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Home My WebLink About0286 NYE ROAD - Health 286 Nye Road Centerville FIR 147 035 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< .286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. City/Town State Zip Code Date%f Inspection Inspection results must be submitted on this form. Inspection forms may_#ot be altered in any way. Please see completeness checklist at the jhd of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. Capewide Enterprises my Company Name 153 Commercial St. Company Address. feam Mashpee Ma 02649 Cityrrown State Zip Code 508-477-8877 SI 4522 Telephone Number license Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the M information reported below is true, accurate and complete as of the time of the inspection. Theinspection was performed based on my training and experience in the proper function and maintenance of on site: sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ,7 ❑ Needs Further Evaluation by the Local Approving Authority ' 8/6/2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 61-A j � t5ins•11/10 Title 5 Official Ins 'on Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 286 Nye Rd Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 5 Hi Cap Infiltrators, 37'x10'xl' B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M0 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you most indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No El ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ,❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd r l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts L W Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments O °M 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system repaired 9/8/2004 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank (locate on site plan): Depth below grade: .5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 3' 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was recently cleaned and should be done again every 2 years for proper maintenance. Water level was at bottom of outlet invert, tank was not leaking and was structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 286 Nye Rd M Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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 was video inspected and found to be in good condition with the water level even with outlet invert, no signs of past hydraulic overloading. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 hi cap infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil and stone surrounding s.a.s. was probed in various locations and found to be dry with no sign of past saturation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,M 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 286 Nye Rd Property Address SULLIVAN ADRIAN M &IAURIE A Owner Owners Name information is required for.every Genterville Ma 02632 8/6/2012 page. City/Town Stets Zip Code Date of Inspection D. System Information (cont.) . Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes.below, hand-sketch in the area below Ej drawing attached separately /511 Do 00O� MOZ 0 -� 23 �-Z Z 3 13~Z 2� b • . A 3 35 '6'• t31na•11/10 Title 5 Official Inspection Foam;SvbwAaco Swwne Disposal Byetem•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 286 Nye Rd Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 286 Nye Rd M Property Address SULLIVAN, ADRIAN M & LAURIE A Owner Owner's Name information is required for every Centerville Ma 02632 8/6/2012 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file �t t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 DIG SAFE SYSTEM, INC. - Create New Quick Ticket Page 1 of 1 Request Number: 20123106128 Date 08/01/2012 Time 09:04 Latitude: Longitude: State: MASSACHUSETTS Municipality: BARNSTABLE Address/Intersection: 286 NYE RD Nearest Cross Street 1: OLD FALMOUTH RD Nearest Cross Street 2: Additional Information: Nature Of Work: TITLE V INSPECTION Area Of Work: ENTIRE PROPERTY Area Is Premarked:Y Start Date: 08/06/2012 Start Time: 10:00 Caller: KATHRYN M Title:ADM Return Call: 730-530 Phone#: 508-477-8877 Fax#: 508-477-4977 Alt.Phone#: Email Address: KATHRYN@CAPEWIDEENTERPRISES.COM Contractor: CAPE WIDE ENTERPRISES Address: 153 COMMERCIAL ST City: MASHPEE State: MA Zip: 02649 Excavator Doing Work: NO Member Utility List Code Abbreviation Name CH NGRDGS NATIONAL GRID GAS-COLONIAL CL NSTREL NSTAR ELECTRIC-COM CW VERIZN VERIZON HK COMCAS COMCAST-PEMBROKE ON ONTARG ON TARGET LOCATING RJ IDM INNOVATIVE DATA MANAGEMENT . There may be non-member utilities in the area that you need to notify. . Electric and other companies may not mark lines they don't own or maintain. You may want to contact them for more information. e The excavator is responsible to maintain markings placed by member utilities... DIG SAFE ENCOURAGES A COPY OF THIS ELECTRONIC TICKET ON SITE AT ALL TIMES. j Create New .I j Create From,Existin , r icket 9 I L; Print T_ ,,! E. Return.To Menu... I I Return To-Home ► http://digsafeform.digsafe.com/cgi-bin/dlcgi.exe 8/1/2012 Customer History Screen Monday 8/6/2012 Customer number 14011 Customer Type ❑ DP ❑CT ❑ EX ❑T5 ® SP ❑ PL Company Name First Name, Last Name Adriane Sullivan Job Address Entered by: KM Street Address 286 Nye Road City, State,Zip Centerville MA 02632 Tel 508-360-5428 Cell 774-212-0434 Business Phone Fax e-mail adsully@gmail.com Billing Address Delete ❑Yes Street Address 286 Nye Road City, State, Zip Centerville MA 02632 Vessel Pumped Septic Tank Gallons 1000 Auto Schedule ❑ 3M ❑ 6M ❑ 12M ❑ 24 M 036M Dig Safe Info Activity Do date Start End Comp CC ®X Title v Inspection 8/6/12 ON Pump Septic Tank 7/5/12 Y NO Pump Septic 7/15/08 Y CC Notes W.k...Af...8/..6112.......T..itle..u.1n.s.p.CG.flan........................................................................................ 71..15/0.8...PUMP...I.Q.AQ....2.1.0-0.0.................................................................................................. 71..5/..1.2...p.uMp..T..1.0.00....2.1.5..0.0..p.a.id.................................................................................. ............................. Special Instructions Cr..,...Cand...on...Fi e.......Paid......................................................................................................................... Last Pumped 7/5/12 ...............................................................................: ........................................................................................................... Job Status ............................................................................................................. Records Found PC Sent 0 Yes ❑ No Date sent 6/12/2012 1 No. Fee THE COMMONWEALTH OF MASSACHUSE'TTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for 33igpogar *p5tem Con!truction Permit Application for a Permit to Construct( . )Repair(x)Upgrade( )Abandon( ) O Complete System > Individuai Components Location Address or Lot No. Z,13 Owner's Name,Address and Tel.No. C$Cl-�Rlv�� e iM CAI C, Assessor's Map/Parcel 14 ® M C Installer's Name,Address,and Tel.No. to-1 13—S3\O Designer's Name,Address and Tel.No. 539' -49 La(p c 5&6�c Q 5-'c2�Zn� % YGc Type of Building: Dwelling No.of Bedrooms Lot Size 19,Uke-t sq.ft. Garbage Grinder Other Type of Building N0A )2 No.of Persons 6 Showers( ✓)'Cafeteria( Other Fixtures Lak3o,-1\xw,_A latc,k . L 6L M, Design Flow gallons per day. Calculated daily flow gallons. Plan Date q 1.-!) 104+ Number of sheets Revision Date Title 6 Y. o & � �C UR zrr. 2 Size of Septic Tank I low \kac1 &%sue Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) `tom- lr 45-b 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 provisi s of Title 5 of the ig�k ' de and not to place the system in operation until a Certifi- cate of Compliance has been i y his Board Signed _ Date ql,'e7 L// Application Approved by Date Application Disapproved for the following reasons Permit No. l uo si_ Date Issued '. M No. �Q HTHE ,i, Fee Entered in computer: COMMONWEALTH OF MASSACHUSOTTS,�`- Yes PUBLIC HEALTH DIVISION - TOWN OaBARNSTABLE, MASSACHUSETTS ZfpPlication for biqaal 6potem Cow5truction