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HomeMy WebLinkAbout0017 OUTPOST LANE - Health 17 OUTPOST LANE, CENTERVILLE A= nri RECVCtpp UPC 12543 Mo �srco��'� HASTINGS,47n TOWN OF BARNSTABLE UYCATION LZ Oc)i ,•t- . SEWAGE # `•2.00 —f( VILLAGE ASSESSOR'S MAP & LOT /0 INSTALLER'S NAME&PHONE NO. ff a�ee:5 L aE2, ,,o 112C-KS'39/ SEPTIC TANK CAPACITY 11 LEACHING FACILITY: (type) (size) i NO. OF BEDROOMS pp BUILDER OR OWNER 1 c ra kC PERMITDATE: p I ® COMPLIANCE DATE: Separation Distance Between the: . Maximum Adjusted Groundwater Table to the Bottom of Leaching FacilityFeet 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 � - G-°' C a` r - $— c �.de .37 - 1 No O /©`=� THE CQMMONi'WEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH L�--- Tj'OW/4 O F e 9-1,1 Te-ILy I LL LS APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade (?. Abandon ( ) - ❑Complete System �4 Individual Components I7 O%JTFQST XQ 40 < (�y�l�- �-mc4Ac � /4,41-E-Y Location Owner's Name SAP I7X nor ( v6 /��m . Bad S9�t OS7��Itu� -A i ap/PPrcel# (Joe ` 'i1- ®ddre�ss-Oil 1 �t# �l 'T Telephone# DAr.Cc ez- i Arf-".( I staller's N Designer's Name i t' sAdress �1•~1J� Pe0 ot0 �S I O f7-���!IIC G �4 ®�G�5 Address _ V e) 4?)--99 09 Telephone# Telephone# Type of Building: "YIP i'NWA Lot Size Sq.feet Dwelling—No.of Bedrooms 3 ey t s% Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) 3 U gpd Calculated design flow gpd Design flow provided313-`I gpd Plan: Date fi&06 Number of sheets ` Revision Date Title Description of Soil(s) (-It,4��'Ly �� 1'4 "`A T^o F/n4e, S4 A Soil Evaluator Form No. Name of Soil Evaluator A Jaff"J,fan! Date of Evaluation 3./1/06 DESCRIPTION OF REPAIRS OR ALTERAT ONS LPG �9/�O c✓ Q /N F�'c r%1-���5 7`L �W ',Al 0vLIX-A-L P �rXtfT/ECG o0 s`o 1 TC N 7�q,rth The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the s stem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ' Date - �1 •- -� Inspections ZI FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No �0 6? THE CC?M,I bN'WEALTH OF MASSACHUS TTS FEE f�®�rZrPAt�c� BOARD OF. HEALTH, ,, APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora Permit'to Construct ( ) Repair ( ) Upgrade //()C4 Abandon ( ) - ❑Complete System ,Individual Components 1-7 o�+T P o S T R-o 4 U �l� X°/vat,L o 14-4 t E Y �K A-*J,K110L7-rt; Location Owner's Name ARA-P F 7,z L o r t a 6 A.d . 8 0 s9 9 o sT rQ--r 10-tr Ma /Parcel# / Address fr04) 4;L 6 -2-,21�. Telephone# t o tF ,,a c o N Installer's Name Designer's Name te1,�,n o.rrc--v,e`& a 6 SS Address 1 Address 'rbTelephone# Telephone# Type of Building: el/De N VA L Lot Size Sq.feet Dwelling—No.of Bedrooms 3 E7,1 S r Garbage Grinder g ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures '111')l Design Flow(min.required) 33 0 gpd Calculated design flow gpd Design flow provided 343.1 gpd Plan: Date 0 6 Number of sheets / Revision Date Title �. Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator A jp ff 43ynl Date of Evaluation .3/1 Q/o 6 - r DESCRIPTION OF REPAIRS OR ALTERATIONS E/'C�¢C� /�/GE/5 r,✓ Q F/L rM7v,.s `L-Y- /,a �W X/ 'f/w a v ti +c L 46t-P Ls'Y-I iT//4( /oo o LLo fL'l97`C 'CAN))7-4,4K The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place thestem in operation until a Certificate of Compliance has been issued by the Board of Health. SignedI'l / Date -3 - s� .) g c. Inspections 2r 6 FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. g!:�2 nO62 /0641 THE COMMONWEALTH OF MASSACHUSETTS FEE � nr l �caGa� BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: 1, Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired(_) Upgraded( ),Abandoned( ) at 17 '2. to k Q0'S 4- J as been installed in accordance with the provisions of 310 C R 1).00 (Title 5) and the approved design plans/as-built plans relating to application No.2.r7('6 10 b dated � ��-I � Approved Design Flow 3'�iC...a (gpd) - Installer e A ��_,1e) Designer: 3.,+ np\ tc '�CJ tc N-C-%C, NInsp� toc��r _aj) Date -� 1 The issuance of this certificate shall not be The as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. TH o o� H FEE Inner _ E�COMMONWEALTH OF MASSACHUSETTS �(IlS-lf t0�(f BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( Repair (7C, ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at 7 42 rX)i 3>_.C) as described r / in the application for Disposal System Construction Permit No. -2.6rr� 1�1�v dated � _(/l96 Provided: Construction shall be completed within three years of the date of this permit.All loca�ditions must be met. Date/ 6 Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) _�H&W,- HOBBS&WARREN TM PUBLISHERS- BOSTON °Ft T Town of Barnstable Regulatory Services r • ' • r • BARNSfABLE. 9s g Thomas F. Geiler,Director 'Foy' Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Designer Certification Form Date: 6 Designer: ���'''` �� j O 14Nj O"1 Address: 531 O STeA-y 1L_L9-1( M�4 On b 6 Qo-j6- 0A_0""W was issued a permit to install a (date) (installer) septic system at o�7- P DST &'4"r eleNTF based on a design I drew, (address) dated 06 I certifythat the septic stem reference p y d above was installed substantially according to the design. �{ I certify that the septic system referenced above was installed with changes but in accordance with State & Local Regulations. Revision or certified as-built by R designer to follow. (Design 's Si VU re) P VY 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 0 Town of,Barnstable P�ppTHE lOh�.O Regulatory Services T , Thomas F. Geiler, Director + BARNSTABLE, 9 MASS. $ Public Health Division 039. ♦0 A,Fp ,�A Thomas McKean;Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 3'a Sewage Permit# 20(XQ-IDG Assessor's Map\Parcel V-7A- taco, A Designer: � 1 b C4 t J y�,►OS pc0 Installer: Address: Address: On 3 Z I b G �p`91 c�S \240 W Owas issued a permit to install a (date) (installer) septic system at 17 00* S� �„ �� based on a design drawn by (address) .l �(�de `�bl,(V�� dated 3�`—� ©signer) L' 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. Stripout (if required) was inspected and the soils were found satisfactory. t 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. Stripout (if required) was inspected and the soils e found satisfactory. f (�I aller Signature) (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:\Septic\Designer Certification Form Rev 03-09-06.doc Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM 1, DAM t EC, a J o Sa� ,hereby certify that the engineered plan signed by me dated 3115106 ,concerning the property located at Q OUT-POST R.Oh-D meets all ofthe following.criteria: • Two soil evaluations excavated for detailed examination(no hand augering) and two percolation tests shall be conducted. • This failed system is connected.to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to S minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 6 B) G.W. Elevation 3? +adjustment for high G.W. DIFFERENCE BETWEEN and B I SIGNED : _ DATE: 3//1/0 6 NOTICE Based upon the above information, a repair permit will be issued for 3 bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASepdc\percexemp.doc LO CAS ION ot/7 SEWA G E PERMIT NO. LOB OZ VILLAGE INSTALL 'S NA E i ADDRESS 011d BUILDER OR OWNER C DATE PERMIT ISSUED DATE COMPLIANCE ISSUED . , .. , a - ' ��.' �'� � � ° � � �� �� ..