolation Test Results Performed bY---------- ---------------------•----•--------••-------•-•----•----------- Date___-•----------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_.._____--__--__-.-.._.. ;14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth ground wate /� J- i ---- - + C - 1� , D Description of Soils �� 4 -------- ----- �t ------• - --- Tom' U ------------------------------------------------•---•------------••. ......•--•----•----••-••-•----------..... . ...... ___ -___ _ _ ____________________________________________________________________________________________________ _______________�__~___��__-.a_______-___ ._. _ _ ___.______ _ _.A__.._.__...r U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ --------------------------------- ------------------------------------------------------------------- --------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersi ned further agrees not to place the system in operation until a Certificate of Compliance has been issued by tboar of health. Signed-- -------------- ------------- --------------------•-----•----...-•--•-•-------- ------ ."-"-- Date Application Approved BY---- - ../7,C!n -- �!�( Date Application Disapproved for he following reasons:..._.. ------•---------------------•--------------•-•-"-----•----------------_-•--•---------------- ..--•--•-•-•----•-------"•-•----•-----------"---------------------•--------•----•---------•--------.................................................................................................... Date PermitNo......................................................... Issued........................................................ Date -j 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH lit ........................OF.............:.......... L.....'..................................... Trrtif irttte Of TiMplittnrr 2-HI CE " IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........... _ ' tie-- --- ` 2 q� 1/ 'j ,• Installer 4t (Iw+1iL�( at-----"-•--- .....-----••----------------------- ----•----••----•-----•---------•-•-- --------......--------------.•----...--•---••---•------..__....._._._.__._.....-•----•-----------. has been installed in accordance with the provisions of -QCr I j�I of he State Sanitary C¢¢��'�� a ,describe the application for-Disposal Works Construction Permit No. 7 f-__:�__ ______________ dated_.____,T ___A ..��.____. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARARTEE THAT THE SYSTEM L FUNCTION ATISFACTORY. DATE...... � InspectorR THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA T 69) j v....................OF.......... ��C r. ..-------------•----------.... No..... `� ............. FEE_ ..................... uinvma Ontitru tion ramit Permission is b ranted....... o . ...:.: to Constr c ) air ( Individ Sew e Djsp 1= ystem s at No.-` �/ ....!?.`. .... .....-- �"'--iF��.. .....y����------------------------�W' .... 3 Street � ,,�, Construction r it -_ _-____- Dated-._.- --'••ems-•-•• as shown on the application for Dis osal Works PP P� Board of He DATE............................. .................................................. FORM 1255 H0813S & WARREN. 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'VG l',"':. r w e .:t ar .,.:4fkC .r i,.,.V7 r ?i,..."...„ 4ri 3:P'°r..S.w..�,. .'. ,_...'�,'.c:,..e.,...r.a,.w,.u.•..,,w._.:.c:,.,.t...,...,.:.1„c�.-+�e�.Skt.u�a.:.a-:.db,..are,i ,".r:•I Race Lane Centerville,MA t; MPECTION NOTE• PRIOR TO FINAL INSPECTION BYTHE ENGINEER,SYSTEM a► NEEDS TO BE COMPLETE INCLUDING BUILDUP FOR COVERS. N 28°08'06°E a � 200.00' ar Wooded' ''` ' i Wooded Area 1 � ,� �' c° Area Rhododendrons 1 Holly Tree LOTUS Locus Map 3 T Sine E g@ Lawn SAS - --SPA1.)Assessor's Map 191 Parcel 216 28565 Page Note O, G � 3.)plan Book 2pa Se 58 Lot 52+53 .,,._. ..