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0785 OLD STAGE ROAD - Health
ti '85 Old Stage Road Centerville, MA A= I UPC 12534 0.2-153L0 , TOWN OF BARNSTABLE L'�CATION �L zt-� SEWAGE# jiC�- VILLAGE ASSESSOR'S MAP&PARCEL J- :P/67 INSTALLER'S NAME&PHONE NO. 2--L I. a SEPTIC TANK CAPACITY CK i f-rj K. 4 Loc- LEACHING FACILITY.(type) 14— (size) 1x_ItL•:3 X� NO.OF BEDROOMS .� SO- 6Z m— e,9- L OWNER I G1 ati( /d PERMIT DATE: COMPLIANCE DATE:J at �Io Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 4 ,!�_ Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) H Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �7g'� ��'`' �i �. ab' y� � - �6 , r �> �l b ` ����' TOWN OF BARNSTABLE LOCATION S O�U � � �U- SEWAGE # f 1 1 VILLAGE 1� 1i\�1 e'r�t��l�.- ASSESSOR'S MAP & LOT_ aaec rNAME n � S 2 �t' &PHONE N0.__ \�U��- �. SEPTIC TANK CAPACITY A c- LEACHING FACILITY: (type) b Q Ac,-( (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMIT DATE: nwoG DATE: O L4 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching.facility) Feet Furnished by -. a 0 ` t No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 14 LIC HEALTH DIVISION -,TOWN OF BARNSTABLE, MASSACHUSETTS Yes PU 9pplitation for Disposal 6pstrm Construction Vrrmit �Appljicaon for a Permit to Construct( ) Repair(, ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. y� ®� s �� d Owner's Name,Address,and Tel.No. �oia-6 5/� Assessor's Map/Parcel / Installer's Name,Address,and el.No.`9A 93 9 9 Designer's Name,Address,and Tel.No. ! r l-c>lctt�,Clocr►s�-ru� i vim,Inc ��i,�9ay A) 2 Type of Building: Dwelling No.of Bedrooms 3 Lot Size /55 0 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 c) gpd Design flow provided 3 gpd Plan Date Number of sheets Revision Date Title i Size of Septic Tank EX;STf" / Type of S.A.S. - IU i Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Cod to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date / Application Approved by Date // �- /G Application Disapproved by Date for the following reasons Permit No Date Issued �� �� No `1 Fee �® THE COMMONWEALTH OF MASSACHUSETTS Entered in c mputer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Mi5pDBAY 6pstrin Cunstruttiun i3Prmit oplicp, a on for a Permit to Construct( ) Repair(A) Upgrade( ) Abandon( ) ❑Complete System P Individual Components Location Address or Lot No �� s 4Q Owner's Name,Address,and Tel.No. Y a8• Co3.76 n - _ •/ C? ssfv h¢� i n san �7{3'01�5 tar Assessor's Map/Parcel f// I Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. rs r+S 1, ' i.ro G�7S Type of Building: !. Dwelling No.of Bedrooms 3 Lot Size /55?v - sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures - Design Flow(min.required) 3.3 Ca gpd Design flow provided �� gpd Plan Date QcjL6, ,;v) ao/(o Number of sheets Revision Date Title + Size of Septic Tank @X S"t 1/1 lD(�;t;J �e �,k Type of S.A.S. I -(F{ , a I Description of Soils(F p /J� i�•83 x aS' C7 .d s 3 Nature of Repairs or Alterations(Answer when applicable) - 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-nit to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. / Signe Date Application Approved by Date Application Disapproved by Date for the following reasons //-- t; Permit No. t� '' Date Issued I ^� h.y THE COMMONWEALTH OF MASSACHUSETTS ,, BARNSTABLE MASSACHUSETTS CPCtlfltatr of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�) Upgraded ((�� ( ) Abandoned( )by.I.�rAd \ insl(C..Y--L coin -a nc- at 9g 1r %(1 & �p��(UI Ie has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No_-;?E/6 -:51Qlated //�4- ,f 1, Installer Aoc- 'UU.[ C(�F�Sk>rt.x-�lClY1 [• Designer �('u!'