� L � �� ��>�✓ t: 6�� �. TOWN OF BARNSTABLE LOCATION`�/Z 0� •SEWAGE # VILLAGE ASSESSOR'S MAP Ca LOT INSTALLER'S NAME Cr PHONE NO. !Y SEPTIC TANK CAPACITY LEACHING FACILITY;(eype) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 0 o oo / 0 a Post 1-�r (9) ,& av No................_....... Fm$....30............... THE COMMONWEALTH.OF MASSACHUSETTS BOAR F• F-I E . T H ....... ---....T ...............oF.. ... . p�t. . Appliration for Disposal Works Tnnstrnrtinn thrmit Application is hereby made for a Permit to Construct V<or Repair ( ) an Individual Sewage Disposal System a : ..... :.. Lw " .... ...... ................ .............................................................. t; (� ca n•Address c ........ � 1 .. V.......... ©_... ...... :�°t t.l. - _____......_ - -C..... ..a. ....._... _. '- .. _. ......�i... .. :... .+N.dre.o . .._!-x.�i� Installer Address // Type of Building Size Lot_..\L0- '-_..___.Sq. fe Dwelling—No. of Bedrooms.......... ........................Expansio Attic (No Garbage Grinder a'4 Other—T e of Building No. of persons Showers YP g ------•--------------------• P •-•-._....---------- ( ) — Cafeteria ( ) Other fixtures ----------------------------- --------- Design Flow................ �_..................gal lons per person er day. Total daily flow.............. _®_._..._....._gallons. WSeptic Tank—Liquid capacity_! .gallons Length... .... Width.1.�._.._ Diameter................ Dept ......... �. Dis o __'�exe -- No.........1.......... Width-...[.............. Total Length....._�_..........Total leaching area. .�?._____sq. ft. Seepage Pit No.-;!;"* o. ......... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ((,� Dosing to k ( ) Percolation Test Results Performed by.___.. �.. .�. �.___ ._ M__BK___..____ Date ��._ .._!___:_L �-.� Test Pit No. 1. .,�-___ �,.•_- minutes per inch Depth of Test Pit_.__.��_.._..._. De h to ground water..N___��:_ 44 Test Pit No. 2................minutes per inch Depth of Test Pit............... Depth to ground water........................ 9 ..............i.... ---•--------,••••--•- -------•;••- .................................... 0 Description of Soil........jZ ' 2------� �.M A-_�U.�;sa-',-L ........... i � x •------------------------- "t-- --- ��.------_-_------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------•-•••-------•-•-----........_...----•--•-••-----................--------_-----------------------------------------------------------------•--------------._....----. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. e Sign _Sisf ---;is.1Z;7-6-=--�y..-- . • Aez .... rl Date Application Approved BY_ ........... Date Application Disapproved for the following reasons:...-............................................................................................................ ---•---•-•----•--------------•------------•-••-•-----=---•--.........-•------------------....