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HomeMy WebLinkAbout0290 PATRIOT WAY - Health 290 Patriot.Way Centerville A = 193-163 UPC 12543 0 NO. 53LOR �w,h s" �+OCTN17C MN I R COMMONWEALTH OF MASSACEIUSET''S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI S v DEPARTMENT OF ENVIRONMENTAL PROTECTIO Copy � d e� �p^M SJev y^�°�i=[) INSPECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION i Property Address: 290 PATRIOT WAY HYANNIS, MA 02601 Owner's Name: JUDI DWYER Owner's Address: 3212 HA.STINGS RD. HUNTSVILLE,AL 35801 Date of Inspection: 6/23/03 Name of Inspector: (please print) JOHN GRACI, INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 so- Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address:.nd that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes _ Conditionally, sses _ Needs Furth r valuation by the Local Approving Autho:ity X Fails Inspector's Signature: ' Date: :"/23/63 The system inspector shall submit Tn. py of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspect 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 r1ort to the appropriate regional c"fice of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approv:;;g authority. Notes and Comments SYSTEM FAILED TITLE V INSPECTION. LINE FROM SEPTIC TANK TO D-30X IS BROKEN AND NEEDS TO BE REPLACED. D-BOX AND LEACH PIT ARE FULL OF SOLIDS. ****This report only describes conditions at the time of inspection and under :',c conditions of use at that time. This inspection does not address how the system will perform in the future under tile same or different conditions of use. Titl(' S Incworlinn Dorm 6/1 i/)nf1(1 1 e Page 2 of 11 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 290 PATRIOT WAY HYANNIS,MA 02601 Owner: JUDI DWYER Date of Inspection: 6/23/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM FAILED TITLE V INSPECTION. LINE FROM SEPTIC TANK TO D-BOX IS BROKEN AND NEEDS TO BE REPLACED.D-BOX AND LEACH PIT ARE FULL OF SOLIDS. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a F Page 3 of l 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 290 PATRIOT WAY HYANNIS, MA 02601 Owner: JUDI DWYER Date of Inspection: 6/23/03 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 290 PATRIOT WAY HYANNIS,MA 02601 Owner: JUDI DWYER Date of Inspection: 6/23/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS, cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 290 PATRIOT WAY HYANNIS,MA 02601 Owner: JUDI DWYER Date of Inspection: 6/23/03 Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant, or Board of Health _ X Were any of the system components pumped out in the previous two weeks? _ X Has the system received normal flows in the previous two week period? _ X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X _ 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 ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 290 PATRIOT WAY HYANNIS,MA 02601 Owner: JUDI DWYER Date of Inspection: 6/23/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: n/a Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): NO r ` J Last date of occupancy: 2/1/03 33®c' COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components, date installed(if known)and source of information: 1976 PER AGENT. Were sewage odors detected when arriving at the site(yes or no): NO IPage7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 PATRIOT WAY HYANNIS,MA 02601 Owner: JUDI DWYER Date of Inspection: 6/23/03 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron =40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is a.ge confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS, Sludge depth: 9" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 19" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. LINE FROM SEPTIC TANK AND D-BOX IS BROKEN AND NEEDS TO BE REPLACED. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a 7 I Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 PATRIOT WAY HYANNIS,MA 02601 Owner: JUDI DWYER Date of Inspection: 6/23/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND HAS SOLIDS IN IT. D-BOX NEEDS TO BE REPLACED. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 PATRIOT WAY HYANNIS,MA 02601 Owner: JUDI DWYER Date of Inspection: 6/23/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' x 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): LEACH PIT IS FULL OF SOLIDS,SAS NEEDS TO BE REPLACED.BOTTOM IS AT 10 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a a • Page 10 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 PATRIOT WAY HYANNIS, MA 02601 Owner: JUDI DWYER Date of Inspection: 6/23/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 4A A SO in IPage I I of I I i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 290 PATRIOT WAY HYANNIS, MA 02601 Owner: JUDI DWYER Date of Inspection: 6/23/03 SITE EXAM _Slope. _Surface water _Check cellar _Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from systeln design plans on record- If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. TOWN OF BARNSTABLE \ LOCATION - � � ��� ��/ SEWAGE #P2W—. VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY C �— LEACHING FACILITY: (type) NO.OF BEDROOMS �l BUILDER OR OWNE PERMITDATE: COMPLIANCE DATE: I tP O3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by f �� �� �¢ �-�.9 ' � a s. p �`S� ��- aQ ' (3a- 3a . ' -No. f� FEE IS 0 Board of Health, e-�[)GAc )eiltr_ MA. APPLICATION FOR DISPOSAL SYSUM CONSTRUCTION PERMIT Application for a Permit to Construct( ) RepairK Upgrade( ) Abandon( ) - ❑Complete System Xndividual Components Location 2. () Owner's Name v Map/Parcel# I 13 Address 3212 Lot# Telephone# 35$01 Installer's Name ,Gf; V• Designer's Name Sa Address C., Address 13 �D.`mo ft Telephone# r�_ v8 Telephone# 8 �b 0 Type of Building ke-s s?wrNA-ia` Lot Size T Zoo Y— sq.ft. Dwelling-No.of Bedrooms -\U:s� 3 tQr% Garbage grinder 4 Other-Type of Building N m4e- No.of persons Showers (V<Cafeteria (i;' Other Fixtures LA,0ATDP_y , k,-rcAAzKx 1-pjyAw9_Y Design Flow (min.required) gpd Calculated design flow_ Design flow provided gpd Plan: Date d�2L Number of sheets Revision Date Title Description of Soils) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not t ploee operation until a Certificate of Compliance hasGaeen �00 fiNMM&G&W a l'tI-ERVI i' Sign Date _ j INSTALLATION AND CERTIFY IN WRITING /6 _3 I HE SYSTEM WAS INSTALLED IN STRICT ACCORDANCE TO PLAN. Inspections `!d"'�*t.,,,r+'�r-'.?4-r•.Kwr.-�w.+w�.� ,� 1�4:..y1^..rr->r .},r,-+..^7�'"`tiv''"' .vi.. � � -,. ,4y '*�- v s,�' �•...a � �''"�^ h., ."`*.^^♦v`�^--"t.••.,,�..*yr• ., 41 No.5??13 FEE �a COMMONWEALTH OF MASSACHUSETTS Board of Health, 2)c< - d6e MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - ❑Complete SystemAIndividual Components Location ZCj Q � 't CA Wr\ �P n V �; Owner's Name J\�C,`- y� A e.C- hap/Parcel# IJ I9 � ( t Address -3Z12 c. Wq,- t? V Lot# -t�— - Telephone# Installer's Name �, ,fie 5 5tPr*%c 5(KU,%CjDesigner's Name V �01clot-)OVJY" Cx\ , Address r.� T 0� 51 ar Q Address Telephone# - �, �- 531� Telephone# 54 f ! Type of Building E' \t1i E 1. ,la-1 C3 # YP $ Lot Size T, Q� sq.ft. l Dwelling-No.of Bedrooms l a.�l'�. �Z� -3'CAE,S1CL(1N Garbage grinder *+ tlier-,Type-of Building Of V en �-+ No.of persons 4 Showers (i�Cafeteria (t.)'' Other Fixtures 0ATI�PY 1Z,-re"-V E1"A L9oAwP-y i Design Flow (min.required) ��� (D gpd Calculated design flow ,5?0 Design flow provided 331 -80gpd Plan: Date e ' ! 