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Home My WebLink About0475 PINE STREET (HY - Health (2) 470 Pine Street Centerville P jI A = 228 106 uu � No.2�153L3OR HASTINGSo MN I TOWN OF BARNSTABLE LOCATION q'I S PrO e 5 t- SEWAGE# VILLAGE Ce,,��etu A'I ASSESSOR'S MAP&PARCEL , 8 � INSTALLER'S NAME&PHONE NO.' �J(j% A T�i t9;:a,�) T()R -q?p-'1. oy SEPTIC TANK CAPACITY 6-ic rshMs L4ir LEACHING FACILITY: (type) a 5-FbAd ;o6cmbefs (size) i a, V..'X 15—X J— NO.OF BEDROOMS K OWNER ( ir� PERMIT DATE: -0 '•1 COMPLIANCE DATE: Separation Distance Between the: tAisil�( p,.�Cvu�ft✓ li 1' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J me r(pe/L 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 yvcs�t coon -I .c. T No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in comp r: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYiration for Misposal *pstrm Construction permit Application for a Permit to Construct( ) Repair(vj'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ti,75- i�w r- S t Owner's Name,Address,and Tel.No. Ce,il-e:a,ilx W oo Assessor's Map/Parcel a cL Vi Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. t7- oos lc,s =,.:c Type of Building: Dwelling No.of Bedrooms 3 Lot Size J(, sq.ft. Garbage Grinder( ) Other Type of Building (fas or,*1C'I No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '3 30 gpd Design flow provided 3N162,'j gpd Plan Date 1 2'1•-1 Vs Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. C_ '5-00 Description of Soil Nature of Repairs orrAlterations(Answer "when applicable) l aVS}t� 1 a JA•-L() N �eeC1C�ic C[�[,n,�NI PfS C�n?C IJ NW W `t 6t �� V 1-(c'k`1? N) ( ns sf1�tA 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. ne Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued N �J t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS � L fipfttation for Misposal 6pstem Construction Permit Application for a Permit to Construct Re air U ade Abandon Complete System Individual Components PP ( ) P P� ( ) ( ) ❑ P Y ❑ P Location Address or Lot No. N75'�,N! 5 4'° r Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �. Installer's Name,Address,and Tel.No. ; Designer's Name,Address,and Tel.No. 11"row.v 'L n/c Type.of Building: Dwelling No.of Bedrooms 3 Lot Size (G !S' sq.ft. Garbage Grinder( ) Other Type of Building (t•�c,��,� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) :3 IC2 gpd Design flow provided 3Q ,.r► gpd Plan Date 1 _ -� Number of sheets Z Revision Date ,Title Size of Septic Tank (aq r Type of S.A.S. 0 gz eyll Description of Soil r �! ,D Nature of Repairs or Alterations(Answer when applicable) �t �- Jn-!n (re�G.-J� Aft C kr,-be/s r . s < le� - Date last inspected: Agreement: 1 r.. 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. /y,ry A A-- ,,, Date /• Application Approved by -• _r v � /� / J`� Date /� t y v•y�r Application Disapproved by -----� / `, Date 1 for the following reasons Permit No. � / '- / m f Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS,TO CCEERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( 1s)' Upgraded( )f Abandoned( )by 1 _ter p 14 c A ick ,a ej at 07-S'- V:.,j_,_ y4- s eeadly- has been constructed in-acco ance with the provisions of Title 5 and the for Disposal System Construction Permit No. 1 �/' •J Rated Installer I— '. r A , .!1' _7_;.c Designer _ ,�y7 r.e/f"llwd,-^✓r #bedrooms Approved design flow gpd The issuance of this p/erm/�'f shall not beecc'o'"n'strued as a guarantee that the system will functtio as designe. Date In/ ��J [ Q Inspector `.�� -- - -----.------ - ---- ---- --ter _ ------------------------- -------------- - Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ]Disposai *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( �/ Upgrade( ) Abandon( ) System located at J!�Pn�6�'✓�-///iP and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mussf be completed within three years of the date of this permit. / Date �/ 2 M7/ Approved by Town of Barnstable pFTHE Tpk- Regulatory Services y�y yo, Richard V. Scali, Interim Director * BARNSTABLE, MAC. a i639• Public Health Division ap `gym ' Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 509-962-4644 Fax: 505-790-6304 Installer & Designer Certification Form Date: Sewage Permit# AOl9- 1`71 Assessor's Map\Parcel Xg ..1OG Designer: l:n ;�,cer'� Wa►-its, (raC . Installer: i�� 1r�K �} �G��,,� Address: 1Z W, Cebsst-,e (d izd Address: '?,�j j� 1q5 �o re S�o(a l2 INti� 6 2� y C&Q M f il Ale /1 c, OagL On-� ' �� -f�, �,I� ,`��c :��x Tl\,C was issued a permit to install a (date) (installer) septic system at Ll t 5 Pore s-1- e,J+L-4 0 Alt based on a design drawn by e,.i o f i, (address) e �ne�<<nc. WoAu 11 C , dated_j (designer) 1 I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (Le. 