HomeMy WebLinkAbout0016 MUSKEGET LANE - Health 16 Muskeget Lane
Centerville P
A = 170 038
I
Oxfoa ® NO. 1521/3 ORA
"0
9
i
TOWN OF BARNSTABLE
LOCATION /41!/Sk�;n . SEWAGE# J20 f/ — iI Z6
VILLAGE C e v�`Ce�y,�`f. ASSESSOR'S MAP&PARCEL /?6 -,39
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY tT�pQ
P
LEACHING FACILITY:(type) -Soso (size) // ya
NO.OF BEDROOMS LI
OWNER
PERMIT DATE: % i- nj -.10 1/ COMPLIANCE DATE: '
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 2.00 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leachi facility) D Feet
FURNISHED BY - aNgs,,
\I'LL
O
/q"O of
No. a (I �J ' Fee C�✓
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for !Disposal *pstem ConstCULttoll Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. / S Owner's Name,Address,and Tel.No.
6_e r�rttv- C�ltuC` 1L
Assessor's Map/Parcel ry /r76 P 3
Installer's Name,Address,and Tel No Designer's Name,Address,and Tel.No.
-��eX4_,7 �a 1
Type of Building:
Dwelling No.of Bedrooms / Lot Size l 6 sq.ft. Garbage GrinderWP
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided y S S gpd
Plan Date 1 I I Number of sheets Revision Date
Title
Size of Septic Tank 4 go Type of S.A.S. g-e .� O S7S wl 3'5A4P
i
Description of Soil y�, S k 10.?,SAY l �S
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o ealth.
Signe Date I (
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 2. l - �(EZO Date Issued 2
o
No. Fee U ./
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASSACHUSETTSYes
f
4plication for Disposal 6pstem Construction Permit 1:7, ,
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. US ^L Owner's Name,Address,and Tel.No.
0 f tk-T V- CICI ���5
Assessor's Map/Parcel M /76 Q 3�
Installer's Name,Address,and Tel.No Designer's Name,Address,and Tel.No.
V)D- 6Y8 -9241
2 -
Type of Building:
Dwelling No.of Bedrooms / Lot Size Ei l sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) y y gpd Design flow provided L) S S gpd,
Plan Date 1 IQ I 1 Number of sheets Revision Date
Title
Size of Septic Tank �a0 Type of S.A.S. rt d S 71! �� 3 S ✓1 P
Description of Soil �l.S /U �T JX • �S
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement: '
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this RBoard ealth.
Signe �Cd�._ �e.�_. Date Z I 1
Application Approved by r Date
Application Disapproved by Date
for the following reasons
l
Permit No. 2 Date Issued 12 A111
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed epaired( ) Upgraded( )
Abandoned( )by 1A k c, koe--p�Z 0 d t�<<7—
at /6 //,�'/ U S 14f 1✓`7- /—A"N 9s`bben�— stMidted191aecordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 11 '�a 0 dated
Installer C k �jr (ib,J � Designer d
#bedrooms Approved design flow -Y-SS gpd
The issuance of this permit shall nodbe construed as a guarantee that the system yvill f�unctioe��,
Date / �p� � Inspector `\
---------
No. )0 z��d Fee /DU THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Dispo8 6pstrm Construction Permit
Permission is hereby granted to Construct( Repair( ) Upgrade( ) Abandon( )
System located at V
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.
4 Date t '2 G1 /f f Approved by (� S
I dll�'
[' `�
CS1 l T �J ro
TPsc�nsas F. Gefler Director
t BL.ICT'IS£ABIE.
m-ABS. s T�blp� �iea th Di7v is L�L1.
T hQ1illa5 MCl eaIl➢9 DI `i -toy
200 Maim sheet,Hyammis,>`�t1 A 02601
Office: 508-862-4644 Fax: 508-790-6304
i nstafler & DesiMeZr cCertUftation Form
Date- 11i Sewage Permit-it C:4/ 1 4v Assessor's MapTa cei J
l�esignnere 11J0� (� /f1RA Innstaner, C o'h.J AC�G1`
AA V
Address..I / 41 Address- �� � f
Mu �t a 11 4L'q
On was issued a permit to install a
(date) / (installer)
septic system at 6. /"t m e, based on a design drawn by
Q
(addres
lkyn
i 2 - c2 LK_
dated
(desib er) I,
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations, Flan revision or
certified as-built by designer to follow.