•------••------•-•--•--•--------------------•-•------------••-•---•------•---...._--------------------•••-- Date PermitNo..................................... .................. Issued_.-1--•................ ........................ Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA No................_....... Fuic............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD.-OF HEALTH Apli irFation for Uiipuaal Workii Tonfitrnrtion 11amit Application is hereby made for a Permit to Construct (/or Repair ( ) an Individual Sewage Disposal .... ........... .... .. t tt Location-Addressf Lot No. - QVG �.. �?lrl61 t i7 �. 'J;NLI C"1 > >U `S ( .�?1,� �( ..� Address) a ....�... 1(-- Lam... f r� Installer � Address Type of Building Size Lot... feet Dwelling—No. of Bedrooms.,_.»_._x:...............................Expansion Attic ( I _O Garbage Grinder aOther—Type of Building ---------------------------- No. of persons._... ................. Showers ( ) — Cafeteria ( ) dOther fixtures. ••••.....•••-•-••-•••---•••---••••-•-•--------•--•-•-•-•-••--••-•••••-•••-•......••. . -- ......•. W Design Flow..................5 5.........._......gallons per person per day. Total daily flow................ r-''..........._gallons. 0� Septis-1a k—.Liquid capacity 3.. gallons Length___ _... Width.-+. _.._. Diameter................ Depth �......__. W Disposal Trench— �.......-. Width-...�.. _.'._._.. Total Length Total leaching area__2_ :fir_____s . ft. x P ----....... g g q Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (L,.)'� Dosing tank ( ) . (i_ Percolation Test Results Performed by........ -------------------------- ---------------- Date . ._.l-i....5..`... Test Pit No. 1..---__.--r�:-..minutes per inches'Depth of Test Pit-__-_�.�� ._... Depth to ground water...,..1:1 S kZ'-"":. G4 Test Pit No. 2................minutes per inch` Depth of Test Pit.................... Depth to ground water........................ R'+ --•-----•--•------------•--------------------•------•--•-•-------......................................................... D Description of Soil......•........... z ..... k . t. . x .. UNature of Repairs'or Alterations—Answer when applicable......:........................................................................................ --------•-----------------------•---.........--------------------------------•------------------------------------•-•-----•--••...•-•............•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I'LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. 2 Sign f t /�� / '!a = j - ` � r/ f tr"� - Application Approved By...... ._... . .= Date Application Disapproved for the following reasons:............................................................................................................... ..........................................................------------------------------- ------ ----------------------------------------------------------•------------------------ Date PermitNo..............................•............................ Issued....................................................... Date ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................... ............................................. s Tr if ira .of Toutpl'anrr TH j T fit.. div' al wte Dispos in constructed ) or Repaired ( ) by . . .. ......... at.......................................................................................------- .........- •-------------------------------------.......