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, Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructs nce with the terms of the I\A approval letters (if applicable) � S%OF PETER T. • G/ CNIL Installer's Signature) No.35109 ��Q/8TEp (Designer's Signature) (Affix Designer tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLLkN10E WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QAScptic\Dcsigncr Ccrtification Form Rev 3-14-13.doc Town of Barnstable P# Department of Regulatory Services ?M� • ��. • Public Health Division Date �10 17 MASS -- --_� i639. � 200 Main Sheet,Hyannis MA 02601 last 13 Date Scheduled �/ �TJ h Time_/ Fee Id. Soil Suitability Assessment,f or 6' age Disposal Performed By:— Q�2/8' 4� �✓��-2 ��i ��Z Witnessed BY: Q �- 11'�OCATION & GENERAL INFORMATION Location Address Z S Owner's Name, + C25� 'C✓1/lll,t ( Address � ( G :, Lt VW Assessor's Map/Parcel: l® e'l?A 0 � Engineer's Name -� .•i Fi\4 O�S'�l ilt.'f`IO�I. REPAIR Telephone ri Land Use Slopes(%) Z " Surface Stones Distances from: Open Water Bbd >� &2�_z,�, _l A- AJ � lS� P YL�' ft Possible Wet /�"�� —ft Drinking Water Well _��ft Drainage Way / ft Property Line /C)/"CRl_ ft Other -ft SKETCH:(Street name,dimensions of lot,e ct locations of test holes&pere tests,locate wetlands fn proximity to holes) 14 2 i Qrwoe Parent material(geologic) 0 UrVJC►1 Depth to Bedrock; Depth to Groundwater: Standing Water in Hole: r D✓.P____ Weeping from Pit:Nee NO Estimated Seasonal High Groundwater / 3 Z t ^ DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing'.;in obs.hole: _-- in, Depth to sail mottles; Depth to weeping from siije of obs.hole: _ in, Groundwater Adjustment Index Well 0___ Reading Dale:___--- Index Well level Ad,I,factor Adj.Groundwater 1.evul PERCOLATION TEST F ation �p - 1 `Cime at h"f Perc 32 _ Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak �n /S � 9 Rate Min./Inch ^Z Site Suitability Assessment: Site Passed_!.L_— Site Failed:—_ _ Additional Testing Needed(Y/N)� _ Original: Public Health Division Observation Hole Data To Be Completed on Back------------ r * *If percolation test is to:be conducted within 1.00' of wetland,you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:\S EPTIC\PERCFORM.DOC 1 •� DEEP OBSERVATION;HOLE LOG Pole#—11' � Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,%Gravel) -- 2y -►3 C DEEP OB,SERVA'TION HOLE LOG I;(ole# "Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottli:.-ig (Structure,Stones,Boulders. Consistency,%Gravel) - - z�—G32 C� 1 s sY ti ; DEEP OBSERVATION HOLE LOG Hoae# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface in. (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ( ) Consistency,9'o GravetL_ DEEP OBSERVATION HOLE LOG. _ Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,°k Orayel)__ Flood Insurance Rate Maw. Above 500 year flood boundary Nor Yes_ . Within 500 year boundary No__C^ Yes Within 100 year flood boundary No Yes Depth of PLaturallly Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on �(date) I have passed the soil evaluator examination approved by the Department of Envir nmenta,l Protection and that the above analysis was pe:,formed by me consistent with the required trainh expertise and experience described in 310 CMR 15.01'I. Signature. _ Date I�7 Q:\.SEn1C\l'ERCF0RM.D0C SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete'items 1,2,and 3.Also complete A. Si nat item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse: X ❑Addressee so that we can return the card to you: g, R 'ved by( ' ted Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece; or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No Mr&Mrs William_ Campbell. 1 475 Pine Street Centerville, MA 02632 3. Service Type ❑Certified Mail ❑Express Mail ! ❑Registered ❑Return Receipt for Merchandise 1 ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 1 2. Article"umber ..5 5,9 9 E 0 0 0 0 2 E 0, T-0 0 L ((Transfer from service labe/J '` ____``_=_ ` PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 -- I UNITED STATES POSTAL SERVIpE"' First-Class Mail -Postage&Fees Paid Permit-Nd.'G-101 • Sender: Please print ybbr`,'Aaf�ie, address, and-ZiP+44R-this-bex--6--- PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE 200 MAIN STREET HYANNIS, MASSACHUSETTS. 02601 Postal ,CERTIFIED MAIL REC,EIPT1,1 1'1.1 `- Ln - . OFF1C1AL USE Ln Postage $ -,57 Ln +a Certified Fee I.D '3 " Postm Return Receipt Fee Here M (Endorsement Required) n C7 b Restricted Delivery Fee 4 b (Endorsement Required) *� i n Total Postage&Fees $ru M Sent Tq� o rd� I_rsi.Cl__ f C�---- .. - -�- 10-------------- Street,r l Apt.No.; t3 or PO Box'No.- C ------------------- --------------------------------------- ------------------ o citySeaee zrP�e I Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece o A signature upon delivery n A record of delivery kept by the Postal Service for two years Important Reminders. S o Certified Mail may ONLY be combined with First-Class Mail or Priority-Mail. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee;a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is required. e For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". e If a postmark on the Certified Mail receipt is desired,Please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry._' PS Form 3800,January 2001 (Reverse) 102595-01-M-1049 C�INE Tp� Town of Barnstable BARNSTABLE, * Regulatory Services .