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HomeMy WebLinkAbout0275 PATRIOT WAY - Health 275 Patriots Way Centerville A= 193-180 S M E A D No.2-153LOR UPC 12534 smead.com • Made In USA �J 2 M US®NYM PflOMM SFIWMTKSOUMM OF TK SR ,, CERfIFlEO SOURGNG VYWWSFpROGRAMORG ( 7 G " ; al Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9pplication for -Misposat 6pstem Construction permit f Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System [K Individual Components Location Address or Lot No. ;175 PA7R t 6T Wig/ Owner's Name,Address,and Tel.No. ; Assessor's Map/Parcel 3 ($ -C�' 2?T p�Rs 4T Lf,4V / Installer's Name,Address,aild Tel.No. 5O$-4'77-5$7'J Designer's Name,Address,and Tel.No. N.(oG�r j)G 5PTZ9WK(6� is sl- N/A, ' Type of Building: 5 Dwelling No.of Bedrooms Lot Size s .ft. Garbage Grinder q g Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �tVS'T',�.L(, AIX Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heath. Signed Date 3 -L Application Approved by Date _ 3-1 7 Application Disapproved by Date for the following reasons . Permit No. p20 _ d 5 Date Issued ---------------------------------------------- ---------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance M THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned( )by C APE:tcl rT E&Eit at oZ 7 S p�'�-! k(zrr w&I C'V(L.� has been constructed in accorda�nnce with the provisions of Title 5 and the for Disposal System Construction Permit No. a /� 1� -b 5dated 3' 3 Installer C14PLcoCIJle� EUT��pt(tom_ Designer IJ/� #bedrooms /v Approved design flow 1\ /V/� gpd The issuance of this permit s all not be construed as a guarantee that the system will (ncti n 's�Ilesigned. Date j Inspector -------------------------------5(j Fee No. V 7lj Fee �15 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construttion permit Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at D-7 [?Azr&t t t (A.) and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date 3"� Approved by i 1 , NO. v�V1}f� \ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS fipfication for Misposal 6psteut Construction Aerudt Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.alp►5 (>A7RlOT W AW Owner's Name,Address,and Tel.No. Cc—;vTE92v 1 V)-r7o-tA sxour Assessor's Map/Parcel (q 3 ISO . .A.75 OCf_WkYV__fLkjE Installer's Name,Address,and Tel.No. 5O9—q-77 $$7"7 Designer's Name,Address,and Tel.No.SA 8—072_.mac-r13 C4 P&_U. D C_ &_7QNSWQSGS 41cC_1 LWG-uJ ua>C� c¢?ciax.s LNG d.5 Type of Building: Dwelling No.of Bedrooms Lot Size ; la, �Ej�f sq.ft. Garbage Grinder( ) Other Type of Building S!A )y j A No.of Persons Showers( ) Cafeteria( ) Other Fixtures c Design Flow(min.required) 330 gpd Design flow provided 33 1• 8 gpd Plan Date 9—a?(Z,A 013 Number of sheets Revision Date Title ZI 7 5 Bid!l2 aT fit KN e ,3 ill U_67 Size of Septic Tank 1.00 d Cd t.c..caJ Type of S.A.S. S U 0 G64C.• 6 Il..t'y,G�lYs Description of Soil F i yJ E "' MG 1 V 9. �a(,ac� ,3(�k � v EG ?LJ4&j Nature of Repairs or Alterations(Answer when applicable) (a) j 0D G�4«- o 0 LLa4Gk(QCo �44')2.. (,.)MA q'GF STOCJ6 00'emes _;V0P ewbS Date last inspected: " Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. gn d ( Date �1 a Application Approved by Date Application Disapproved by Date for the following reasons Ot Permit No. Date Issued TOWN OF BARNSTABLE LOCATION a75 Parf a o+. (/Lxy SEWAGE# )L.O 4 3 VILLAGE Ger1- 1/� ASSESSOR'S MAP&PARCEL off INSTALLER'S NAME&PHONE NO.C g4e w i cJC Cn lerp� s�S LLB, 50�- 7�8�7) SEPTIC TANK CAPACITY /000 04 LEACHING FACILITY.(type)7 G�1 �l 6",h�)(size) 13,d6'Q_3 NO.OF BED,/ROOMS 3. OWNER V o ®''i CA C • Sew PERMIT DATE: 2 COMPLIANCE DATE: vZ f3 Separation Distance Between the: Nrj �jc,�Ctw4t`er Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 6"Vnf'el011 Of 44eet Private Water Supply Well and Leaching Facility(If any wells exist on e , a site or within 200 feet of leaching facility) /v ."t Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ®�® Feet FURNISHED.BY C A�rat4)CD6 �� - U(_ 1 A- 1=3q- 0 0 I r A-a-3l -3=38 A a� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ,N RppYitation for Misposal 6pstem Construction Permit Application,fora Permit to Construct( ) Repair(N Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. a Ij 5 fy;IRIOT wA%4 Owner's Name,Address,and Tel.No. Assessor's Map/Par el ' �j "I g O 2-75 O VI Installer's Name,Address,and Tel.No. 509 -477-S8 7 7 Designer's Name,Address,and Tel.No.SO g-q77-s.r/3 Lc< 606.1 etwi"rs s'NG. G uc e1 etD� D•¢«: Type of Building: Dwelling No.of Bedrooms 3 Lot Size a o"�T t sq.ft. Garbage Grinder( ) Other Type of Building QF-G I DDW Y(o. �, ',wNo.of Persons Showers( ) Cafeteria( ) _ Other Fixtures . ,. J� Design Flow(min.required) 330 . \ gpd Design flow;provided 331. 