9 Q,� Number of sheets Revision Date Title \� •K '`cpseA 5�.,.p-k::t DLO Glbq rc-` C Description of Soil(s) k _r r to Soil Evaluator Form No. ''�� � Name of Soil Evaluator 1./+�'.k'(,,tih Date of Evaluation � �, ^�;•� r' DESCRIPTION OF REPAIRS OR ALTERATIONS � I r The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to pthe to fin operation until a Certificate of Compliance has been issued by the Board of Health. Sian, "�,. rigs- �+l p Date 71-• 51) r v -�/45 3 Inspections � A No. 3 `��C'> COMMONWEALTH ` ¶ F ( FEES s, Board of Health, MA. CERTIFICATE OF COMPLIANCE Description of Work: NAPdividual Component(s) O Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded (V Abandoned ( ) by: Y)"AS S 1' 01\LA at c -qQ DAMA -T tAJ14V 1 t has been installed in accordance with the ptrov' ions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 2603'3143 , dated 1f(5-3 . Approved Design Flow (gpd) f Installer �y Designer: Inspector: Date: J ,1r C The issuance of this permit shall not be construed'as a guarantee that the system will function as designed. No FEE .+ Board of Health, agr?NS'tr,,0c— ,MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is herebygranted to; Construct( ) Repair(C.-)--rpgrade( ) Abandon( ) an individual sewage disposal system at ) -N- -d-17 l,,A A --a,`T as described in the application for 1 Disposal System Construction Permit No. dated 4 '' Provided: Construction shall be completed within three years of the d e of th's it. l local conditions must be met. f � k Form 1255 Rev.5/46 A.M.Sulkin Co.Boston,MA Date 7b-�k3 Board of Health 't I TOWN OF BARNSTABLE I; LOCATION ' per✓ SEWAGE ' VIIrLAGE -^'•, ` ASSESSOR'S MAP &LOT i3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACENG FACILITY: (type) (size) NO.OF BEDROOMS vJ BUILDER OR OWNE PERMTTDATE. 11 S 0 COMPLIANCE DATE: d3 Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) acil tywetlands exist Edge of Wetland and Leaching Facility( Y Feet within 300 feet of leaching facility) Furnished by t (3a-- 3A` a ,a CARMEN E. SHAY (508)-548-0796 ENVIRONMENTAL SERVICES, INC. P.O.Box 627,East Falmouth,MA 02536 July 16, 2003 RE: Certification of Title V Septic System Installation: Residential Property 290 Patriot Way, Centerville, MA Dear Sir or Madam: On July 15, 2003, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at 290 Patriot Way, Centerville, MA, based on a design drawn by Shay Environmental Services on July 11, 2003. XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan I Certify That the Referenced Above Septic System Was Installed With Changes but in Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow. The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is Required. If you have any questions, please do not hesitate to call the undersigned at (508)-548-0796. Sincerely, CARMEN E. SHAY ENVIRONMENTAL SERVICES,INC. y ` 4s� , S�iAY � Cam . hay, R.S., C.S No. I I j President o r FG/STERN SgN17AR�PN 5eN - 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 N • u� SRS;oi )TICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only, PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM ae-b-4c-m - g`' hereby certify that the engineered pian sip ed by me JLtec 03 concerning the propert located at -90eS��e'��-t �G C"61&mieets all of the icl!owmo cr.teria • This failed system is connected to a residential dwelling only. There are no :ommztrzial or business uses associated with the dwelling. • The soil is ciass:f:ed as CLASS l and the percolation rave is less than or equai to 5 rt:nutes per !rich. The applicant may use historical data to conclude this fsc: or may :orduct )re!irm:,,ari tests ac the site without a health agent present • There :s no increase to now and/or change in use proposed • "ihete are no vanances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen aonve the maximum adjusted groundwater cable elevauon. (Adiust the nundwater table using the Frimptor method when applicable) 1.Please complete the following: -1.i fop -3i Ground Surface Elevation (using GIS information) 8; G.vY' E Icvat:or, ad;ustment for high G.W. �TT-T..RENC .. E EN and B S.G. IED _. DATE: 3 .......... ---- -- NOTICE 3ascc j-,-ort t^e above information, a repair permit wil! be issued For bedrooms +� No bedrooms ase authorized to i` -, future without engtncerec I ept!c syaem plans. 