� +1t9 40 , N98) a++ � t4&71 (5T r0 n pg $ , 4.)This property is riot in the State Approved o, .� rr �of-4Q,1? �, Zone 11 Water District •- .- orch � is not in the Wellhead Protection District Z basa) a ataosaoo` i (493 5)This property is not in a Flood Zone House #25 s a Gas Wooded 3 Bedrooms Garage ' �'"�� LEGEND Area TOF El=50.5 i48-0j EXISTING SPOT GRADE (40 tassl 24XS PROPOSED SPOT GRADE . . - ' (4e2) 24 -- PROPOSED CONTOUR EI®c Water ! ohw OVERHEAD UTILITY LINES W- WATER LINE 4e """• 30.000t Sq. Ft. D/W i G = GAS SERVICE LINE EDGE OF CLEARING 240.p — ,� FENCE S 28°08'06"W TEST HOLE LOCATION ST 5EPTiCTANK of DISTRIBUTION BOX MOnOl1'tO Circle - SAS SOIL ABSORPTION SYSTEM y t' 40'RightofWay ' '.,.', '� ,: c'Z S r.3"s \t t Prepared fo � Margaret Macleod 255 Monomoy Circle Centerville, MA p No.122 ? Proposed Sewage Disposal System I CERTIFYTHAT I AM CURRENTLY APPROVED BYTHE DEPARTMENT OF 255 Monomoy Circle Centerville, MA ENVIRONMENTAL PROTECTION PURSUAMTTO 310 CMR 15.017 TO CONDUCT Prepared by: SOIL EVALUATIONS AND THATTHE ABOVE ANALYSIS HAS BEEN PERFORMED BY ME CONSISTENT WITH THE REQUIRED TRAINING,EXPERTISE,AND EXPERIENCE DESCRIBED IN 310 CMR 15 017.1 FURTHER CERTIFYTHATTHE RESULTS OF MY All Cape septic LLC SOIL EVALUATION,AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, GRAPHIC SCALE 618 Route 28 ARE ACCURATE AND IN ACCORDANCE 310 CMR 15.100 THROUGH 15.107. ao is eD '� West Yarmouth, MA 02673 SCOTT MCGANN,CERTIFI SOIL EVALUATOR (IN FEET) (508)771-4200 Email:allcapeseptic@gmail.com 1 inch-'L ft. 30 By;MA cheat sM Project Noa ACas • ; • t Date:_TOr31/16 Sheet 1 of2 J I A a f CONSTRUCTION 1 S`t i ,�"F n j� t �� TOP OF FOUNDATION MINIMUM 20"DIAMETER CONCRETE ._. ` O 1�j L U / O�V EL=50.5± COVERS RAISED TO WITHIN 6"OF FINISH GRADE(OR AS NOTED) 1.)ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE,TITLE S(310 C44R 15.000): EL=49.5*- EL=49.4± STANDARD REQUIREMENTS FOR THE SITING,CONSTRUCTION,INSPECTION,UPGRADE,AND EL=49A* EXPANSION OF ON-SITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FORTHETRANSPORT AND DISPOSAL OF SEPTAGE,AND THE LOCAL BOARD OF HEALTH REGULATIONS. 2J ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE IS POTENTIAL FOR ?' VEHICLES OR HEAVY EQUIPMENTTO PASS OVER IT SHALL BE DESIGNED TO WITHSTAND AN H-20 48.1± � LOADING, IF UNDER AN IMPERVIOUS SURFACE,SYSTEM SHALL BE VENTED TOTHE ATMOSPHERE. 46.4 GEOTEXTILE FABRIC (IN PLACE OF 1/4%1/2"PEASTONE) 3.)TO MINIMIZE UNEVEN SETTLING,SEPTIC TANKS SHALL BE INSTALLED ON A STABLE be MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE- 47.7t U4I.I A62 46.03 4.)COVERS OVER THE INLET AND OUTLETTEES OF THE SEPTIC TANK,THE DISTRIBUTION BOX,AND 46.95 46.40 3/4"to THE SOIL ABSORPTION SYSTEM SHALL BE RAISEDTO WITHIN 6"OF FINAL GRADE. LEACHING , 4 .9 iv 1-1/2"STONE FIELDS,TRENCHES,AND EITHER SOIL ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL C)t3^3 (Double wash] HAVE AT LEAST ONE(1)INSPECTION PORT CONSISTING OF PERFORATED 4°PVC PIPE PLACER GAS BAFFLE H-20 Rated VERTICALLY TOTHE BOTTOM OF THE SOIL ABSORPTION SYSTEM WITH A CAD;TIED WITH MAGNETIC D-�OX 43.9 Tb LEACH CHAMBCa ER WITH 4'OF CONCRETE ONE ON MARKING TAPE,ACCESSIBLE TO WITHIN 3"OF FINAL GRADE. t ENDS AND 4'ON SIDES 5.)PIPING SHALL CONSI T OF 4°SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A Lw --4 EXISTING 1,000 GALLON � ' 3 s' ------.¢ 5.1 MINIMUM CONTINUOUS GRADE Of NOT LESS THAN 3 %FROM THE BUILDING TO THE SEPTIC TANK, (TO REMAIN) L�nge�t Run LEACH CHAMBERS ANDNOTLESSTHANI %OTHERWISE. SEPTICTANK (ENDVIEW) 6.)D1STR111t1TiON LINES FOR THE SOIL ABSORPTION SYSTEM SHALL BE 4"DIAMETER SCHEDULE 40 FLOW PROFILE EL-36.8Bottom Test Hole 25.0' NOT TO SCALE PVC(OR EQUIVALENT)LAID AT 0.005 FT1FT.UNLESS OTHERWISE NOTED.LINES SHALL BE CAPPER AT END OR A5 NOTED, 4'�8.5' �S,S' 7,)LINES FROM THE DISTRIBUTION BOXTO BE LEVEL FORTHE FIRSTTWO(2)FEET BEFORE ( 4 SYSTEM DESIGN CA CU LAT!