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HomeMy WebLinkAbout0015 OLD STAGE ROAD - Health 601j) ftl) S M E A KEEPING YOU ORGANIZED No. 12534 2-153LOR SIUSTAINABLE FORESTRY MIN,RECYCLED jM INITIATIVE CONTENT70. CoOedRbw curcin➢ POST-CONSUMER www.aupro➢re 9 ff!OS➢4D MADEWUSA GET ORGANIZED AT S(IGF.A =11 cam, Commonwealth of Massachusetts C2 9.s �e - ,9 Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 19 Old Stage Rd Property Address owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. Inspector Information c J'�' 1�0%�3 forms on the computer, use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address Centerville Ma 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3-22-21 s Si9fiature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Old Stage Rd Property Address owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: At time of inspection this system met all passing requirements. This report can not predict the future performance under the same or increased usage. 2) 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 FIND (Explain below): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 P Commonwealth of Massachusetts �v 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts I? Title 5 Official Inspection Form 11.� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Old Stage Rd Property Address owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^ � 19 Old Stage Rd Property Address owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: according to as-built card this system consists of a 1000 gallon septic tank d-box and 24x11.33 leaching area Number of current residents: 0 I, Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: water dept never returned my call for water readings. Sump pump? ❑ Yes ❑ No Last date of occupancy: seasonal Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Old Stage Rd v� Property Address owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Scott Frank Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Tank truck Reason for pumping: maintenance l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v=' 19 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 4. 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): Approximate age of all components, date installed (if known)and source of information: as-built card ststes system installed 9/27/12 by Condons excavation Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / 19 Old Stage Rd Property Address owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 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 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 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 in need of pumping so it was pumped at time of inspection for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Old Stage Rd Property Address owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 I Commonwealth of Massachusetts r: l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): box was functioning properly at time of inspection t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts �e I? Title 5 Official Inspection Form 11.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Sas observation port was opened and clean dry sand was seen in the pipe. Type: ❑ leaching pits number: ® leaching chambers number: 24 (plastic)?? ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): as-built calls s.a.s a 24x11.33 bed it does show some sort of chambers but does not name the components. Observation port was located and opened and was dry at time of inspection 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Old Stage Rd Property Address owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L � 19 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: not encountered at perc 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: As-built card form installer Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts I3.� Title 5 Official Inspection Form 1° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� 19 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3-22-21 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i Assessing As-Built Cards Page 1 of 2 �q TOWN OF BA�RINSTABLE LOCATION 01= Spv%5e rr wa SEWAGE#>/_2 2�y VILLAGE CPV14{ � ASSESSOR'S MAP&PARCEL r'->05 1 SS INSTALLER'S NAME&PHONE NO.COvAc&,S L Yc Wfr 776 5 9 63 SEPTIC TANK CAPAcny 100-0 `4►A, LEACHING FACILITY:(type)&A 1 AQScr k-w (SeJ (size) 2 y tr //.3 3 NO.OF BEDROOMS 3 OWNER Lr sKeltvL e PERMIT DATE: /2 COMPLIANCE DATE: 9127/i l Separation Distance Be;...the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility tiOk Oct Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) h6%A� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 11__ nmA a Feet FURNISHED BY�1 1..��nAn' A BACk 13 30 39 .. i B 4 146 kD https://www.townof bamstable.us/Departments/Assessing/Property_V alues/HMdisplay.asp... 3/28/2021 Assessing As-Built Cards Page 2 of 2' https://www.townofbamstable.us/Departments/Assessing/Property_V alues/HMdisplay.asp... 3/28/2021 r IST Commonwealth of Massachusetts aO8— Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v ` 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. Inspector Information When filling out I� 5� 4r- 1:5 A.(oLf forms on the computer,use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address Centerville Ma 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number r• B. Certification 1 certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3/22/21 Inspect Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 1 Commonwealth of Massachusetts �. lip Title 5 Official Inspection Form �1° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: At time of inspection this system met the minimum passing requirements. This report can not predict the future performance under the same or increased usage.system was installed in 1995 per as-built 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 1 Commonwealth of Massachusetts �m l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ry I9 Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ~ � 15 Old Stage Rd v� Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form �m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments =� 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,�p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c , Commonwealth of Massachusetts �m ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 15 Old Stage Rd Property Address Lennon Owner information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Per as-built card this system consists of a 1000 gallon septic tank d-box and 600 gallon leach pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: water dept never returned my call for water readings. House is vacant. Sump pump? ❑ Yes ❑ No Last date of occupancy: seasonal Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c , Commonwealth of Massachusetts �m I? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •L 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Scott Frank Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? tank truck Reason for pumping: maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts itp Title 5 Official Inspection Form 4� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 1995 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �. lip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22121 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 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 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 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 in need of pumping so it was pumped at time of inspection by Scott Frank. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Ib Subsurface Sewage Disposal System Form Not for Voluntary Assessments �L =' 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): Box looked typical for its age with some corrosion. box was functioning at time of inspection. t5ins .doc•rev.7/26/2018 Title 5 Official n P 0 cial Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I Commonwealth of Massachusetts �m lF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ~ � 15 Old Stage Rd Property Address owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 600 gall ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts j. Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit was dry but had a stain line about 12 inches from pipe invert. pit was installed in 1995 but met minimum passing requirements at time of inspection. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts iip Title 5 Official Inspection Form fl° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts n ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v � 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^ � 15 Old Stage Rd Property Address owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater then 5feet 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: design plan for#19 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Old Stage Rd Property Address Owner Lennon information is Owner's Name required for Centerville Ma 02632 3/22/21 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Assessing As-Built Cards Page 1 of 2 6267 TOWN OF BARNSTABLE LOCATION ,P SEWAGE # 9 s' VILLAGE GL°/�>`�/ ASSESSOR'S MAP& LOTA'D�~/_5, INSTALLER'S NAME 6i PHONE NO. �/ 0 rne,/t i/y U Z-3G�, SEPTIC TANK CAPACITY �DDG 1 LEACHING FACILITY:(type) L.r_',4.e_/E a tv'_ (size) (,©0 NO.OF BEDROOMS �-- PRIVATE WE�L-L OR PUBLIC WATER BUILDER OR OWNER �,y� ✓� el 74�I DATE PERMIT ISSUED: �-•j �1�•+� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No e•t Q e 3 - c = �� k L4 I https://www.townofbamstable.us/Departments/Assessing/Property_Values/HMdisplay.asp... 3/28/2021 Assessing As-Built Cards Page 2 of 2 https://www.townof bamstable.us/Departments/Assessing/Property_V alues/HMdisplay.asp... 3/28/2021 TOWN OF BARNSTABLE LOCATION i 9 OIL- .S F"CX M Ad SEWAGE#,;XO VILLAGE (.�✓ i-Cr U1 11L° ASSESSOR'S MAP&PARCEL a�?5 1555 INSTALLER'S NAME&PHONE NO.Q S L Jr'XC 0S' 776 �9 b3 SEPTIC TANK CAPACITY 100-0 Q vS 1 LEACHING FACILITY:(type). 61 ApS& k(L-H 13t� (size) `J Y-- J/J 3 NO.OF BEDROOMS 3 OWNER 1-7b e L.ef Aployl PERMIT DATE: .Z /2 COMPLIANCE DATE: 9/274 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ylo. i ;✓VEifrFeet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) V\0%A- _ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY E j A 13AC 3 :30 13 39.y B3 Bq y( go No. �' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOW OF'BARNSTABLE, MASSACHUSETTS Yes ot� 0(pplication for Xhoogal *pmem Comaruction Vermtt Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components 0 nn Location Address or Lot No.190/ .S 1� /Io B ? Owner's Name,Address,and Tel.No. 13i , t/Ja,>4,.�/ a ICe11y 1�� Assessor's Map/Parcel !ZO67 1S4 sq/p q Sg90 c Installer's Name,Address,and Tel.No. 1 7 T 4✓ t N C �CdV�s �?C'C Designer's Name,Address Tel.No.�f� S C�f��Y � �Or��JC_� 30�C jciclr`.- %jV rl?6 q(p 3 /#! g� 4 4 -%,. �.0 L&l Sok s2q`.3ro06 Type of Building: Dwelling No. of Bedrooms Lot Size 00 sq. ft. Garbage Grinder ( ) Other Type of Building 0(.C1114 No.of Persons °,Z Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) .:330 gpd Design flow provided 33S gpd Plan Date 10 Number of sheets Revision Date Title n(� Size of Septic Tank '0®O ��1 Type of S.A.S. .jc., (KA kkk4-&r- Description of Soil 10-00-kV ,S t'aA .5 J u C C AffC S AP Nature of Repairs or Alteration(Answer when applicable) Prp l o c e �e 4c4t�,(' t 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 t ' Board of Health. Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued y a * X - 4 90 No. Fee � THE`COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION TOWN O'F'BARNSTABLE, MASSACHUSETTS Rg1tcation for nfopooal *potent Conotruction Permit Application for a Permit to Construct( ) -Repair(-.) :Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or,Lot No.19 016 ,S4 A *8AOn` Owner's Name,Address,and Tel. ,r J ��rc� !fie ll L�►'�v\G ti Assessor's Map/Parcel 59 - 5y�o Installer's Name,Address,and Tel.No.C.J.-,� 1)ec Designer's Name,Address and Tel.No. .0 4 ,5 SL>rue 1"t C rVATV%AW1C_l� 1#1 1?,�- 64 3*,4Wte 5oF-S2q(3600 s �94 9143 O Y '72 SA%AVwic T�e of Building: / Dwelling No.of Bedrooms .,3 Lot Size 00 sq. ft. Garbage Grinder ( ) Other Type of Building QL,,cljj%4 No.of Persons Showers( ) Cafeteria( ) '�, Other Fixtures - .Desigr;Flow(min.required) 33O gpd Design flow provided .33,.5 gpd 4, e;.. Plan, Date 17 //Q Number of sheets Revision Date {"* 3 Title a Size of Septic Tank loop fo,t..I Type of S.A.S. ��p 1(ck y Description of Soil V1, (� NUJ S ►r n� 13 �Ukk�y S A�u►� 5 �t C CoArye S Aa Nature of Repairs or,Alterations(Answer when applicable) 0 r 1:21 ytc e 1-e%4c tt"c rt-i ' 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 t Board of Health. Signed Date Application Approved by Date Cj .��/• /�' � r Application Disapproved by: Date for the following reasons r I Permit No. I Date Issued c7 L THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (i,w. Upgraded ( ) Abandoned( )by A VAT o {� _ at K has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ,� C ��� � ���� dated / , Installer Designer 2 #bedrooms Approved design flow J / gpd The issuance of this permit 11 of be c fistrued as a guarantee that the system/w�nction as designed Date InspecLol tor j Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS i 'Wtopooal *potem Conotruction Permit i Permission is hereby granted to C-onstriuct ( Repair ( ) pgra ( ) Abandon ( ) System located at 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 must be completed within three years of the date of this er Date �J 1;2 C1 Approved by r ffII TOWN OF BARNSTABLE p s p _ LOCATION I OK= .Sh11C;e- ro Ad SEWAGE# ` VILLAGE t�C✓1 cCr U1 1J& ASSESSOR'S MAP&PARCEL 156, INSTALLER'S NAME&PHONE NO.G S L XC Jr'0�r 79 G 9 9 63 p SEPTIC TANK CAPACITY {00-0 Q A 1 LEACHING FACILITY:(type).( 4A-6S&Xk-A 13&V (size) Ay'r //03 3 NO.OF BEDROOMS 3 / OWNER L e&& Le- Kyioin PERMIT DATE: 9 LQ Y /2 COMPLIANCE DATE: / Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1164- @Cr c;W Feet. Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) VNG% 4- Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY .7� I f gh h . �h 8 � ,htrt4 s as L0C"A:TJON SEWAGE PERMIT NO. �,.�/� �/C•d ����',F' / I L'AG _ C G-%y%FGc'1��.L.G cam" VIVIAGE IN.STA LLER'S NAME & ADDRESS B U I'L DE R OR OWNER D T E PERMIT. ISSUED DATE COMPLIANCE. ISSUED r . � �.� , _ .� , �� , , � � , , , 'y, `�Q y„•1 e,. �� � � �_ -_- L0C-'&TION SEWAGE PERMIT NO. VIi LAG E IN.STA LLER'S NAME & ADDRESS B U I-L D E R OR OWNER DO E PERMIT ISSUED DAT E COMPLIANCE ISSUED ja- i1/-7�?�� ���� I � , .� ��U�� � � G ! � � � � r / �� ���k � �� i � Y�i' 020 Town of Barnstable Barnstable SHE °i Board of Health j�'er``a�j I `�$ 200 Main Street, Hyannis MA 02601 fp59. BARNEWAU 0. 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. JunichiSawayanagi November 21, 2012 Mr. Edward A. Stone P.O. Box 1729 Sandwich, MA 02563 RE, 1901d-Stage"Road,•Centervllle A_ 208155,. Dear Mr. Stone, You are granted variances on behalf of your client, E.K. Properties LLC, to construct an onsite sewage disposal system at 19 Old Stage Road, Centerville. The variances granted are as follows: 310 CMR 15. 211: To install the soil absorption sysiem with five (5)feet away from the property line, in lieu of the ten(10) feet separation distance required. 310 CMR 15. 