1 .11h:gAci pcimtrnp Permit Number: Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: 29 �O��C'� Qq , QO:)REtl tIke Lot No. 41- - Owner: Ti1C�(,Nc��s�lt,RQ&" Address: �j M Contractor: SARd Qk , (Wclress: Notes: STEP 1 Measure depth to water table �'�9 tonearest 1/10 ft. .............................................................................. .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well.................................................... OWater-level range zone ..................................................... C STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... 4(0. mont year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water level zone (STEP 213) determine water-level adjustment ................................................ .... ................I. ......... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water 2 level at site (STEP 1) ............................... ....................:.......................................................... 2�•� 1; Figure 13.—Reproducible computation form. 15 No..........1..._....... Fil-B ....................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH SS......j...............OF.......�T..�'r..�.......... ............................................. Appliration for Uiipoii al Warkii Tonstrurtion Frrutit Application is hereby made for a Permit to-Construct ( ) or Repair ( ) an Individual Sewage Disposal System at �.y,............................. -------------- ---- -- ---- .............................. 0. �+ ration-Ad es or t No. 11wner ddress ✓.. ------------------------------------------- •--- .. :.... ............ Insta 11 er �. Address d Type of Building Size Lot.. ./..ee .._k..Sq. feet U Dwelling—No. of Bedrooms......C91...............................Expansion Attic eL j— Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ..------•--••---••--•--••---.• .. W Design Flow..//d.Y.�3..................._gallons per person per day. Total daily flow......3.a.0...�_'�'�:gallons. Septic Tank—Liquid capacity'y.9�.gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet....... r. Total,leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) l ��,j��� �� �`�V77 Percolation Test Results Performed by..... .17/!w?.,!h ....�.1 _ �1 Date......2'_y l._...7.�...... aTest Pit No. I________________minutes per inch Depth of Test Pit....&6(--.... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •------------------------------••-•-•---•--••-•-----------------.....----•------....------•-•---•---......................................................... O Description of Soil.....XiP / !!t� ... c............. ! 'f-----------------------------------------------------------------------------•--... V ......•••-•••--•--•-••••----•••-•---•- ��?.r-C.�� �� °' 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 TA ITA!; 5 of the State Sanitary Code— The undersi ned urther agrees not to place the system in operation until a Certificate of Compliance een is by�t_h / Sig e` ..�. �. y. l3 Date .. Application Approved BY �2. ..._ Y... / �--44-1i'- ----------------------•-----• Date Application Disapproved for the following reasons:.............................................----------------•-------------------•-•-------••-••••••--•-....... ................=......................................................................................................_..................................•--••-••••••--------•-••-••------•••-•---•---- te Permit No......................................................... Issued---1 ` =7\-•--. _......... ..._. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH a:.....OF,. ... .....Y..'.. ................................ •�'� C�rrf�f�rtt�r �� f�unt�r�tttnrr T "IS CE IFY That the Individual Sewage Disposal System constructed (r Repairedby.... ...... . --c._... -........................... ...........---------------.....---------............-----.....---..._._........------.._..._._......._ nsta has been installed in accordance with the pr isions of j of The State Sanitary Code as describ d in the application for Disposal Works Construction Permit N .o ? .�. ..._. ,...................... dated------- ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI ACTORY. DATE..... ............................................................... Inspector...-- •--- ................ ✓ :... THE COMMONWEALTH OF MASSACHUSETTS BOARD OA HEALTH �1 ," FEE.... �.............. i �r r tt kJ5 (gad liftinn amit � Permission is reby granted:--•-- ------••--•--------•---•-. ...... � -------- to Construct or Repai n Ind' dual Wage Disp st at No...`" T/" -----•- .. -� -t'�,•---• --"__'J. Street r--........-- as shown on the application for Disposal Works Construction Permit"........... .. �. D -�d....._I"G?..- -------------------- Board of Health DATE---•-•- ------- FORM •1255 HOBBS & WARREN. INC.. PUBLISHERS - No..........f... ...... Fss.......`................ THE COMMONWEALTH OF MASSACHUSETTS BOARD ,OF HEALTH .t s:5" � N " .. O F........... ...................':....."7.............---•-----------...._..._....... Appliration for Dispniia1 Workii Tonstrur#iun Vautit Application is hereby made for a Permit to Construct (`'.. ) or Repair ( ) an Individual Sewage Disposal System at n .. .._.. TA .. ...... ...... t. ........................................................ tion Ad se rn s �'a Corsd, dort e•Nss .�........................-.�--- . -•--_.. ....o ....... ------ ........ ........... ,4 ddress d Type of Building * Size Lot../?/P?_.�t..Sq. feet Dwelling—No. of Bedrooms......CA...... ......... ... !__....Expansion Attic Garbage Grinder aOther"Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ........................... •..... ....................................................................... --.. ......._... W Design Flow ; ��?. :___.._. gallons per person per day. Total daily flow.___._ .Q � '�galions. WSeptic Tank=Liquid capacity' •S_gallons Length................ Width...................: Diameter:-._.......... Depth................ Disposal Trench—No..................... Width.................... Total-Length............:........ Total leaching area___...----_-------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet..- ------ Tota leaching area... ..:.._....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) uwQ .w ` "�` 77 '-'t Percolation Test Results Performed by._...1 �!�!i./ :_.,,. � + _ Date......:':"'_l ................... ' Test Pit No. 1.. ------minutes per inch Depth of Test Pit....14. .... Depth to ground water........... ............ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.__...............:.:__- •• -• -=--.-••-• •-•--••••................ .........._....•-•-- ......................................................... fQ Description of Soil / rA.�t ,Ot-.. -%P, I f.`" ................................................................................ V W .................................... e • ' ! !'' --- - � s10 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 iITL L 5 of the State Sanitary Code.—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ; een issued by the bo r f*edt•h-_* ' Sig d- ` = ............•� Date Application Approved By ..... r L. _ ............................ -•--•� jl�-`72------- Date Application Disapproved f or the following reasons---------------••------------•-------•------------------•---•-------------------•---------- ---- ---•------------•------------------------•-•----------------------------------------------------- ----------•------ Da te _ _ Permit No L ..................................... Issued..... 411t•' r( r Date . 4y r - 49�, ca.pU. 15Pc'SAL PIT - test=.�({�c�a G/�t .. .► ;f tcJp SF >c 2.S '7`a G.P.b. C-YPSD 3 TOTAL »E;SIGhI `('t>T!J t_ ID,d l Lam( �.PD. f i Ion4J 4 PCiZGDLL�TIOt�I �I�TL- ("t+.l 'L.AA k) 02 LESS,. f 14-.77 -rl -,T Tor YN tay.a _2��,• �ls+�Q�,�.. �"I;F-� lam !u�`�G.g �:� SAD INV. / -Box �` � SE-prtc IC 1 69.tl ICR_ GAL. '�'v C(G'l 7 LEA-N '�GtO PIT MEv �vtrN c' �VAS►.tED pip 0 Ljo �cbL H, � I CV!�tZ-T`t P' T h ! t-1,�T T 1-�G '�,C.a 1J:/b"CiUu St-kcx�u 4J _ Qt_u,1.1 .t C..G I i-lc:i�t,t5+.1 Cc:�ti�Pt_�(C �J 1"T•.-t T+-ice ;IUD' t_i+-.ts=- ._.__`-". ._.__r..�_._.� 0;= Ttac c�W�'�o-�r mt—c— &` L G . ,► "C,�7 t71�'rE� 1 ( 1 L� p j j-1-;t�-• t7 t_/at-.{ l� t-,C�'C ��,/_. C�'.�? tit-► (Lr,,! C7`;"fC Cw/1t._t_t": o fvC�L;��, .t.r1-L>:.1?.rtl�W; �j(.1:,'�!t'-�' �. ''f't1(:_ L.:l=t:"•;r�C-�� •'i1-1e,t 7� >i- >•'.>t;_ u--'c i�.a tDC i'( f_�. 1! 1.,!' f• I_-{ ! (i: - �r}^� Crt.Y.. � 1 SECTION A -A LETt fir'• r = 2000• 10' min. from *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. PROFILE VIEW OF ADDITION TO LEACHING SYSTEM[ �P SF Ni � tr �oovER �or9p°o Existing Foundation house to septic tank sir . TOP OF FOUNDATION = ELEV. 100.00 (Assumed) Sep' � O01r's WwA M 3' of 1/8' - 1/2' Washed Peoeton u[vEi FOR AT LEAST 2 tT .11►�n 6 in. of fiiA•d grad• 3 4 to 1 1 2 ' Washed Crushed Stan GJ ow Septic Tmi-9600 0,0&•w O-em- 9d00 ow SAS-9e00 / / + 3-!r OFS ,. - � �. KMOOCOUIS unus .r ' Y //J\ _ s ' a SITE 7 . OunET 31E p5b`1 �, s- 0 t2' INLET 3 • EXISTING s-a01 a Greater 3 DIST. BOX O r tbdxr•sr Corr Top of SAS- D... -9a00 r �� C,oP f1 Cf �- (n 13' $ 1,000 GAL n �. s- 0.01'Per toot Eft•ctM Oyu tS6• 4' - 9f3i. 40 T t.Ts' a o rAM EXIST. Fa1MMTMN •i SEPTIC TANK n a 401 H-10, .; 3 units a &M' 30' PLAN SECTION CROSS-SECTION11m aQ ATE FLU o ~ g in r7 0.83 I in ' (10 inches) 3• 3 V ; a ao I31.25 6 kAf 3/r-1 1/r' s o 37.25' 3 HOLE H-10 DISTRIBUTION BOX SYSTEM PROFILE d� ; Effective Length NOT TO SCALE Not b scale - e o LOCUS MAP s 4' 4' SDIL ABSORPTION SYSTEM (SAS) c rr c > 0', -;, INFILTATROR HIGH CAPACITY (H-10 LOADING)/ GEORGE O'BRIEN GENERAL NOTES e to of 3/4'-1 1/Y C aompoet•d •tan• Eri•etly VIdMr OR EOUNALE Not to Scale ( 1. Contractor is responsible for Digsafe notification Bohan+ d Test HdaObm 1 Et•v.14r mo NOTE: OVERALL HEIGHT OF INFXTRATOR IS 18' CT1.VE HEIGHT is 10' and rotection of all underground utlities and No Oroundwt•r Ob•rvd•ta4'-"--_ 2. The septic tank and distrr uution box shoal be sett level on 6" of 3/4 -t 1%r stone. 3. Backfill should be clean sand or grovel with no stones over 3` in size. 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. r „ 5. The contractor shall install this system in accordance P E R C 0 LATi 0 N TEST _ S87d 10 45 E ,� with Title V of the Massachusetts state code. the approved pion i and Local Regulations. Date of Percolation Test: JULY 9. 2003 f 04.56 6. If, during installation the contractor`encounters any Test Performed By. CARMEN E. SHAY, R.S C.S.E. j O� soil conditions or site conditions that are different Results Witnessed By. WAIVER ( per Barnstable B.O.H.) l i I ,�� from those shown on the soil 'tog or in our design I i instollu ion must halt do immediate notification be SHAY ENVIRONMENTAL SERVICES, INC. 1 I f9 b Percolation Rate: Less Than 2 MPi O 32` made to Carmen E. Shay - Environmental Services. Inc. 7. No vehicle or heavy machinery shail drive over the t septic system unless noted as H-20 septic components. I 0 8. Install Tuf-Tits gas bafties�or,equais on ail outlet tee ends. Test Hole No. 1 �� f C 9. All Distribution Lines shall be 4* diameter Schedule 40 NSF PVC pipes. 