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0284 MONOMOY CIRCLE - Health
284 Monomoy Circle Centerville A= 190 - 211. 111 � UPC 12534 .2.153LL i ,w -tell .21/ ommonwealth of Massachusetts dtion Form wubsurface:Sewalge Disposal System Form-'Ivt t for Voluntary Assessments e M 384 M2nomoy ircle, Centerville Property Address Sus anna Downs Owe Owner's Name � ,r &,; L84 Monnmy Circle, Centerville '� m Ma._ 02632 91972016 page. ityrrown 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 et�mpleteness checklist it the end of the form. filling 1 34 i ry"" rf 5X 1197-/ on tile corr" user 1, Inspector: key t yr ; Samuel Speakman use the _t.: • Name of Inspector. - - key. Speakman Excavating LLC k� Company Name ,.,.. 15 Speak Way Company Address g Har ...... � �._ .. .. ._ City!`rown state Zip Code 508-432-6565 S113817 Telephone Number License Number Cedifidation ! 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 timeof the'inspection.The inspection. was performed based on m 'training and experience in the proper function and.maintenance of an site !sewage disposal systems:[am at DEP approved system.inspector pursuant to Section 16.340,of 'Title 3(310 CMR ti6 qp0).the.system: Passes . ❑ Conditionally:Passes O Fails E] bleeds further Evaluation by the Local Approving Authority _._....... .._... peetor's signature bate The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or.DEP)within 30 days of completing this inspection. If the system is. 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,describ"conditions atthe time.of inspection and.underthe conditions of use at that time This inspection does not'address how.th+e system will'perform in the future under the same or different conditions of use. s Yids 5 Official Irispvdion form:Subsurface Sewage Oispasol System•Paget of!7 k Commonwealth of Massachusetts 13, 11 Subsurface,Sew a pls ds'al 5 stem;Form»hlct for llolunta Assessments + P y ry 4 284 Monomov Circle,Centerville _.._ ...._. - ---------- Property Address Susanna Downs ovvnef C3wner's Name _..... ......... 1$4 Monomo Circle Centerville Ma - r€quire * f v :.. r ._...... y...,... _....... �__.. 02632- 51912016 page. Cityfrown State Zip Code Date of Inspection . Certification (colic.) Inspection Summary: Check &B,C;D or E l 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; 8) System Conditionally Plisses. f-1 One or more system components as described in the Conditional Pas s°`section need to be replaced"or repaired..The system, upon completion of the replacement ar 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 deterrriined," please explain. The septic bank is'metal and over'20 years olds'or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exhitration 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. n Y [j N '❑ ND.(Explain below): ...... Title 6 ofliciat In Form'Subsurface Sewage[listsasai 5ystam•.Paga 2 04 37 Commonwea th of Massachusetts Rill Subsurface 5eaiieg+e Disposal System Form-Not for Voluntary Assessments �. 284 MonomoyCircle, Centerville- ............. _. property Address Susanna downs owl ef ... ,wnees Name 2"Monomo Circle, CenterVille Mai 0263 91912016 ri�C a1r ., r y _ Zi Code Date of lns page, uitytiowrt Mate p potion . B. C8 ficatioll {cont,j 0 Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumpslaiarms,are repaired. B) System Conditionally Lasses(cant.), 0 Observation of sewage backup or breakout or high stetic 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): El broken'pipe(s)are replaced [l Y R N ❑ ND(Explain below): obstruction is removed 01 Y Q N Q 1dD(F-_,x aid below): Q distribution box is ieveled'or replaced R.,Y ❑ N . M ,NC}(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 C]. ND(Explain below): Q obstructian is removed [J Y n N a❑ ND(Explain below): fi C) Further Evaluation is Required by the Board of Health: n 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 inrlll pass unless Board of Health determines in accordance vdith 310 CMR 15.303(1)(b)that;the.system Is not funoticoning In a manner which.wUl.protect public health, safety and the;environment: Cesspool or�privy is within 60 feet of a surface wu iter' Cesspool orprivy is within 50 feet of a bordering vegetated wetland or a salt marsh TWe 5 OffidN IrAped on Form:Subsurface Sewage Dtspusa!System page 3 of 17 r Commonwealth of Massachusetts 15 i f � r tr Form E 1 Subsurface Sewage l),isposal System Form-Not for Voluntary Assessments ;At lVionomoy Circle Centerville .u� ...._ _.__.. Property Address Susanna Downs Owner Cvrterls Name 284 ll onomoy Cable Centerville Ma _Kt?2fi�t2 91912 16 _ . � page-, oitylrawn State Zip Code Date of Inspection . Certification (CA!It.} 2. System will fail unless the 8oard'of Health(arid Public Water supplier,if any) determines that the system is functioning in a mannerthat protecft the public health, safety and environment: The system has.,-a,septic tank and soil absorption system(SAS)and the SA,S is within 100 feet of a surface water supply or tributary to a surface water supply. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. [j The systerrt has aseptic tank and SAS'.and the SA is within 50 feet of a private water supply well. ( The system,has.aseptic tank and SAS and the SAS is less than lul3 feet but 5O,feet or more from a private water supply.well"*. Method used to determine distance: �*Th s system passes if the well water.analysis performed at a DER certified laboratory,for fecal coliform bacteria indicot s absent and the presence'of;ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,:prouided that no other failure criteria are triggered. .A copy of the analysis must be attached.to,this form. 3. tither: b) system Failure Criterla Applicable to All Systems: You:must indicate"Yes"or"No"to each:60hefollowIng for all inspections:- Yes No Backup of sewage into facility.or systm.compunent due to overloaded or clogged SAS or cesspool . Discharge or ponding of effluent to the surface of the ground:oi surface waters. due to an overloaded or clogge.d;SAS:oi desspool. - Z Static liquid level in the distribution box aboue outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool.is less than 5":below invert or available volume is less than'/x day flow t`ws.3,, Two 5 owfoal Inspection Foam'Subsurtsoi Swags D spmal System>Pale 4 of 17 ` Commonwealth of Massachusetts " y Subsurface Sewage dsosat.System Form-Not-for Voluntary Assessments. 284 Mnnbrnoy Circi Centerville µ_..._.,..:_ 'rnperty Address Susanna Downs,: Owner Ovmer's Name requir � ' 2ti4 Monomo Circle Centerville Ma; 02632' 9l912016 page. Wityfrown state Zip Code` datef Inspection f . Certification (cont.) , Yes No Required.pumping more than 4 times in the last year NOT due to clogged or 11.1 obstructed pipe(s).Number of times,pumped: Q N Any portion of the SAS, cesspool or priVy is below.high ground Water elevation. Z Any portion of cesspool or privy is within.100 feet of a surface water supply or tributary to a surface water supply. 0 Any:portion of a cesspool or privy is within,a Zone 1 of a public well. Any portion of a besspool or privy is within 50 feet of a private grater supply well. 0 Any portion of a cesspool or privy,is less than I00 feet but greater than 50 feet. from a private,-water supply:well with no acceptable wawr:qumlit 'anal'rsis. I'This system passes if,Ahe,well water analysis.perfarmed 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 mtist,be.attached to this fo t.] The system is a cesspool serving a facility with a design flow of 2000gpd- 10wOgpd.- The.system. ils. l have determined that one or more of the above failure criteria exist as described''fn.310:CMR 15.303, therefore the system fails. The system owrier°should contact the.Board of Health to determine what,wili be necessary to correct the failure, E,) Large Systems. To be.considered a large systeim.the system'rnust serve a facility with'a design flow of 10,000 gpd to 14,000 god•. 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 [I 0 : the''system is within 400 feet of.a surface drinking.water supply [l ( 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 ll of a public water supply Well If you have answered"yes"to any question;in Section E the system is consideredA 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 threatunder Section E or failed under Section D shall upgrade the system in accordance with 310 GMR 15.304.The system owner should contact the appropriate regional office of the Department. Title 5 tafficia)Inspection form:.Subsurface Sewage Disposal SMom Page 5 of 17 =� Commonwealth of Massachusetts Title ff �ctal.:Inspe�ctior� Fora r31 = , z :t Subsurface Sewage Disposal System Form-Not'for Voluntary Assessments Y 284 Monomoy Circle, Centerville Property Address Susanna Downs f 3nxrtct Oj,vner`s Name requ red 284 Monomoy Circle Centerville Ma 02632 91912016 Page. City/Town _ � State Zip Code Date.of Inspection C. Checklist Check if the following have.been done. You must indicate"yes"ter"no"as to each:of,the following: Yes No 0 E3. Pumping information was provided by the.owner, occupant, or Board of Health C] 0: 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?. Haye large volumes of water been.introduced to the system recently or as part of this,inspection? Q Were as built plans of the system obtained and examined?(lf they were not availatila note as N/A) Was the facility or dwel ling.inspected for sigris:of sewage back,up,,. C] Was the site:inspected for signs of break out? Were all system components, excluding the SAS,10cat6d.on site? Q Were the septic.tank manholes uncovered, opened, and the interior of the tank inspected far the,condition of the bafflesor tees; material of.constructien, dimensions;depth of liquid, depth.of sludge and depth of scum? W. as'the facility owner(and-occupants if different from owner),provided with information on the proper maintenance of subsurface sewage disposal systerns? The size and location of the Soil Absorption System{SAS},an the site has been determined baser on: C] Existing information. For example;.a plan at the Board of Health Determined in the field(if any of,the failure criteria related to Part,Cis at issue approximation of distance is unacceptable)[310`CMR,15.302(5)] D. yttel"lG'f,li'f orIi'' a,tibn Residential Flow Conditions: Number of bedrooms(design): 3 --- Number of bedrooms(actual): � r DESIGN flow based on 310 CMR 15 203(for example: 110 gpd x#of beedrooms) 330 fide:5 Officiel:4tspaWw Form:St:bsurraca SewaSe Disposal System•page 6 of 17 Commonwealth ofMassachusetts � ¢t TitleCuff ci I r�spect n dorm m Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 2 1 onoMgy..C#rcle, Centerville Property Address Susanna Downs Dinner's Natnt§ 84 vonoyCcle Cetervte Ma 02632 919/2016 .2 ni ... _.... page. Ay/T wn State Zip Code Date of lnspection �D. SyS em,10fd rmnation Description; 2 Number of Current residents Does residence have a garbage grinder? ❑ Yes Z No is lour dry on a separate sewage system?