211: To install the soil absorption system with 15.7 feet away from the foundation wall, in lieu of the twenty (20) feet separation distance required. This variance is granted with the following conditions: (1) No more than three (3) bedrooms are authorized within the dwelling served by this septic system. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) The septic system shall be installed in strict accordance with the engineered plans dated July 7, 2010. (3) The designing engineer shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the plans dated July 7, 2010. The propos d system was designed to replace the failed system. . This variance is granted because t proposed plan appears to meet the maximum feasible design standards contained within th tate Enviro mental Code, Title 5 and local Health Regulations. Since �urs, Wa, ne M' er, M.D. Chlairma Q:\WPFILES\Stone1901dStageRoad2012.doc i e V b �of1HEtp� DATE: ;' Z FEE: �—�— • BARNSPABLE, y MASS'1639. �AIED AAA'I A`0 REC. BY Town of Barnstable SCHED. DATE: CAAO Board of Health 200 Main Street, Hyannis MA Q2601 Office: 508-8624644 Wayne A.Miller,M.D. FAX: 508-790-6304 Junichi Sawayanagi Paul J.Cannifl',D.M.D. LOCATION VARIANCE REQUEST FORM �,y Property Address: "� ' O � � -cv UL E d 3� Assessor's Map and Parcel Number: Z4 j - L 5 S Size of Lot: l SF, y,,�r Wetlands Within 300 Ft. Yes Business Name: No Subdivision Name: ,y/a I , APPLICANT'S NAME: NOtJ Phone ;;W?- 5-9¢1' S4 70 Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PERSON LL Name: G 1S.Qd `�' ►JoIJ Name>� 5� � ��a� !� •� � clkJ� Address: GdgTC �. SFl Address: f4 � Phone: _4o/7 ,j 1 - Sle7D Phone: �Ozg— .5r ANCE FR M REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) J -ra Iv S` &v -e t —ro6 1�Lt IJ 14464%:am 3B2S4Vh4 teS" C'2AA-�L 2v ILK t (5•-7 r P r.40 L 4,61 NATURE OF WORK: House Addition ❑ House Renovation ❑ Repair of Failed,Septic.System Checklist (to be completed by office staff-person receiving variance request application) ' Please submit copies in 4 separate completed sets. - Y Four(4)tropies of the completed variance request form Four(4?,copies of engineered plan submitted(e.g.septic system plans) Completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or r gistered sanitarian Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/lessee only), outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed)) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne Miller,Chairman NOT APPROVED Junichi Sawayanagi REASON FOR DISAPPROVAL Paul J.Canniff,D.M.D. C:.\cache\Temporary Internet Fi1es\0LKAE\VARIREQ.D0C Town of Barnstable �OFtNf 1py Regulatory Services Thomas F. Geiler, Director .BA"SrABLF- . Mom. Public Health Division A�0 T£o � Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form ,LU 1 Z- Z94- Date: 2 S 2 Za l 2 Designer: Installer: d Address: 2�� ? Address: ` On 2 I Z Lv, e, was issued a permit to install a (dat ) J (installer) i csYII se ti stem at VX�M..4MI(e based on a design drawn by P address) _T),1-11lr) 7 . _— , .4C(?_T ,2 dated -7 7-2y10 12�itS24 -2'Z1,�201Z (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. ZN OF ( ler's Signature) �o DAVID 0 D. FLAHERTY, JR. u� No. 1211 0 (Designer's Signatur (Affix D ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PU14LIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form r,/ Certified Mail#7005 1160 0000 0191 0690 Town of Barnstable hw '� Regulatory Services t, BARNStA"M wars. g Thomas F. Geiler,Director �ArFb g�9 b Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 3, 2009 Maya Jaklitsch PO Box 547 Brewster, MA 02631 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 15 Old Stage Road, Centerville was inspected on September 2, 2009 by Timothy O'Connell, R.S. Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint. The following violations of the State Sanitary Code were observed: �(0 �d 105 CMR 410.190—Hot Water—There was no hot water within home due to a failed r water heater. �( , The following violation(s) of the Town of Barnstable Code were observed: 1§ 70-4- Certificate of Registration. Unit not registered with Town of Barnstable Health Division. Along with unit 19 Old Stage Road. You are directed to correct the violations listed above within twenty-four(24) hours of your receipt of this notice by making a good faith effort to restore hot water to said unit. You are ordered to correct the violations listed above within fourteen (14) days by registering all units you own and rent within the Town of Barnstable. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health QAOrder letters\Housing violations\Rental ordinance\l5 old stage cent.doc Banknorth Kristin Kelley Head Teller 700 Main Stre Dennis,MA 0216387y T-508 385-2658'7` Kristin.KeIley@`DBankIIo�•com TDBanknorth.com . ' Health Master Detail Page 1 of 1 �1n r, o..:Xg�:a«.- ealth s a< .a r ,�iY::,. App5i atio 1 Center Parcel Lookup Selection It'n,s Parcel Septic Perc Tank I Parcel: 208-155 Location: 19 OLD STAGE ROAD, C NTE VILLE Owner: JAKLIT C , FRAN Business name: Business phone i Rental property: Deed restricted: { Number of bedrooms Contaminant released: r Fuel storage tank permit: Save,,,Parcels hanger y R'eh' t04L kup Parcel Info Parcel ID: 208-1.55 Developer lot:LOT Ili 4 Location: 19 OLD STAGE ROAD Primary frontage:60 Secondary road:PINE TREE DRIVE © Secondary frontage: 1A3 Village:CENTERVILLE Fire district:C-O-MM Sewer acct: 76 , Road index 11.74 Asbuilt Septic Scan: 208155 1 �� Interactive map Town zone of contribution:Ill•' (Aquifer Protection Overlay District) State zone of contribution:OU.I.. Owner Info Owner: 3AKL.ITSCFi, FRANZ Co-Owner:MAYA JAKL.ITS0 i Streetl: PO BOY 547 Street2: City: BREW STER State: MA Zip: 02631 Countr Deed date: Deed reference:C63808 Lana Info Acres: 0.26 Use: Multi Hses MILL-01 Zoning:RD-1 Neighborhood: 01 Topography: Level Road:Paved Utilities: Public Water,Gas,Septic Location:Rear Location Consfr6ctrczn Info BuilC,ing No Year BuiitlEff ctivt',`,i=r aBed'roams Bcthrou is 1 1935 782 2 Bedroom 1 Full 2 �1875 1080 3 Bedroom 1 Full Buildings value: �203,900.00 Extra features: 42,400.00 Land value: S139,000.00 http://issql/Intranet/healthMaster/HealthMasterDetail.aspx?ID=208155 9/2/2009 Citizen Web Request Page 1 of 2 lr r ° s y . f�� ✓ S'� l � i,lam _� Y �..A'y a,:,,� f � >„ Citizen Request anagement - Internal Use ..____...................................................._......................................_._`____ __..._......._................._-.................._..................................... __._......................_. .............. Request ID: 26903 Created: 9/2. ._........._....__ .............._....... Status: Assigned To Staff Assigned To: O'Connell,Timothy Health Office Anonymous: No Category: Chapter II : Housing Substandard E.C. Date: 9/17/2009 h Created By: Wadlington, Ellen Citations: z Health Office Time Worked: 0 Response Time: 0 Requestor Details: 1 Email: Mira v Request Location: 15 OLD STAGE ROAD Centerville, Ma 02632 Parcel Number: Map: 000 Block: 000 Lot: 000 Request: j No hot water in home. Has been out for five (5) days. Landlord says problem might continue for two weeks. I Request Work History: Internal Note History: System entry on 9/2/2009 9:34:13 AM: Assigned to O'Connell, Timothy http://issgl2/intemalwrs/WRequestPrint.aspx?ID=26903 9/2/2009 r Message. Page 1 of 1 O'Connell, Timothy From: Miorandi, Donna Sent: Wednesday, September 02, 2009 8:59 AM To: O'Connell, Timothy Subject: FW: Health Division Complaint Hi Tim, Has Tom McKean forwarded this complaint to you? Donna -----Original Message----- From: Town Main Mailbox Sent: Wednesday, September 02, 2009 8:49 AM To: McKean, Thomas; Miorandi, Donna Subject: FW: Health Division Complaint Thanks, Lawrie From: Kelley, Kristin [mailto:Kristin.Kelley@tdbanknorth.com] Sent: Tuesday, September 01, 2009 12:04 PM To: Town Main Mailbox Subject: Health Division Complaint To Whom It May Concern: I am renting a home in Centerville that currently has no hot water. The landlord said that we may be out of hot water for another 2 weeks and it has already been 5 days. Is there anything that can be done about this? Thank you for any help! Kristin A. Kelley 15 Old Stage Road Centerville,MA 02632 - g7TU 9/2/2009 Town of Barnstable Department of Regulatory Services 11I SUBM i Public Health Division Date hd/d o a1� 200 Main Street,Hyannis MA 02601 Date Scheduled Z ` Time F� 4v1 ee Pd.