9 gpd 4 F Plan Date -,;?Q-,a O(3 Number of sheets t' t Revision Date ' Title 5 �AjV_ttt7-L"L j Size of Septic Tank 1 000 C7,(U-O&J Type of S.A.S. SO 0 CrA G._1,9"0-6 99*&E ,f Description of Soil F I y 19 — 0) 3(0 4 k4w Nature of Repairs or Alterations(Answer when applicable) U56 P Y-(,ITrLdsb ly E C.c1 1 C Ti WK- 7n D--60r- TV 1 0 ' G ArQ0E O*J som !ON EMbS Date last inspected: 1. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. gn d` 1 ( Date �- Application Approved by , Date Application Disapproved by Date for the following reasons Permit No. ++° Date Issued CJ` dF THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( � Upgraded( ) Abandoned( )by CAK-w l)E at .17 (?4TQ jpT LU, � C.�7,1?t��d//L�l� has been constr cted in accgd7�with the provisions of Title 5 and the for Disposal System Construction Permit No. Installer / A-PEZeA19 C&M tO jP Designer � [ wb-px #bedrooms 3 Approved d ign ow 3 ti gpd 40 The issuance of this pe 'es all t be cops rued as a guarantee that the system A fund ion is d' i ed �Jf C�J Date / Inspector // l I �(,'J /li VV r -----------r---------- ----------------------------------------------------------------------6�---~-- --- - No. L./ Fee- ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstetn (Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at _Rkcp 1 L-M LeJkt cewzmw 4,I-g 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 t be compl ted within three years of the date of this permit. Date Approved by /Rs `� :■� 08/29/2013 16:05 5084775313 ENGINEERING WORKS PAGE 01 ■ ■ ■ ■ ■; Town of Barnstable Regulatory Services Thomas F.Geiler,Director t a MM s Public Health Division tOs9 Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: Sewage Permit# ;to 13 -3�-7 Assessor's Map/Parcel l e%3 •-1 f c Installer di Designer Certification Form Designer: .,g,;n .•.; lNor4s. Inc . Installer: CnHiyo4S-7 Address: Address: i�� �d M 0A-elll6 7-1. -C. On $ �-a ao 3 Caw.ake t-cito I wit, issued a permit to install a (date) (installer) septic system at_ 2-75 ��- r✓} W ta G-*--- based on a design drawn by n (address) dated 20 13 (designer) 1 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. 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 systems)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required)wa, cted and the soils were found satisfactory. of a y PETER T. McENTEE �instaI16?s ature) CIVIL ti No.Sal 9 �Q18T@R�o��4? (Designer's Signature) (Affix Design ) ELEA.$E RETURN IQ 11AMSTADLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- UILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC,HEALTH DIVISION. THANK YOU. gAoffice formsWesignercertification form,doc NEC Town.of Barnstable P# IDepartiment of Regtdatory Services Public Health Division Date �A 039. �m 200 Main Street,Hyannis MA 02601 Date Scheduled— JVT Fee Pd. D Foil Suitability Assessmentfor S a e is a d Performed By: �� `— I �C S �L/Wit• /�� � Witnessed By: i LOCATION& GENERAL INFORMATION Loeadon Address Owner's Name V[ 7� ���1�l (.R)a4�( T-rOArA aAcaf-T ( i3O ?T 6P V l U Lzz ddress ,X7 s PATIU®e LJ All Assessor's Map/Parcel: (q 3 / .I so Engineer's Name d.A06uj ia& �� s NEW CONSTRUCTION REPAIR ^ Telephone# 250S—471 Land Use- V\ Slopes M. 0 Surface Stones //Uo Distances from: Open,Water 134rl - ft Possible Wet Area 1 a ft Drinking Water Well r S�t Drainage Way 7�0 0 ft Property Line ft Other ft SIMTCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands(n proximity to holes) #Z?5 11�`w i Pw i o 7- &0A QvCh Parent material(geologic) �wa Depth r e , pt i lq,Hed ock " n Depth to Groundwater. Standing Water in Hole: 1 / V Weepi ini ng fro�m F Plt lice Estimated Seasonal High Groundwater _ Al e�P t� w�Q �`n ky, e� DET'ERAUNATION FOR SEASONAL HI(,H WATER TABLE Method Used: Depth Observed standing in obs.hole: -Ill. Depth to soli mottles: Depth to weeping from side of obs.hole: Ill, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level__� Adj,factor— Adj.drouttdwater Level YE RCOLA7T10N T E� T' Date T me Observation i Hole# 2 f C 0 W-rinle,at h" Depth of Pere � ( �� Time at 6" Start Pre-soak Time @ -7 1 ( 1 Time(9"-6") End Pre-soak G vA � Rate Min./Inch 50( ` 5 -5 S Site Suitability Assessment: Site Passed C,- Site Palled: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***1f percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\.3PPT1C\PERCFORM.D0C 1 DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil . Other Surface(in.) (USDA) (Munsell) Mottling .