(Include laundry system inspection C] Yes, Co No information in this report,,) Laundry system inspected? ❑ 'Yes 9 No Seasonal use? ❑ "Yes 0 No Water meter readings,.if available:{last ;,years usage(9pd}): Detail 2015: 127"00(} 2t114 �?,�Qt# Sump pump? ❑ Yes No Last date of Occupancy. : Current _.._......._...., Date Commerciallindustriai blow Conditions: Type of Establishment: Design flow.(based-on 310-:CMR 155.203) Gallons per daY(9pd) Basis of design flow tseatslpersons/sq.ft:;etc:): Grease trap-present? ❑ Yes F1 No Industrial waste holding tank present? _ ❑ Yes ❑ No Non-sanitary waste discharged to the"Title 5 system?. ❑ Yes ❑' No. Water meter readings, if available. .: Tine 5 Oft al inspection Form:Subsurface Sewage 01spossi System Page 7 of.7? Commonweal th of Massachusetts � ¢ T itl 0ff l ial Inslaect + ' h Form (` Subsurface Sewage disposal System form-Not for Voluntary Assessments 284 Monomoy Circle Centerville r-operty Address ._ Susanna Downs OwnerOwner's Name Circle, Centerville Nia2632 9l912016 pace, Cityrrown State. Zip Code Date.of inspection . System 1nforM#t en'(cunt.) Last date of occupancy/use: —-- - _. .-w ........ .................... Date Other(describe below):, General'lnformatiori Pumping Records: Source of information: __._ Was system pumped.as part of the inspection? ❑I.Yes 0 No If yes, volume,pumped: gallons How was quantity pumped determined? Reason for pumping: - - - Type of System: Septic tank,distribution box; soil absorption,system 0 Single cesspool 0 Overfow cesspool Privy El Shared:system (yes or no)(if yes,attach previous inspection records, if any) 0 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 tinder contact [� Tight tank.Attach a copy of the CEP.approval. ( Other(describe}; m;4•s 3'1 Tide 5 Official Inspe0on form:Subsurface Sewage Disposal Sftfem Page 8 of 17 ' Commonwealth of Massachusetts �} f Title 'Officia l Ins a ction Form Subsurface Sewage Dis I System Form-Not for Voluntary Assessments tl 284 Monomoy Circle Centerville __ ............ .,_ .,__ W..:............. Property Address Susanna Downs Oww Owner's Name re ir-,d 284 Monornov Circle Centerville Maw, 02632 9/9/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if ki ownj and source of information: Were sewage odors detected'.wihen arriving at the site? ❑ Yes Z No Building Sewer(locate on site plan): 8' Depth below grade: ................ . Feet Material of construction:; 0 cast iron [Q 40 PVC n other(explain): Distance from private water supply well or suction line: 1 Net Comments(on condition of joints,venting;evidence of leakage, etc.)' . ln_qood condition rto signsnf leakage©r.failure. Septic Tank(locate on site plan)i 2-611 Depth below grade: feet Material of,construction: ED concrete 0 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) 0 Yes El No Dimensions.. 1000 gallon Sludge depth; _._..._ Title 5 Officeai hupecrmn Fain:Substkaw Sewage.Dlsptlsal Systam•Page 9 of 17 .ommor>;wealth of Massachusetts at ;'subsurface Sewage.Oilsposail System Form-Not for Voluntary Assessments • 284 Monomoytrle Centerville w. ,roperty Address Susanna Downs Corner Owner's Name 284 Monomov Circle, Centerville Ma 02632 W912016 page, N ty/Town State Zip Code. Date of inspection System Information (cont.) Septic Tank(cortt.) Distance from top of sludge to.bottom of outlet tee or baffle 29,f Scum thickness , 31' Distance from top of.scum to top of outlet tee or baffle Distance from bottom of'scum to bottom of outlet tee or baffle 12" How were dimensions determined measured+1- Comments{on,pumping 1reo6mmendations; inlet and outlet tee or baffle condition, structural integrity, liquid levels.as related to outlet invert, evidence of leakage,etc.): Tani{in abod condition,". w Grease Trap(looate on site plan): Depth below grade: feet _. Material of construction: ®concrete El-metal [I fiberglass ©:polyethylene 0 other(explain): Dimensions: W W:_ 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 TWe 5 Official InspWian Fart;;Subsurface Sewage Disposal SYs=am*Page 10 a117 Commonwealth of Massachusetts x� a Subsurface Sewage Disposal System Form w Not for Voluntary Assessments 284 Monomoy Circles Centerville ..... ........_ 'roperty Address Susanna Downs Cd ter Owners Name inf�r;;s* requket$., ..:<. 234 Mon©mov Circle, Centerville Ma 62632 91912016 ' Page. State Zip Code Date of Inspection . 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 0 fiberglass n.polyethylene ...