OF'44,48S9cy
DANIELA. �s
J rt— 6r_ m
(installer's Signature) o OJALA Cn
CIVIL Cn
o No.46502
P��QFG/STER�O���r .
_ L ASS/ONAL ENG
(Designer's STgriatLire) (A° n Desi�ei s stamp s
g����
LLEASL RETURN TO BARNS RUBLE PLJBLfC d EAL'9'lE 1� VISION. CERTIIG' OF
�OAIP"a,IATdCE WILL NOT 'BESSUkD �i�'b'FL BOT�IL 1Hs FORM\ AND As-B�7T�LT C ARE
R �CEFV EID BY TBE BAIL i' r�
4STABLL PUBLIC BEALTH MSION. TI�1�
E YOU
Q:heaiL /5eptic/Designer Certification Fonz 3-26-04.doc
Town of Barnstable P#
BIKE ro,
� DepartinGnt of Regulatory Services
Public I-le�ll�lla Division Date
200 Main Street,Hyanuis MA 02601
• A U pAA'I� � y��
Date Scheduled_ Time u ee ��•
Soil Suitability Assessrizent for Se,'Wage 's 0gall
A- /' r i 1Yltnessed B
t'crl'onned Dy: Jr� � y� -
-- — ]L0 CATION & O]CNE, AL l[NFOJ[BIVIIAA' ION -
Location Address // /y� / Owner's Name
Address
Cngincer's Namc e�0lAJ//V\., IAN
L�
Asscssor's Map/Parcel; 1'7Q/ly�-
NEW CONSTRUCTION REPAIR +' Telephone It
[14/��� '
Laud Use slopes(%) U Z Surface Stunes NGAC
Distance's From: Open Water Body tt Possible Wet Area Aft Drinking Water Well �ft
Drainage Way _Ft Properly Lille ft Other ft
SK1L,'`IC'CH, (Street uame,dimensions of lot,exact locations of Iesl holes&pert tests,locale wetlunds-in pro)(in to holes)
za
M
J
oX�
VKU�j l� e_
Parenl material(geologic)_ �l Depth to Dedraels
^� Depth to Groundwaler: Standing Water in hole:�N(�N Weeping Plain Pit pfloe
Estimated Seasonal High Gioundwater
D7CTEBAIINA7['ION FOR SEASONAL HIGH WA71'EM TABLE
Method Used:
Depth Observed standing in obs.hole: ln. Depth to sill trlotllss; In.
Depth to weeping from side of obs.holc: Ill, t7rtlullrJWalar AdJuslment,� Fr.
lndex Well I# Rcading Dalc: Indcx Well leYol �r Ac�j,fractot' _ ArJ,0,,tptth(IWater Lc el
Observation ]PERCOLATION71'�CST Date � 'a'jitifl 404w
tIolc# Time tit 9"
I( f.
Depth or Per
__ �_ I'luie at 6" _
Start Pre-9oak Time @ dU Time(9"-6")
End Prc-soak t t;
Rate Min./Incli GZ 4
p�
Site Suitability Assessmunt: Site Passed_ Sitg'-Failed: Additional Testing Necded(Y/DI)
Original: Public Health Division Observation Hole Data To Be Colnpieted on Back-----------
***If tlercola9tiou test is to be conducted within 100' 0f Weillalndy you must first Uotiiy dRe.
Barnstable Conservation Division at least 011c (A) Welch pricir t0 beginiuing.
QAS EPTla'ERCFORM.DOC
t
D11C]Cp.®BS]I✓]f�'6�ATIO�T TIOL t ]LOB
Depth from Sa
Soil 1-]orizon ]I$
Texture ole .�''
Surraee(in.) 'oil Soil Color
(USDA). S01I' Other
Wunsell) Mottling (structure,Stones;Boulders,
Con istenc %a'a ravel
SL �eyf2 ��
DSoil Ho O�S]E]f��TA'�ION ROL ]LOG
Depth from Soil Horizon 11®.In? }�-
Surface(in.) Soil Texture Soil Color
(USDA) MIDI
(Mansell) Mottling (Structur ,0eIer
Stones, Boulders.
ConsiS e c %Oravel
Z -5 i yip G/
DE
Depth from Soil-Horizon Surface(in.), Soil Textura 110LE LOG
Soil Color
(USDA) Soil
(Muns4ll) Other
Mottling („truclure,Stones,Boulders.