�,�� c�, Soil Suitability Assessment for Sewage isposal Performed By: �� 5���1 Witnessed By: V, &A LOCATION& GENERAL INFORMF105 I.ocatio Address /� �� /fG� r �� O °er' .N mi/� V,��f _ n �6� � C/ rJf A� t 5t�� Assessor's Map/Parcel: ` (I,' Engineer's NameG% ��U NEW CONSTRUCCTIONQ� REPAIR Telephone# ,:57V— rl—Z5_ A_0 Land Use 345X Slopes(35) ! Su cil�e 3fones / zi9;r,4— / Distances from: Open Water Body A114, ft Possible Wet Area� �-t/ft Drinking Water Well 2 � o y i Drainage Way 2 ft Property lane LU ft Other Afe SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) � J I Parent material(geologic) 146-1 Depth to Bedrock Depth to Groundwater. S ding Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater > Z / DETERNUNATION FOR SEASONAL HIGH WATER TAME Method Used: Depth Observed s nding in obs.hole: _,r in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# A// Reading Date:Ail_ Index Well level_ Adj.fhctor&� Adj.Groundwater Level,44�Z_ PERCOLATION TEST Date 6 z /owe 1141 Observation Hole# �, Time at 9" Depth of Perc J(� Time at 6' Start Pre-soak Time @ ,' lime(9"41 End Pre-soak t ' 2 J Z 4 J1I v Rate MinJlnch to Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) . Original: Public Health Division Observation Hole Data To Be Completed on Back------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. yEteinc ravel��di d e41a /6 -3 2 /3 '° 76YQ 5/6 DEEP OBSERVATION HOLE LOG Hole# Z Xl C310,6 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten % o- r� Cr ^` o ,Z 41 94 - Al 7,syrZ 6/ 31-1 4 �45MO /VXX 1,14 �o (9/�vYNd �c�ev cG�j er DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. Consistency. Flood Insurance Rate May: / Above 500 year flood boundary No_ Yes ._._✓__ Within 500 year boundary No= Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? " -Q he depth of naturally occurring a ious material? . If not,what is t p y g p Certification I certify that on � (date)I have passed the soil evaluator examination approved by the Department of En tronmen 1 Piotec' an hat the above analysis was performed by me consistent with . the required trai g, xp se e e e described in 310 CMR 15.017. Signatur Date ?� QASEPTICIPERCFORM.DOC FORM30 Clw HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE H CITY�OWN --b ' (;_14 DEPARTME L""'. ADDRESS GSM yv 9 y`o TELEPHONE Address Occupant- A 7M I Floor Apartment o. No. of Occupan No. of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units_ No.Stories Name and address of owner (�_ _7 T�� " 1-i 4 ck, �( 0 k �q C Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls.- Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Su p p I y Line: — q(Q j ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 11220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub.- Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPOVJS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES ' INS PECTOR TITLE — DATE DATE l 7 I TIME A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises,shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical,plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0) shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. tkk iLf 200 � f ,�z„ Cc„Ne a',40 THE Town of Barnstable Wjt CS bs Barnstable kzlkd Regulatory Services Department - BA,RNS-r.ABLE. MASS. Public Health Division �,SIC o.-rs o6 039. �0 200 Main Street, Hyannis MA 02601 �, 2 d �� ' . q, ",'7Q 10 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205009427 5/04/2010 Franz Jaklitsch Maya Jaklitsch COPY PO Box 547 �YJ Brewster, MA 02631 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 19 Old Stage Road, Centerville MA was last inspected on April 10, 2010, by Mark Polselli, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace.the septic system within the deadline period will result in future , enforcement action. PER ORDER OF T BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments l 9 old S��9� t� d Property Address Owner Owner's N e information is re,4e,,i,i e. AU �ot63o� /0 /� required for State Zip Code Date o Ins ction every page. Cityrrown Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out l forms on the 1 �, computer,use 1. Inspector: only the tab key to move your C d K cursor-do not Name of Inspector use the return key. .L A iflp — TC Gil Company Name/21 r V m Company Address � City/Town State Zip Code Telephone Nu ber License Number B. Certification .. I gertify 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 Oilwiis performed based on my 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 system: t� y gg ❑ Passes ❑ Conditionally Passes Fails " Needs Further Evaluation by the Local Approving Authority fi Insp ctor'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. t5ins-09/08 Title 5 official Inspection Form:Subsurface Sewage Di oral System-Page t of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J Old 1 R j Property Address Gl I Il'lips C Owner Owners Name // / O �V information is �oZ(�d2 required for City/Town/Town �vr f v� State Zip Code Date o Insp lion t every page. B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: re riteria ❑ have not found any 310 CMR 15 303 or 3101CMRon h15.304ich 1exist Any failure ccates that any of riteria unot cevalua evaluated are ed n indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Title 5 ofRdai Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t5ins•09/08 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form - Not for Voluntary Assessments 0/c/ S� Rd Property Address Owner Owner's Name information is �j¢ Q�6 /D required for State Zip Code Date of frispebtion every page. CirylTown 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-09f08 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 19 0/c/ Property Address --, / 1, f Sc c kip Owner Owner's Name6el /�information is 4eV-Vj/4— /7 4 0 required for State Zip Code Date of In pection every page. cityrrown 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 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 o ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ u� 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 '/2 day flow t54ns•09/08 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 Property Address Owner Owner's Name �/7 3 inform lCeo � 0)c information is ,r��/' / /0 o required for State Zip Code Date Inspection every page. City/Town 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. ❑ Q/ 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. ❑ [?I'- 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. LK ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-OWN Ttle 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments % 9 old Properly Address Owner Owner's Name y✓/// 0 /77 information is required for eH State Zip Code Date of Indbectron every page. Cityrrown 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? ,- /El available as built plans of the system obtained and examined? (if they were not 2 available note as N/A) l� ❑ 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): I5ins.09(08 Tllle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Tale 5 Official ial Inspection Form p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 old Property Address J--��� Owner Owner's Name 4 information