10. All solid piping, tees do fittings shall be 4" diameter DEPTH SOBS ELEV. I , Failed a �� Schedule 40 NSF PVC pipes with water tight joints. � o eaoo f i - Leach Pit , Loamy I �� 11• Municipal Water is Connected to ALL OF The Residence and Abutting 1 s«,dr f I -- ------------ ST. 5' Properties Within 150 Feet. 10 A,n 7.25 { �� THE PROPERTY LINES ARE APPROXIMATE AND p I COMPILED FROM THE SURVEY PLAN GENERATED BY Loom i ,' i ALL BAXTER do NYE. INC. ` OF EAST OSTERVILLE, MA to r1t s/a ' D-Box . ENTITLED " CERTIFIED PLOT PLAN OF #290 PATRIOT WAY I CODI I GP`RPGE , . CENTERVILLE. MA", DATED DECEMBER 23, 1977 z' AND IS NOT INTENDED TO -BE A`SURVEY PLOT PLAN e 32' 83.33 i ~ iT SHOULD BE USED FOR NO PURPOSE OTHER THAN 1 I h Sand ll �X TT!T HOLE #1 I � u r 6/6 i � �- � LOT #16 THE SEPTIC SYSTEM INSTALLATION. 132'- 54' 3.50 1 N i , t �. ELEV.=`$8.00 t , ' �� EXISTING LEACH PiT TO BE PUMPED OUT AND Meal-Fine i �''' REMOVED TO MILITATE INSTALLATION OF NEW SAS. Sand Q \ �.'t ASPHALT t �' i zs r T/4 C 3 .\ t DRIVEWAY �'�_-_ �� --- -- ------ - - - - - -- -�---- - -- -- i54.- 144 .00 t.0 .\ ; \ _ ___ F- NOTE:" ANY STRIPPED OUT SOIL CONTAINING LEACHATE _ - -- - 'DECK ` 0 FROM THE EXISTING LEACH PR TO BE DISPOSED * _ OF AS PER BOARD OF HEALTH SPECIFICATIONS. Iy C `� •i' AMS77NG Ebsr• 1000 tom• NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY `. 2 BEDROOM S� Tank PROJECT BENCH MARK Perc #1 Depth to Perc: 54` to 72" . o ,�� ei . DOUSE TOP OF FOUNDATION LEGEND Perc Rate- Less Than 2 MPI ,' cCkn \\ ELEV. = 100.00 (Assumed) No Observed ESHWT V 1290 //- ,\` No Groundwater Observed 0144" O �' opt l `. DENOTES PROPOSED 1 L , 104X1 SPOT GRADE x 104.46 DENOTES EXISTING LOT #117 SPOT GRADE t I f7 200 SquarA Feet t/- C%' L O PL t PROPERTY LiNE tit ` 11L i o 96 PROPOSED CONTOUR -_ - - _ .-- -97 EXISTING CONTOUR 94-- '`. t � �� �.'' � Gravel � ibrivewayt ® DEEP TEST HOLE & 2-18' EXAM. ACCESS MANHOLES t �• \ . -- ; i 90.87 PERCOLATION TEST LOCATION .- `� :• \0' S88d 49' 06" lf' 6 FOOT STOCKADE FENCE b \\��-��----------I---------------------� L------------------- ~ THE ACCESS COVERS FOR 1HE SEPTIC TANK. �\ INLET DISTRIBUTION BOX AND LEACHING COMPONENT cu SET DEEPER THAN 6 NCiiTS BELOW 5' OF ED •�� P LOT PLAN �- �- GRADE SHALL BE RAISED 7C tNTFiIP1 6 OF ` FINISHED GRADE INSTALL TUF-TILE GAS BAFFLES OR EQUALS of R ORCE[) PRECAST CONCRETE CA p 1V C.R O .S'B Y � O.A_D OF PROPOSED SEPTIC , SYSTEM UPGRADE STIn PLAN VIEW (40 FOOT RIGHT OF WAY) PREPARED FOR 3-.24'REMOVABLE CO,M� MS. J U D I TH E. D WY E R I AT :�. ..�_. .....� . . - r #290 PATRIOT WAY INLET -r r mom'. • NT RVI OUTLET - CE E LLE, MA w 5 -T 5' -T eSl n tCUtd E$ 4'-W min. ���t{OF MA PREPARED BY: . �"id dVth umber of Bedrooms: 2 Equivalent to 220 Gal./Day (330 Go!./Doy Min. per Title V) o�� 1I ��N Garbage Grinder. No , • Leaching Capacity Proposed: 330 Gd.Jboy (Minimum (Min. Per Title V) lRHEW E. SHA Y • at z--z� _ i Septic Tonk .: 3 x '330 Gd./bay = 660 USE 1,500 GAL. Septic Tonks 0 20 40 50 SHA `n ENVIRONM[ENTAL SERVICES. INC. 4' -to' SOIL ABSORPTION AREA: Us'Inq percolation rate of <2 rnin./Inc►l N •-1 CROSS SE Bottom Area. 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gdlons 'P P,O. BOX 627 - CTiON END-SECTION Skfewoll Area: 0.74 `zeal./sq. ft. x 78 sq.,ft..= 58 gallons `cOISTE4` s ��� EAST FALMOUTH, MA 0253.E g '_ :;31.80 gallons IN 1 F ,. . ProvidM _ TEL/FAX 508 548--0796 USE EXISTING 1000 GALLON ' H- 10 SEPTIC' TANK Use: (5) INFILTRATOR HIGH CAPACITY H-10. UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1"=20' A 1"= 0' W Y• TO BE USED WITH ;4.0� OF WASHED "STONE'ON THE SIDES, AND 3.5' OF WASHED STONE SCALE: 2 DRAWN 8 . CES . ' DATE: JULY 11 2003 NOT TO SCALE ON THE ENDS. No STONE UNDER. - PROJECT#SD448 . FILENAME:- SD448PP.DWG SHEET 1 OF 1