[] other(explain): Dimensions: Capacity. _....._., gallons Design Flow: gallons per day Alarm present; ❑ Yes M No Alarm level; w.. _ Alarm in workin order.g []:,Yes F1 No ©ate of last.pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of°current pumping contract(required). Is copy attached? ❑ Yes ❑ No 5i 1• b Title 5 Offlciai inWWion form:Su3iwftee Sewage Disposal System•-Page 11 of 37 Corm onwealth of Massachusetts P Title 5 Offiel"al'Inspection Form .. Subsurfade Sewage Disposal System Form No for Voluntary Assessments 284 Monomoy Circle, Centerville Property Address Susanna Downs Owner Owner's Name r ,} Centerville Ma 02632 91912fi116 required—i e .,';l ._Sd Man moy Circle, _.. page. C'ItylTown _ __. state Zip Code Date of Inspection . System Inf rmatlon {cunt.} Distribution Boo(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No D Box with this system__. Pump Chamber(locate on site plan): Pumps in working order-.:., n Yes n No* Alarms in working order: ❑ Yes ] No* Comments(note condition of pump dhamber, 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: Sirs a aJ"s TWO B f3rf 1ai Ins{iedon Forts Submidam Sewage Disposal 8ystam•Page 12 of 3? ,g Commonwealth of Massachusetts `�'if � ffi cl : pe ion-form ubsurface Sewage Dlspasal system Form-Plot for Voluntary Assessments 84 Monomn,, w Circle Centerville Property Address Susanna Gowns �7tatts?r C�rNnBr`S t3�tt�8 '#o` :" 284 Monomoy Circle, Centerville w�. Ma�µ 02632- 9/9/2016 Fagg, ity/Town State Zip Code Cate of Inspection 0. System Information (cont) Type: leaching pits number: 0 leaching nhambers number. El leaching galleries, number: leaching trenches number, length leaching fields number, dimensions:, overflow cesspool number innovative lalternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach Pit#1 is full Leach lit#2 water level Is 2:from the invert. Cesspools (cesspool must be pumped as part of inspection)(Innate 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 Q Yes fl No 5•i;°'3 Titte 6 Wrciai trmpaction form`SLsskdac&Sewafo Disposet System•Page 13 of 17 Comil onwealth of Massachusetts t F 'Title5ffc% Inpec. i Fora Subsurface Sew ige Disposal 5ystbr Farm-Not for Voluntary Assessments Monomov Circle, Centerville 13raperty Address ausanna Downs wnef 3 uner's Name : 284 Monomqy.qircle, Centerville. Ma..:W_._. 02632....,.._.. 919t2016 page;, .;ityfrown _ _......,....._. State � Zip Code,: Date of.}nspection . System 106, ination (cunt.) Comments(note condition of soil,suns of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on Site plan): Materials of construction: ---- .,,-_ Dimensions _._ : _ n Depth of solidi . Comments(note condition of soil; signs.of hydraulic failure, level of ponding condition of vegetation, _..._... I t,>irs•ut:3 Tale 5 Official inspoctinrr Form:Subsurface Sewage Disposal System Page 14 of 17 CommonweaElth.of Massachusetts Jry � °Tltl ff ei l Inspection Form 3 Subsurface Sewage disposal.System Form-Not for Voluntary Assessments 284 Monomoy Circle]Centerville Property Addy Susanna Downs G; r Owner's Narrie 284 Monom2y.Circle; Centerville Ma 02632 9/912016 r City/Town State Zip torte Date of Inspection D. Seger» tnforrnation (coat.) 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 106 feet. Locate where public.water supply,enters the building:Check one of the boxes below` hand-sketch in the area.below 4wwft attached se arately L : • r t 1 ' 2w i ommonwealth of Massachusetts pectl f yi tbsurface Sewage 1Disppsal System Form-.Not for Voluntary Assessments W "' 134 Monooy Circle Centeville I ioperty Address 3usanna Gowns lvr;et _..._ _ .._.._ Owner's Name requ,r ;:, ,,t :, ' d i ran n7 Circle Centerville_ _ Me 02632 91912016 ... re" '.ikylTawn State Zip Code Hate of inspection : . System Information {cont.} _ Site Exam: 23 Check Slope Z Surface water Z Check cellar Z Shallow wells 12' 16' Estimated depth jo'high ground water: feet Please indicate all methods used to determine the high ground water elevation: [ Obtained from systemdesign;plans on record If checked, mate of design plait reviewed __. Date . abserved'site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You Must describe how you established the high ground water elevation Per inspection b Joseph N,1V4artMS of Accu Sepcheck dated 8/23/2016 Before filing this Inspection.Report,please see Report.Compieteness.Checklist on next page. ;; `:? Title 6 OrWai inspedi h farm;Subsurface Sevragg Dispazsgl System•page 16 of 17 ommonwealth of-Massa husetts " Offi lal Ins pection Fc _rr Subsurface Sewage Disposal System Form N©t for Voluntary Assessments 4 MonomaY Circle Centerville v .__ )r4perty Andress 3usanna Downs Quirt t), ner's Name ,t nrrrr !84 Monomo Cy ircle,Centerville Ma U2632 l I l t7�6 W.._........_ .._...._ ....................._.., ,...__..:., _ t :ityfTown State Zip.Code Cate of Inspection ii. Report Completeness Checklist Z Inspection Summary:A, B, C '©,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 _ Title 6 Official fnspe'.ition Film:Subsurface Sewage niWssi System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION_ � �-1 /��d�1 f� P�°0-� L'�+ G �_. SEWAGE # � VILLAGE �. „• ,k y,�- ,:�,�.- ASSESSOR'S MAP LOT _& . INSTALLER'S NAME PHONE N0. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �r �� �� o'r' (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER) BUILDER OR OWNER +f 7z) f -- q='r DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No LL N(� zit' 3Zr 1000 GA j �LPTtc TNT , f>6kS-rlN , ICU-) GAS Fk- •- AsT RT.