is �Q✓, �B✓��(�� /�� ��6 �o� o /� required for State Zip Code Date of nsp ction every page. City/Town D. System Information Description: �D ti� S� 1 C � 11� d Number of current residents: Does residence have a garbage grinder? ❑ Yes (�No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ff"No Laundry system inspected? ❑ Yes 3--'No Seasonal use? ❑ Yes P No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: 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: Isms•ogios Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - Property Address / a 4-4�S, _ t Owner Owner's Name ��ti Tc✓�� /� /� (� information is I��/O�/ 0�6 S� required for City/Town /Town State Zip Code Date of I spec' n every page. tY D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Q r"L", cr- Source of information: ' Was system pumped as part of the inspection? ❑ Yes 0 If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sys m: 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•091o8 Title 5 Official Inspection Forms 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 Property Address Owner Owner's Name information is required for State Zip Code Date of Inspection every page. CitylTown D. System Information (cont.) Approximate age of all components, dat installed (if known) and source of information: — -/ 9n = 66 /f Were sewage odors detected when arriving at the site? ❑ Yes — ', Building Sewer(locate on site plan): Depth below grade: feet �iaconstruction: cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material f 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: Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 7 00 ' Owner Owner's Name 4e,M // /�,r 0� 6 31 7 l d information is (�r, !(e '!� required for State Zip Code Date of lifspecdon every page. City/Town D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle rr 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Oo C LoH C`T,p h I 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-09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° T old P �� Property Address VT7,wl TsC Owner Owner's Name I-einformation is e pa t 3� bh yy// required for State Zip Code Date of'Inspettion every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page I I of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments / y Zvi .—S-4a5e- Property Address o, �✓�i Sc 4 Owner Owner's Name 6h�� Ile— I information is � /{.. 0 required for State Zip Code Date of/nspe ion every page. City/Town D. System Information (cont.) Distribution Box (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.): f ko 4za/-s 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: l5ins•09f08 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 / 9 Id SSG Property Address 1 C. A f G Owner Owner's Name /f/��1 �a oa 3� information is ���' vj// � " required for State Zip Code Date of Inspection every page. Cityfrown D. System Information (cont.) r.e _ �x6 � Type: h leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 00 C+ n �► Jrc c, If c /<, l U,,e� 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 13 of 17 t&ns•09l08 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is 4 evi Ile AW Q.)(031 required for State Zip Code Date f Ins ection every page. Cityrrown 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts fD Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / o/c/ Property Address T`� � I /� ,/�� S'C h Owner Owners Name information is CP y v� �jg 0,2 �//p��0 required for every page. Cityfrown State Zip Code D to a 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 wher public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately � G tv t5 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts kipTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments — / � , Old Property Address Owner Owner's Name information is / required for State Zip Code Date of In pection every page. City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water / 0 ❑ Check cellar r o✓, ❑ Shallow wells l Estimated depth to high ground water: 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09M Tille 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 / 9 told S � Property Address Owner Owner's Name ✓j information is required for State Zip Code Date of Inspection every page. City/Town 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 ketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09v0S Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 __ it I t. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address J A�/ fG �St� 0y WIa J Owner Owner's Name // JJ Q���a l D/'(_0 information is �Q•vt y ,,vl Ile I Date of Inspection required for State Zip-Code every page. City/Town submitted on this Hess checklist at theorm. Inspection end of the formforms may not be altered in any Inspection results must b way. Please see complete Important: A. General Information When filling out I forms on the computer,use 1, Inspector: only the tab key )/Y�a d'h� /z to move your cursor-do not Name of Inspector use the return key,.. Company Namg,,L7 Company Address 0,2C 1Y Zip Code aom City/Town State License Number Telephon Numbe B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: U)_ d(AkS Passe Conditionally Passes ❑ Fails s ❑ d h —A IS In ❑ Needs Further Evaluation by the Local Approving Authority o T " 'Inspect is Signature Date co of this inspection report to the Approving Authority(Board A", 9 0/ G The system inspector shall submit a copy 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 ` '"` ro riate regional office of the DEP. The original should be sent to the system owner report to the app p 9 sand copies sent to the buyer, if applicable, and the approving authority. a V__ ""This report only describes conditions at the time of inspection and under the conditions of use`s 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 official tnspecfion Form:Subsurface Sewage Disposal System•Page 1 of 17 t5ins•09108 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments I S old �, J Property Address " Owner Owner's Name information is e," 4-e✓t'i Ile— required for State Zip Code Date f Inspection every page. City/Town B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System ses: 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: / 0A P �� S o � O!�► �? o I, 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): 15ins•09/08 Title s Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments C � o/d S)-�n �. Property Address r— J Owner Owner's Name /_ 6)-IL 6 information is GeN t�✓vl G required for State Zip Code Date of Ins ection every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 3 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments old Property Address Owner Owners Name i�'� !/ /Ijf� 6 3� /o �(I information is required for C� ` State Zip Code Date f Ins ection every page. Cityfrown 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 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 ❑ r--j Discharge or ponding of effluent to the surface of the ground or surface waters Liz 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 ❑ r,, / Liquid depth in cesspool is less than 6" below invert or available volume is less lam' than '/2 day flow Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page d of 17 t5ms•OW08 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name ✓I�, W l / V�6 ��Z 14"SZt P information is e✓t �-Gd'I/l /� required for City/Town State Zip Code Date o I every page. 