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0340 PINE STREET (HY - Health (2)
4 'ipe street Centerville A=228 037 UPC 12534 0.2-153L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Pine St Property Address f,I Douglas Cowley } Owner Owner's Name information is ✓ required for every Centerville Ma 02632 5/10/19 11- page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information fz3 gZ(p on the computer, Michael DIBUonO use only the tab key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane OQ Company Address Cotuit Ma 02635 Citylrown State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1.. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/15/19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1000 Gallon septic tank as well as a concrete distribution box and two 500 gallon chambers in stone 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �4. 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r Commonwealth of Massachusetts p Title 5 Official Inspection Form J i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is Centerville required for every Ma 02632 5/10/19 page. Clty/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,�-p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5ins .do •re v. Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 6 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �V 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 198 Gpd 9 ( Y 9 (9p ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �n p Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Pine St u Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 12/14/2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3 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.): System is vented at the roof line t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owners Name information is Centerville required for every Ma 02632 5/10/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" � Scum thickness 3" 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 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ,z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of etc.leakage, : ) Level in tank was normal. Minimal solids 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day l5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form _ Ira Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: two 500 Gallon chambers in stone Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Functioning as designed 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage_Disposal System Form - Not for Voluntary Assessments 340 Pine St `J Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 340 Pine St. Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 5/15/2019 Assessing As-Built Cards . I ruwty ur'lsnicir�rnts�i; . I LOCATION 3440 P]�� S1. SEWAGE#_&1G 1 VILLAGE. .C.tr tx11;a(e , ASSESSOR'S MAP&PARCEL V 37 INSTALLERS NAME&PHONE NQ. { ,. SEPTIC TANK CAPACITY 1=& ._ LEACHING FACILITY:(type) -4rn 1• } L...t (size) 30' I NO.OF BEDROOMS OWNER T PERMIT DATE:I'L-G-OG COMPLIANCE DATE: / 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 ion site or within 200 feet.of leaching facility) Feet Edge of Wctland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY L i in �nLcr . r • Qi-Z� A2-zz o a� https://townofbarnstable.us/Departments/Assessing/Property_VaIues/HMdisp]ay.asp?mappar=228037&seq=1 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+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: 12/6/2006 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data provided by B.O.H. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Pine St Property Address Douglas Cowley Owner Owner's Name information is required for every Centerville Ma 02632 5/10/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSTABLE LOCATION Z440 1' .n� S�. r SEWAGE#2C�X- VILLAGE �. �erip`�Nt- ASSESSOR'S MAP&PARCEL N,,p-27Sr cA d , INSTALLERS NAME&PHONE NO. 4t-a.,,- ' , SEPTIC TANK CAPACITY 1 Xt`J�o.�, d LEACHING FACILITY:(type) L-5, 6n&e-A• (size) NO.OF BEDROOMS OWNER PERMIT DATE: 12- ®G COMPLIANCE DATE: / 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 C.,c j�e— A2- Z2 A 2_2`" . x 2 Z3- no (�. No. 0 Dc:p" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer' 1 ' .