--•--••- ------------------------- - has been installed in accordance with the provisions of 5 'Ze State Sanitary i6lksc A,in the application for Disposal Works Construction Permit No......................................... dated__:.-_____.__-__--___:__,-A_;._._.........._._... r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. :"7 DATE. .._.". ._,! . _......-•••••-•-••-•--•--•--•---•-_. Inspector .,_ ... '� ... �... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.. : ....:...:.............:_._.-...: .,-:..................................... 56 No......................... FEE........................ �t �trr it r Per is ion ierr .` grante . i••• -- , ---•-....... .--.?"-- .... ............... to Cpn aird1 1 -Sewva s , ' atNo. ........................... ....... ......•---------•• • --- . ----••-- •••. •-•--••--••-• --- . ......... j�. Str t " as shown on the application for Disposal Works Construction P No.. .I} . Dd.... of Board of Health » DATE--- -----.-.-./-/----�---(-��.....................................•--•--....... ,... FORM 1255"HOBBs & WARREN. INC., PUBLISHERS " LOT 4 11/ ry 4 4 1 t x `,S g ' -_;-___--- LOT�i d • {5 U Y P r ylp' l00 0 4d , 5 L-0 i' 3 o . �p ^01 r t rt _) qy J W Fx 1 i 110 { 1 1 LQNE s : LEGEND � — CERTIFIED PLOT: ' PLAN EXISTING SPOT . ELEVATI ON Ox0 EXVSTI'.NG CONTOUR - - p /v R0fiERr G. (-OTE 38 Qu-r6}asY LRr� ' F9NISHED SP OT ELEVATION 0.0 ,� _ F� IiED CO'NTOU-R =— gp.� C�^1rV1! _ d 6. �� - i c3UNOK1•S i I N No.22162 O , " APPROVED : BOARD OF HEALTH i S ON AI i DATE :JAw , ,DATE. -AGENyT SCALE F'' - ,0 #. ENGINEERING CO. IN 8a sf A BL4 I CERTIFY THAT THE PROPOSED=„ C L I E N T EGISTERE� rREGISTERED �pB Np,'_��n���: BUILDING SHOWN ON THIS PL AN CIVIL I LAND CONFORMS TO THE ZONING LAWS ENGINEERS,1 SURVEYORS DR. BY : OF BARNSTABLE , MASS. 71 j2 MAIN 1, CH. BY _� '_ ._ � �:- , f�l /`� '// 'I f' HYANN1'.;, 'vl",''. SHEETJ— OF ::._.__ DATE REG. LAND SUR'VEY¢RL,— . ............. yk� P ej z J A VVI W, 77 co v -4,A ooe W� c coiVeRong CAST 0,V C' AM-,T SA44 4- DR &sa F/eu Ica, 0 , % A OR4400 CC)P,4iF*IT CLEAN -TANAO .. . . . . &AC.Ao=1Z_,L Lj.9v1D LEVEL 2 1 AY.-R 4"CAST /RON pr 0 6A4. 9 4a 0 0 WASHED 57DIVE _i,&R p-r. SEPTIC 7AAo',K 4 d,p VY, 0 0 a 6 WA5N,=,P STONE 0 0 a 0 0 0 a- PRECAST 5ZASR4 6 C 0 d o q o 0 m m e o a e o P17 OR ZVVAV. o p -r. LmAhl- IMYERT AT BUILDINGFr C(5EE TAB414A-r) INLET SEPTIC 'r.4NK 'orr �D,UTLET SEPTIC F7- OROUND NITER 7ABLE 11VLFr-V/-5,7R145I17-1,0H BOX OF 4QUrLE7-,D15-rA?1A&"'r1oN Box F7, -7— /)v4—=r LEACHINa do=v7- 015.,00SAL SY 7-AJ414ATIDIV SCALE : Y4 4- 0 01"IENS1 ON A DR516H Cql TER IA 10 NX-N5,9 JV al FT. FT. /o/, ,V4/,A-f8ER OF 49.-DRO-OMS SO/L 1-06 t G,4_RdA4G_Ic'jP15.P05Ak 4VVJr Toll 7wsIr ?30 GAJ../0AY SO/L TEST *1 SOIL 7_-=S7-#R ,VUAjaER O.F-LOAZWIN6 A;1173 7, 1�.eZffAl 970_ SAE 0,9- 50/,L'7-Z.57- _j 5/0—E LEACH/Mar PERAP17' ska PT. 40 0 r-r01W 4S4 CHlAfC-JOIE R P/ Ar A&M C04AWON A-4 TZF TOTAL LZ4CH1Wer- AREAARA F77 T 4, S* ROBERT, l cP. 7 ' -BUNIKIS C No.22162 0 CIS T % Ib NA . v�_ w 0MM Z� Aw A, L -7 k 'jib. i DATE._5/12495 PROPERTY ADDRESS:_ 1 Qut�ost .Lane____-__ Centerville,Mass. 02632 ' ------------------------ MAY 2 ?