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 l� 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 analysts [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- ❑ Eir 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15,304. The system owner should contact the appropriate regional office of the Department. (Sins•OW08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form nt Subsurface Sewage Disposal System Form Not for Voluntary Assessme s old S �� Property Address J� I h �so 4 Owner Owners Name � IT-e- (`, 6�� 4Daof o /-Oinformation is en (/! �'�1_ required for CityfTown State Zip Code Inspection every page. 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 LJ 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 een 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 1 P-P I t5ins-OW06 �_V-� Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 17 ao Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address - t Owner Owner's Name C,+�v, information Is / �6 ho required for State Zip Code Date of Inspection lug every page. Cityrrown D. System Information Description: / /600 6 a �lo�� �' �� O _ Number of current residents: Does residence have a garbage grinder? ❑ Yes ©moo Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No . Laundry system inspected? ❑ Yes E3 No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes o Last date of occupancy: 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: t5lns-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I4 .� Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments / I old Property Address Owner Owner's Name information is ✓v�Ile required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Wass Y pumped stem um ed as part of the inspection? Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S em: 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•09/08 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 /S �/d Property Address Owner Owners Name J �� �ot 6 J� v l information is eve vI Ile— /� required for State Zip Code Date df Inspection every page. City/Town D. System Information (cont.) Approximate age of all components, ate installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of 'structi;40--�PVC ' cast iron ❑ other (explain): Z3 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): l� Depth below grade: feet :tr eial o struction: 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) ,p ❑ Yes ❑ No Dimensions: Sludge depth: 7 t5ins-09108 THIe 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /C! Property Address Owner Owner's Name information is Ce v,�ev required for State Zip Code "ection every page. City/Town D. System Information (cont.) Septic Tank (cont.) O �� Distance from top of sludge to bottom of outlet tee or baffle 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 PO/a je Vie-,e, How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): rat v"I r h f1 T ji�i�'-e cr G `�1/S~ 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 Title 5 Official Inspection Form:subsurface Sewage Disposal system•Page to of 17 15 ns 8 commonwealth of Massachusetts Title 5 official Inspection Form t Form -Not for Voluntary Assessments Subsurface Sewage Disposal System / --r. old Property Address 4l / / 49 f S G �7 Owner Owner's Name Nvv /� information is V/ required for State Zip Code Date of I nspection every page. City/Town 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 Titre 5 Official Inspection Form:Subsurface Sewage Disposal system-Page>>of» t5ins-OWS r Commonwealth of Massachusetts Title 5 official Inspection Form Form • Not for Voluntary Assessments Subsurface Sewage Disposal System :Pro;perty l5 Old -k6 AddressOwner w Name // /�/L information isvl e �r required for state Zip Code Date of I spe ion every page. City/Town D. System Information (cont.) Distribution Box (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.): C 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: Title 5 Official Inspection Form:Subsurface Sewage Disposal System'Page 12 of 17 t5ins•09108 Commonwealth of Massachusetts Title 5 official Inspection Form Assessments ' Subsurface Sewage Disposal System Form Not for Voluntary o/d Property Address Owner Owner's Name information is CeH ✓vi �� required for State Zip Code Date of Insp coon every page. Citylrown D. System Information (cont.) 6'x �1 Type: < leaching pits number: 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.): t h z l J*1-C- �3 01-e /a k1_1 I L-4 P'4-1- 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 t5ins•09108 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1� Q Property Address Owner owner's Name J i✓ t "1 e �9 6 3� �!o /o information is Ce✓' ✓✓i ll{ /l�/� Vim— Date of Inspection required for State Zip Code every page. Cityrrown 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.): Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 t5ins•OW08 •� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ 1 old 5 Property Address Owner Owner's Name information is A L""L ©v� required for State Zip Code Date of I pectton every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal reference landmarks orbenchmarks. Locate disposal al p llwells within 100 feet L including ties to at least two permanent Locate t where public water supply enters the building. Check one of the boxes below: E/hand-sketch in the area below ❑ drawing attached separately d , t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts Title 5, Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address Owner Owners Name / 0 information is ce,An required for Stat Zip Code Date o Inspection every page. City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water t ❑ Check cellar Cow ❑ Shallow wells r ` Estimated depth to high ground water: 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) Q�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: Ci _ r l IH r d' fn✓�-i/ Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 17 t5ins•09/08 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " L • o/d M Property Address Owner Owner's Name ✓/ /1 /I�71 63� d information is Le� ✓ ((-� ����/ required for CirylTown State Zip Code Date f Inspection every page. E. Report Completeness Checklist inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ED---S'ystem Information — Estimated depth to high groundwater ketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Tide 5 Official Inspection form:Subsurface Sewage Oisposat System Page 17 of 17 EK Properties, LLC 19 Old Stage Road Centerville, MA 02632 Edward Lennon,General Manager To whom it.may concern, I Edward Lennon as General Manager of EK Properties, LLC appoint Edward Stone of EAS Survey, Inc to represent me at a Board of Health public hearing regarding the replacement of the Septic system at 19 Old Stage.Road in Centerville,.MA. .I.f there are any questions or concerns please contact me directly. Sincerely, Edward Lennon General Manager EK Properties, LLC 617-594-5470 TOWN OF BARNSTABLE LOCATION /5 .�]Li4-S e lPq SEWAGE # CI S VILLAGE (' e/v - ASSESSOR'S MAP & LOTV04?° 1,5, INSTALLER'S NAME & PHONE NO. 7P Y o/z//,) 3 2_3 SEPTIC TANK CAPACITY !J LEACHING FACILITY:(type) (size) NO. OF BEDROOMS �—` PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: /���►.S~� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No eA - � - `3P y 700_� No. - •- OFxs..... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE e AVVI ation for Dim oiMl lVorkii Tomitrurtiort `Ormit Application is hereby/made for a Permit to Construct ( ) or Repair (•�an IndividV Sewage Disposal System at: ............................................................... �-L atio -A dress 1 or.Lot No. a � Owner Address .................... ------•%'t___�-•--'v----•----•-••-•--•-------•----•-------- — ------------------•-----------1' --- _.....--- P ... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—ether fixtBuresillg ..............:..::..:..::.: No. of persons_::.::::::_:_______________- Showers ( ) — Cafeteria ( ) d W Design Flow.................. .........................