Permit Application for a Permit to Construct( •r)Repair(x)Upgrade( )Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 2 g(Q $ Owners Name,Address and Tel.No. Assessor's Map/Parcel t 0 Ufa M E Installer',s-Name Addres ,and T�1 No. Q0`� 53�0 Designer's Na►he,Address and Tel.N . S 3c= —4'1 U� Type ofkBuilding: t` Dwell ng No.of Bedrooms Lot Size 19,6�Qt sq.ft. Garbage Grinder(m/�) - Other Type of Building Npt l2 No.of Persons 3 Showers( v�Cafeteria( Other Fixtures LcVQ Aa' Ck,(" cJtc)k ;- 1_C.Uc-6S Design Flow gallons per day. Calculated daily flow �� gallons. Plan Date Number of sheets ` Revision Date Title y'Co VQsq :;�E.&C. Sv,SNet`, u C'GC\q 1 Size of Septic Tank iOLO �r1-q-��, xis Type of S.A.S. °` =n .\ � 5 Description of Soil Nature of Repairs or Alterations(Answer when applicable) r 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 provisi ns of Title 5 of the En#onmental Code and not t4lace the system in operation until a Certifi- cate of Compliance has been i e y ihis Board of/ e Signed 17 Date Application Approved by `t f��r � t9 /r� l,C-`�/j (/ ,, Date Application Disapproved for the following reasons�6 Permit No. UO y- Date Issued "I I) U 11 THE COMMONWEALTH OF MASSACHUSETTS BARN TABLE, MASSACHUSETTS Certificate of CoII p ance ,,��JJ THIS IS TO CEiiIF , that t e On-site Sewage Disposal System Constructed,( ) Repaired ( )Upgraded(�1) Aband at <.�( (a C Kew (W7WUl has/been constructed in 6ccordance with the provisigtas�if e 5 and the for `isp/o��al yste Construction Permit No. Q �� " Y dated Installer dt Q 7 l/ 2 Designer �1 The issuance�df tr hi rmit shall not be construed as a guarantee that the s ste_mNwilel function as esigjipd. Date I j1 Inspector .-/, ►M ` r``� 1 i No. 00TIT — -- ---------------- — -- Fee ✓_ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mtgogal *pgtem Con! tr ctiori Permit Permission is herebyd to Cosrt c ?Re a' Ugr/'ade System located at /V ( ��' ( ) 1� _ ��Y and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her.duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction us b completed within three years of the date of th'" ,.. Date._. !!1 Approved by 1. Q TOWN F�AB�A/R�NSTABLE LOCATION 6 O`er�' SEWAGE ( # �� VILLAGE Ge+r-� ASSESSOR'S MAP & LOT ± 0 ® INSTALLER'S NAME&PHONE NO. b d SEPTIC TANK CAPACITY LEACHING FACILITY: (type) . �• � Lj siae) ( i.ot X l NO. OF BEDROOMS BUILDER OR OWNER ��c PERMITDATE: COMPLIANCE DATE: ` b L L Separation Distance Between the: Maximum Adjusted Groundwater Table and 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.Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 12/06/2014 18:30 FAX 16 001/002 Town of Barnstable s"E' Regulatory Services Thomas F. Geiler, Director MAS8 Public Health Division rb � Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fags: 508-790-6304 Installer & Designer Certification Form Date: 09/08/04 Designer: Shay Environmental Services, Inc. Installer: Robert Septic Services. Address: P.0, Box 627 East Falmouth Address: 5 Trenton Street MA 02536 Yarmouth,MA On 9/07/04 Robert Septic Service was issued a permit to install a (date) (installer) septic system at #286 Nye Road Centerville, MA based on a design drawn by (address) Sha Environmental Services, Inc. dated 9/06/04 (designer) �— I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow, � J'H OP Mgs,s� (Installer's Signature) g' CARMEN cyu' c E U SHAY No. 1161 �FG/STEP'�� (Designer's Si gna e) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTI1F'ICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q;Health/Scptic/Designer CernYieation Form r SEP-9-2004 THU 05:51W ID: PAGE:1 TOWN F BARNSTABLE LOdk-1'7UN- SEWAGE VILLAGE Cle \� ASSESSOR'S MAP & LOT E D 15� INSTALLER'S NAME&PHONE NO. dt 3 SEPTIC TANK CAPACITY A, C LEACHING FACILITY: (type) V��C•2w�Ls �ti`��/�(size) c�7 �o .l NO.OF BEDROOMS BUILDER OR OWNERvp PERMIT DATE: COMPLIANCE DATE: C b 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility._ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300feet of leaching facility) Feet ,Furnished by - t O Sz 2 -3 2--) FAILED INSPECTION COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION IOAP ` .