Consistency 9a Omvel_7
DE EP 013SIERgrA7['ION HOLE, ]LOG
Depth Earn Soil.Horizon Hole#
Surface(in.) Soil Texture Soil Color Sall
(USDA) •, (Munsell) MottlingOther
(Structure,Stones; Boulders,
Consistency,
E111od Insurance Rate 14ypa
Above 500 year flood boundary No Yes
'within 500 year boundary No Yes. _
Within 100year flood boundary No yeg
DD !l of 7 atuirally occuarrMp L( li[7ylous Material
Does at least faun feet of naturally occurring pervious material exist in all areas observed thl•oughout the
area proposed for the soil absorption system`
)it not, Farhat is the depth of naturally occurring iervious materials
C�e>rtiif- eca�c?on •
k certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental,Protection and that the above arlaly.;is,was performed by me consistent with
the regl6red training, expertise and experience described in V10 CMR 15.017.
Signature
Date
Q:1S,L??TfCIPEP CFO RM.DOC
TOWN OF BARNSTABLE
LOCATI7N �COi%'/L� /L� � SEWAGE # J7—;9�ea;Z,
! VII.LAGE(�.� �/.��i�r_ �s9� ASS SSOR'S MAP & LOT
INSTALLER'S NAME& PHONE NO..—
SEPTIC TANK CAPACITY
LEACHING FACILITY: (typeV6t4_/ � f (size)
NO. OF BEDROOMS 31
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Veee
ac g Facili (If any wetlands exist
within ) Feet
Furnishes
• n-._..
K
i
i
� � j/�
1 ��
1 �� 32y /
1 f �
1 �/
a — � � �
DATE:8/30/0
PROPERTY ADDRESS: 16 MuskAget-Lane ------
Centerville,Mass.--__--- rod
--
02632 ao 199
------------
-------------
On the above date, I inspected the septic system at the above addre
This system consists of the following:
1 . 2-1000 gallon precast leaching pits.The leaching pits
are in series. ( 6 ' X10 ' )
Based on my inspection, I certify the following conditions:
2. This is not a title five septic system.— _
Thi's - is a sewage system.- The sewage system 1s in
3proper working order ,at.. the ..present- time, r-�
4 . #1 pit waste water is 4" below the invert pipe. #2 pit waste
water is 66" below the invert pipe.Stain line on pit 42" below
the invert pipe.
SIGNATUR
Name: J .- P . -Macomber-jr.
Company:Joseph Pam_ Macomber _� Son, Inc.
Address :-_sox _QQ________-___
ba--Q2632-0066
Phone: 5 0 8-7 7 5-3 3 3 8
---------------------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 16 Muskeget Lane
Centerville,Mass.
Owner's Name:Wendy Mullin
Owner's Address: Same
Date of Inspection: g 3 o I o 2
Name of Inspector: (please print) Joseph P.Macomber Jr.
Company Name: J_P_Macomber & Son Inc.
Mailing Address:Bnx 66
02632
Telephone Number: 508-775-3338
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
appfoved system inspector pursuant
/tooSSection 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall Vubmit 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
****This report only describes conditions at the time of inspection and under the conditions of use at that
I
,time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Pape 2 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 16 Muskeget Lane
Centerville,Mass.
Owner:wendy Mullin
Date of Inspection: 8 30
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. ystem Passes:
c
!� have not found any informatio J=which indicates that any of the failure criteria described in 310 CMR
15.303 or to 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
,The sewacre system is in proper working order at the
,prpsg-nt time.
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.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explain.
AU 6 The se tic tank s 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.
ND explain:
Observation of sewage backup or break out or high static water level in th distributio b'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
obstruction is removed
distribution box is leveled or replaced
ND explain:
XThe 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
obstruction is removed
ND explain:
2
°age 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 16 Muskeget Lane
Centervi e,Mass.
Owner:wendy Mullin
Date of Inspection: 8/3 0/0 2
C. Further Evaluation is Required by the Board of Health:
VO 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:
4L,J 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
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.
Q The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
/lk)The system has a septic tank and SAS and the SAS is less than 100 feet but?0 feet or more from a
private supply well"'. Method used to determine distance yG�fZl
"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 are triggered. A copy of the analysis must be attached to this form.