(Structure,Stones;Boulders. onsistency, (10veil 4 -3G DEEP OBSERVATION HOLE LOG Hole# -I-- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) ' Mottling (Structure,Stones,Boulders. Consistency,% ravel Zy- /z6 -_M S�MA � DEEP OBSERVATION HOLE LOG Mole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con i to c (]ravel) I DEEP OBSERVATION HOLE LOG Mole# Depth from Soil Horizon Soil Texture Soil Color soli Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cans' ten Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perviot.s material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring per ious material? Certification I certify that on 11 (date)I have passed the soil evaluator examination approved by the Department of Envir &mental Protection and that the above analysis was performed by me consistent with . the required t n' g,expertise and experience described in�10 CMR 15.017. Signature Date Q:\S�EPTl0PERCPORM.DOC Town of Barnstable Barnstable SHE Regulatory Services Department edca Cft '1M I� Public Health Division jEO a`� 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2850 9941 August 29, 2013 Vittoria Sauit 275 Patriot Way Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 275 Patriot Way, Centerville, MA was last inspected on 7/24//2013 by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Septic system is in hydraulic failure. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH sUKean, R.S. HO Agent of the Board of Health I Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\275 Patriot Way Cent Aug 2013.doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=13942 ca 7- �..��q_��,-�a. �'" t"./� f�ti[i/C/� ✓``al.�� Jf/j�';F`jy/}�x� ,� .''4� Logged In As: Parcel Detail Tuesday, August 13 2013 Parcel Lookup Parcel Info Parcel ID 1193-180 � �� Developed LOT 49 � Location 1275 PATRIOT WAY Pri�254 ' Frontage Sec r• _ _______.___ __ _ _ , Sec Road' Frontage - w __._._ Fire Village ICENTERVILLE � C� O-MM_�--� District Town sewer exists at this Road�1 - ----' — J -' 2__20 address INo Index Asbuilt Septic Scan: p Interactive � 193180_1 Map Owner Info Owner ISAULT,VITTORIA C Co- Owner Streetl 1275 PATRIOT WAY Street2 City ICENTERVILLE , State�MA Zip 02632 Country j Land Info Acres�0.59 ^� Use Single Fam MDL-01 Zoning[Rc I Nghbd 0106 Topography;-,Level Road[Paved _ I Utilities Public Water,Gas,Septic Location Construction Info Building 1 of 1 Year 1981 Roof Gable/Hip Ext Wood Shingle Built Struct Wall Living 1182 - � �Roof; AC Asph/F GIs/Cmp , one � - Area Cover; Type Style Cape C Int- Bed od Wall pDrywall J Rooms 13 Bedroomsa_ o Int - Bath Model�sidential � Floor Carpet ) Rooms i2 Full �) t Heat -_�__._ _ Total{__..__ W Grade iAverage Type f Hot Water Rooms 16 Rooms II Heat _ __�_..__.__�f Found- —~__._____,_. Stories(1 1/2 Stories I Fuel Oil J ation Poured Conc. Gross http://issg12/intranet/propdata/ParceIDetail.aspx?ID=13942 8/13/2013 ul 2513 09:19p p.1 r. tr I!; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information is required for every Centerville MA 02632 7-24-13 page. C'ftylrown State Zip Code Date of Inspection Inspection results must be submitted on this form.inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important When ng out forms A. General Information on r the Computer, .\ �IK OF fMgSS�i,��i use only the tab 1. inspector: key to move your o = .y cursor. return D.not James D Sears = JAMES U' use the return key. Name of Inspector = y Capewide Enterprises,LLC Company Name TtF '�o 153 Commercial St. ''��,45 INSP� .o``�� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and th#the O information reported below is true, accurate and complete as of the time of the�ins��pection. Tie ins�.ection was performed based on my training and experience in the proper function and„�matin(enance:ofon%ite e '* I vW I +"^ sewage disposal systems. I am a DEP approved system inspector pursuanttq`Section 1-5.34Q of Title 5 (310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Falls rX) E5 5- ! ❑ Needs Further Evaluation by the Local Approving Authority ("D r- spy rrti 7-24-13 <gidpectot'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. LV d l � p t51ns•W13 - - TWO 5 ofioier 1spa0ts, Sewage Oi al System•Page 1 of 17 Jul 25 13 09:19p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voiuntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information required for every Centerville MA 02632 7-24-13 page. City/Town State Zip Code Date of Inspection B. Certification (cant.) Inspection Summary:Check A,B,C,D or E I 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: 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 ❑ NO(Explain below): 15ins 13113 Title 5 OtRdW rnspecdw Foam:Subsudaue Sewage Disposal System•Page 2 of 17. Jul 25 13 09:19p p.3 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owners Neme information is required for every Centerville MA 02632 7-24-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ 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-3113 Title 5 OfrKaer Inspection Form.Subsurface Savage Disposal System-Page 3 or 17 Jul 2513 