_ 199 i HEALTH DEPT. On the above date, 1 Inspected the septic system at the ab 9�SJRNSTABL;E This system consists of the following: A. 1 -1000 gallon tank. B. 1 -dis`trib-Ution box. I C- 1 -1000 gallon leach pit. Based on my inspection, l' certify the following conditions: I A,.;-This is a title five septic system ( 78 Code ) .B. Septic tank was pumped for maintenance purposes only. C. L _stalled one collar the leaching pit. D. Replaced line from the septic tank to the distribution box. j .E. The septic system is. in proper working order at the present time. SIGNATURE: i N a m e:__,T,,p,, her_►IL�------ i i Company: J_P•Macomber & _Son Inc. j i Address:— Box 66 ------ ----- ----- Centerville,Mass . 02632 -------------------- Phone: 508-775-3338 i i THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • LP. MACOMBER & SON, INC. anks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections 66 Centerville, MA 02632-0066 775.3338 775-6412 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property Q ObTrrbST LA tva Cc,u Owner 's name Jane Eshbaugh.. Date of Inspection OAksq %-z 19955 PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two veeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility .or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. . 46 rvDc� �2 iT iZ.-GWCG -174C; r-e C 7?,-1 e 3• �.cC p w�u� crt.�.0 .1�DQ �rU 6 12t S�,� oV ai2_ L. � 7D 2a fD G 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION F ITION If residential o0s t wA.-S LOC. � (�c��D ).icy► Get number of, bedrooms A-Gc.e=,S5 number of current resid nts 5 garbage grinder, yes or laundry connected to system, yes or AJ seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: njQ,¢, '►"� U�`"�"'O`�-i'y Last date- of occupancy GENERAL INFORMATION Pumping records and source of information: V- rno-0 OF 'Pu wg P eUG (0 7-Pc-ANT � System I Y pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy ' Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed information: , if known. Source of o 'S 15A M �S �C c�F t-toC�S(3 _!,� Sewage odors detected when arriving at the site, yes or no � 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: f�v (locate on site plan) depth below grade: material of construction: _,concrete metal FRP other(explain) dimensions: 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. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evVC-:CAVACA,tC--(UC> ence of leakage, recommendations for repairs, etc. ) PU OILPi A3 6 FQrL MA t 7ff7N ANGy FU POS — 7 DISTRIBUTION BOX: v (locate on site plan) . depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) �!0 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO `,FrT PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not re approximated by non-intrusive methods) quired, but may be If not determined to be present, explain: 6`A, p�eT' Utupr=- ,2— t s--t eua Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition soil, signs of hydraulic. failure, level . Of pondirig, me . condition of vegetation ation, recommendations for maintenance or repairs,etc. ) - 2 c C.o I f rr C�I� J CESSPOOLS (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 (cesspool must be pumped as part of inspection) . Comments: (note condition of soil, signs of hydraulic failure, level 'of pondin condition of vegetation, recommendations for maintenance or repairs,etc. PRIVY: (locate on site- plan) ` materials of construction dimensions depth of solids Comments: (note condition -of soil, signs of hydraulic failure, - level of.pondin condition of vegetation, recommendations for maintenance or repairs,et •�,- ) c, .