� E -(VYj-rIT(hr-w ' W�3res� �z �tDN� TOWN B STABLE LC?--ATIOrI 0�ky IV040d SEWAGE # VILLAGE ASSESSOR'S MAP & LOT Z INSTALLER'S NAME&PHONE NO. 7 � SEPTIC TANK CAPACITY LEACHING FACILITY: - D (type) `-(L r! �/ (size)L � NO.OF BEDROOMS ••//Jam. • -i3UILDER OR OWNER S r PERMITDATE: 91) LIA COMPN DATE: L3 0J Separation Distance Between the:Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 7 7 3 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet-of leaching facility) /V �T Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fag*)1)AARTINS Feet Furnished by ACCU SEPCH.ECK Sbe►wl� 5 vT ID) f r j fez 13 �z _ /s z Z 7 i G --V7 4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: a 0 v monomo� L ' rG l e Owner's Name: �5 � `""(C4 pR► ;S i Owner's Address: l b 60 Date of Inspection: 3 Name of Inspector.(please print) Joseph M.Martins Company Name: Accu Sepcheck Mailing Address: 17 Northside Dr., S.Dennis,MA 02660 c� Telephone Number. 508-385-5891 - CERTIFICATION STATEMENT 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 <f: Y Conditionally Passes `Needs F 'on.by the Local Approving Authority Fafls Inspector's Signato Date: / 6 The system inspector shall submit a copy of this inspection'report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ' Notes and Comments: Coen�' ✓" Uf l?rQ�/1 � .e laump C Aq#7 �s7- LP�C �i7- u 3 ytove-s . ****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. Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: 284 Monomoy Circle, Centerville, MA Date of Inspection: Parisi f Z3/2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys to Passes: I have not found an information which indicates that an of the failure criteria Y y 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 repla repaired.The system,upon completion of the replacement or repair,as approved by the Board of H ,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. of determined"please explain. The septic tank is metal and over 20 years old*or the septic tank esker metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank fail imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approv the Board of Health. "A metal.septic tank will pass.inspection if it is st ucturally d,not leaking and if a Certificate of Compliance indicting that the tank is less.thad 20 years old is a .4, . i ND explain: Observation of sewage backup or out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, end or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The em required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass insp ion if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: . Page 3 of t t OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 284 Monomoy Circle, Centerville, MA Owner: Parisi Date of Inspection: d /23/2005 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 ac ance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will pr ct public health,safety and the environment: Cesspool or privy is within 50 feet of a face water _ Cesspool or privy is within 50 a bordering vegetated wetland or a salt marsh 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.toa surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public supply. _ The system has a septic tank and SAS and the SAS is within 50 a private water supply well. ; The system has a septic tank and SAS and the SAS is 1 100 feet but 50 feet or more from a private water supply well".Method used to determine ce "This system passes if the well water analys ormed at a DEP citified laboratory,for coliform bacteria and volatile organic compounds" uates that the well is free from pollution from that facility and the presence'of ammonia nitrogen an trate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A of the analysis must be attached to this form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address- 284 Monomoy Circle, Centerville, MA Owner: Parisi Date of Inspection: O /2.3/2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _V 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%Z 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 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. s/ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria I are triggered.A copy of the analysis mast be attached to this form.] Na (Yes/No)The system faiLs.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,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- .. You must indicate either' or�cnor to each of the following: ('Ihe following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking wa supply the system is within 200 feet of a tributary t surface drinking water supply the system is located in a nitrogen itive 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. Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: 284 Monomoy Circle, Centerville, MA Date of Inspection• Parisi $ /23/2005 Check if the following have been done.You roust 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 V/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 N, 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 breakout !