09:20p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information e every Centerville required far eve MA 02632 7-24-13 page, City/Town State Zip Code Date of Inspection B. Certification (Cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: 'R This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool . ® ❑ Liquid depth in cosaW is less than 6'below invert or available volume is less than %day flow P., 7' [Sins•3113 Tdle 5 Official 1 napectlon Form:Subsurface SavmBe Disposal System•('ape 4 0117 IL Jul 2513 09:20p p.5 Commonwealth of Massachusetts Title t e 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owners Name information 1s required for every Centerville MA 02632 7-24-13 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 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15,304.The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Offidel Inspedlon Form:Subsurface Sewage pisposel System•Page 5 of 17 Jul 2513 09:20p p.6 Comrnonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information required for every Centerville MA 02632 7-24-13 page. CityrTown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yesn 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 NIA) ® ❑ 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)1310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms); 330 [Sim•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 or 17 Jul 25 13 09:21 p p.7 Commonwealth of Massachusetts ffim- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information is required for every Centerville MA 02632 7-24-13 page. cityfrovirirl State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. tank D Box and pit Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2011-19,000Gais 9 ( y 9 (9Pd))' 2012-15,000Gal's Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: Present Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day tgpd) Basis of design flow(seatstpersons/sq_I'L,etc.): Grease trap present? ❑ Yes ❑ No 1 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3l13 Title 5 official insp ection Foam;Subsurface Sewage Disposal System•Page 7 of 17 Jul 25 13 09:21 p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owners Name information required for every Centerville MA 02632 7-24-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract - ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins-3M3 Title 5 Official Wnpaction Form:Subsofam Sewage Disposal system•Page 8 of 17 Jul 25 13 09:21 p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information is required For every Centerville MA 02632 7-24-13 page. Cityllrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 1981 Permit # 81 -254 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 38" Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Pipeing NA Note: Full system tank and pit. Septic Tank(locate on site plan): Depth below grade: 28"Peet Material of construction: ® concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast Sludge depth: 2" l5ins-3r13 Trds 5 Official inspection Form:Subsurface Sewage Disposal system•Page 9 of 17 Jul 2513 09:22p p.10 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information is Centerville W 02632 7-24-13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 0" Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Asbuilt-Tape 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.): Tank and outlet cover at 28"below grade wrinlet cover at 4". Tank level full to cover. 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 15ins•3113 rifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Pop 10 of 17 Jul 2513 09:22p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information required for every Centerville MA 02632 7-24-13 page. City/Town 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-3M 3 Tile 5 Offidal Inspection Form:Subsurface Sewage Dispose{System-Pape 11 of 17 . Jul 2513 09:22p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information is required for every Centerville MA 02632 7-24-13 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert over 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.): D Box not opened. Box noted on asbuilt. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official n Form:rrn.Subsurface Sewage Disposal System•Page 12 or 17 Jul 2513 09:23p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information required for every Centerville MA 02632 7-24-13 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 1 ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is a 1000 Gal. Precast pit. Pit is full up into risor. Pit not leaching. Need to replace leaching. 