�X�e ty) 10 #bedrooms L� Approved design flow 3 u� gpd The issuance of this ,ermit shall not be construed as a guarantee that the system will�iol�as desi- ed. r Date ,'2 I Inspector )7 L --------------------------------------------------------------------------------------------------------------------------------------- No. J 0t., 9 d-- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS MispoBal *pstrm CoustCULtion J)PrmIt Permission is hereby ggraan+ted to Construct( /) Repair(1,� Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction in s tie co �Ieed within three years of the date of thi permit. / Date / G� Approved 15 f ��- 3 VI Town of Barnstable Regulatory Services x Thomas F. Geiler,Director '* BnxxsTnB MASS. �0$ Public Health Division Tenr�rda Thomas Mclean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: Sewage Permit# 2-0)� Assessor's Map\Parcel/,9/ /6 7 Designer: 4 W v,, f Installer: o✓ /6 y� Address: 23? Jt Address: 0 "0- 40?- 7d VIP.— eaiE On i ( �r� �!�✓7'l�/'J--/1 ,--was issued a permit to install a (date) �(installer), septic system at /�� Q�� e- (�r�C based on a design drawn by \ (ad ess) U a►.��( 0 oLJa PC P!1' dated /.,-= esigner) � 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 s n)but in accordance with State&Local Regulations. Plan revision or certifie a - ui y designer to follow. A ,;'6 of MAs. DANIELP,. �o OJALA (Installers Signature) CIVIL No.46502 r ' � o ` E 61 I S V- S/ONAL E' (Designer's Signature) (Affix Designer's Stamp Here) 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 PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form 3-26-04.doc Y �$790 ff 'Town of Barnstable P# I) par�tment�of Healtll,S�afectY'and cEnv�ro�Wr� c,�$,; a3 P-ublicra�i�ealth D><���isi�o;>n Date. l0 7 M 'n'St ms MA 02601'36 a� reet,I-Iyaa ' ^ snriNaTABrF � � � O a Fee Pd. 1 L� (p Time��M b0 20 reo�tw Date Scheduled • a ti i+ Soil Suitability AssessM,ento for Rw - ! •e DisposalMc Y� �y Performed By: Witnessed By: B"'° vu •• l . ................: Location Address 7p,r 014 J' Owner's Name Q 0 6 r � �(e/)ttrt/t�(e rAddress; ,. l.�, w1 0 EngJn.eer's`Nam, (!NIA+ e " Assessor's Map/parcel: 1`e 7 NEW CONSTRUCTION REPAIR Telephone Land Use Y4Arj►�+�K-JC lA�LJ` Slopes - Surface-Stones Distances from: Open Water Body k 7D0 ft Possible Wet Area>'710O It Drinking Water Well> a tt - Drainage Way 1 \a ft Property Line �� ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) QIz ram. 14 N / — ,V 94� t • yam, �— toBedrock 7 `o Parent material(geologic) D�- � �-�`��" Depth. Depth to Groundwater: Standing Water in Hole: f..j Weeping-from Pit Face IA- Estimated Seasonal High Groundwater.. _._ .._. . Me n. Depth.to thod Used: in, Depth Observed standing in obs.hole: i �soil-mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment A. - - index Va+elt# t'eedir!g Rages_•__ _ Index Well level•__' A(ljAactor " 4 - Adj:•Gioundwater Level__ `1 Observation ,> TimeHole# i., " ' Depth of Perc Time af`6"` • Start Pre-soak Time® Time�(9"-V) t.' End Pee-soak s` i Rate Min./Inch e Site"Suitabiliry'Assessment: Site Passed. +' Site Exiled: --Add itional_Testing,Needed: Original: Public Health Division Observation Hole]Data To i$e�.otttg�ieted on'�aa k Copy: Applicant 4Depth from Soil Horizon SoilTezture 1 3' #1tSdi lNColor';' '::' Soil Ot ier Surface(in.) (USDA) (Munsel) Mottling (Structure,Stoa es,Boulderes. L:,.. t • - 'r',,y :::::�i:>i:iY:':::.;"::.�::._::.:: >�!.:::::.;'..:;::.::+.:.:.:'.;'_:%��:::..•::.::::,.:':.�.;:.:;.;:._�:.:y:.:.:::;'.�;.;'::.;:::::;::is:i:;;t.i:.s:.ii::iii>ii: ............. . ... :;::;•;:.;:.:::;;<::.;:::.,:::::....::.:::.......::•: Other Depth from Soil Florizon Soil Texture Soil Color Soil Sa`rface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistgnpy.%Gravel) o �•r � � Gf i � 10 2 S�b X. jy .;:::::...;::;:.::.::::.:::::::.::.:::;.::.......... ... ......:..:.....:....::.:.....:..... •I)'epth from Soil Horizon Soil Texture Soil Color Soy flier surface from (USDA) (Niunsell) Mottling (Structure;Stones,Boulderes. o i nc /a Gravel) :. :;::•: ."•> :::: ::>.,'is; `.:%^.:': ::.`• (`r:>:?«>> 'z..... .. �.... ..:......................... De"pth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,°o r e r ifio®dAnsutam'ce'k-M-0 sllVian. hi Above 500 year flood?boundary. No.