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01 pplicatiou for Migpogat 6p5tem Con5tructiou Permit Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑ Complete System U Individual Components Location Address or Lot No. 3Ve �^v C tS Owner's Name,Address,and Tel.No. ac>3 Assessor'sMap/Parcel e�a�_�3--y�a� /� dirr t/G o2��7�Z Installer's Name,Address,and Tel.No. / ��o�¢� "J� Designer's Name,Address and Tel.No. �.' 06 ' xoX) S`7J�'��' E13�5�/ Grry7Ci,�lk�syt �!)I✓� Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( /410 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(m=Iu ired) 330 gpd Design flow provided -336 gpd Plan Date � 4, Number of sheets J / l Revision Date f Title s S f�� D 3 �B �iat S, C rrrf� A, Size of Septic Tank J,6b, � ,�.� 9 Type of S.A.S. �— SZ29 GuG G,.wtfind C/,�,� Description of Soil P1 Nature of Repairs or Alterations(Answer when applicable) Rye,.- L �ov�g 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 B o h. igned c � Date �Z 1G�6 Application Approved by Date A •Application;Disapproved by: .Date for the following reasons + Permit No. (�C�C? S`� Date Issued v - ,�".:a,:.i• �. ., .. r. --�...-..,. .,�;�.mow..-:ynN......•.-..,►^r.,.<...��. ..:rs_.�.-..,... yr:. .,,. �.,y,,.. r No. �- Fee Ente red in computer" THE COMMONWEALTH OF MASSACHUS&Y3'_,` - s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,;MASSACHUSETTS Rpplication for Migpogal *pgtem Construction Permit Application for a Permit to Construct( ) Repair("grade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. 3y0 /ti S Owner's Name,Address,and Tel.No. 6-rw,t cc Assessor's Map/Parcel g /3 7 Installer's Name,Address,and Tel.No. / �li/o�f GA"�'J Designer's Name,Address and Tel.No. '"� s?�� s-Pp yrl•/I7,ils Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder (h) Other Type of Building No.of Persons Showers( Cafeteria( ) qW Other Fixtures Design Flow(min.required) 33 gpd Design flow provided 3 3 gpd '' Plan Dater 17j/, Jti,)GYJ Number of sheets f / / Revision DateD��7ate f Title s 5, , Plloj, 9 3 ti/a Piwr• ST c/ri, fir l/Al I- 14 Size of Septic Tank' ) ;6) Go �+c,5 p i Ct i vr� Type of S.A.S. SZb Gu L G-.wc y r_,4e,07�_7 Description of Soil �:-,- D/6-7 Nature of Repairs or Alterations(Answer when applicable) �Y{/�r,� L- l fir»•1, 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. Sig end Date I Application Approved by v Date / (A 6 Application Disapproved by: Date for the following reasons _..:Permit No. n-0 6 ,"',_.;,_?a _�. -Date dssued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that th>) On-site Sewage DisposalSysta_m Constructed ( ) Repaired ( Jpgraded ( ) Abandoned( )by e� _1r �al`�r / CD LaJy�Giow �• at 3y0 P'i�� S� lin »✓�lIT has been constructed in accordance l)_ with the provisions of Title c)5 and the for Disposal System Construction Permit No. LOO(O —'�� ! dated Installer /,30- 4)/o f j Designer /Q•W o #bedrooms 3 Approved desig flow .,y-�336 gpd The issuance of this permit shall etcto/nstuied as a guarantee that the system will func �n�as 1 esigned. Date (.� �✓ �` l© Inspector _ —————^——————————————————————--——————— No. ooCD _5 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS x1h5pogat 6pgtem Cori. tructton Permit Permission is herebyranted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) g P System located at yO tit S , C�h�- �I& and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special.conditions. Provided: Construction must a completed within three years of the datebQyzt_ ���� Date 1 �P Approved 1 FROM :down cape engineering inc FAX NO. :15083629880 Dec. 15 2006 08:51AM P1 Town of Barnstable Regulatory'Services _ Thomas F..Geileir,Director Public Health Division, 'Thomas McKegn,Director 2001Main Street,Hy"nis,MA 02 I Office: 508-862-4644 Fax: 508-79043D4 Installer & Designer Certification Form Date: Seovage Permitft aC 6� 5,7.1 Assessor's MapWarcel Deas><gner: 0 r1 e-- Installer: � Address: Y 0.1 e\ �P . Address: q 57— On l2 (o O( /_ _r�d � C�j2 __was issued a permit to install a (date). L (ini;Wlerr) n e, � �• based ap a design drawn by septic system atdlo (address) r ff 4_16� dated 117146104 (d iper) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or sepdc tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. N CWMA ARNE H OJALA (In er s Signature) civil_ 1 e; No. 30702 6TP- MA IW, En�' (Designer's S:gnatur (Affix Designer's Stamp Here) PLEASE RETURN TO BARN5'[ABLE PUBLIC_ HEALTH DIVISION. CEIt IFICATE Of COMPLIANCE WILL NOT BF, ISSUED UNTIL ROTA THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU Q:Health/Septic/Desigur Certification Form 3-26-04.doc V -\ COMMONTVVEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL A:FFAI:RS. Y� DEPAETMENT'OF.ENVIRONMENTAL PROTECTION � A , TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM: PART A CERTIFICATION Property,Address: .1)' Owner's Name:{ Owner's Address ` : J i . 