� RECEIVED PARCEL ;_,�-��5---~ AUG 0 9 2004 r1T .V TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 286 Nye Road Centerville MA 02632 Owner's Name: Dorothy Douthart Owner's Address: Date of Inspection: July 26, 2004 Name of Inspector: (Please Print) James M. FordZZ c� Company Name: James M. Ford r, Mailing Address: P.O. Box 49 _ Osterville,MA 02655-0049 ' Telephone Number: (508) 862-9400 , r0 73 CERTIFICATION STATEMENT ""y CD —1 I certify that I have personally inspected the sewage disposal system at this address and that the inf rmationCFi Porte-1 below is true,accurate and complete as of the time of the inspection. The inspection was performe based (fa y rn training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste Passes Conditionally Passes Needs F her Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: July 28 2004 The system inspector shall submi 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,4he 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. , C^' - Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 286 Nye Road Centerville, MA Owner: Dorothy Douthart Date of Inspection: July 26, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health, *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 286 Nye Road Centerville, MA Owner: Dorothy Douthart Date of Inspection: July 26, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 286 Nye Road Centerville, MA Owner: Dorothy Douthart Date of Inspection: July 26, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %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. ✓ 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 forma Yes (Yes/No)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 System: 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"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 286 Nye Road Centerville, MA Owner: Dorothy Douthart Date of Inspection: July 26, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period ? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site i� inspected for signs of break out? P ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: 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)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 286 Nye Road Centerville, MA Owner: Dorothy Douthart Date of Inspection: July 26, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: I Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 5117184-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 286 Nye Road Centerville, MA Owner: Dorothy Douthart Date of Inspection: July 26, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 3" Material of construction: ✓ concrete _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: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: S" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of failure GREASE TRAP: None (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 baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 r Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 286 Nye Road Centerville, MA Owner: Dorothy Douthart Date of Inspection: July 26, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 286 Nye Road Centerville, MA Owner: Dorothy Douthart Date of Inspection: July 26, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pit was full. Liquid was up to the inlet pipe. The leach pit was in hydraulic failure. The bottom to grade was 8'. The cover was 15"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 286 Nye Road Centerville, MA Owner: Dorothy Douthart Date of Inspection: July 26, 2004 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 enters the building. aAtk B, i Al -oe-ck - - � Q iy as 0 a ao a� 3 O 6 3 Y S 33 10 r Page 11 of I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 286 Nye Road Centerville, MA Owner: Dorothy Douthart Date of Inspection: July 26, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet 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: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps, the maps were showing approximately 25'+/- to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection andlor this report. 