:Oter-):
This is a sewa e s stem. The s stem consists of
2-1000 gallon precast leaching pits in series. W X10 ' )
See page 10 First pit acts as a septic tank_ Contains soild
waste in place and also leaches-The effluent passes to
the second pit.
3
Page 4 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 16 Muskeget Lane
Centerville,Mass.
Owner: Wendy Mullin
Date of Inspection: 8/30/02
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no" to each of the following for all inspections:
Yes No
d/�ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_Y 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 bo above outlet invert due to an overloaded or clogged SAS or
cesspool
�iquid depth in� I is less than 6" below invert or available volume is less than ''A day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped Q.
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.
_ t//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 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
are triggered. A copy of the analysis must be attached to this form.]
(YesNo)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 now of 10,000 gpd to 15,000
gpd.
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes now
o 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 11 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.
4
Page 5 of I I
OFFICIAL, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 16 Muskeget Lane
Centerville,Mass.
Owner:Wendy mull in
Date of Iospectioo: R f-30102
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
—/+oere any of the system components pumped out in the previous two weeks ?
_ _ Has the system received normal (lows in the previous two week period ?
/Have large volumes of water been inrroduced to the system recently or as pan 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;—d?luding the SAS, located on site ?
�Ja' Were these tic tank anholes 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 ?
Z. 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.
Yes no <xisti=ng
information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b))
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 16 Muskeget Lane
Centerville,Mass.
Owner: Wendy Mullin
Date of Inspection: 8/3 0/0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):A, Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):
Number of current residents: _
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no): 616 [if yes separate inspection required)
Laundry system inspected (yes or no):
Seasonal use: (yes or no): �Q
Water meter readings, if available(last 2 years usage (gpd)):
Sump pump(yes or no):i�
Last date of occupancy::
COMM ERCIALJNDUSTRIAL
Type of establishment: 16Y
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): /12
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):.G/I
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available: iQ
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records ,.�
Source of information: AZ_ Ql
Was system pumped as part of the inspection (yes or no):.//d
If yes, volume pumped: 0 _gallons-- How was quantity pumped determined? �Ll
Reason for pumping:
TY,PE OF SYSTEM
.l Septic tank, distribution box, s�1 absorption system
7 Single sess�eei,k � MJ
Overflow4"6peel*;441A,
,j& Privy
4,�e 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)
L Tight tank �4/0 Attach a copy of the DEP approval
Other(describe): 10
Approximatt age of all components, date installed (if known)and source of information:
eA- �
Were sewage odors detected when arriving at the site (yes or no):.L�La
6
;Page 7 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 16 Muskeget Lane
CentervillefMas
Owner:Wendy Mul in
Date of Inspection: 8/3 0/0 2
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron 40 PVC,I��other(explain):Distance from from private water supply well or suction line: 414
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints App a t-i ght _Nn Pyi dPnnP c)f 1 PakagP ThP Rystem is
vented through the house vents.
SEPTIC TANK,Zc�iLdlocate on site plan)
Depth below grade: &44 .
Material of construction:�concretet)Ametal,V�fiberglass,kpolyethylene
4mother(explain) A)%q
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no):,pZ(attach a copy of
certificate)
Dimensions:
Sludge depth AM
Distance from top of sludge to bottom of outlet tee or baffle: �J/A
Scum thickness: ,AN
Distance from top of scum to top of outlet tee or baffle: _A)4
Distance from bottom of scum to bottom of outlet tee or baffle:
How4ere dimensions determined: I'A
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Septic tank is not present,
GREASE TRAP locate on site plan)
Depth below grade:,
Material ofconstructio;-- concrete emetal,60fiiberglass�� �i/olyethylene other
(explain): d2
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: i9/
Distance from bottom of scum to bottom of outlet tee or baffle: i'
Date of last pumping: —d,�4
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not Present
7
Page 8 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 16 Muskeget Lane
en ervi e, ass.
Owner: Wendy Mullin
Date of Inspection:8 30 02
TIGHT or.HOLDING TANK.IJdd2j�. (tank must be pumped at time of inspect ion)(]ocate on site plan)
Depth below grade: -,&1A
Material of consnuction: �A)Aoncrete A)Qmetal A�4 ftberglassNla,polyethylene e,�_other(explain):
Dimensions
Capaciry: liq gallons
Desien Flock gallons/day
Alarm present (yes or no): k�)_
Alarm level: AZ4 Alarm in working order(yes or no):
Date of last pumping: 4)4
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOM�(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: _dL
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.):
Distribution box is not present.