-- Yes *31him500-year.boundary No Y Yes ..r b�lilfi�iii=t0'O:year'floo'$ undary'Norv._ ,. fYt, bb-pth 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? lf,:not,what.is the depth of naturally occurring pervi us material? Certification P certify that on (d"ate)I.hi ve passed the soil evaluator examination approved by the Departmeti of-Edvironine"ntal7,Pl•otection_and,that'the=above analysis was performed by,me.consistent.with ,the required training,expertise and experience described in 310 CMR 15.017. Signature Date YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO according to M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1" FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. DATE 13 / 2—ot Fill in please: APPLICANT'S YOUR NAME/CORPORATE NAME r, BUSINESS YOUR HOME ADDRESS: -7e9S o TELEPHONE # Home Telephone Number NAME OF NEW BUSINESS C._3L TYPE OF BUSINESS C-- C_ t7 ti��i IS THIS A HOME OCCUPATION? V YES NO Have you been given approval from the building division? YES NO ADDRESS OF BUSINESS MAP/PARCEL NUMBER When starting a. new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate .your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual ha e informe f th e mpts that pertain to this type of business. Authorized Sign ure** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual ha e n infur' d f t li ensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 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. General Information When filling out I forms on the computer,use 1. Inspector: only the tab key to move your A.Riker cursor-do not Name of Inspector use the return key. R.L.0 Company Name Q P.O. Box 726 _ Company Address a� South Yarmouth MA City/Town State Zip Co.`de 508-776-6460 S14590 Telephone Number License Number L i B. Certification r1 5 M 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 16.340 of Title 5 (310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 04/17/2010 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. LA I I t5ins•09/08 Title 5 Official Inspection Forth:Subsurface ge Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System was observed to be in working condition with no failures observed. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins 09/08 Title 5 Official Inspection Form:Subsurface Swage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is Centerville MA 02632 04/15/2010 required for _ every page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (font.) 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 ❑ ® 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 Cl ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 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 ayes"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 lame 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate ayes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 330 Number of bedrooms(actual): 3 --- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330gpd t5ins•09M Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: System is constructed of a 1000 gallon precast septic tank with pvc pipe flowing to a precast concrete leach pit with approx 2'stone on sides and six feet in depth. Number of current residents: unk. Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available Oast 2 years usage (gpd)): 2009=64 GPD 2008=17 GPD Detail: Water records were obtained from COMM water dept.Very limited history cf occupancy due to bank forclosure and vacancy. Sump pump? ❑ Yes ® No Last date of occupancy: unk. Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System For n -Not for Voluntary Assessments a 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. CityrFown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Barnstable Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: not required. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f 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): Septic tank and leach pit with no distribution box. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known) and source of information: unable to locate records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): copper to cast iron in interior Distance from private water supply well or suction line: 20 feet Comments (on condition of joints, venting, evidence of leakage, etc.): All plumbing dry and tight Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) precast concrete tank with concrete baffles If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5' Hx5'Wx91 --- Sludge depth: 18" t5ins•09/08 Tde 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7_85 Old Stage Road Property Address One West Sank Owner Owner's Name information is Centerville MA 02632 04/15/2010 required for every page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle -16" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Pumping should be done in the near future as maintence. Tank was observed to be installed at correct invert elevations with no obvious defects observed. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville NIA 02632 04/15/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No distribution box was located and there was no indication of one found on prior inspection . Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1@1000gallons ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/aftemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leach pit was dry on inspection with staining only half the pits effective depth observed. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'r 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 _ every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•091W Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. City/Town State Zip Code pate of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately R Repl Ui •� (VM/ �/V e � _ y� ;.� a,Q• 9 3 1 ,s �C>U '. `ov t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: > 15' no water observedfeet 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: Checked GIS topo maps and USGS maps You must describe how you established the high ground water elevation: hand augur to 15'with no indication of water at same elevation on property. Check local topo maps and Cape Cod Commision water level maps and current well data and adjustment zone. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-0910B Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 785 Old Stage Road Property Address One West Bank Owner Owner's Name information is required for Centerville MA 02632 04/15/2010 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 '• � COMMONWEALTH OF MAS SACHUSETTS•..;*:"< EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONME'PT. PROTECI�ON r 200ru JUN -3 Pri, I1', 23 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: CA2 Owner's Name: �- U Owner's Address: Date of Inspection: Name of Inspector: lea e prin Company Name: G Mailing Address: rvn� _ �bZ two 1 Telephone Number: .-t CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature• 4 Date: a Li�z( p S The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 ti Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: e Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: —j— I have not found any information which indicates that any of the failure criteria described 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. in 310 CMR Comments: t A B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaire a system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. jAnswer yes,no or not rmined(Y,N,ND)in the for the following statements.If"not determined" leas explain. please The septic tank is metal and over ears old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or a tration or tank failure is imminent.System will pass insgeetion if the existing tank is replaced with a complying septic as approved by the Board of Health. *A metal septic tank will pass inspection if it is struc sound,not leaking and if a Ce0fieate of Compliance indicating that the tank is less than 20 years old is available. J, ND explain: � /ter Observation of sewage backup or break out or high stati" w cater level in the bution box due to broke obstructed pipe(s)or due to a broken,settled or uneve disbution box. System will pass lion if(with nor approval of Board of Health): broken pi e(s)are replaced obb ft lion is removed _ Adistribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed l ND explain: T;*la G