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•3113 Title 5 official Inspection Form:Suhuwrscs Sewage Disposal System•Page 13 of 17 Jul 2513 09:23p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owners Name information is required for every Centerville MA 02632 7-24-13 page. C"rrown State Zlp 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•.3fl3 Title 5 Official Inspection Fo m Subsurface Sewage Dsposa',System-Page 14 of 17 Jul_25'13 09:23p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owners Name Information is required for every Centerville MA 02632 7-24-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: 0 hand-sketch in the area below ❑ drawing attached separately e i , A5_ a /4 _3 _ yam- � ! o ❑ O 13 _3 3 L -G 1 a 3 -4/ = i 0 ' t5ins 3713 Title 5 Official Inspection Fmm:Subsurface Sewage Disposal System•Page 15 or 17 Jul 2513 09:24p p.16 CommonweaM of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 Patriot Way _ Property Address Vittoria Sauit Owner Owner's Name information is required for every Centerville MA 02632 7-24-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells D N Estimated depth to high ground water 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed. 7-10-79 Date ❑ Observed site (abutting propertylobservation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain_ ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on design plan 7-10-79. No G.W. at 12'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inepection Form:Wbsurfece Sewage Disposal System-Page 16 of 17 Jul 2513 09:24p - p.17 f Commonwealth of Massachusetts Title 5 Official Inspection Form nl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 275 Patriot Way Property Address Vittoria Sauit Owner Owner's Name information is required for every Centerville MA 02632 7-24-13 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 III t5ins-3113 Ttie 5 Official Inspedon Fonts Subsurface Sewage Dispaeal System-Page 17 of 17 W �� T �► PE ; NO. LO. CATIONP SE ACE VILLAGE INSTALLER'S NAME A ADDRESS s U I L D E R on OWNER DATE PERMIT ISSUED DAT E CO.MPLIANCE ISSUED /�>/�� r ..._.��'t-n 4� s���-�, --ate Y �r6� �;a- it ��, � .- ............... THE BOARD COMMO�NWEALJHOF OF HMASSACHUSETTS� ---,-, ' EA H . ....-OL164----- I ......OF... ... ......................... Appliration for M-4patial Works Towitrurtion Vrrutit \N Application is hereby made for a Permit to Construct System at: or Repair an Individual Sewage Disposal r- ... ......................................................................... 1_o.cat',,on,,.Addres or Lot No. . ............................................. .................................................................................................. )W �r Address w r .............................................................................X.- lc_4 ............................... ............................................ --ie tta I�r Address Type of Building Size Lot_. feet U Dwelling—No. of Bedrooms............ __________________________Expansion Attic (L.4- Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Other fiY ,t."res ...................................................................................................................................................... Design Flow..........52...........................gallons per person �a�ly flp,,v.......... 3.-0...................gosons. V Septic TaWnk—Liquid capacitv/oaaallons Length___- day. Total ...... Diameter_--------------- Dept .... Disposal Trench—No.-7,06W............ Width......... Total Length............/...... Total leaching area------_--_------sq. f t. /I Seepage Pit No.____--_-.`---.---- Diameter--------/0----- Depth below inlet---6............ Total leaching area.....ZP-----sq. ft. Z Other Distribution box Dosing�ank ) Percolation Test Results Performed by.... 4- _e....... ....... Test Pit No. 1................minutes per inch Depth of Test Pit-__"______-__---_--- Depth to ground water_-_-_._._--_____:.._.... Test Pit No. 2..........2---minutes per inch Depth of Test Pit.................... Depth to ground water---_------------------ .. V............. .... .... . ......... ......... ...0 Description of Soil- .. U ..... ......................................... ------------ ---------- --./_ �.... ..................................................................................................................... ........................ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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"TTLE, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in 1— operation until a Certificate of Compliance has been.issued by the board:;f lie h.Signed-. . .....0 A . ... .............. ... Application Approved By........ .. .. ..*. Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date ,,Permit No......................................................... Issued....................................................... Date No......................... Flcs............... ............. THE COMMONWEALTH OF MASSACHUSETTS _ __,BOARD O°F HEALTH (f' , ppliration for Bhgp sal Work,i Tonstrurtiun thrmit Application is hereby made for a Permit to Construct (,4) or Repair ( ) an Individual Sewage Disposal System at: �..-- _ '...!..... ..__� 8' --...1 f - j �� :f.......•--------... ------------------------------------------ Location-Address or Lot No. /jjp+ iYi/✓'i f'.'1--'fit��--''� ......... .........^------------.._..__.._.._....._....._._....._...------........_......_..._......._..... / Owner Address o .......................... ... . � - •-----------`--•--------------••- --------------------- •-------------- --------- -•--•••-......... •--------------------........ r ~Installer ` Address d Type of Building Size Lot.... _._.'..._.. l.f..Sq. feet Dwelling—No. of Bedrooms.__.:........ ___________________Expansion Attic ( �.) Garbage Grinder ( ) p4 Other—Type of Building _______________________'___ No. of persons............................ showers ( G) — Cafeteria ( ) a ------.•--- Design Flow...............Other fixtures.....((.........gallons per person per day. Totaldaily flow.............................................Fa pns. WSeptic Tank—Liquid capacity_____________gallons Length_____.._____/__ Width._K.'/_ ___ Diameter------ Depth�..___.�..�� xDisposal Trench—No- _:-_______________ Width_____......................... Total Length............. _____ Total leaching area__________________sq. ft. Seepage Pit No............. `.___ Diameter--------/n---- Depth below inlet...f�............ Total leaching area____<_ 'Sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by.__..%�,:_+� !. ._.: ,'?_ !a.! _________ Date,_ _F ,.__._*` _ rf--• --•_-- Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water_-___.-.__-______.____.- (s, Test Pit No. 2................minutes per inch Depth of Test Pit_-.______-__________ Depth to ground water........................ a -----•-----/------------------------------- -- ........... ........................._.......---- = .,rrr._.��?.r .,�• .. "..s...-/-iG'.J...'. �l'fY% (--- J*• lY�s/`�.. aJ-----.__ f.,t8 ✓ f.iS Description of Soil i.................J`=• _ ............•. -------•-- ,.---•---------------------------------------:--- - = � v ---- W --••------------------•----------------------------------------•------...................-----••-----••-•--------------------------------•-•----••••--••••-•---••••-•-•............•.._...__.._..••-- VNature 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 1? 5 or 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 off hea lh��/`�/ -•gried-. f'-=�- �.....%t..........�.. A?•.. ..=ia` ApplicationApproved By••-•-•-••••.............•••-••------ -----•..................................................... ........................................ Date Application Disapproved for the following reasons---------------------------------------------------------------------------------•----------•-••---•-......•..... -----------------------•--•--------------•--------•----------------------•----------------------------------•--------••---------------------------------------------------------------- ......... Date PermitNo.................`........................................ Issued....................................................... a Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ lr ._....r................................... .......................-................... ................................. Trrfif iratr of TontpliFanrr THIS IS TO CERT�.,V That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) �-, ........ .. . . e.fir�``. by... ............... . ..... •:..— . .--.. ..----•--...•.__Installer---•------•-•--•------__.---------•-------------------'--------'------•__.._----•----.._....._ .._. f has been installed in accordance with the visions of SY The State Sanitary Code as described in the r application for Disposal Works Construction Permit No......................................... da.ted.......... .--_-_-___--__-.___-_______________ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. p DATE........................... 7 K�--•--------------------------- Inspector------.... 'd K n----------------- THE COMMONWEALTH OF MASSACHUSETTS - — BOARD OF"�:`HEALT ol-fr"i S' ................................ ...OF...... .........................r,/,4Z ................ No......................... FEE........................ Binposal-, urkii Toup#r iun rrnti# Permission is hereby granted______ ______________________________ to Construct or_, epai�(. ,) an ndivi 6ew age Disposal System atNo.. /•• 1------..... % f ..............�.._.: _..