� MASS. g 1639. Thomas F. Geiler,Director rF0 MA'S A i Public Health Division Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 I Office: 508-862-4644 Fax: 508-790-6304 July 19, 2005 Mr&Mrs William Campbell 475 Pine Street Centerville, MA 0263 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 14 Centerbrook Lane, Centerville,MA was inspected on June 10t', 2005 by James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has"Conditionally Passed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: Leaching pit was previously full of sewage to the top. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HE TH DEPARTMENT Aft COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION Sve _ TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 14 Centerbrook Lane Centerville MA 02632 Owner's Name: William &Deborah Campbell Owner's Address: 475 Pine Street ? Centerville MA 02632 F= Date of Inspection: May 26,2005 Job#05-159 Name of Inspector: PATRICK M.O CONNELL Cu Company Name: SEPTIC INSPECTION SERVICES CO. — Mailing Address: 189 CAMMETT ROAD {=� MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 N, CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste OFM Passes Conditionally Passes Oa• 'Cy P TRIC :in Needs Further Evaluation by the Local Approving Authority = M• , X Fails — - CL 6�; Inspector's Signature Date: 5/26/05 %,• F1�••'pP;`�� The system inspector shall submit a co of this inspection report to the A iFS� "PEG\\��.�` PY p p Approving Authority(Board of Heaft�h or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching pit and septic tank previously full to top. ****This report only describes conditions at the time of inspection and under the conditions of use at that. time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Centerbrook Lane,Centerville Owner: William&Deborah Campbell Date of Inspection: May 26,2005 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: 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 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: 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: 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: Titla G inonanfinn P^— </i ai,)nnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Centerbrook Lane,Centerville Owner: William&Deborah Campbell Date of Inspection: May 26,2005 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. I. 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 **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: T410 9 Tncn-rtinn Rnr A/1 VIAnn 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Centerbrook Lane,Centerville Owner: William&Deborah Campbell Date of Inspection: May 26,2005 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 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ 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 _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. 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 forma _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 — _ 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 Il 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. TitlA C Tnonortinn Rnrm�iT�nnnn 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 14 Centerbrook Lane,Centerville Owner: William&Deborah Campbell Date of Inspection: May 26,2005 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? _ 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 ow maintenance of subsurface sewage disposal systems? owner)provided with information on the proper 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. 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)] T410 f Tnc..Ai*;,,,, Fnrm ail ai�nnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 Centerbrook Lane,Centerville Owner: William&Deborah Campbell Date of Inspection: May 26,2005 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):440 Number of current residents: 0 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): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2003—65,000 gal.2004—71,000 gal.=186 gpd. Sump pump(yes or no): No Last date of occupancy: One month prior to inspection. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): 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): Pumping Records: None GENERAL INFORMATION Source of information:Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 1/11/85 Were sewage odors detected when arriving at the site(yes or no): No Titlo 17nrm A/i imnnn 6 I Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Centerbrook Lane,Centerville Owner: William&Deborah Campbell Date of Inspection: May 26,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 2' Materials of construction:_cast iron _X_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: XX (locate on site plan) Depth below grade: 18" Material of construction:_X_concrete—metal fiberglass_polyethylene _other(explain) — If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide—1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Baffles intact,previously full to top.Recommend replacing precast baffle with a PVC tee when new leaching system is installed GREASE TRAP: No (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.): Title C Tncnunfinn l:nrm 4/1 S/7nnn 7 r Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Centerbrook Lane,Centerville Owner: William&Deborah Campbell Date of Inspection: May 26,2005 TIGHT or HOLDING TANK: No (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: allons/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: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" 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.): Previously full to tog PUMP CHAMBER: No (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.): Titlo C Incnanfinn Fnrm 4/1 v,)nnn 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Centerbrook Lane,Centerville Owner: William&Deborah Campbell Date of Inspection: May 26,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: One 6x6 pit. leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Pit previously full to ton of structure has no effective leaching. CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Titi.C lncnartinn l n�m 4/1 aiinnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Centerbrook Lane,Centerville Owner: William&Deborah Campbell Date of Inspection: May 26,2005 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. Centerbrook Lane #14 Deck 16 28 36 29 32 36 Title incnnrtinn Fnrm A/i gmnnn 10 Page l l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Centerbrook Lane,Centerville Owner: William&Deborah Campbell Date of Inspection: May 26,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-'If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: A perc test will be performed prior to repair to determine groundwater elevation. Titles G Tncnantinn Fnrm 6/1 v')Ann I 1 �1 213 5 1 • S111\ COMMONWEALTH OF MASSACHUSETTS G EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ? DEPARTMENT OF ENVIRONMENTAL 1r;Mc rTIiQN $ LE Z005 APR 19 Ply 1: 33 Clf b'fStt3i�`''"" TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION i Property Address: 475 Pine Street Centerville MA 02632 'z Owner's Name: John Taylor Owner's Address: Same Date of Inspection: March 14,2005 Job# 05-49 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a Rnr►►► approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:�0��H pF�,jq��/ii�� _X_ Passes S�:' '•"9C� '% Conditionally Passes PA K • .y� Needs Further Evaluation by the Local Approving Authority Fails = LL Inspector's Signature: - — Date: 3/14/05 TLF IFS/NSP�G� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health 1111 or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of lth or 00 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: System in good condition, recommend pumping tank. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 475 Pine Street,Centerville Owner: John Taylor Date of Inspection: March 14,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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: 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 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: 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: 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: T:Nn C Incns.rfinn Rnrm 4/1;11n0n 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 475 Pine Street,Centerville Owner: John Taylor Date of Inspection: March 14,2005 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 "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: Titlo C 1»c—t;—Pn — 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 475 Pine Street,Centerville Owner: John Taylor Date of Inspection: March 14,2005 A 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 '/z 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 — _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 I 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 forma _No_(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 — _ 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—I WPA)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. T41.S 1"cnurlinn Fn•m 411 v,)nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 475 Pine Street,Centerville Owner: John Taylor Date of Inspection: March 14,2005 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_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)] Titles G incnantinn Fnrm ail annnn 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 475 Pine Street,Centerville Owner: John Taylor Date of Inspection: March 14,2005 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 Number of current residents: 2 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): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2003—86,000 gal. 2004— 121,000 gal.