Tnonn�*;nr�17nrm All ai)nnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: S C),C) S 1 e Owner: Date of Inspection: 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 'Il pass unless Board of Health determines in accordance with 310 CNN 15.303(1)(b)that the Sys tem is n t functioning in a manner which will protect public health,safety and the environment: — Cesspool o vy is within 50 feet of a surface water Cesspool or pn is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health and Pu W ( ater Sup ' r,if an determin system is functioningin a manner h r es that th that protects the public P p bhc hea ty and environment: lThe system has a septic tank and soil absorption syste SAS)and the within 100 feet of a surface water supply or tributary to a surface water sup — The system has a septic tank and SAS and AS is within a Zone 1 of a public water supply. — The system has a septic tank and SA nd the SAS is within 50 feet of a private water supply well. The system has a septic tank a SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Me od used to determine distance **This system passes if th ell water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile or 'c compounds indicates that the well is free from pollution from that facility and the presence of amm a nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are ggered.A copy of the analysis must be attached to this form. 3. Other: Titlo 4 Tnenartinn V^rm A/1;i)nnn 3 Page 4 of 11 OFFICIAL INS PECTION FORM—NO T F SUBSURFACE SEWAGE DI OR VOLUNTARY ASSESSMENTS DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Q. PJ Owner: p Date of Inspection: S D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or J clogged SAS or cesspool _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool —{ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow N Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s .Number / of times pumped gg P P ( ) 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 _ Jwater supply. . Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private.water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or ve failure criteria exist as described in 310 CMR 15.303,therefore the system fails.rThe system e of the oowner 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 desiow of 10,000 gpd to 15,000 gPd• You must indicate ei "or"no"to each of the following: (The following criteria apply to large sy to-the eria above) yes no the system is within 400 feet of a surfa drinking water supply the system is within 200 feet o 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 y 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. Title i Tnennrtinn T:nrm!./1 S/7(1(1!1 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �J CA e , J Owner: Date of Inspection: 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? 9 / Have large volumes of water been introduced to the system recently or as part of this inspection? W A 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? ✓✓✓/// `f 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? J _ Was the facility owner(and occupants if different from owner)P r maintenance of subsurface sewage disposal systems? ovided with information on the proper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes n Existing information.For example,a plan at the Board of Health. — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] T41a C Tnonorfinn Fnrm A/1 ci)nnn 5 Page 6 of 11 J OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �0� Owner:-=O�SL A j Date of Inspection: off 1-2- FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):I Number of current residents: 'I- Does residence have a garbage grinder(yes or no):1 lib Is laundry on a separate sewage system(yq or no): ft6[if yes separate inspection required] Laundry system inspected(yes or no).N-v Seasonal use:(yes or no):11O Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): S'l6 �1 Last date of occupancy: ev �' COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): apd Basis of de ' flow(seats/persons/sgtetc.): Grease trap presen or no):_ Industrial waste holding to nt(yes or no):— Non-sanitary waste discharged to the i stem(yes or no): Water meter readings,if available: .Last date of occupancy/use: OTHER(d cribe): Pumping Records GENERAL INFORMATION Source of information: 1 Was system pumped as part of the inspection(yes or no): C1 O If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: �E OF SYSTEM Septic tank,-diisft*ntt6ft1ox;soil absorption system _Single cesspool _Overflow cesspool —Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: ))NI C 1OS.L)Y Were sewage odors detected when arriving at the site(yes or no):)!