-----------------------=------------------------- -------------------------------- ................. Street as shown on the application for Disposal Works Constru r=6 No.__,.cg.r__ Da ed................................._........ 1 ---------- ......r ------------ __..____.._____... __..__._.____________._.___.._.A.._.__._.... ----------••............................ Board of Ht lth DATE............... _�_�d".�✓ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS — 20 FT. MIA(. /F E/THEM THE SEPTIC TANK OR �EACN/NG P17 AME /YORE THAN /2 QELONI 24 01AA4 ETER CONC�E°.GTE C'OPC,? ,SH S SHALL BE BRO(JGNT TO 4RAOE.( f,4N ,EX77RA�- 4/P TVC PJPE �—�` p; s GONCRCTE i A Vy Ci'1 T /R O/Y CO//EI! ALL BE [J S EI� CODERS M/N. .o/ CN h�E p /f/N DR/vEy+i,+v Y c - 2% M/.V. eCO/VCRF TE CO✓ER C'L EAN .SANG BACXF/LL _ L 9VID LEvEL d^` 4"CAS 2~LAYER .. l � IRON P/PE c 0 � o• M/N.P/TCN �O G G ST o' ep 1 • • • • • .• • v �„' W SHFD S7t7NE SEPTIC TANK D/ • , 1 • •@ • • • • • , • . , 6aX O 1 I V • r ♦ too •rr • .::,.. 'i •EFFECT/✓C � • � 4 � �2 :'�a.. • v • DEFT: ♦ •• ' WASHED STONE p o • •. . • • . • • • • • • o •f P PRECAST SEEPAGE a lNV4PK7 CLEVi1T/GNS o �� • • • • . • • • pew v P/7 OR E41�/✓. G 6 FT. Db4M. /NNERT AT aL//LD/NG >> FT. y'-4 /NLET SEPTIC Ti4/VK G+ FT, ' _ FT. O/AM• C(SEE TABUL.4TlON, ptJTLET SEPTIC TANK 0 G FT. /NLET OJSTR/4!/TIOH BOX ' FT. SECT/O/V OF GROUND NI,ITER-TABLE � Ot/TLETD/STR/BUT/ON BQX 7S+ FT. /NLET tEs�Cf!/wG h�T 24;,2 FT. SEWAGE D/SPOSA t SYSTEM TAQIJLATlDN L EACH11VG PIT 3 7 �,•ti' SCALE DIMENSION A FT. 1 DES/G/V CR/TER/.� D/HENS/ON 8_ FT. A141AI ER OF BEDROOMS D/HENS/ON C '� FT GARe.4GE DISPOSAL UNIT SOIL LOG SD/'L TEST TOTAL E1T/M�47"EQ FLOsw G GAL.�DAY SO/L TEST #/ SOIL 7 STglt2 NUMBERF O LOACNUVG PITS_ L_ f`FLEY. 53"� rE�CEY, ��+ ,DATE OF SOIL TEST 7 �� 7¢ SIDE LEACHING PER P/T �7� SQ, /'T. O . 2 ,0 O 3/ d RESULTS /'VITNESSEO dY G ~l eUTTOM LEr4CH/NG PER P/T �sC_$Q. fT. L QZ� t F.4s ���� s ,i g PERCOLAT/ON RATE At/ '4jf W.,A'/INCH ; TOTAL LEACHING A qeA 3 a So. FT. , , PovcO4AT/ON RATE A&2 M/N.//NC)Y RESERME LEACHING AREA_3G $Q• f T. F/ht a r ROBERTi c�v C'/h•t P. 5' BUNKS Cl) � NO.22162 4 r ELOREDGE ENCr/NEVER/NG CC,//VC. A?p�FG/gTEP���� �7I+ I C!. 7// 7/2 MAJN ST. ~,'� ❑ NO GRO4/NO YVi4TER ENCOU/VTERJSd HYANN/1, MASS. •`"^ F yS L GMOUNO Lti/ATER AT ELAW �� JOB No. G SHEET 0 F ` LEGEND LOCUS CAP'N CROSB Y LN - N CD I - gg -- EXISTING CONTOUR ® apK gSRE� o a av 63.52 64.32 x 100.98 EXISTING SPOT GRADE � 64.58 -�H.- -- OVERHEAD WIRES B'dh t ,� ------ SEE pond REFERENCE SITE BENCHMARK 64.0o EXISTING WATER SERVICE o may; 3 PondCi , NO TE 5 \ W g q, post h`n 64.81 TEST PIT D °A o EXISTING LEACH 'PIT .13 BENCHMARK SET ♦ BENCHMARK oP'�P6 r°F� a `r os(�n TO BE PUMPED, FILLED WITH 4 t �`^� °S OUTSIDE COR.1 BOTT. STEP e� 4'a oo� ��c SAND AND ABANDONED \\ \�6 ��8?22, EL.=63.58 `' o°�� (� a° PROPOSED SEWER CONNECTION VENT Q�P 4, 5,01 64.22 Q INV,=59.92t(VERIFY) IF REQ'D N�. LOCUS MAP M '` NOT TO SCALE 100' BUFF�� 47 ^1 O A -2 BV "ra4 9 -,1164.09 PK'SE T ,40 .SHED o EXISTING SEPTIC TANK \ 0 \ �;. 63. 3 . . GENERAL NOTES: TOP OF TANK, EL.=61.52 \ INV.(OUT)=60.19E \\ 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL + 3,5.2r'. \\ \\ 62 2 x 7� 25, BOARD OF HEALTH AND THE DESIGN ENGINEER.63,50 62,38 r 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS GARAGE OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE \\ 62.1e 62,73 � 63 . �''�VELVgy„, ``�� LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: -310 CMR 15.405(1)(b): 58,10 \ 6M,58 { \ / � 61.78 O 1) A 1' variance to the 3' maximum cover requirement, for up co U to 4' max, cover. S.A.S. shall be H-20 and vented. \ \`�`_ �X 6 26 0 3, THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR \ - -EX/STING ,�' � � TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 1 �� HOUSE(#275) 62.29 \ f oo DESIGN ENGINEER. 62,26 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING a _ i � o FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN � ��� r' 00 DECK do. ENGINEER BEFORE CONSTRUCTION CONTINUES. \ � � 5. ALL ELEVATIONS BASED ON MEAN SEA LEVEL TAKEN FROM SITE _ �__-__- ��/ . BENCHMARK OF RECORD SEPTIC UPGRADE PLAN FOR 241 CAP'N 2 --� S�,\` �C'. o CROSBY ROAD, J.C.ELLIS DESIGN, BREWSTER, MA, DATED DEC 18, o 2012. LOT 49- �� �\���, 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 4 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 52.80 't-_._. -'� �'MBL �" 80 \� ��O HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. `EDGE O g�- �\ '-,25,714 ±SF(CALC) �y 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. rV01 0 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. LE 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS EDGE F'wq�R (AU 2G O13) `,�T_ \�E�✓/ \\ \\\mil AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. ���• ��� 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY DRA/NAGE)EASEMENT THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 135,00 CONSTRUCTION. Pond 88'49'06; W--- 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 49.70 IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND HEADWALL REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 53.70 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 44S NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. 