11 oas ------------- Noft.- Fxx �'....C.2............. THE COMMONWEALTH OF MASSACHW 'ETTS BOAR® V" HE�A Lq T H C- O.W.-A...................OF...........I..(�. ...k _t---T Appliration for UhnVusal Workii Tumitrurtion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: kjlj... id ......I.- .... .. ... .................................................. ................;.............................. • ti n dress 7 7 _ �. ........ 2 ....L.......................... ......... dress ��- ►� .. . ....... 0........................ ............. .......... . ....................... ........... ----- 00------------------- Installer Address Type of Building Size I �rJ/Sq. feet U Dwelling—No. of Bedrooms--------3_----------_----------------Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otrfixtures ........................................................................................ ................ . ............................... Design Flow___._____s...................I_________gallons per person ydr d T t ay. o al Wly flow....__............®................. lops. 1:4 Septic Tank—Liquid capacity.1.000gallons Length---V........ Width....7......... Diameter................ Depth............. Disposal Trench—Nj�- -----................ Width . ........ Total Length......... ..... Total leaching area............ sq. f t. Seepage Pit No---------- ---- lameter....../ '.'rC' Depth below inlet Total leaching area-' Other Distribution box Dosing tare D. Z S/1-C_ Date...3/9/s. Percolation Test Results Per-formed by......................... ...... -------------- 1-1 Depth of Test P Test Pit No. I......Result per inch Pit-__.__ Depth to ground water Test Pit No. 2................minutes per inch Depth of Test Pit..............__.... Depth to ground. water-- ................. ........... .etit..... .. 0 Description of Soil .......................................................................... .......................................................................... ............................. e------- ..... -----------------------------------------------------------------------------------------------------------------------------------*-------------------------*------*------------"--------------------- .................................................................................................................................................................................................... UNature 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 TL Ili LZ 5 of the State Sanitary Code— The un"-rsigned further agrees not to place the system in operation until a Certificate of Compliance has been )sued by the oard of health. ? I _byi6 , j Signed..................... .................................................... . ................. Ve ApplicationApproved By..... ......................................................................................... .................... Date ing reasons:................................................................................................................ Application Disapproved or e Ifollowsm ........................................................................................................................................................................................................ . Date PermitNo......................................................... Issued_...---------------------------------------------....... Date NoF—Z... ..Z .............. THE COMMONWEALTH OF MASSA. C USETTS BOARD f-%.FHEAL ....................OF............ .41ifiraffou for llhipagal Works Tonotrurtion 1hrmit Application is hereby made for a Permit to Construct -.(A) or Repair an Individual Sewage Disposal System at: • ............................................ ...... ---- ............ ... .. ... .......7.....P........ 0 a* n- dress tK 1 ut. 4 ... ......es 4 0. ....... ......... ........ ............................ ........ ....... ......... dress er ..................... ....... �.D....................... ...................... ... ........... --------/--------------- 0 N Installer Address Type of Building Size L ..........Z.Z...Sq. feet U Dwelling—NL 'of Bedrooms________3---------.....................___..Ex [�Garbage- Grinder p#sion Attic ep Building PLI Other ................ ......,,7——Type of B .... No, of persons___.__....___________.____'- 3- Showers Cafeteria PL4 k.i i i � ,. ,Otllerfixtures ......................................................................................... .............. ....... . 3. ... ................... Flow_....53................... ....3 , y . Design F1 gallons per person&p day. Total, ijy 56W...... ........7...................alons. 94 Septic Tank—Liquid'capacity.45�'gallon"s Length---C7......... Width.........----. I Diameter---------------- Depth"lly Disposal Trench N Width.i. Total Length..... Total leaching area Sq. f t. A*lp Dii ............ Depth e Total leaching ared.Mll _:3.K,_ Seepage Pit,-No Y.,__ Diameter..... pth below M.71 -7, Z Other Distribution box Dosing to J.131, ........... Percolation Test Res It Performed by_________________________________ yr...... ... tA .... P6 inch I.Iminutes' Depth a . ......... Test Pit No. 1.7� .. .........--- Depth to groun d water Test Pit No. 2...........t...minutes per inch;, Depth of Test Pit................. Depth to ground water. ................ Description of Soil............... ....... . . �7 .... ..... ... ............................................ ............ ------------*........ 0 -----------------------------------------------;7:7-------------- ------------------------------------------------------- --------------------------------- ................ ------------------------------------------- ......................................................................___21 �.............................. .......................... ............... Nature of Repairs or Alterations—Answer when applicable--------i.............................................................. ...... .......... ................................................................................................................ ............................................... .............................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT LEj 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 board of health. /.................. Signed...................................................................................... ------ ApplicationApproved By..... .......................................................................................... ........ ............................. Date Application Disapproved or e following reasons:......................................................................................... .................... .............................................................................................................................................................A........................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................... ................OF..................................................................................... Tntifiratp of Toutpliaurr T� IS TO CERTIFY, That the Ind; * ual Sewage Disposal System constructed ) or Repaired ..........by------- 77----- ...............Installer............................................................................................... ---------- ....... . ........ e� P at........... ... ..........e.......... ... ............................................................................................................................... has been installed in accordance �Vith the provisions of Tff " of2lhe State Sanitary Code as described in the application for Disposal Works,-Construction Permit No.- P.................... dated___.._____.___....._:_____.___......._._...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 2_::B..�............ Inspector............ ....................................................... DATE........................................... ....... ------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ...........................................OF............................ .......*------*11111111...... No... FEE........................ #osdl Workii Tottstrudion "prrutit Permissionis hereby granted-----... ........................Z............................................................................................ to Construct or �tepair,( an Individual Se`,vQge,,1DisposaI System at No. ...... ......e ----------------S-,t,r-e-------------------------------------------------- ---------- as shown on the app i ti for Dispol9f_4orks Construction P�errq. o..................... Dated....._._____.............................. 7P�"/ ............................................................I................. Board of Health DATE......... ................... .......................... FORM 1255 A. M. SULKIN..INC.. BOSTON l0 C T ION SEWAGE PERMIT NO. .2/ Z— VILLAGE bo , INSTALLER'S NAME i ADD SS iCAI �. S U L D E R OR OWNER DATE PERMIT 19SUE D DAT E COMPLIANCE ISSUED a V ckc S L 0 C TION. SEWAGE PERMIT NO. Jos VILLAGE bo iINSTALLER'S NAME & ADDRESS Cd. d• » t U L DE it 0R'\, OWNER DATE PERMIT ISSUED ?v OAT E COMPLIANCE ISSUED all 3) a� w �Y' SECTION A -A 0Rrt<%.Ta1�,�T3AL'.1 NOTE: ALL PIPES ARE TO BE 4 SCHEDULE 40 P.V.C. ALL OUTLET PIPES FROM THE 10' min. from " VENT PIPE (0 Least 24 Inches tall PROFILE VIEW OF ADDITION TO LEACHING SYSTEM DISTRIBUTION Box SHALL BE Existing Foundation 1-house to septic tank 11 Schedule 40 PVC w/Charcoal Odor filter SET LEVEL FOR AT LEAST 2 FT. 12' CONCRETE COVER 4',i` .,1A TOP OF FOUNDATION = ELEV. 100.00 (Assumed) $eptic tank covers must be 3" of 1/8" - 1/2' Washed Peostone +r within 6 in. of finished grade - , Grade over Septic Tank - 98.00 Grade over D-Box 9&00 over SAS - 9&00 3/4" t0 1 1/2 " Washed Crushed Stone - 3 - 5'OUTLET --+-' ''-'--'- 2 -- 'C KNOCKOUTS ` f 4-PVC(CAPPED)INSPECTION PORT 1D BE 5.5- - f 12' INLET S - 0.02 3 HOLE H-10 INSTALLED AND TO BE WITHN 8' OF GRADE ;,• OUTLET DIST. BOX 3' Maximum Cover Top Load - Elev. a94.38 �, EXIST. S-O.ot Or Greater -qqR - fR,; r J a 1 cE 4n "U� to1,000 GAL. s- o.o,' foot . 185' 2" ,"'F u° 2Si Nse Rd \=: tLEV PIPE o 25' p 4" - SCH. 40 . ! nMfl rR�L EX][ST. FIXMDATI@dSEPTIC TANK O 10"Effective Depth - ,�$, 4,yr r Se in to PLAN SECTION CROSS-SECTION ai co 20 5 Units a 6,25' _ 30'-10 CONCRETE FULL FOUNDA II a rn ri 0.83' (10 inches) •... 6 h.of 3/4"-1 1/2" d �. n 37.25' 3 HOLE H-10 DISTRIBUTION BOX < ,$ "° ,"; SYSTEM PROFILE compacted stone � i Cn grd, c v d rn Effective Length NOT TO SCALE -t` toe Not to Scale - - > a 4' 4' I11 SOIL' ABS❑RPTI❑N SYSTEM (SAS) ® ++*t+�Y�c ro unArrEo �•'�' c c a, toy > INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN GENERAL NOTES compacted stone Effective oath - { )OR. EQUIVALENT Not to Scale NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE w a 1. Contractor is responsible for Digsafe notification IV Bottom of Test Hole 1 Elev.=87.0o m NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18' FFECTIVE HEIGHT IS 10" and protection of all underground utilities pipes. No Groundwater Observed O 132' P goun es an P P ----- -----'------� - 2. The septic tank and distribution box shall be set level on 6" of 3/4"-1 1/2" stone. 3. Backfili should be clean sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation NIF GEORGE FRANKLIN by Carmen E. Shay - Environmental Services, Inc. LOT #4 5. The contractor shall install this system in accordance PERCOLATION TEST ST I with Title V of the Massachusetts state code, the approved plan I L I and Local Regulations. 6. If, during installation the contractor encounters any Date of Percolation Test: AUGUST 20, 2004 I ` soil conditions or site conditions that are different Test Performed By. CARMEN E. SHAY, R.S., C.S.E. I 96.43' from those shown on the soil log or in our design Results Witnessed By WAIVER ( per BARNSTABLE B.O.H. i `� installation must halt & immediate notification be SHAY ENVIRONMENTAL SERVICES, INC. I �� made to Carmen E. Shay Environmental Services, Inc. Percolation Rate: Less Than 2 MPI ® 36" 1 �\ 7. No vehicle or heavy machinery shall drive over the \ septic system unless noted as H-20 septic components. 