1l tri, A 8 Dz�Cloc �fT Date of Inspection. CJ a Name of Inspector:1please print) P 4-, Company Name Mailing.Address: C7 Telephone Number: CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below:is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper.function and maintenance of oWsite sewage:disposal systems'.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR.15.000) ;The system: Passes. Conditionally Passes Needs Further Evaluation by the Local Approving Authority 'Fails Inspector's Signature: . Date:. The system inspector shall subunit 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 101000 apd 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,gproving authority: 1 Notes and Comments r ` v� ****This report only describes conditions at the time of inspection,and under the conditions of use,t that time.,This inspection does not address how the system will perform in the future'under the same or different conditions of use: n Title-5 Inspection Form . 6/1572000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORIVM[-NOT FOR 'OLUN'I' RY. ASSESS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: C al rn kca.P Oboe � A 4 IC/i4 Owner:, ✓��t Date of Inspection: p —('Y)( Inspection Summary: Check A,B,C,D or E./ALWAYS completL 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 15304 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: Answer yes,no or not determined(Y,N;ND)in the for.the following statements. If."not determined"please explain. The septic tank is:me1aI and over 20 years olds or the septic tank(whether meta] 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: Observation of sewage backupo _ .. b or break out or high static.water.level in the distribution box due to broken or . obstructed pipes)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: The system required pumping more than:4 times a year due to broken P g y or obstructed pipe(s).The systemwill ass inspection p p on if(with.approval of the Board of.Health): broken pipe(s),are replaced obstruction.is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION:FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFA(JEI SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: `/ ) �L: z• �j_—i-_Pp Owner �.J.17- _ %� �' ✓dam Date of Inspections_ , f' . 4 x — 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(i)(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`rnarsh Z. System will fail unless the Board of Health(and Public,Water Supplier, f 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]00 feet of a. surface water supply or tributary to a surface water:supply. The system hasa septic tank and SAS and the SAS is within a Zone I of a:public water supply. . The system has a septic tank.and SAS and the SAS is within50 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 I **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 p'pm,provided that no other failure criteria are triggered. A copy of the analysis:must be attached to this form. 3. Other: 3 Page 4 of. I 1 . OFFICIAL INSPECThON FORM,-.NOT FOR VOLUNTARY ASS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property.Address: A Owner: Date of Inspection: L u J 91 LXC69 - D. System Failure: Y Criteria applicable to all systems: PP You must indicate"yes" or"no."to each.of the-following fore all inspections: Yes l No. , - VBackup of sewage;into:facility orsystem component due to.overloaded or clogged SAS or:cesspool Discharse or pending of effluent to the surface of'the ground.er surface waters due to.an overloaded or clogged SAS or cesspool Static liquid level;,in the distribution box above.outlet invert due to an overloaded or clogged SAS or ` cesspool Liquid depth in cesspool is less.than 6" below