®N5 PITCHINGTO THE SOIL A650RPTION SYSTEM. DISTRIBUTION BOX SHALL BE WATERTESTEDTO 4 ASSURE EVEN DISTRIBUTION. - k a SEWAGE DESIGN FLOW REQUIRED:3 BEDROOM DWELLING @ 110 GPD/BEDROOM=330 GPD SJ GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES REQUIRED IN ORDER TO PROVIDE A WATERTIGHT SEAL. , q SEWAGE DESIGN FLOW PROVIDED.TWO(2)500 GALLON LEACH CHAMBERS WITH 4'STONE ON 9.)HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE THE ENDS AND 4'STONE ON THE SIDES DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. Vt=((25.0 x)2.83) F 2(25.0+12.83)(2)x J4&349 GPD PROVIDED 10.)IN ACCORDANCE WITH 310 CMR 15.221,ALL SYSTEM COMPONENTS SHALL BE MARKED WITH 349 GPD PROVIDED>330 GPD REQUIRED MAGNETIC MARKING TAPE. ` `� 31 11.)THERE ARE NO KNOWN WELLS WITHIN 100'OF THE PROPOSED SOIL ABSORPTION SYSTEM. SEPTIC TANK CAPACITY REQUIRED;330 GPD X 200%=660 GPD REQUIRED 12J FROM THE DATE OF THE INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL RECEIPT OF SEPTIC TANK CAPACITY PROVIDED;1,000 GALLON PROVIDED(EXISTING) THE CERTIFICATE OF COMPLIANCE,THE PERIMETER SHALL BE STAKED AND FLAGGED TO PREVENT D-Box A GARBAGE DISPOSAL IS NOT PERMITTED WITH THIS DESIGN FLOW USE OF THE AREATHAT MAY CAUSE DAMAGETO THE SYSTEM. VIVA OF M�s9c� s 13J THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNEDUNLESS 0 K1r CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE kt 2 S C O T T DESIGNER, PLt�sR g A. Ln n 14.)THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF THE / PL orlu C `0d N y BOARD OF HEALTH ANDTHE DESIGNER,THE DESIGNER SHALL CERTIFY IN WRITING THATTHE { 1 ov - 17Ge`� "� NO 1224 SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITHTHE TERMS OF THE PERMIT nl`P'$ �c�s AND THE APPROVED!PLANS,48 HOURS ADVANCE NOTICE IS REQUESTED. TF 15.)LOCATION OF UTILITIES IS APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FOR SAN���� DETERMINING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO TEST IME LOGS COMMENCEMENT OF ANY WORK.THIS INCLUDES,BUT IS NOT LIMITED TO,REQUESTS TO 61GSAFE, Test Hole E#1 (EL=40.8±) ANY PRIVATE UTILITY COMPANIES,AND THE LOCAL WATER DEPARTMENT. 1 ayer Soil Class Soil Color 16.)CONTRACTOR SHALL VERIFYTHAT ALL WASTELINES ARE CONNECTED BY WATER TESTING Depth Elev. Comments Assessors Map 1511 Parcel 216 WITHIN THE DWELLING PRIORTO INSTALLATION OF ANY SEPTIC COMPONENTS, W-10" 49.1 A Sandy Loam IOYR 3/1 173 CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANY Proposed Sewage Disposal System SEPTIC SYSTEM COMPONENTS. i d"-26" 47.5 B Loamy Sand 10YR 5/6 IS.)TEST DOLES COMPLETED PER STATE ENVIRONMENTAL CODE,TITLE 5. SOILS CAN BE 28"�-56" 45.1 C1 Corse/Med Sand ZSS M�rlfll�,fly Circle Centerville, MA VARIABLE AND TEST HOLE DATA IS NO GUARANTEE OF SOIL CONDITIONS IN OTHER AREAS. IF w/2096 stone/gray. 2.5Y 7!4 SOILS DIFFER FROM THOSE SHOWN IN THE SOILS LOGS,DESIGN ENGINEER ISTO INSPECT'THE 56"-1 32" 30.8 C2 Medium Sand 2.5Y 6/3 Prepared for: Prepared by: SOILS PRIOR TO PROCEEDING WITH INSTALLATION OF ANY SEPTIC COMPONENTS, Margaret Macieud All Cape Septic LLC 19.)EXISTING SEPTIC COMPONENTS TO BE LOCATED,PUMPED DRY,FILLED WITH CLEAN SAND AND DATE OF TESTING: 10/31/16 255 MonOrnoy Circle 618 Route 28 ABANDONED IN PLACE OR REMOVED AS REQUIRED.AREATO BE COMPACTED TO MINIMI2P SETTLING, SOIL EVALUATOR: SCOTT MCGANN Centerville,MA West Yarmouth,MA 02673 BOARD OF HEALTH AGENT,DAVE.STANTON (500)771-4200 PERCOLATION RATE: LESS THAN 2 MIN/INCH IN"C"LAYER AT 60^ 411capesepticegmall.com NO GROUNDWATER ENCOUNTERED' Date:10/d 1/16 Shnet 2 Of 2 l y:MA Check:SM Project N0.AC-79-ShW2 i