=283 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Y Non-sanitary waste discharged to the Title 5 system ystem (yes or no): Water mete r readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records: None GENERAL INFORMATION Source of information: - Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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): Approximate age of all components,date installed(if known)and source of information: Compliance date: 4/22/97 Were sewage odors detected when arriving at the site(yes or no): No T41. S Incnortinn Anrm ail cnnnn 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C' SYSTEM INFORMATION(continued) Property Address: 475 Pine Street,Centerville Owner: John Taylor Date of Inspection: March 14,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 18" Materials of construction:_cast iron _X_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: XX (locate on site plan) Depth below grade: 2' Material of construction:_X_concrete_metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 10.5' long x 5.8' wide—1500 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 7" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear liquid level at bottom of outlet wipe Recommend nuMin2 tank now and every two to three years. GREASE TRAP: No (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.): Tit1A G incnartinn Fnrm ail cnnnn 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 475 Pine Street,Centerville Owner: John Taylor Date of Inspection: March 14,2005 TIGHT or HOLDING TANK: No (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/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: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" 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.): Liquid level at bottom of outlet pipes no solids or hieh stains present PUMP CHAMBER: No (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.): Titlo C Incnur*inn Fnrm 411 VIAnn 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 475 Pine Street,Centerville Owner: John Taylor Date of Inspection: March 14,2005 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers, number: leaching galleries,number: _X_leaching trenches,number, length: Two 30' trenches leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Trenches show no evidence of hydraulic failure probed area of trenches and found no damp soils No excessive vegetation or breakout observed CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of etc.,vegetation, : g ) PRIVY: No (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.): Titles G incnortinn P^—411 cnnnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 475 Pine Street,Centerville Owner: John Taylor Date of Inspection: March 14,2005 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. Pine Street #475 32 26 20 38 Garage T�Ho C incnPrtinn Rn—411 Vnnnn 10 Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 475 Pine Street,Centerville Owner: John Taylor Date of Inspection: March 14,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.20 and topo map shows property above el.40. T7t10 C Tncnartinn Fnrm 4iT Ci,)nnn 1 1 `-tebf,3t s WN OF BAARRNSTABLE LOCATION4G7-xz'Tr* ,J,' #Y' �— J ! ee 31 r SEWAGE # VILI AGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. �YY eJ CAA(f 5:3 7—ao/9 SEPTIC TANK CAPACITY LEACHING FACELI TY: (type) r';yC 1v5 (size) NO.OF BEDROOMS BUILDER OR OWNER Md T6A PERMITDATE:�7 �7 �7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �� Doi � f P ,��7rs 0 i� F � 4 No. " �/ ""h� Fees mil? THE COMMONWE TH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Digpogar 6pgtem Congtruction Permit Application for a Permit to Construct*Repair(A )Upgrade( )Abandon( ) KJ Complete System ❑Individual Components Location Address or Lot No. %75 P,--A;' S ,-ee 7" Owner's Name,Address and Tel.No. J6 AAJ 7y T e* Assessor's Map/Parcel Da-S I6(, ^ _ InA0c er's Name,Address,and Tel.No. ,/o. -A�oes, C &c e Designer's(Name,Address and Tel.No. pf Cc�S ( G o��ST i � /YYA Type of Building: J Dwelling No.of Bedrooms J Lot Size sq. ft. Garbage Grinder( ) Other Type of Building e No.of Persons co Showers( ) Cafeteria( ) Other Fixtures Design Flow _�� 7 gallons per day. Calculated daily flow .'?3® gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank j�cQ , � n Type of S.A.S. /mac,c A,,j 6 -Tr e a f 4 r Description of Soil A- i'Wh/ Nature of Repairs or Alterations(Answer when applicable) ," CesS ea RP L_,e i.v "TA 60 j /tom Q - go D. lre,C 4.A , %,-Ax/A,-5 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 Certifi- cate of Compliance has been issued IN this Board of Health Signed Date 1 ✓��' ` Application Approved b - Date Application Disapproved for the following reasons Permit No. °"" / Date Issued WN OF BARNSTABLE LOCATION err eT SEWAGE# S VILLAGE 6C14.' e r o llY- ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. JcI 01 fs 52 9— olg SEPTIC TANK CAPACITY 6 CY- 10/J LEACHING FACELITY: (type) /r�iJC �irS (size) NO,OF BEDROOMS BUELDER OR OWNER •T� 14,o PERMITDATE: I7 / 7 COMPLIANCE DATE: t I ia 1 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Ll I �� b X`� '. 1 No. IT FeeTHECOMMONWEH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migogal *p.5tem Cougtruction Permit Application for a Permit4o Construct )Repair(X)Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 7+rt e y T� �,� to,-.Fe � Owner's Name,Address and Tel.No. 4 � F!'r Assessor's Map/Parcel ^:L9 F166 Installer's Name,Address,and Tel.No. �U_AAvio'S C ac C Designer's Name,Address and Tel.No. pio '60X G$"G, t�orrsT��le /Yva 6o1G VY Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building 6ti r No. of Persons co Showers( ) Cafeteria(,, ) . OtherFnxtures Design Flow g _'4 � 7� gallons per day. Calculated daily flow ,��..3� MJ gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1..5 oo . 