invert or available volume is less than %day flow Required pumping more than 4 times in.the last year NOT due to clogQed or obstructed pipe(s).Number of times pumped yV _ ✓ Any portion of the.SAS,cesspool.or privy is..below high ground water elevation. Any:portion of cesspool or privy is within I00.feet of a surface:water supply or tributary to.a.surface water supply;.. . _ ✓ . Any portion of a cesspool.or privy is withinn-a Zone l of a,public well. _ Any portion of a cesspool or privy is within.50 feet of a.private water supply well. _ Anyportion 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 colifor.m bacteria and volatile organic compounds indicates that the.weli.is free from pollution from that.facility and the.:presence of ammonia nitrogen.andInitra.te nitrogen is:equal:to or less than 5 ppm, provided that no other failure criteria %1�Jj��j are triggered.A copy of the analysis.must be attached to this form.] 1 ✓(Yes/No)The system fails. 1 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 larger system the system must serve a facility-with a design flow of 10,000 gpd to 1.5,000 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 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. Page 5 of I OFFICIAL EN'SPE:CTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE'4�A�E DISPOSAL SYSTEM INSPECTTON FORM. PART B CHECKLIST Property-Address: e h`i .� Qw,�ul,y0� Owner:, Date of Inspection I T'_lLe e3 J � Check if the following have been done.You must indicate"yes"or"no" as to each of the-following: Yes....-No Pumping.information was provided by the owner,occupant, or Board of Health' Were any of the system components.pumped out in the previous two weeks f 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 1.note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ' U Was the site inspected for signs of break out? _ Were all system components, excluding the SAS,,located.on site tank tic Were the se a a uncovered, _ p t manholes unco red, 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 sludgeland.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: Yes no, Existing information. For example, a plan at the Board of Health. V r 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)J Page 6 of l 1. OFFICIAL INSPECTION.FORtIL=I'�iOT FflR-VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION Property Address: /I . Owner: Date,of Inspection: t. FLOW CONDITIONS RESIDENTIAL Number of bedrooms.(design): Number of bedrooms(actual): DESIGN flow based on'3 I U CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents:. ID Does residence have a garbage grinder(yes or no): Is laundry on.a;separate sewage system (yes or no). [if ves separate inspection.required] Laundry system inspected(ye$.or no):A,7U Seasonal use,: (yes or no;): ` Q. _ Water meter readings, if available (last 2 years usage(gpd)): "( a J� 0 Jar` 70,AVSlump.pump (yes or no): / (� Last date of occupancy:L AMA-d /G� COMMERCIAL/IND USTRIAL.WO Type of establishment Design flow(based on 310 CvIR 15.203): gpd Basis of design flow(seats/persons/sgft,eic.):. Grease trap present(yes:or.no); Industrial waste holding..tank present(yes or no):— Non-sanitary waste discharged to the.Title 5 system(yes or no):_ Water meter readings:if available: Last date of occupancy/use: OTHER(describe): . GENERAL INFORMATION Pumping Records Source of information: �;; r s C� Was system pumped as part of the.mspecdon( es or no): 42 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) Tight tank _A;ttach.a copy of the.DEP approval r_ GOther(describe):f pzrj .� p ��-/�.✓ e > ��_ l App �imate age of all components,date installed(if known) and source of information: Were sewage odors detected when arriving at the site(.yes or no):. 6 Page 7 of i l . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'C I' §YSTEMJNFO`RMATION (continued) Property Address: (,): 12 Owner, i°.•.,Y. 