PUMP CHA1,MBER4L,& (locate on site plan)
Pumps in working order(yes or no): Al
Alarms in working order(yes or no):7
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is nor Present.
8
Page 9 of l l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 Muskeget Lane
Cen ervi e,Mass.
Owner:Wendy Mullin
Date of Inspection: 8 30 02
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
-1000 aallon precast leaching pits in series ( 6 ' X10 ' )
If SAS not located explain why:
T.nnatart _See age 10
Ty leaching pits, number:4� 47 J`e+Vc'.-S`
,420 leaching chambers, number: C9
i d leaching galleries, number: O
/00 leaching trenches,number, length: O
Leaching fields, number, dimensions: n
,07) overflow cesspool, number:
cD irmovative/alternative system Type/name of technology: 4&,, ���
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to medium fine sand,No signs of hydraulic failure
Qr Ponding. Soils are dr .Ve etation is normal. # ipit waste & waste
water is 3" below the invert pipe. #2 pit Waste water is 66 e ow
the invert pipe.Stain line #2 pit is 42" below the invert pipe.
CESSPOOLS(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: p
Depth —top of liquid to Net invert:/t)
Depth of solids layer:
Depth of scum laver: _
Dimensions of cesspool:
Materials of construction: —&
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not present
PRIVY,()ocate 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.):
privy i - _nr)t nrPc;Pnt
9
Pagc 10 0( 11
OFFICLAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSA-L SYSTEM INSPECTION FORTY?
PART C
SYSTEM INFORMATION (m)dnvcd)
ProP(Mr A00fC,,: 16 Muskeget Lane
Center LlL1 ,Mass.
Oxon: Wendy Mullin
0ii( o( Inl9m oo: $/30/42
S>LTCH OF SCWACC DISPOSAL SYSTEM
Pio. o� 11tmh o! ?)c iiwiI( o"Poiil )y11cm inclvding 11c1 10 al Ica;( nvp Pennancnl refcrcnec IenCma x, �.
o�ntr✓nvki Lodi( iu ..,ui w;,nln 100 (m, Loccic w�cr< Pvblic wain o ply inch it c bvilor i
i
1 � �
' 1 �
0 _
i
10
Page I I of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propem Address: 16 Muskeget Lane
Centerville,Mass.
Owner:WPndy Mullin
Date of Inspection: g/'1()/09
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record - If checked, date of design plan reviewed:
Yes Observed site (abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain:
YES Checked with local excavators, installers- (attach documentation)
YES Accessed USGSdatabase-explain: http; //town.barnstable.ma.us.
You must describe how you established the high ground water elevation:
)sed; Gahrety R mi i 1 A,- model 1 2/1 6/94 Ground water elevations above
sea level
)sed: USGS_ Oh-,Prvation well data June 1992
)sed: USGs- Techin 'apal Bonletin 92-000-1 Plate #2 Annual ranges of ground
water elevations.January 1992
Leaching
Pit ;eel
Groundwater. reel Below Bottom of Pic High Groundwater Adjustment 1.8 ft per Fnmpter Method
Therefore, the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is
feet.
11
- rT T�TT—\�T�T RTTITRT..TI..TT.:•.T•*:1T1•:'I'i�TT1•!T.•T'Gi l'TLT.•1'CT.IJ'S ... —. .TT•TT- -TTT�..-. •�...F
k „ R• Barnstable
TOWN OF (lUARU OF HEALTH
0 SUIISURFACF SFHA(;F DISR)SAL SYSTEM INSPFCTION FORM - PART D •- CERTIFICATION
•••—••••T"".'.f—!.11!^.�.T.T.R!fl•R:ITITR'.T.'T\i TTTT•.T•.•IrfIfTR'�STII•fRT•-•1"�CYaT RTSRIP'iTTTCI� RTIMTR!"T1'TSiO�rrrrrrrr.•.-.r rr r-.-,. ....
—TYPE OR PRINT CLEARLY—
PUOPERTY INSPECTED
STREET ADDRESS 16 Muskeget Lane Centerville,Mass .