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacitvl4_ allons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit Nof._= .�-.-U. Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1________________minutes per inch Depth of Test Pit-_______.______..... Depth to ground water........................ rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 9 ------------------------ .................................................................................................................................... ODescription of Soil........................................................................................................................................................................ W --- ------------------- - U Nature OJLRepair Alterations—Answe pplicab ._ y ._ „ ._ - •------------ - • - - ----•----•---- ...... -- ------- - --- - -!f'�--...... ....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environme de—The undersigned further agrees not to place the system in operation until a Certificate of Compliant as b e issued the board of health. Signed ............ ? .... . .. .......... =... .. . - .ems-.. - y� Application Approved BY - ------ ------ ---®------- - -- - ------- ------ J Application Disapproved for the following reaso ---------------------------------------------------------------------- ---- ------ ---------- --- - - / Permit No. .... Issued -!e� . ....... Date ------------ -------------------------------------- ------------ -------- - - - -J No...... .. -------.. 15 Fas............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE R Appfiratinn for Ditjipwial Workii Tnnutrnr#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair (.(_* an Individual Sewage Disposal System at /,C--0f Cl ,� / 'e xaey ' Lgc`atiyon• Address or.Lot No. —� 5�7 :_..... Address r .................. wner as Ost..el...••................................... .......................... Address ........................... I (r" UType of Building Size Lot................ Sq. feet Dwelling— No.- of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures . P P P Y Y --• ------•---gallons. W Design Flow_______________.______.__......._._...._____.gallons per person per day. Total daily flow..__.._.____._......__._....._ . C4 Septic Tank—Liquid capacity,44;�r allons Length---------------- Width---------------- Diameter_------------- Depth................ Disposal Trench—No. .... ............... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit Nof_'��1.....�:. Diameter..........:......... Depth below inlet.................... Total leaching area............_.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.__--._________--__.-_. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a. •------ ---------------------------------------- -------------------------- •----------------------- ---------------------- ------------•-------••------.------ O Description of Soil...........................................................................................................................................................=............ x (� ----------------------------------- •-----------•-•--•---•-•-•-•------•--------•----------------•--•---•-•-•--------------------•-------------•------_--------•-•-•-•---••--------------•-------------••- VW ----------------------------•------•--...--- ............ ------------------------------------------ --_.--- /I Nature of Repatrs4or Alterations Answer=wh pplicable � �.._�� - --• _-� 1� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ' the provisions of TITLE 5 of the-State Env 1ronmenta•1••Code—The undersigned further agrees not to place the system in-operation until a Certificate of Compliancy has been issue the board of health. Signed .......... .. .. x r XApplication Approved By --- �-�/��.-1--.---- ° I 1 ---------------------------- ............... - j - / Date Application Disapproved for the following rea.ro,_ .................�--------------------------------------------------------- ............ ................................... ........................ -- = ---= ------------------------------------------....---........----------------------------- ............ -Y�f Dare Permit No. -... i... ........ h Issued ------------------- /.1..... .....------------ .. ' �..o....`J................... � /Dare / 1 ----------------------.--------.---------_ - ——_._._.--------.-------- ------ —.—.—..—"'0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Gerti rate of Complianre THIS,1 �,;CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( *^) Y •`"`" at . ` ---------0-/. ........... .... ------------------.. ---------..----- - ----------------------------------------------------------- has been installed in accordance with the provisions of TITLE p The Stay E v'ronmental Code as described in the application for Disposal Works Construction Permit No. .......�.... .. - .. dated ............. .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E CONSTRUE S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �--------------------------------.... Inspector&��_ /.t� j. DATE. '�'� -, "'....... '. ------ ------------------------------------------------------------------ -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No. - .......... FEE..I0..... P �iu�rnu�tl tnrrku��nnutr�trtinn �rrmit .- Permission is hereby granted............... ...1....-__...... .......... . ....7J_................................................................................ to Construct ( ) or Repair�_(� ) an Individual Sewage Disposal System Street � as shown on the application for Disposal Works Construction�ermit No_f�_......,_�.- Dated.................. ..4---------------- ------------------- I Board of Health DATE.. T I --------------------------------------- FORM 3850E HOBBS B WARREN,INC..PUBLISHERS PATIO LOCUS MAP of , PLAN REF: 287/42, 277/4, LCP 12422F & 124221 ALSO EASEMENT PLAN BY BAXTER & NYE (09/05/80) TITLE REF: CTF#63808 (ESTATE OF MAYA JAKLITSCH)) PARCEL ID: MAP 208 LOT 155 OOM i i M ZONING: "RD-1" SETBACKS: 30'F-10'5-10'R VG 2 3 i i FLOOD ZONE: "C" 14' //- COMMUNITY PANEL: 250001-15C DATED:08/19/85 2 � ,/. � ss SRo. SEPTIC SYSTEM // A ,//„�. , i/ REPAIR PLAN LOCATED AT: - ao M 1 \ °Hw - - _ _ #19 OLD STAGE ROAD Ali - CENTERVILLE, MA. GAS G ) °� GAS _ _ Zr) �' PREPARED FOR N77• , ASPHALTo r EDWARD & KELLY 5g � _ DRIVEWAY LENNON 59.7.3, ' SCALE: 1"=20' JULY 07, 2010 OF M4ss9 o"Or 146 CO NC. i #1 Jr '•,,/ �o�'� DAVID tiG�, ��� EDWARr c�G� , ,,,, —BEDROOMii W ' o c°� A. ARCEL ID: , / o FLAN TY, J s 0 E 208 155 �� . DWELLING , \ o wv Q N 1 b 0,28 $ c I p A=1.1,005f S.F. 2-CAR i� ,'TCF=36.0' c,sTE�`�`� GARAGE , ,;,,,, , \� I sqN!T. ,A AL LA►0 Lu / S2 I 0, o 001 Q 39. F �I /� F-- E. A. S. 189'06'00"E 55.00' o 0 voil ,� 1 (� SURVEY, INC. •'� 36 S8 "� 141 ROUTE 6A SALT POND BUILDING P.O. BOX 1729 _ _ _ o/ J SANDWICH, MA. 02563 TREE DRIVE Erw _No 0 BUS:(508)888-3619 CELL:(508)527-3600 SHEET 1 OF 2 J 1255SEP CENTERVILLE REQUESTED: • VARIANCES 28 1) S.A.S. TO PROPERTY LINE. (10' MI'N., 5' PROV.) 5' REQUESTED ROUTE 29 2) S.A.S. TO CRA' SPACE (20' MIN., 15.7' PROV.) .4.3' REQUESTED O o o r N ?o �, v N 1k m PARCEL ID: 3Q �.v. PARCEL ID: P� 208/157 V 268/15600 LOCUS N PINE TREE DR 30 5'S 11.33, 40 20„E 7' �2.18 PA T10 LOCUS MAP r/• Mj N \\ 2 i W I , PLAN REF: 287/42, 277/4, LCP 12422F & 124221 ^ �.. ii \ 31 � ��"i i!��� tij� � � �� , ALSO EASEMENT PLAN BY BAXTER .& NYE (09/05 80) 32 #19 ^^� , TITLE REF: CTF�I63808 (ESTATE OF MAYA JAKLITSCH� \ 5' i \ r 0) PARCEL ID: MAP 208 LOT 155 3-BEDROOM ZONING: RD-1" SETBACKS: 30 F-10'S-10 R ss ss 5' #23 DWELLING N� �... ., .� FLOOD ZONE: "C" � 16.5. . �. TCF=33.14' �� �.