5�1� o� PETER T. �G� PROPOSED SEPTIC SYSTEM UPGRADE PLAN S M CIVIL EE N 275 PATRIOT WAY, CENTERVILLE, MA 35109 ewide Enterprises, 153 Commercial St., Mash pee, MA 02649 �p Prepared for: Cop p p GIST OWNR OF RECORD FS ENG� SAULT, VITTORIA C Engineering by: SCALE DRAWN JOB. N0. ` Engineering Works, Inc. 1"=30, P.T.M. 201-13 V 275 PATRIOT WAY 9 g CENTERVILLE, MA 02632 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 8/20/13 P.T.M. 1 Of 2 ..y NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL 1 FOR ADS DISTANCE OF 5' AROUNDETHE 1 /EXISTIW 11 PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-Box HOUSE(#275) GAR PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL RISER & COVER OVER EACH CHAMBER AND T.O.F. OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE SET TO 3' OF F.G. TO',SERVE AS INSPECTION PORTS SHED EXISTING F.G. EL.-63.5f F.G. EL.=63.6t F.G. EL.=63.8(max.) VENT(IF REQUIRED) Co N 6 St• Do W N �� W S=1% MIN.) L = 5' Try . / \ ® '�. 4"SCH40 PVC © S=1% (MIN.) 2" LAYER OF 1/8" TO 1/2" 4'SCH40 PVC 6" DOUBLE WASHED STONE to"I 66 as (OR APPROVED FILTER FABRIC) / to SEWER CONNECTION 8 aaaaBaa EXISTING 48" LIQUID INV.=59.92 aaaaaaa .3/4" TO 1-1/2" DOUBLE �® LEVEL WASHED STONE ADD J . PROPOSED _ 4' 5.2' 4' SPIKE SET AT END ON GAS BAFFLE INV.=59.87 _ INV.-59.65 '/ VINV.=60.19±3 OUTLETS (MIN. �� EFFECTIVE WIDTH - 13.2 CENTERLINE OF S.A. 1 EXISTING > PROPOSED INV.=59.65 EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS S.A.S. SURROUNDED WITH STONE AS SHOWN H-20 RATED S.A.S.LAYOUT TOP CONC. ELEV.=60.3 I NOTES: BREAKOUT ELEV.=60.15 "EFFECTIVE seas 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=59.65 eases INVERTS, PRIOR TO INSTALLATION. eases BOTTOM ELEV.=57.65 2) D-BOX SHALL BE SET LEVEL AND TRUE TO 317.0' 3' GRADE ON A MECHANICALLY COMPACTED SIX 4' OF NATURALLY OCCURRING LENGTH = 23.0' INCH CRUSHED STONE BASE, AS SPECIFIED PERVIOUS MATERIAL ®U U U 0 U U U Ell IN 310 CMR 15.221(2). 5' (MIN.) ABOVE G.W. U U®U U U ® U U U 3) INSTALL INLET & OUTLET TEES AS REQUIRED. LEACHING SYSTEMI SECTION ►- 37" 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE NO G.W„ EL.=53.5 = * w U®®U®® U U U U U AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. EST. HIGH G.W. EL. = 49.0 N Z ®�®U®U U U®U U * ESTIMATED HIGH GROUNDWATER ELEVATION = 49.0 TAKEN FROM RECORD SEPTIC UPGRADE PLAN FOR 241 CAP'N CROSBY ROAD, BY J. C. ELLIS DESIGN, BREWSTER, MA, DATED DEC 18, 2012. SEPTIC SYSTEM PROFILE 102" SOIL LOG 4" KNOCKOUT DESIGN CRITERIA DATE: AUGUST 12, 2013 (REF#14,107) 20" DIA. COVER SOIL EVALUATOR: PETER McENTEE PE(SE#1542) NUMBER OF BEDROOMS: 3 BEDROOMS WITNESS: DONNA MIORANDI R.S. HEALTH AGENT 4" KNOCKOUT 4" KNOCKOUT . 62" SOIL TEXTURAL CLASS: CLASS I ELEV. TP- 1 DEPTH ELEy. TP-2 DEPTH 0 DESIGN PERCOLATION RATE: <2 MIN/IN 64.4 q 0" 64.0 q 0 LOAMY SAND LOAMY SAND 4" KNOCKOUT DAILY FLOW: 330 GPD 63.9 10YR 4/2 6" 63.5 10YR 4/2 6„ DESIGN FLOW: 330 GPD B B GARBAGE GRINDER: NO LOAMY SAND LOAMY SAND 500 GALLON CAPACITY, H-20 LOADING LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF 61.4 C 10YR 5/8 36" 61.7 C10YR 5/8 28 .74 GPD/SF CHAMBERS EXISTING SEPTIC TANK: 1000 GALLON CAPACITY N.T.S. PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 2-500 GALLON LEACHING CHAMBERS IN SERIES CENTERVILLE, MA SURROUNDED BY DOUBLE WASHED STONE-ALL SIDES F-M SAND r F-M SAND 275 PATRIOT WAY, ' , S SIDEWALL AREA: 2(13.2' + 23.0') X 2 = 144.8 S.F. 2.5Y 6/6 2.5Y 6/6f 126' Prepared for: Copewide Enterprises, 153 Commercial St., Mashpee, MA 02649 53.9 126" 53.5 BOTTOM AREA: 13.2' x 25.0' = 303.6 S.F. t Engineering by: SCALE DRAWN JOB. NO. ' TOTAL AREA:..............................................................448.4 S.F. NO GROUNDWATER ENCOUNTERED Engineering Works, Inc. N.T.S. P.T.M. 201-13 PERC RATE <2 MIN/IN. ("C" HORIZON) — ON FILE DATED 7/12/79 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET No. DESIGN FLOW PROVIDED: 0.74 GPD/SF(448.4 SF) = 331.8 GPD "C" HORIZON SOILS ARE CONSISTENT WITH PERC RATE OF RECORD (508) 477-5313 8/20/13 P.T.M. 2 Of 2 1 E f '!{ , , j,r " '' �cif.A • .� :R� -. � \ �, ! ,t t � .1 IL"a., �� � 1 r Ir h \ s. r•!f{- �. .y 41, J/'J) 1i t 4 4 05 W tt b l F •, C •� t1, I •a I = r�: ' •v` ,..��` gyp, i " I PL ,` � Y '1 . ' b.-L?i-�8•^x��"/3- ....*'i.�rY.. ; ; 4... '�''• f f !e�'�.r I� �, �{ 1.�.�•.F't ✓„fit'.'3, .,,'