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Test Hole \\ TEST HOLE #1 �� \ 10. All solid piping, tees & fittings shall be 4" diameter No. 1 \�\ ELEV.= 98.001--- \\ Schedule 40 NSF PVC pipes with water tight joints. j DEPTH SOILS ELEV. 8� - �� 37.25' 5• \� \\ 11. Municipal Water is Connected to ALL OF The Residence and Abutting 0 98.00 _" \ \ Properties Within 150 Feet. Sandy Loam 1 p - . - \ \ THE PROPERTY LINES ARE APPROXIMATE AND f \ \ COMPILED FROM THE SURVEY PLAN GENERATED BY 0"_10" A s7.t5 t 4" PVC \ \ LOWE & WELLER, INC., SURVEYORS OF S. YARMOUTH. MA VENT 1 \\ ENTITLED " CERTIFIED PLOT PLAN OF LOT #3, NYE ROAD, CENTERVILLE Sandy D-Box i \ MA", DATED MARCH 19, 1984, & PLAN BOOK 350, PAGE 55 and The Loom \ N F GEORGE FRANKLIN \\ DEED DESCRIPTION ( BOOK 4230 PG 233) i Io YR s/6 I IT SHOULD BE USED FOR NO PURPOSE OTHER THAN ;10'- 36" B. O EXIST. 1000 gal.95.00 25� \ Mee. Septic Tank I \\ THE SEPTIC SYSTEM INSTALLATION. Sand O \ 2-5 Y 7/4 FailedJ f \\ EXISTING LEACH PIT TO BE PUMPED OUT AND 36"-132' C, 87.00 Leach Pit DECK fr \\ �, ABANDONED IN PLACE. \ NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE \LOT #2 FROM THE EXISTING LEACH PIT TO BE DISPOSED ; \\ � \ OF AS PER BOARD OF HEALTH SPECIFICATIONS. - _ ---- - EXISTING NO WETLANDS _ O f - - ----- \ -- - .ARE- PRESENT WITHIN 200 OF THE PROPERTY- EXISTING f \ tO 3 BEDROOM GARAGE I \\\ ASSESSORS MAP 147, PARCEL 035 HOUSE LEGEND #28s \\ - Perc #1 I t \\ Depth to Perc: 40" to 58" I I I \ 104X 1 DENOTES PROPOSED Perc Rate= Less Tho 2 MPI i I \ SPOT GRADE I I 1 \ Groundwater Not Observed ' No Observed ESHWT 1 r i DENOTES EXISTING TOP OF FOUNDATION ADJUSTED H2O Elev. = None PROJECT BENCH MARK ` tl x 104.46 SPOT GRADE , � I I ELEV. = 100.00 (Assumed) LOT #3 L / 1 I �' 1 PL PROPERTY LINE 19,664 Square Feet +/- 9- 1 �' I r ASPHALT ----[96P PROPOSED CONTOUR k'� I DRIVEWAY I -97 EXISTING CONTOUR I ,,_�_- 97.30 DEEP TEST HOLE & DR ES 2-18' AM. ACCESS MANHOLES 98- --`--------- ------ I \ ► - _____--- PERCOLATION TEST LOCATION _ I 6 FOOT STOCKADE FENCE �. - *-_.=�-.:,�' a -�- -��•`.: 96, -------__------ - ,� �. �`�_._-----' _ - x�<• rr I --------------------------------1------------- THE '/.. •-� is INLET � _..___ ACCESS e��NG��ENT - P LOT PLAN : :+ OUTSET DEEPER THAN 6 MCHES BELOW FINISHED GRADE SHALL BE RAISED TO WITHIN 6' OF _ FINISHED GRADE. .3 `T r.• --.:• .: INSTALL TUF-TITE GAS BAFFLES OR E(M1ALS _ZV 0,4 -0 OF PROPOSE SEPTIC SYSTEM UPGRADE STEEL REINFORCED PRECAST CONCRETE PREPARED FOR PLAN VIEW (VARIABLE RIGHT OF WAY) MS: DOROTHY DOU IT HART 3-24"REU0VA81-E COVERS l ' 11 � AT ' #286 NYE ROAD i. 3 min. clearance L I13' l4LET INLET 8-mk-0 :2 min. inlet to outlet r m►+. .. OUTLET = CENTERVILLE, MA 1 0'min. --� u' ? I cu 5. _,. ; ___ Design Calculations Eg I _-• 4•-0' min. PREPARED BY: + b Llwa depth Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal.%Day Min. per Title V) C EN CtiG - Garbage Grinder: No Capacity � C�1R .�llj E. ,L�'H�1 �' Leaching P Proposed: 330 Gal./Day Minimum {Min. Per Title V) 4- _10- I Septic Tank - 2 x 330 Gal./Day = 660 USE EXIST. 1,000 GAL. Septic Tank. ENVIRONMENTAL SERVICES, INC. CROSS SECTION END-SECTION SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch 0 20 40 5 0 81 Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons a P.O. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft., = 58 gallons 'sTE�`` EAST FALMOUTH, MA 02536 USE EXISTING 1000 GALLON H- 10 •SEPTIC TANK Providing: = 331.so gallons S4NIrAEZ\P��' Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1 "=20' TEL/FAX : 508-548-0796 NOT To SCALE SCALE: 1 "=20' DRAWN BY: CES DATE: SEPT. 3, 2004 TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE ON THE ENDS. NO STONE UNDER. PROJECT#SD625 FILENAME: SD6250PP.DWG SHEET 1 OF 1 j, Yi, 0, 11AX:, "'k Y� 40,-1-- 77� 6 x T 45 pl. -75 -5 --- ----- --- 4/07 t9 e,L F= 4 c L C- W�THIAJ i5�X t 17 qe6urlc PF ri I Z:,:7 T 0 r 0 P. v C., Ole sci 4,:�! At c ZD F= 40,4f Z- /'7 ZD 14 0 C 7 7 a ,r C- Al/9 C r 4e. 4f: A 144" 77/4 C=- 6U1LD1AJC- 40 7 A2 0 UAJ D .3 ZD r-- VI Ai EV H -K fy r7 C ' L L :5 C �5e-re 49CAf r T7 )4E 7 C)