/aCGv / Were all system components g e SAS,located on site _V _ Were the 9cp is tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the/taffies 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 she and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no 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(3)(b)J Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. 284 Monomoy Circle,Centerville, MA Date of Inspection: Parisi FLOW CONDITIONS F' /7-3/2005 RESIDENTIAL- Number of bedrooms(design): 3 Number of bedrooms(actual): 33 DESIGN flow based on 310 CMR 15_�03(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes r no):ITT [if yes separate inspection required] Laundry system inspected(yes or no): ZgDq - y4`000 Seasonal use:(yes or no):__No 10 Water.meter readings,if available(last 2 years usage(gpd)): ZDQ 3 /.r�0a Sump pump(yes or no): �V v /v Last date of occupancy:—�� f AV E 6'00.P 27T COMMERCIAL/INDUSTRIAL 'J Type of establishment: Design flow(based.on 310 CMR 15.203): gpd Basis of design flow(seats/pe soiWsgft,etc.): Grease trap present(yes or no):— Industrial waste holding tan k es or no): Non-sanitary west arged to the Title 5 system(yes or no): Water m ifavailable: of occupancy/use: OTHER(descnbe): t GENERAL INFORMATION P Source o inferRec as Source of information: Was system pumped as part of the inspection(yes or no): /V O If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM t., S tic tank,distribution 4soi l absorption system &J Z /0 /1 _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) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of a �ponen�d installed(if known)and�ource of information: �Uf Were sewage odors detected when arriving at the site(yes or no): NO I Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 284 Monomoy Circle, Centerville, MA Date of Inspection: Parisi $ i23i200s BUILDING SEWER(locate on site plan) "Depth below grade: a-3 Materials of construction: cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: '>1 p 1 Comm (on condition of joints,venting,evidence of leakage,e SEPTIC TANK:_(locate on site plan) Depth below grade dt41i Material of construction:Vooncrete metal_fiberglass_polyethylene __other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate)Dimensions: J�AY/l d p `� r 61' X -�-t 7/1 Sludge depth: 1 3�it Distance from top of sludge to bottom of outlet tee or baffle: Same.thickness: /1 Distance from top of scum to top of outlet tee or baffle: 511 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: /Y►,PIJt!1/RPd Comments(on pumping recommendations,inlet and outlet tee or bade condition,structural integrity,liquid levels as related to outlet in evidence of 1 etc.): �P7 GREASE TRAP: (locate on site plan) Depth below grade:_ 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 ba Date of last pumping: Comments(on pumping recommendations ' and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence age,etc : Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 284 Monomoy Circle,Centerville, MA Date of Inspection• Parisi ' 8 /2;/2005 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal iS�gglass_polyethylene other(explain): Dimensions: Capacity: gallper Design Flow: lons/day Alarm present(yes or no): Alarm level: arm in working order(yes or no): Date of last ' g: Common dition of alarm and float switches,eta): DLSTRIBUTION BOX: ((ifpresent must be ocate on site lan�� plan) Depth of liquid level above outlet invest: 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 or no): Alarms in working order(yes or no): Comments(note condition of pump ch ,condition of pumps and appurtenances,etc.): 1 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: 284 Monomoy Circle, Centerville, MA Parisi, 2ooS SOIL ABSORPTION SYSTEM(SAS): (locate on site pl�n�ei4#9%n not required) If SAS not located explain why: T Y leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: L Z ; 6�mU e ®� leaching fields,number,dimensions: r overflow cesspool,number: BUvn'L innovativetalteinative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.)- L/&Ol l S� sec �ir/o 8 �V�- _ ice/ i Z f�� � Z/QV! Lpj/P 1 = .��� � C711�P �lP I S CESSPOOLS: (cesspool must be pumped part of inspecti&Xlocate on site plan) - Number and configuration: yx i J , 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 o>of'Aaulic Comments(note condition of soil,signs failure,level of ponding,edition of vegetation,etc.): PRIVY: 09w, en an). Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,I ponding,condition of vegetation,etc.): Page 10 of 1 I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 284 Monomoy Circle, Centerville,MA Date of Inspection: Parisi F /;3/2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply antes the building. . I W -A3 2-7- 2-7 Page 1 I of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 284 Monomoy Circle,Centerville, MA Date of Inspection: Parisi SITE EXAM g /l 3/2005 Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12, 16 Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) ✓Accessed USGS database-explain:_T7�#0� 367 4-" t*Ole- G 1 s -P?P7 M �� You must describe how you established the high ground water elevation: f P / alp I LO -RMIT M-0... 17 D4-T-E P-E-R-M1T 1_5SUE-D _ e � ,��' j. � . . ., .. - � •Sr. ._... ... .. � .. ., • ...r u..