6,60, n Type of S.A.S. c � .'N t� �r.w C Description of Soil ffiec Nature of Repairs or Alterations(Answer when applicable P C t'SS/oo Re I tir.r v ; Q eT . S'G�o ---- - 2. /��c ,41, .-5- 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 Certifi- cate of Compliance has been issued IN this Board of Health (/-1�/, Signed — Date Application Approved b Or Date - Application Disapproved for the following reasons Permit No. Date Issued ——————————— —————————————————— —— ——— , THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CEERRTIFY, that the On-site ewage Disposal System Constructed( )Repaired( , ,)Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. I, ated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date L.d `7 -0 7 Inspector \ 1 °— 0.- If i s r � a F e No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Di5po5ar *pttem (Con5tructiou Permit Permission is hereby granted to Construct( Repair(i4 ade( )A andon. System located att �G /� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mu t be completed within three years of the date of this p it. Date: �� Approved by 't��. is � � ; ,�� l�i'>'t I�✓��cl _ � _ �� a�d S� y�• J _ � � �. a. + I � ---� l�. �{._ .4./ i e�. „�.._ ! ._.�- � -N..� - ..q��_..Ml. _.'� ..j. _.-N-.- �{.�— -IF ._ .J-- '�.'- �-rF ll- Y t j ---�--t---'-- -i--.ate, , 1 , i I � I , ! j � I � r A � } I I I I , i + t I i I i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) h �J 14P1rS Gt C(, hereby certify that the application for disposal works PP p o s construction permit signed by me dated ��- �� 7 , concerning the property located at j i/U[� J l l- 1 meets all of the following criteria: r • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: LICENSE PTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER C;O [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. No.. ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF •BARNSTABLE Appliration for Bi-wipmal Works Tomitrur#inn rrrmit Application is hereby made for--a Permit to Construct ( ) or Repair (fig' an Individual Sewage Disposal System at: 0 ..�....... - .... ......... __..." _. �.: �._ ............ ........................ _..-- Loc •A ress �! t No. r Of LO ............................ in.=-a•{.... . ... l.. ............................... .................... .._.__...._..... _..�....... ................................................... /�a ` Uwne n Address .. 6V�. .'�\r�f1 t�i��V� Y�1� `fC✓ ......................... .................. ............ .............. .................. ...... ..: Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms- ....................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures •----•••••-•-----•----.......•••.............••-•-•---.•-••---••-----...-••••..........•.•--...........................................-•••--•--_--_.. Design Flow...........a. r...............gallons per person per day. Total daily flow... .-_?-..0......................gallons. Septic Tank t Liquid capacity 4)0(,gallons Length.-.J7........ Width.!........... Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....../........... Diameter...)�)-f........ Depth below inlet.....VJ........ Total leaching area..................sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........ ................................................................. Date........................................ Test Pit No. l................minutes per inch Depth of Test Pit....--.............. Depth to ground water..........--............ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Descriptionof Soil•---•••-----••-•-•-•--•--••-••---•••-••••....-----•......-•-------.....•---•-----•-•------•--•---•-••••--•-•.............•-•---•••••-....•............................... Nature of Re airs r Alterations—Answer when applicable..< iK-S- A-.��.. ��1 .r�x P ..: 19-�. ............ ........................ 4�.........�t.S ...._............. Agreement: The undersigned agrees to install the aforedescribed Tndividual Sewage Disposal System in accordance with the provisions of:ITi.i; 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the ard.of health. p Sign .....' -• . ....... .................... A.......... .........�....... ..........�......... Application Approved By...................... ........ . ....... ......;, .--...... ................._..... .- Date Application Disapproved for the following reasons:..............................................................................................................- ...............•--•-----..._......----.............------........................----•.........-----•--•-........---.............----............`.....---•-........................................... Q Issued. --- Permit No...... •n�c�---•..............Dace...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of BARNSTABLE Tlertifiratr of fgnmphattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by------------------------------------------------ ..VV. .. V_� .c��.�f- ........