'a �� r Q t / �. Date of In h ectiq�C BUILDING SEWER(locate on site plan) /A/6 Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain), Distance from private water supply well or.suction line:. Comments(on condition`.of joints, venting, evidence of leakage, etc.): SEPTIC TANK: locate on site plan) Depth below grade. Material of construction: concrete_metal_fiberglass Polyethylene —other(explain) If tank is metal list age:_ Is aQe.confirmed b a Certificate of Compliance(Y es or no :i attach.a co of Y ) — .Py. certificate) ✓ Dimensions: < u Sldge depth: Distance from top of sludge to bottom of outlet tee or baffle'.. `J Scum thickness; Distance from top of scum to top of outlet tee or baffle`.. bGe'/ Distance fi-om bottom of scum to bott m of outlet tee-or baffle: !Z_ How were dimensions.determined: ,�,��"h �,z p� p �J�A) Comments ('on pumping recommen ate, inlet and outlet tee or baffle condition, structural integrity,,liquid levels as related to outlet invert,evidence of leakage, etc.): , G EASE TRAP: ;_locate on site plan) Depth below grade: 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: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of I OFFICIAL.INSPECTION FORM:—NOT;FC►R:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 Owner 2;? /" el,4 .Date of Inspection:. . 1 & a TIGHT or HOLDING TANK:f IlC- (tank must be pumped at time of inspection)(]oc.ate.on.site plan) Depth,below grade: Material of construction: concrete metal fiberglass_polyethylene. other(explain)- Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:/ (if present must.be opened)(locate on site.plan) Depth of liquid level above outlet invert: Comments(note:if box is level.and distribution to outlets equal,,any evidence of solids carryover,.ziny evidence of leakage into or out of box,etc.): PUMP CHAMBER::/.(.l()(locate on site plan): Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber, condition.of pumps and appurtenances,etc.): 3 Pate 9 of 1 1 OFFICIAL INSPECTION FORM._—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE:DISPOSAL SYSTEM INSPECTION`FORM PART C SYSTEM INFORMATION(continued) Property Address: gjj� _P� Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): ,,(locate on site plan, excavation not required) If SAS not located explain why: Type leachina.pits, number: leaching chambers,number: leaching.galleries, number: leaching trenches, number,length: leaching fields,number, dimensions: overflow cesspool,number: __.inn ovative/alterna.ti.ve system Type/name of technology: Comments (note condition of soil, signs of hydraulic.failure,level of ponding, damp soil,`:condition of vegetation, t ��'�"'"�✓1,///�/� CESSPOOLS::(cesspool must be pumped as part of inspec4on)(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 or no): . Comments (note condition-of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc:): 'PRIVY:46(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.):. 9 Page 10 of 1.1; OFFICI-ALI INSPECTION FORM--,NOT FOR:.OLUiNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART SYSTEM:INFORMATION(continued). Property Address: J Al2 Cd- Owner: Date of Inspection:. C � 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. 30 LR i � � P i O dr' J io Page,1 l of I 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ (gip V Anj 1-2ae ^Vy .A Date of Inspection: , SITE EXAM Slope Surface water" Check cellar Shallow wells Estimated depth to ground water feet - Please indicate(check)all methods used to determine the high groundwater elevation: Obtained from system design plans on record-:If checked,date of design plan ieviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked'with.local excavators,installers-(attach•documentation) _Accessed USGS database-explain: You must describe how you established the high groundwater elevation- 0 I ' r0 �� i 11 Permit Number: Date: Completed by: E HIGH GROUND-WATER LEVEL COMPUTATION Site Location: J C/O 41JIe 1/ . �ell tl)1/11e Lot No. Owner: y� . Address: Contractor: ;:G Address: �i �9CSJ 3� Notes: _ _... STEP 1 Measure depth to water table P f to nearest 1/10 ft.'..............................:.........:..................................... .Date month/day/year STEP 2 Using Water-Level Range and Index Well Map locate site and determine 0 4p.propnate.:mdex well .: OB Water level range zone ..:................................. STEP 3 Using monthly report 'Currerif. Water:Resourc's Conditions determine current depth to water level or"'I anrell ................. month/Year , STEP 4 Using Table of-WateMevel Adjustments for index well--(STEP. 2A),-current depth to water level for index-well (STEP 3), and water level zone (STEP 2B) -� determine water,level adjustment .......................................................................................... STEP 5 Estimate depth.to high water by subtracting the water level adjustment (STEP 4) from measured depth to water �- level at site (STEP 1) ............................ 