�.. .. .... }'... ... No ..y..2 F Fxs THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... w'^--.......OF ... ... ............. Appliratiun for Dispuiittl Marks Tonstrnr#tun rami# Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: MoAl D A4 dly :. .`� Dlti iA Yho1 C , ----•---- �: Location $gess C or Lot No. Owner ..................................................... --� Address n Installer - naaress Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..7------------------•-_•-.-__---Ex Expansion Attic a p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures .. - • - W Design Flow........... .............................gallons per person per day. Total daily flow.._...71 ..r�..................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length............... ... Total leaching area....................sq. ft. Seepage Pit No.........1.......... Diameter......../:)�'. Depth below inlet....... ....... Total leaching area...........:......sq. ft. Other Distribution box ( ) Dosing tank ( ) W Percolation Test Results Performed by.......................................................................... Date.................................... Test Pit No. /................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........................ --•------•-------•--•--••-----------•................................•--•--.-.-.---•----•---•--•---------------------------------------- •----------------- .. O Description of Soil.......................................................................................................................................................................... U W x •---•••--•••--------•-•-----•-----••....---••---•-•-•--•--------•••-----•-..:.-----••--•--••-•----•---------------- 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 KITH% 5 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 boaro of health. Signed.---------� Dat Application Approved By... �...----............................................... `' Date Application Disapproved for the following reasons--------------------------------------------•--------------------•-----------•----------•-•••-•................. ..................•-•-................c ••--•-... •--•••------...•••---•••............--••-•--.......-••--•--•-••---••-••-•--......----•••--•-•......•-•.................... Date PermitNo...............................................-•••--•-- Issued....................................................... Date TOWN OF BARNSTABLE LOCATION act-'A, _. SEWAGE # VILLAGE �•� - 1.� � ASSESSOR'S M-AP & LOT INSTALLER'S NAME & PHONE NO�� , SEPTIC TANK CAPACITY LEACHING FACILITY:(type)�l �>��pr/�',,1� (size) 00 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATT R BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ' IIOf 2W 321 ExStSTt N(� 10pp GA� P?tC TNy— 61q (��•c:WST�C,T PVC <061 C ms THE COMMONWEALTH. OF MASSACHUSETTS BOARD OF HEALTH • .G a.1(�-, ...oF......` .u.v-v�S�t c L,`.P�................................. Tntifiratr of Toutplittnre THIS IS T-LO—CERTIFY:T-hat the,Individual Sewage Disposal System constructed ( ) or Repaired ( �� ->- --\ by................. .. ..----............. J' ..... p� - ----•----------•---•---•---•...........----.....---•-••---•--•-----••--•--..............-----.........._ Installer at......................... .. ....1.......... Gtl. ._...-••-•�t-�4` -------------------------------------•----•- has been installed it accordance with the provisions of 'P T iZ4 iZ4 5 of The State Sanitary Code ads-described in the s application for Disposal Works Construction Permit No ....... ?__1..... dated........%.r__./-�._f..��r-. �.._...._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAti;ANTEE THAT THE SYSTEM WILL F NCTION SATISFACTORY. DATE................... / / /a---._...•-•-_. Inspector.................................................................................... �-, -� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.........�R>� .if J% .5�.�.(o�...�- ..................... C�� Nor. . _.f..._....: FEE........................ �- Disposal� nrks�n p trrilo an plamit Permission Is hereby granted ................................ to Construct ( ) or Repair (,•)>an Individual Sewage Disposal System f at No------------------ 'E ................t!1✓t i)V� =` �,1 v�. 5 . Street as shown on the application for Disposal Works Construction Permit-No..- �L—�__ Dated..........(f%.: Via.._...... I.._ Board of Health DATE.......... ,, >Z� ...........=_ > ------ ' AFC. :Fr ; ��✓ o No '.---�22" >, FEB......... _..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A lirtttilan for Ui paiittl arks Tonstrnrtiun JIrrutit Application is hereby made for a Permit to Construct ( ) or Repair �ah Individual. Sewage Disposal System at: .M(),A,/ e ,4A dll ................_n. ...`_............... - -...-•----....... Location.fdd.6ess t co.r.Lvo l N........... .�.=u .................. - w:-.. - . - -- -•----••-----•-•-- .................-�...�. .................................................... Owner Address �� a -----------------------.................... ------. :-.--_---_�>-Y:?�`-_...------ s------------"'••?��"........._.......... Installer 7 Address ' Type of Building ---- Size Lot............................Sq. feet ►-� Dwelling—No. of Bedrooms........ ................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T ype of Buildiu g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ................................................... W Design Flow...._.....�S....6 ..................gallons per person per day. Total daily flow....... 2L. _CC---_.......__._....gallons. WSeptic Tank—Liquid capacity............gallons Length._._.__._...'.. Width....._......__. Diameter________________ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area........_...........sq. ft. Seepage Pit No.........J.......... Diameter........ Depth below inlet.......(lE. :. Total;leaching area..................sq. ft. Other Distribution box ( ) Dosing tank ( ) 6 W Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No.,. 1_-_•-_•_- _--minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit-No., 2................minutes per inch - Depth of Test Pit........._.......... Depth to ground water........................ a , .J ----•..............•---•---•-•-•......................................................... Descriptionof Soil ....................................... ......•:-----•---•----•-------••--••---•------••••---•••••---•-------••••------•---------- ...................................:�_.__. -----------------------------------------•---___--------..-__-_•-•-..__.. --- _-___--_--__..__.--____.-_-----_--•_-•--_---_-•_-___--------. ..._._..__....___.__....._.___. . V Nature of Repairs or Alterations—Answer when applicable-.--_••_-._/���� Ll �� ........... ....��u 4 = ' �... v�;� ......... / .._ �)y Agreement: '"`1 1=..J (1 The undersigned` agrees; to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of.-.I.:.i; 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b'y the board of health. _. �! . _F_ _= •�r ~�s'�J,�^" 'i!. -'-- _ �--•:. ..........-Signed 1 -". ' .. ._ .. .? .._. Date Application A roved.B ' Application Disapproved for the f ollowiny�`reasons:-----•--------------------------------------------------------•-----------------•----------•nate._......._._. { ,.......... Date Permit No......:'... 2 ��' '' - Issued.....................................................- ... t/ rf Date 18'-6° Addition to to 6'-10" 284 Monomoy Circle 1 -�� DI Centerville, MA 1 j c7 WASH 2/DRY R I I _ Mark Sangiolo,Architect 23 Willow Street -o.6s 00 W. Harwich, Mao26�7i T-1 1/ ' I I J I I I I I I I , I I I a I I I I I - I n. I N EXIST.SEPTIC TANK I � A ' A� I — — — — — — — - — — — — — — — r — — — — — — —)I— — — — — — — — — - I i I FAMI�YROOM I ,' zys a I I ±-qx;-4 CAS. I DH, i 3' O„ BARSINK I I ' 4'STEP I I, I I � Sliding � I I ————————————————————————————— — — — - I - I sil.vletal I 1 ±RISERS @,.;°NIA.\. TREADS @ 6x6-8 4x6-8 EXIST. \ REb1OVE DOOR � I i EXISIT.GAS METER (IL_:E.:-Z Wd:!9)1,819n:v I KITCHEN \ INIDYG ROOM y1f NEW TUBE SKYLIGHT OVER .RED ARC, z-4.x,--x DFI EXISTING WALLS $^M,—, c O do.74" fO 0 NEW WALLS WEST HARMCH. 3x6-8 L X rn 0 2' 4' 8' LIVING ROOM FIRST FLOOR PLAN AZ i GARAGE N 4-16-16 _ 3x6-8 I ' I C 1 9 PH 5�37 MAP 190 LOT 213 #81 5�02 W REBAR SET REBAR SET N 5g•49' , _ MAP 190 LOT 212 #308 MAP 190 LOT 210 � MAP 190 LOT 211 1 #268 AREA=15,058.6t S.F. l O 0.345t ACRES 1 f 18.5, c A>aPR0Y,. o z a1 r °c �SEPTI cn o tK SYSTEM ° a o f= a. - o -- - _ "goo �'� N, l a a � = r G 1.010 z t�1 CONC. BOUND f" EXISTING 1-STORY FOUND 4� DWELLING #284 5: REBAR SET .�r g t.-1 .` r �- L=4 99.73' !Y tt�) � �- X L- , w E � 1 288 T,1 �REBAR SET-4 � 30.97 ►-.�''� C `_ ' `�'` -R=230.97' CHb a 1'24'S�',W < G u'� CH 172.14' Gc wWG W 6' 0 /]// cif? A .....3( r1 ft - 7Z1 o4f0jv 70 ZONE: RC MIN. LOT AREA: 43,560 S.F. MIN. LOT FRONTAGE: 20' MIN. LOT WIDTH: 100' MIN. FRONT YARD: 20' N MIN. SIDE YARD: 10' MIN. REAR YARD: 10' J t i 30 0, 30 60 90 SCALE 1"-30' REV. 1 : 12-06-16 ADDED BUILDING ADDITION MGC PROPOSED PLOT PLAN M 284 MONOMOY CIRCLE CENTERVILLE, MASSACHUSETTS OF I CERTIFY THE LOCATIONS AND TIES SHOWN ON THIS PLAN RESULT PREPARED FOR � � FROM AN ACTUAL SURVEY MADE ON THE GROUND ON THE DATE p? JAEES OF FEB. 23, 2016. TOM G LED H I LL PET ERSON 284 MONOMOY CIRCLE No.34824 , CENTERVILLE, MA 02632 SUH��dt' •GISTQ RED PROFESSIONAL LAND SURVEYOR o DATE O DATE SCALE DRAWN FIELD CHECKED t ALPHA SURVEYING AND ENGINEERING INC. 2/23/2016 1"=30' AMC RAP/AMC I RAP conr�\. 695 WAREHAM STREET SHEET No. DWG. NO. JOB_ NO, ��� - sut��nNa AtdF� MIDDLEBOROUGH, MASSACHUSETTS 02346 ENGINEERING INQ (508) 295-5505 1 of 1 1 6107.d wg, 16107 t 1 18'-6" Addition to to , . 1 10 6'-10" 284 Monomoy Circle -g\_-,DF >- Centerville, MA 1 --j 3 cM WASH 2/DRY1 R v I Mark Sangiolo,Architect 23 Willow Street -o,6-s 00 3 W. Harwich, Ma 02671 T-1 1/ ' I I I I I I I I I � I I I -1-- A EXIST.SEPTIC TANK A I — — — — — — — - FAMI�-Y ROOM �Jx x I I =-yx DFI3-+CAS. I i / I I BARSINK I I 3-0n 4"STEP l , I I� / Sliding i I 3-0 6-8 ' f I LU I.D4et1l I I I - I I I j 1 x RISERS n 7.5"NIA\. TR1 ADS @ io.5" 6x6-8 4x6-8 EXIST. REMOVE DOOR � I i D EXISIT.GAS METER KITCHEN \\ I INIDYG ROOM NEW TUBE S KYLIG FIT OVER �tiaED qRo 3 =+�5^DHmm�iiii EXISTINGWALLS ����FSA,pca'¢ E No.74" 0 O NEW WALLS VV-ST"4RWQM' 3x6-8 x x 91 0 2' 4' 8' w r LIVING ROOM FIRST FLOOR PLAN AZ GARAGE N 4 4-16-16 3x6-8 i ' I