\,_C Ti41a i Tnenartinn Rnrm Ail;mnnn 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: e— Owner: Date of Inspection: < I p BUILDING SEWER(locate on site plan) Depth below grade: — % Materials of construction: cast iron _40 PVC ✓other(explain): "'c�- 3 U Distance from private water supply well or suction line: +L%,J n Comments(on on 'on of joints,venting,evide ce of leakage,etc.y� �C-a� � rvo�F SEPTIC TANK:-d(locate on site plan) Depth below grade: �5tt Material of construction: concrete—metal— fiberglass__polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: CA Sludge depth: �—(r Distance from top of nudge to-bottom of outlet tee or baffle: 1 < Scum thickness:�— Distance from top of scum to top of outlet tee or baffler` ev2� 5 Distance from bottom of scum to bottom of outlet tee r baffle: 7�` How were dimensions determined: SJ�Q �[� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet' vert,evidence of leakage,,et : KnIce GREASE TRAP:,_,(locate on site plan) Depth belo Material of construction:— �metal�fiber 1 e y ene other(explain): _ — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TitlA S Tnenantinn Fnrm!./1�/7(1!1!1 7 Page 8 of 11 J OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: c d d 5+ (Z d Owner: Date of Inspection: z-S TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below gr Material of construc ' concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: al o -�~ Design Flow: gallons/day r Alarm present(yes or no): Alarm level: Alarm i=workingor e o no): Date of last pumping: Comments(condition of al ,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liq 'd Level above outlet invert: Comments(note ifbo -klevel and distribution to outlets equal,any evidence nc e of soli ds carryover,into or out of box,etc:. any evidence of PUMP CHAMBER: (locate Pumps in workin rrder(yes or no): �Co�ntslarms in ct'mg order(yes or no): (note condition of pump chamber,condition of pumps and appurtenances,etc.): '1 TO+'-4 TnvnP fVln P—m A/1 r%l,)n A 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: T -7leaching pits,number: 0 (Doi 0.\ 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.)` CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number a onfiguration: Depth—top of 'd to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic evel of ponding,c n of vegetation,etc.): PRIVY: cate 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.): T41. Tnanantinn W—r,/1 ai,)nnn 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �7 o Owner: Date of Inspection: O SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. • o 0 w �o s t �vS�eS J ' in « Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: e 0 Owner: 1E Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water k Meet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentatio Accessed USGS database-explain: J — 2S Z 611e- C — �J Yo must describe how you establis ed the hi ground water ele ation: n LAIN k z e v —0 o d—� 0 0 Titlo S Tnonvrtinn Rnr Ali, /rmnn 11 ALL TEM LL SYSTEM PROFILE MARKED WITHCMAGNETICTTAPEAOR BE NOTES COMPARABLE MEANS FOR FUTURE LOCATION. tfeet PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) ok 5 1. DATUM IS NAVD '88 ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2" PEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3" GRADE Three ponds \ FILTER FABRIC OVER STONE 2. MUNICIPAL WATER IS EXISTING TOP FOUND. EL. 59.7' 8" PER FOOT.MINIMUM PIPE PITCH TO BE 1/ MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 57.4 3. 