1 C�5 -...__..__. Figure 13.7Reproducible computation form. 15 j IDv L. fey ;. 5:;7 SYSTEM PROFILE NOTES TOP FNDN. AT EL. 50.1' Ro to 28 ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) ACCESS COVER TO WITHIN 3" OF FIN. GRADE 1. DATUM IS ASSUMED ACCESS COVER (WATERTIGHT) TO WITHIN 6" OF FIN. GRADE ro y 49A' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 49•O, 2. MUNICIPAL WATER IS AVAILABLE fi$ SL�o6 o/ RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. *EXISTING FOR FIRST 2' OR GEOTEXTILE FABRIC Pine St. 3' MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO --EXISTING 1000 LOCUS *EXISTING *46.80' H- 10 GALLON SEPTIC TANK GAS !/ .� 45.56' 46.3'BAFFLE 4573 5. PIPE JOINTS TO BE MADE WATERTIGHT. a og pppp 0 pppp a coo• 45.5' pppp p pp ® p 6" CRUSHED STONE OR MECHANICAL p p p p p pppp 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH DEPTH OF FLOW = 4 COMPACTION. (15.221 [21) 2' pppp p p p p p L43. MASS. ENVIRONMENTAL CODE TITLE V. TEE SIZES: INLET DEPTH = 10" 3/4" TO 1 1/2" DOUBLE WASHED ST(SNE 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO ourLEr DEPTH = 14" BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. Horseshoe Ln ( 6 % SLOPE) ( 1 % SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. , a FOUNDATION EXISTING SEPTIC TANK 17' D' BOX 8 LEACHING 5' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION LOCUS MAP OBTAINED FROM BOARD OF HEALTH. *THE INSTALLER SHALL VERIFY THE **THE INSTALLER SHALL CONFIRM SCALE: 1 = 2,LOCATIONS OF ALL UTILITIES AND MIN. SEPTIC TANK SIZE AT 1000 10. CONTRACTOR SHALT_ BE RESPONSIBLE FOR CALLING 000't ALL BUILDING SEWER OUTLETS AND GALLONS AND ITS SUITABILITY FOR DIGSAFE (1-888-344-7233)" AND VERIFYING THE LOCATION ASSESSORS MAP 228 PARCEL 37 ELEVATIONS PRIOR TO INSTALLING RE-USE BOTTOM TH-1 EL. 38.5 OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO ANY PORTION OF SEPTIC SYSTEM COMMENCEMENT OF WORK. LOCUS IS WITHIN AP OVERLAY DISTRICT LEGEND 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. 100-01 PROPOSED SPOT ELEVATION 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED +100.00 EXISTING SPOT ELEVATION LEACHING FACILITY. 100I, PROPOSED CONTOUR - - 100 - - EXISTING CONTOUR SYSTEM DESIGN: W w EXISTING WATER LINE GARBAGE DISPOSER IS NOT ALLOWED c c EXISTING GAS LINE DESIGN FLOW: 3 BEDROOMS ( 110 GPD) = 330 GPD USE A 330 GPD DESIGN FLOW ' LP EXISTING LEACH PIT SEPTIC TANK: 330 GPD ( 2 ) = 660 _ USE A 1500 GALLON SEPTIC TANK TEST HOLE LOGS LEACHING: 74) 118 83) 2 (. ENGINEER: DAVID FLAHERTY, R.S. LOT 2 ----------�---� SIDES: 2(30 + 9. - 34,190 SFt ---------�� BOTTOM: 30 x 9.83 (.74) = 218 WITNESS: DON DESMARAIS, R.S. i OCTOBER 20, 2006 I TOTAL: 454 S F 336 GPD DATE: i EXISTING 3 BR DWELLING ' PERC. RATE _ < 2 MIN/INCH c9 TOP OF FNDN=50.1' USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR I EQUAL) WITH 2.5' STONE AT SIDES, 4' AT ENDS AND 5' CLASS I SOILS P# 11476 0 _ BETWEEN UNITS ELEV. n ELEV. I BENCHMARK p" `V' 49.0' 0�� `v' 49.0' ,' "; COR CONC GARAGE APRON % ► i ELEV=49.5' MA A A I 1 i APPROVED DATE BOARD OF HEALTH LS LS 10YR 4/2 10YR 4 2 12" 48.0' 11" / 4s. ' ,% `1 s -- _-;_-, o TITLE 5 SITE PLAN B B � LS LS .1 14.T ��\\ i O OF 1 � " 10YR 5/6 10YR 5/6 '� 4os, ";; PAVES , 340 PINE ST. 34 46.2 38" 45.89 P i DRIVE i _:: :•. :v- TH-1 (CENTERVILLE) BARNSTABLE MA � �------ ` `� PREPARED FOR C C ► ► `� PERK 9-------' BORTOLOTTI CONSTRUCTIO N/ FRANCIS CULLINAN MCS MCS I ► I / 10YR 7/6 !' 10YR 7 6 �' I �� � � � ;�, � DATE: OCTOBER 26, 2006 1-66.�4 � , � _ _ G `---------- L----------- ------------EDGE PAVEMENT ���znoFM��sq 126" �-� -_--- off 508-362-4541 38.5' 122" ' _-- --'- F �Q DANIEL fax 508 362-9880 U A. '---`------------- g� °ANiA� `� NOdd� down cape engineering, in c. NO GROUNDWATER ENCOUNTERED PINE STREET 10 A n �©o Scale:1"= 20' 46502 n, t9 �' ` Cl t//L ENGINEERS c s , vE+° LAND SURVEYORS V 939 Main Street - YARMOUTHPORT, MASS. DCE #06-237 0 10 20 30 40 60 FEET DATE OJALA, P.E., P.L.S. 06-237 BORTOLOTTI_CULLINAN.DWG (DDF)