���, � , , 2 � , COMMUNITY PANEL: 250001-15C DATED:08/19/85 7p COR. CRAWL i S SPACE ACCESS Ro. - 'i SEPTIC SYSTEM D-BOX, PIPING & LEACHPIT TO BE REMOVED v'p• �._ �- ,��%� �� REPAIR PLAN -'v LOCATED AT: #19 OLD STAGE ROAD w "� ) •o _ — CENTERVILLE, MA. GAS G ��. GAS _ w / M , - ' ASP _ _ PREPARED FOR N�7 HALT o`�� i EDWARD & KELLY 56 �'=C�L DRI VEWAY j — L E N N O N PARCEL ID: // P� 5g•73'_ ! SCALE: 1"=20' 208/031 // �. / i i . — — _ JULY 07, 2010 A�P\.� // \J/ i W I ��I (H OFlltgss moo"OF,AZgst 8 9 a P LONG. �; #15 , ! off. DAVID . yc :: EDWAf2O Y� I iiiiii t iii2-BEDROOM:: w ! o� o A. 'S PARCEL ID: , ,,. , , O ! � FLAN J " S O E m m 208/155 �` DWELLING , o Wv Q I i N 1 p o'28 $ m . AREA=11,005t S.F. o 2-CAR -i i i \ O! ., : TCF=36.0 I �., GARAGE ^ � ' .gNl7. ,1P+ AL LAND LLJ I7.5' oCD . N89.06'00"E: 55.00' �y;o� 9, O� o!! f— E. A. S GRAPHIC / 36 S�� , � SURVEY, INC. HIC SCALE _ - - - - - -1 - --L — ^� 9 0- L 141 ROUTE 6A SALT POND BUILDING 20 0 10 20 � � _t / P.O. X 1729 - _ - - cLo 0� O SANDWICH, MA. 02563 PINE TREE DRIVE ErW fi — ItN ( IN FEET ) 1 inch = 20 ft. - BUS:(508)888-3619 CELL:(508)527. 3600 SHEET 1 OF 2 J 1255SEP TOP OF FOUNDATION PROFILE OF EL=33.14' 4" SCHEDULE 40 P.V.C. . 10' MINIMUM MIN: PITCH 1/8" PER FOOT SEWAGE DISPOSAL SYSTEM OBS. PIPE W/scREwcAP TO GRADE AT CENTER (NOT TO SCALE) OF OUTSIDE END UNIT .EL=32.0' EL= 31.8 EL= 31:2 e+. ;;� FG EC= 30.7 ,MAX: ... ., .. .,... ..y. ............. .. ...................... .. ...... ....... ......... � CONC. ` 2.8'f CLEAN SAND FILL RISER•& INVERT PER 310 CMR 15.255 2.6't SC 40 PVC PPE EL= 30.93 COVER LEVEL. EL= 27.67 (TO REMAIN) S=0.02 121VS= .03 FOR EL= 28.0 FLOW LINE 13.0' s=.o1 � EL=30.04' " INVERT INVERT - J INVERT 110 INVERT 12" INVERT EL=29.83' MIN. 14 EL= 29.58' EL= 28:97' 6 SUMP EL=28.80' 8" 4' ADD EL= 27.0 GAS y a-m 6" BASE OF MECHANICALLY BAFFLE COMPACTED SAND PROP. DB5 24.0' ELEV 2(e EL= 25.3 DISTRIBUTION 24-QUICK 4 STANDARD INFILTRATORS (H-10) EXISTING BOX (34"W X 48"L X 12"H) EACH Z 1 ,000 GALLON TANK SOIL ABSORBTION (BED FORMATION) o� VARIANCES REQUESTED: SYSTEM (S.A.S.) 11 .33' X 24' nui 1) S.A.S. TO PROPERTY LINE (10' MIN., 5' 'PROV.) 5' REQUESTED 2) S.A.S. TO CRAWL SPACE (20' MIN., 15,7� PROV.) 4.3' REQUESTED(A,0PA%L_LtAIER PaoVIvEo) BOTTOM OF TH #1 ELEV.= 20.0' 11 GENERAL NOTES I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPARTMENT OF (NO GROUND WATER) ENVIRONMENTAL PROTECTION PURSUANT TO 310.CMR 15.017 TO CONDUCT 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED TITLE 5 .AN.D THE TOWN OF BARNSTABLE RULES AND REGULATIONS BY ME CONSISTENT WITH THE REQUIRED .TRAINING, EXPERTISE, AND EXPERIENCE FOR SUBSURFACE DISPOSAL OF SEWERAGE. DESCRIBED IN 310 CMR. 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY 2. AT LEAST ONE ACCESS PORT OVER TANK TEES SHALL BE SOIL .EVALUATION AS INDI ATED ON THE ATTACHED SOIL EVALUATION FORM, DESIGN DATA ACCESSIBLE WITHIN 6" OF FINISH GRADE, :WITH ANY REMAINING AREA ND AN C. O ANCE WITH 310 CMR 15.100 THROUGH 15.107. ACCESS PORTS BROUGHT TO WITHIN 12" OF FINISH GRADE. NUMBER OF BEDROOMS.........---3 ' 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H 10 LOADING UNLESS THEY.ARE t GARBAGE DISPOSAL .................-- NO � -- ` UNDER OR WITHIN 1O' OF DRIVES OR PARKING AREAS THEN THEY EDWARD A. STONE, CERTIFI D SOIL EVALUATOR TOTAL ESTIMATED FLOW MUST WITHSTAND. H-20 LOADING. B ) 330 (110 GAL./BR./DAY X 3 R. ------- 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION 33OGPD X Z00% = 66O GAL OF ALL UTILITIES PRIOR TO ANY EXCAVATION. 5. ANY MASONRY UNITS USED TO.BRING COVERS TO,GRADE. TEST PIT RESULTS. USE EXISTING 1000 GAL. TANK OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. INSTALL: 6. FINISH GRADE SHALL HAVE A MINIMUM OF 2% GRADE OVER THE S.A.S. AND DISTRIBUTION BOX. SOIL TEST DATE: JUNE 18; 2010 24 QUICK4 STANDARD INFILTRATORS (3.4"W X 48'L X 12"H) 7. SEPTIC TANK SANITARY TEES SHALL BE CONSTRUCTED OF AND BACKFILL WITH CLEAN SAND FILL PER 310 CMR 15.255 SCHEDULE 40 PVC AND SHALL:EXTEND A MINIMUM OF 6' ABOVE B.O.H. AGENT: DAVID W. STANTOW R.S. THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND SOIL EVALUATOR: EDWARD A. STONE SOIL CLASSIFICATION..............:.__ _-_- LOCATED DIRECTLY .UNDER THE CLE . E NO LESS THAN MANHOLES. 8: THE INLET PIPE INVERT ELEVATION.SHALL SHALL B BACKHOE OPERATOR: ADAM . RIKER DESIGN PERCOLATION RATE.....S2-WLl,414• 2 INCHES NOR MORE THAN .3 INCHES ABOVE THE INVERT EFFLUENT LOADING RATE.........-_74 ELEVATION OF THE OUTLET PIPE. GAL/_ REQUIRED LEACHING CAPACITY .. 330 DAY 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES. LEACHING CAPACITY PROVIDED ...335 GAL/DAY 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS TH 1 EL.= 32.0 P E R C R A TE�=<2 M I N/ -I N. @ 54 BAFFLE,. 4 INCHES IN DIAMETER AND CONTRUCTED OF 4" PVC: (4) ROWS OF (6)INFILTRATORS = 96L.F. 11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND ELEV. DEPTH (IN.) HORIZON .: TEXTURE COLOR MOTTLING OTHER ___ 96 L.F. X 4.72 S.F. L.F.= 453 S.F. FIRST TWO FEET OUT OF THE DISTRIBUTION BOX SHALL 30.7 0"-16". A / / LOAMY SAND 10YR4 3 BE LEVEL. 453 S.F. X .74 GPD./S.F:= 335. GPD i 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION_ 29.3 16 -32 B LOAMY SAND 7.5YR5/6 TO EAS SURVEY INC. FOR B.O.H. AND DESIGN 20:0 32"-144" C' COARSE SAND I 10YR6/6 --- 10% GRAVEL ENGINEERS REVIEW AND APPROVAL. 335 GPD PROVIDED 330 GPD REQUIRED 5 GPD RESERVE NO GROUNDWATER t `ZH OF Mq q ���N OF Mggsgch CONSTRUCTION .NOTES: TH#2 EL.= 32.8 �o?�� p vI RD��� �o�� ED 0 G�'� SEPTIC SYSTEM DETAIL PAGE .1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND g cn #19 OLD .STAGE ROAD ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING ELEV. DEPTH IN. HORIZON TEXTURE COLOR MOTTLING OTHER U STONE . a WORK ON THE SITE ... : H 31.6 0"-14" A LOAMY SAND .. 10YR4/3 --- ----- N 21 o. 8 , ILLE, M 2. NO DETERMINATION HAS BEEN MADE AS T0. COMPLIANCE � : „_ " .. • 8 CENTERV ` WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT 30.1 .: 14 32 B.: :. LOAMY SAND:_ : i 7.5YR5/6 --- ----- F� �o °F� � JULY 07 2010 IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE' AUTHORITY. 20.8 32"-144" C COARSE SAND ' 10YR6/6 --- 1.0% GRAVEL Sao L A $ 1ISTRIPN 3. ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING a ' TAPE OR A COMPARABLE MEANS. N0 GROUNDWATER SHEET 2 OF 2 J# 1255SEP U - . ...__. ._.---.-._ ..._.-... 3 8'-011 5'-11" 5'-4" —8'-8" 8'-6" 6'-311 1 01-8" 8'-311 v.n 30 c b� WH r u � r�Pe Utility d ? 00 o 'N cyantryLine Q - Kitchen o Linen N \ " M FW/ 00 _ Step 4066 BF N 2-6 CO 2666 �r .3 Y ..�. m.�. 4-0 CO O 2666 Closet .- 2666 o Closet O 11R r'; N 2866 cathedral ceiling lines w+ Step N Living Room . Master bedroom — — — — — — — — — — — — — — O � Bedroom O �p p 2866 .,h , 10'-6" 5'-0" 3'-6" 0 Porch 14'-011 9'-9" 14'-311 EK Properties, LLC / Ed Lennon 19 Old Stage Rd, Centerville, Ma Proposed Plan First Floor Drawn by WHE Scale 1/4" = 1 Foot , 12 12 Fin Clg �. 3056 ' N Asphalt Roof Shingles F_ Fin Clg Fin Fir 3257 3257 6-Ox6-8 2640 o White Cedar Shingles Fin Fir Approximate Grade Approximate Grade Rear View J 12 Fin Clg 12 3054 N , Asphalt Roof Shingles Fin Fir Fin Clg Fin C1g 3056 3056 4156 3056 3056 - - - - ---- - - - - - - bn � v n Fin Fir 7 Fin Fir Approximate Grade Pp Approximate Grade Front View ___EK.Properties, LLC / Ed Lennon 19 Old Stage Rd, Centerville, Ma Proposed Elevations Front and Rear Drawn by WHE Scale 1/4" = 1 Foot r . I r .. ,. t.. i,. .. � ., „ ..i I ns111 1; i; I ,. �. I , i f III I E ...I _ V��'4 n�.uy,s., , i', I E! I Yi Ir I,, }s. if 1 s �:,a. •til ,,, .. ..I+r. i1 ',Y; I. 3 8'-011 0 30x54 I I I Dn — I I i i I ; I I I - � •� I I i � 0 I •� i I I •a� I I I U I I i I I I I i I I , _ I I Roof Lines 0 o i Bedroom I I I I I I I I i I y^,-5„ I I I , I I � I I I I i I I 30x54 14'-0" 24' 0" ' EK Properties, LLC / Ed Lennon 19 Old Stage Rd, Centerville, Ma XFloor Plan Second Floor Drawn by WHE Scale 1/4" = 1 Foot