9sh/P NOTE: 2" MIN. WALL 4. DESIGN LOADING FOR ALL PROPOSED PRECAST o a' PRECAST H-10 THICKNESS REQUIRED BLOCKS OR UNITS TO BE AASHO H-LLQ c o L us RISERS (TYP.) PRECAST RISERS 2'0 56.9' 4"OSCH40 PVC COMPONENTS H-10 5. PIPE JOINTS TO BE MADE WATERTIGHT. r o o � boo PIPES LEVEL 1ST 2' 4' 4' �c •` o pke pt �ENDSSIDES 54. 6 CONSTRUCTION DETAILS TO B IN ACCORDANCE o° 10" EXISTING TEE SEPTIC TANK** TEE *� I]0�� ®®�n] ���I]_ ���Q .;00000000 WITH 310 CMR 15.000 (TITLE 5.) \55.5f >°°°° °° DE2DDDE1OQE3MC� =�DDDDMOMO� >0°0°0000 \\1or a 0000a�a®aac� ����������� 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND F a rt °�°�°°°0°0°� Q ,°O°O°°°° > 000 ° O O °°°o°°o°°°°° °°°°°°°° o 0 0 0 0 o 0 0 o 0 0 0 0 0 o 0 0 °°°°°°°° NOT TO BE USED FOR LOT LINE STAKING OR ANY o e GAS BAFFLE.'.,' °�°O° >00000000 ����D���DOC� ����OOD�OI�O ;00000000 p o a 54.38' 54.21, 52.1 OTHER PURPOSE. po s 00 o0 6" MIN. SUMP f 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. 12" MIN INT. DIM. LH-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. 3/4"-1-1/2' DOUBLE WASHED STONE 4' MIN. (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR ALL AROUND PRECAST STRUCTURES 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.83' CONCEALED WITHOUT INSPECTION BOARD OF eea COMPACTION. (15.221 [2]) HEALTH AND PERMISSION OBTAINEDD FROM BOARD LO OF HEALTH. ( 2 % SLOPE) ( 1 % SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP CALLING DIGSAFE (1-888-344-7233) AND FOUNDATION- EXIST. SEPTIC TANK 56' D' BOX 13' LEACHING VERIFYING BOTTOM TH-X VERIFYING THE LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF FACILITY NO GROUNDWATER FOUND WORK. NOT TO SCALE *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 191 PARCEL 167 PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE SHALL BE REMOVED 5' BENEATH AND AROUND THE CONDITIONS IF NOT SUITABLE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND SAND. 99- EXISTING CONTOUR X 99 1 EXIST. SPOT ELEV. O -[99]- PROPOSED CONTOUR SYSTEM DESIGN. 198.4] PROPOSED SPOT EL. GARBAGE DISPOSER IS NOT ALLOWED TH1 TEST HOLE 60 DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD YYY SLOPE OF GROUND USE A 330 GPD DESIGN FLOW 2� ^�� o UTILITY POLE SEPTIC TANK: 330 GPD (2) = 660 FIRE HYDRANT �a� ` **RE-USE EXISTING 1000 GAL. SEPTIC TANK 0� NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING ' LEACHING: LOT 1A + 55B (PB 297 PG 55) SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD TEST HOLE LOGS 15,570f SF � BOTTOM 25 x 12.83 (.74) = 237 GPD } TOTAL: 472 S.F. 349 GPD ENGINEER: DANIEL E. GONSALVES, SE #13587 4 USE DAVID STANTON, RS �� �� 4/ WITH (4) STONE 500 AALL L. LAROUND EACHING CHAMBERS (ACME OR EQUAL) WITNESS. EXISTING OCTOBER 25, 2016 ��, OAKS DWELLING DATE: �� TOP OF FNDN PERC. RATE _ < 2 MIN/INCH � P� HOL EL. 59.7'LY F. CLASS I SOILS p# 15187 ^cy ( l CLUSTER ///^\> Q ELEV. 1 ELEV. } 26--,0 Aiv) <� MA APPROVED DATE BOARD OF HEALTH 0„ 4 57.4' 0" 57.4' 0 t ��-,\ A A / LP SL SL TITLE 5 SITE PLAN 10YR 3/2 10YR 3/2 21' 2t$ TRI rr-"; 5 OF B B 10" OAK MAPLEI ( l 785 OLD STAGE ROAD SL SL �� 10" PINES 6� + TH 2 CENTERVILLE 8„ 10YR 3/6 57 3, 8„ ' 10YR 3/6 57 3, �� TH 1 \ C1 C1 PREPARED FOR � Si LOAM Si LOAM �,. BENCHMARK: USE TOP OF BORTOLOTTI CONSTRUCTION/ FOUNDATION AT ELEV. 59.7' ROBINSON PERC 1OYR 5/6 1OYR 5/6 r. r r 26" 55.2' 26" 55.2' ,��° OAKS --� � OCTOBER 27, 2016 T31 ; r © -L-1`1(, ��3 �OFF 0 �� ; M/CS M/CS A c ZHQFMgs' , OF��' �jY �s j� s off 508-362-4541 0• F s>, Lkp sq' �ss a�� S��� r.�� e a v3 fax 508-362-9880 NOTE: TRAMPOLINE AREA MQ DANIEL A. �< p`' ��rr C; DANIEL J o DAI0.IEL �„ DANIELA. � , A. �k A downcape.com a o OJALA OJALA to ,Q 2.5Y 6/4 2.5Y 6/4 I CIVIL OJALA OJAI_i�� I • „ 20% GRAVEL 20% GRAVEL f No.46502 CIVIL }#� No 40980 No.4�i0t,0�dowa cape engiaeefI44g, //!c. 126 46.9 126 46.9' + �o �F �° ��� � ° °F 0 �1p 01 m < �FS /STER ��'��TER� �Q ss a� . Est; C/V/l engineers Scale: 1"= 20' & \ONI FSS/0 a fG` c ? Ui V . .: -`�✓Q SUR `, _' y NO GROUNDWATER ENCOUNTERED "` - o land surveyors 939 Main Street ( Rte 6A) 16-348 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 i