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL' SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 �d7 lsod 1n o L Al / 10 J;11� / oo 0 � 0 �cPc�4Csp DEPTH TO GROUNDWATER L l0� depth to groundwater method of determination or approximation: USC-S U 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? Discharge or pond'ing of effluent to the surface of the round or surface waters? g Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day Y Required pumping 4 times or more in the last year? ~•' number of times pumped Septic tank is metal? cracked? structural) unsound? sub infiltration? substantial exfiltration? tank failure imminent? al �t Is any portion of the SAS, cesspool or privy: , lid below the high groundwater elevation? within 50 feet of a surface water? MO within . 100 feet of a surface water supply water su PP Y•1 PP Y 0 r tributary to a surface within a Zone I of a public well? within 50 feet of a ,borderin • ( rives only,g vegetated wetland or salt marsh cesspools and P y, no the SAS) ►�U within 50 feet of a priv ate ate water supply well. �Llless than 100 feet but greater than han 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile QrgLnic 'compounds, ammonia nitrogen and nitrate- nitrogen. 05/18/1995 11:24 508-428-3508 C.-.3.MM. WATER DEPT PAGE 02 KEY NUMBER <6695 > NAME <DIETZ, WALTER H, JR > B-C 1 B-C 2 B-C 3 A-C 4 STREET 17 OUTPOST LANE CITY CENTERVILLE ST MA ZIP 02632-1508 REF 1 REP 2 PHONE ( ) - REF 3 REF 4 METER NO. < 6230> DATE READING CONS STREET <OUTPOST LN NO. 17> 12/31/94 39 16 CITY CEN E L38 ST LOC 06/30/94 23 14 PHONE (508) 428-7875 12/31/93 9 16 09/10/93 0 0 ROUTE NUMBER 30 09/10/93 612 7 SERVICE DATE 04/01/81 06/30/93 605 17 METER DATE 09/10/93 12/31/92 588 17 CAPACITY 7 06/30/92 571 13 STYLE T10 SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR. LEFT SIDE ADDITIONAL CONS 0 ALTERNATE MIN 0 KEY NUMBER <6695 > NAME <DIETZ, WALTER H, JR > B-C 1 B-C 2 B-C 3 B-C 4 STREET 17 OUTPOST LANE CITY CENTERVILLE ST IKA ZIP 02632-1508 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 METER NO.< 6230> DATE READING CONS STREET <OUTPOST LN N0. 17> 12/31/94 39 16 CITY CEN E L38 ST LOC 06/30/94 23 14 PHONE (508) 428-7875 12/31/93 9 16 09/10/93 0 0 ROUTE NUMBER 30 09/10/93 612 7 SERVICE DATE 04/01/81 00/30/93 005 17 METER DATE 09/10/93 12/31/92 588 17 CAPACITY 7 06/30/92 571 13 STYLE T10 SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR LEFT SIDE ADDITIONAL CONS 0 ALTERNATE MIN 0 t SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART D CERTIFICATION Inspector : Peter Sullivan PE Location :17 Outpost Lane Centerville Date : May12,1995 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. Please note the summary of recommendations as presented in this form. Lastly please note 310C MR:15.302(1)Criteria for Inspection. "The inspection is not designed to provide information to demonstrate that the system will adequately serve the use to be placed upon it.by the new owner. The inspection criteria are intended to allow for timely inspection to avoid undue delay in the transfer of property." Very truly yours O eter Sullivan PE INTER Distribution: svuivAroft.29133 Original to system owner iS' 6a� Buyer T Board of Heath At E Lp•r 4 �� � `� _ \, 6 c =� s Q,- 39 . , • u, i i (� uT' Pos LA�� E - CERTIFIED PLOT PLAN. :; �r -- ::gal F:.,'• .. •.. + d oTrR 3t� [Jta t Ft7 a r c.•.r NTE A-y�d.�. # fit ;CON8TRUCCT10N ONLY t T. r, --- G `FEET 1N r'F0# 0 .FOUNDATION IS 7, l :LOIAt POINT OF ADJACENT SCALEt �" = i' DATEtFc,6 ?