ASSESSORS MAP , BLOCK AND PARCEL # /M- Ole
OWNER' s NAME Wendy Mullin
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Ino,.w '
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City Stat• 1PP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 1 790 - 1 578
CERTIFICATION STATEMENT R
I certify that I have personally inspected the sewage disposal, system at
this address and that the information reported is true , accurate , and
omplete as of the time of :inspection , The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
/ System PASSED
The inspection ►4hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
heRlLh or Lhe. environment as defined in 310 CMR 16 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature ` Date
O( wherene copy of this certification must be provided to the OWNER, the BUYER
applicable ) and the DOARD OF HEAL'I'll.
* If the inspection FAILED , the owner orsoperator shall upgrade the system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CPlR 16 . 305 ,
partd . doc
-1
ALL SfSTE
LL
SYSTEM PROFILE MARKED WITHC MAGNETIC TTAPEAOR BE NOTES
NOT TO SCALE
PROVIDE MIN. 20" DIAM. WATERTIGHT ( ) COMPARABLE MEANS FOR FUTURE LOCATION. `IS
1. DATUM IS APPROX. NGVD '9sh�P
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE
2. MUNICIPAL WATER IS EXISTING o
\ TOP FOUND. EL. 52.0' PROVIDE INSPEGAON PORT TO WITHIN 3" OF FINAL GRADE a4 r o0
51.0' 0 I 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. �° ° e�
MINIMUM .75 OF COVER OVER PRECAST 2% SLOPE SQUIRED OVER SYSTEM 49.6 W o h yak �t
PRECAST H-10 4. DESIGN LOADING FOR ALL PROPOSED PRECAST
RISERS
� (TV.) 4"�SCH40 PVCn/
UNITS TO BE AASHO H-LQ L 16
,.: ;..:. PIPES LEVEL 1ST 2' 2" DOUB�F1 WASHED PEASTONE 5. PIPE JOINTS TO BE MADE WATERTIGHT. JJ d c o
OR GEOT TILE FABRIC 47,6' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE
*49.5' 10" 1500 GAL H-10 14" -
49.0' TEE SEPTIC TANK TEE 48 75' WITH 310 CMR 15.000 (TITLE 5.)
00 oc s
GAS BAFFLE::: °°o°o°ono°o� o0 47.1 0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND
' NOT TO BE USED FOR LOT LINE STAKING OR ANY
OTHER PURPOSE.
47.29 47.12 80 Q
4 LIQ. LEVEL (ACME OR EQUAL) �� p 9U/
g 0 45.1 r c
.: s .;•:; 6" MIN. SUMP - ;�' 8. PIPE FOR SEPTIC SYSTEM To SCH. 40-4" PVC. c¢
J°° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ��` H-aC➢'30501NnCWTORS e
• o 0 0 0 0 0 0 0 0 0 0 0 0 0 ° 0 0 o 0 0 0 0 , prn
°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°° 12" MIN. TNT. DIM. oW
'.,00,o�o_r_,?0? ? 0 0 ° 0 0 r-n_n_n_7_q.o O
�� � �� 9. COMPONENTS NOT TO BE BACKFILLED OR �
6" CRUSHED STONE OR MECHANICAL 3/4 TO 1 1/2 DOUBLE WASHED STONE CONCEALED WITHOUT INSPECTION BY BOARD OF
COMPACTION. (15.221 [2]) HEALTH'AND PERMISSION OBTAINED' FROM BOARD
OVERALL DIMENSIONS TO OUTSIDE OF STONE: 41.5' X 10.25' OF HEALTH. Roue
( 2.3% SLOPE) (A.1% SLOPE) ( 1 % SLOPE) 5'7' 10. CONTRACTOR SHALL BE RESPONSIBLE FOR
CALLING DIGSAFE (1-888-344-7233) AND LOCUS A
LEACHING VERIFYING THE LOCATION OF ALL UNDERGROUND &
FOUNDATION 22' SEPTIC TANK 30' D' BOX 4' OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF
FACILITY WORK. NOT TO SCALE
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS BOTTOM TH-1 & TH-2 11. ANY UNSUITABLE MATERIAL ENCOUNTERED
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM NO GROUNDWATER FOUND 39•4 SHALL BE REMOVED 5' BENEATH AND AROUND THE ASSESSORS MAP 170 PARCEL 38
PROPOSED LEACHING FACILITY.
12. EXISTING LEACHING FACILITY SHALL BE PUMPED
AND REMOVED OR PUMPED AND FILLED WITH CLEAN
LEGEND SAND.