-Y E'1VQlN�EIQINI3 Gb.IN 1 CERTIFY THAT THE f�M CLIENT ��:f�, SH0WN ON. THIS PLAN 18 ,LOCATEoC TERED R51STERED �. JO® NO. 1004 ON THE GROUND AS INDICAT . 'A n LAND CONFORMS TO THE ZONING ' $OINEEP $!lI�VEYOR DR. JDD OF ®ARN8T DLF� RAQ�3 5 ` ! Yo T. s s SS, SHEET-J-0.1F 1 DATE A 3RV—Ry .. �tSTPQUTION BOX H 2210 REMOVABLE COVER PL�N o r 5� �� Tr� S t v S TC� 4";CH 40 OUTLET LATERALS Di= RISJ T It3h 90K TO MMEF7 -- SHALL BE SET LEVEL FOR A TEST PIT DATA RE)LI]PEMENTS OF 31OO� MINIMUM OF THE FIRST TWO 11413 SC/� L E :5 K POATERTIGHTNESS. FEET AND CONNECTED TO BSI . Daniel B. Johnson -„``TR' T' ` ? ,-) EACH DISTRIBUTION LINE - - -y /� -- --'17JE WITH SOLID SCH 40 PVC PIPE - �- -4+ 2 - L =95t?3 TP-1 (EL . = 97 . 8) :"(MINI p o c CRUSHED A, SONE TO BE 3i4" S`ASCE LEVEL BASE MECHANICALLY' COMPACTED 0YR2/2 Loam 10YR4/6 Foamy san Bw, . 5YR5/8 :loamy fine sand Fine sand ,'/v rl, TK.q ;oR 5 Y5TEm ` :rounawQ-er I � TP-2 (EL . = 97 . 4) 1/4 l9 fe 371 9� _ TT1r k1 wAtNFD 5rotvE t gn CiWdy SideWIndef Chember riQ E� 'L�1'Y��;L .rOaI: — — OYR4 f 6 Loamy Banc _ rP 9 /o Bw, _OYR5/8 Loamy fine sang - -- — - — q N ! N16'NCAPRuT� 9 - 'i, 10YR5 6 �raveiy coarse sang — ----�' 9 1 s El ��.4 =:r,rr --2, 2 5 Y 8/3 Fine sand C _ - - - - - -- _. ` I D-BoX 'Dt se £SHWT - ----� 37 L X /0 W k ! H 1 eY 4 SCN10 1 PERCOLATION TEST DATA _ S-,0 6• - 9 a --�-_� - o Q 4 SAS - lass _ 0 . �4 '/Sc') IN ;It.i LA ra,t 5 �A5NfD 570n1f APAc.rry \t L T~ 1 ` t ,o'y� r '� a« 5er PLA,J -4 IC w Fore f �' i -� ,� � M Y __ _._..__. _.._._...__._ _ .___.._.._ .._--_ _ . ._.: 3 NO O SCHEDULE OF ELEVATIONS - � r•N d W 1 o TN 2�� 99�1 T Nfl4. rA, 7-0k T A-4 L o- E*Isr�No- , NOTES W T0, - roo.9t W methods sha 1 conform to 4he Title V 15-' and the Barnsrabie Board of Heaitr1 Regulations . ~ sEnICt+MRFLK I �;jim E1.1 - Ioo,00 There a_e kr^ )wn p_:.ate :;r public wells feet/4Lv feet, =espsectively, �f the proposed leaching area . Tod of Co,vG• Fo.u�b• 1 -. OF B _e ..._..� area _ no withi* 1 30 fee- a JLK ERa __ e Pro n � r x^� s r � t e 6,,�NE� `land, nor s the proposed leaching area within 200 Fee- a fi�ter iran*_ the exlstlnc - ?u gd for septic tank is to be pumped aril :.EGEND spectec fc•_ s~ sctura: integrity by the =ycensed rr:.f*' v ins-ailing the new leaching area . - u�G' _. _____._._ - ^e ex;s inng septic rank is found to be st-ucturally _scu a, t:,_e _Ank sna_1 be removes and replaced with a rie':: T.: � r t � iu�d0 - .. _ _ '��. _ _ '-. S•..• _ y r,. -_ r _.. either case- ., rr t TPvS7' ROAD 66Ar. I* 17907 SC A LE - �4 S S'r�Ow _ 101 CXoSS SELT1Ory CENTER -100 . VILLE 99X4 A� ' La�oE `z ' ..ALCULATIONS : 98 A� 9)X3 t °CVS v AOSr 1 I �LJ � Ar �, I _ •..i / 44 °N�,, � ? r+ s rrAIG I ;,q 37 PROPOSED LEACHING AREA: 9 sl 00 of 9 0 s, 3 _. O ��•aO� i q,00 _ ... - .. riN r;-ACL q INF,r ,AT ORS SePrtc Tanik 9� ` -%O H _of A(,IT Y) I aTE 3 ) I i �?I(- �- I U �• I I K j 1 i . ,N STrA L N E w 4 5C.1 4 v O+r(.f T TEE w( F' I- , { I ; E r r _ $oTT.1M TP I ��C•' s�. 8� _ a_ r 7 '- SUBSURFACE SEWAGE DISPOSAL SYSTEM S�cwAAt �sDP-tbw=�t:M ai t 17 Outpost Road, Centerville No. C77' �b >Srw"'I..yl<,s�,�C` •GOER: APPROVED BY: DRAWN BY I„ DATR; Daniel H Johnson- T ----- .�— r --- --- r.1 pf10 ot3c a+40 c+So o*bo v. y I sD 7 0+90 1+00 I+i fl I i.2 D r. Haley s-s Box 594, ostervill•, MA 02655 HOOLk I to )b _ - ! t (' DRAWING NUMBER �� ? ? _ Box 831, ost•rville, MA 02655 J-2065