99-- EXISTING CONTOUR 5 66
X 99•1 EXIST. SPOT ELEV. LOT 16 EppE _ 0'25,
116.781 SF lqw" o.00 x So.2o
99 PROPOSED CONTOUR I
[984] PROPOSED SPOT EL x 50.35 SYSTEM DESIGN:
TH 1 x 0.60 �50.60 x 7 x��3
\ \ 5o GARBAGE DISPOSER IS NOT ALLOWED
\ � �
TEST HOLE y 4 .84
2% SLOPE OF GROUND x 5 4x 50.03 / DESIGN FLOW: 4 BEDROOMS ® 110 GPD = 440 GPD
/ USE A 440 GPD DESIGN FLOW
x
UTILITY POLE /
FIRE HYDRANT x 5 2 • / SEPTIC TANK: 440 GPD (2) = 880
OAKS x '`49 j 6' PROVIDE A 1500 GAL. H-10 SEPTIC TAN
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING i 50 23 x 5 5 1
/ FIREPIT ��^`t x 49.76 LEACHING:
5 49.
2 SIDES: 2 (41.5 + 10.25) 1.85 (.74) = 141 GPD
CES POOL x 49.
TEST HOLE LOGS 50.79 / CESSPOOL 76 �4 4.> 4 4 .71 BOTTOM 41.5 x 10.25(.74) = 314 GPD
/ �
ENGINEER: ARNE H. OJALA, PE, SE 50.63 1 ; `b SHED TOTAL: 615 S.F. 455 GPD
n/ 1 5 o 49. 9.40
WITNESS: DON DESMARAIS, IRS � /50 sg 5 .22 /49 USE (5) INFILTRATOR 3050-S WITH 3' STONE
DATE: NOVEMBER 9, 2011 BENCHMARK 50.67 �5 .15 ALL AROUND
PERC. RATE _ < 2 MIN/INCH FOR 2 KHD 97 41 91.96 / \1.0 I
1.4 51. 5 DECK 51.40''� 15�.6 1�7 / -4 5 .83
CLASS I SOILS p 13448 GAS 5�
METER INV OUTU �1.51 �1.90 %50.9
EL=49.5' 5 •6 50.92 49.77
,(5 49
ELEV. ELEV. TOP FOUNDATION / 1.55 51. 2 ,
0" 49.5' 0" I' 49.4' x 51.22 0 EL.= 52.0 /2.29 51 / CV , MA
EXISTING �� APPROVED DATE BOARD OF HEALTH
A A 51.53 DWELLING 51.57
53 /
. /
SL SL 1 /
10YR 2/1 10YR 2/1 150.6 TITLE 5 SITE PLAN
6" 6" 51.15 51 �71 r56-70
0Z 50.95 50.59 OF
B B 3 50.78 PAVED 50.22
LS LS DRIVE 16 MUSKEGET LANE
10YR 6/6 10YR 6/6 x 51.30
24" 47.5' 24" 47.4' xE}\ s, x51.27 CENTERVILLE
X49.61 .25 3 50 50.03
� �
FOGS OF Pq VeM\ 110 2 ; �49.42 �.55 PREPARED FOR
C c f"T\ 05 PERC x�&8. HICKEY CONSTRUCTION/
� �
\ J48.53 7 x 49.7 KIPNES
I
CS CS ���8.17
MUS48.28 �9 NOVEMBER 10, 2011
9
2.5Y 6/6 2.5Y 6/6 EG��' / l �,
\ �x 4 y �NOFLfgSs jc� 0 4, NOFMASS9 ,p <N�F'vigS
IS off 508-362-4541
Y CANiELA. D.�;�11EL `s fax 508-362-9880
Q �IEL
�� CANIELA. ! A 0JA A � � � downcape.com
o OJALA C7J,6,LA p CIVIL JAL 1 • •
CIVIL id 4 1 I down c4t*e engineering inc.
o. '09 .46502 r No.4098 i ,
120 39.5 120 39.4 �� �No. �a F S °�� �� ,sre,.� ��° _ss `'� civil engineers
Scale: 1 20' TF c�sT"� `> s f SS NAI E " SUR ° land surveyors
NO GROUNDWATER ENCOUNTERED ��=;• :�' y S
939 Main Street ( Rte 5A)
> >-246
0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675