_................._.... ---............... ..LQ at......................................4 ..has been installed in accordance with the provisions of TIWE,� 5 of T State Sanitary Code as described in the application for Disposal Works Construction Permit No....�-�- .......... dated......3. ---_�--._.--.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI %Nr,,TIO"ATISFACTORY. DATE....- •• . .. ......................................... Inspector.................................................................................... No.............� Fm&5! ...... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF •BARNSTABLE Appliration for Diopooal Works Tonotrur#inn Vern it Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at �.... .�.ru..- C-vO................__ .............•-•-••.•--........ � Locationdress r t No .......... .............. .c urt--....1. . . ............................--•--.... ................ owne Address 1........... Installer Address Type of Building Size Lot............................Sq. feet . 'i Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtu��". .-----•--....•...........................•-••-----..............•••-----.............................................................................. Design Flow................ ...................gallons per person per day. Total daily flow........ �3< .........................gallons. Septic Tank Liquid capacityl.fl ..gallons Length........}...... Width.....5.......... Diameter................ Depth................ Disposal Trench—No. .r.................. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..............1...... Diameter--------- ... Depth below inlet................. Total-leaching area..................sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...........................................................................Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ _ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....;................... ----------------------------------•----------•--.......----•--------------•----.....-----•--.--........................._......_............................ Descriptionof Soil.........................................•----........----•-•------•---........------....------------....---•-•-•--..............-•---••----..........•.................. ................•--••---••••......-•---...•---•-......•--•-••----•----•-•-•••-•---•---••••--•---------------•------...........•---•-•••--................................................................ ........................................................................................... --- ------......`... ----- ........ Nature of Repairs or A ter1do s—Ans er when i plic e.......:.. .. . .:. ...........too... 1.��.. �1�� Agreement: r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'A � 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the oard of health. Sin - -------- -- - -- -- ------- --- - _ ......................... ....----- - ... ........ A licatlon Approved BY.................. ........ � l.� PP PP ..... Date Application Disapproved for the following reasons:---...-•------••.......................................•------•-----.............••..........................._ ........................................................... .............• -•--.........................----......................................-•----.............---...................-•---- Date Permit No..,. - Iss' �! Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of BARNSTABLE Tertifirnte of Tomplittnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ()4 b ' ............................................................................................ at......................................P1 ---------- -- has been installed in accordance with the provisions of TIT�Ef_S�f l ,State Sanitary Cod as {le cr .in the application for Disposal Works Construction Permit No................................--------- dated.......---._.....�.............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................•--.........-----...................-••-•-------•-•--•-•-...--- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of BARNSTABLE No. �................. FEE........................ Disposal Workii To/notrnrtiun rrrmit Permission is hereby granted........... A..VA , .5t`'u� ..........................•---......................................... to Construct ( ) or Rgpai ( Ind iu ea age Disposal System at No........--•-•--••--•.....q`..-... (.._.. .. :�..!:......_............... -------•--------•---••--•--•--••---••-•---...... Street as shown on the application for Disposal Works Construction Pert o.. . .W-Dated......................................... oaril�fealth DATE....................................•--.._..........--•-•-•.........---•..--•-•- L'O-t' T ION SEWAGE PERMIT NO. VILLAGE INS R'S NAME A A DRESS 8 U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �A �� r Atli - � I � '12akT. O L P fls W THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f.1WJ'2......oF...... ..... j ................................ A11V iratiun for MuVuual Marks Tunutrnrtiun 11amit Application is hereby made for a Permit to Construct ( ) or Repair (jam- an Individual Sewage Disposal System at ----------- -- � ---•• ----------- ----------- ----------- Location Address o t.No. ------------------- YL�d�� Lo....- ...._...._...... caner Address Installer Address UType of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building a g ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------•--•-••----...-----•.•-•--••.....•---••-----•--...--- W Design Flow............................................gallons per person per day. Total daily flow............,...............................gallons. WSeptic Tank—Liquid capacity............gallons Length.............:.. Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------------------- Diameter.....................Depth below inlet.................... Total leaching area.........._.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil-------••---•.................................... .:.. _.. ' x = �_______ ________•--•-•••-•-•-••-•-•-•--_•--•- U -•••••••-•-••••--•-•--•---•-•-•-•-••-•••--•-•--...._•--•-••-••-••-•----•••--- •--••- W Nature of Repairs or Alterations—Answer when applicable......... .... .,, � )___ - �- .•-•--•--_-••-•-•---•_••---••••-•-•••••- U P � PP • ,l 1��--`- ------------------- --••••--•••••--••••----•-•-•-••--•••-•-•--••••--••-•••--••-•---•...---•----.....•------•-...-•-•••--••--•-••--••--•-•-•-----•••-••---••--•----•-•-•-••......••••-------....•-_:..__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boapi of health. Signed...... Date ApplicationApproved By................................. -•---•••••--•----•-------•----••--••--•-•---------_--•- Date Application Disapproved for the following reasons:_---__•_______________________________________________________•_____-_______•--------.•••----.-_-...---...------ ----•._....---••-----•----•-•---•-•--•-•-•--••----•...-••--•-•....•---•••....--•-•••••-••••--...•-•-•--...--•--•-•....-•••-••-----•---••••-•••-----•-•-•---•••-----•-•---=-----------------•------------- Date PermitNo..................•-•-------......-----------------_.... Issued........................................................ Date --- ------- - -- -- -- - --- - -------------------- No... 3..:`i. FEs. ;�/au... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Uiopoottl Workii Tonoirnr#ion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: 1_- re-le t J' ��J LocationtfAl�ddress / ! og Lot No. .. .._.: _5.... ( .. 1_�...�......-••-----•--... ..............' k',� fis'�!��'�1„,.....----•-•-•--••---------------••-•---.......-- / ! Qwner ,.1 _.. ----•--•............................•••........---- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................. .. .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of ersons........_............______. Showers — a yp g p ( ) Cafeteria ( ) dOther fixtures .......................•---.........---•----••--...................-•--••------................------------........... .......... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ xDisposal Trench—No. .................... Width.................... Tonal Length_....:.............. Total leaching area..._................sq. ft. Seepage:Pit No.........:.......:... Diameter.................... Depth below inlet.................... Total leaching area....................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by................ Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__: .................. O ................................ :................................... y --------- Description of Soil? /---- - ---............................................... U ---------------•----------------------•------------•-----------------------........--- --- U Nature of Repairs or Alterations—Answer when applicable........ , ` / a'}._. ! . ...................,T.._...._.._.. E --------------------------------•--•------------------------------••--•---------•---.....------........-•-•-•------•-----------------------....------.....------------------------.........I............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance,with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been'!issued by the board of health Signed -- ....�... • df Date ApplicationApproved BY..............-•-----------•---...-•------............................•-----..__..._.......... ........................................ Date Application Disapproved for the following reasons:--•...-••....--•---•--•-------•--•-------------------------••--------......-••------••-.._...-•-----------•••-•- -•------...--•••••----•-•----•--•-----•-----•------••---•---•.................•-•-------._.._...................-----------------....-------•---------------- ............................................ Date PermitNo. .................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH e't` 1")........oF..... .,. .. .......................... Tntifiratr of Tomplittna T. IS IS TO C RTIFY; That the Irjd:v dual Swage Disposal System constructed ( ) or Repaired (ram)F t by....�: L ��L� t,3a1r 'Y. °a'`....� -' '.....1� : s..._... y4 )"��, yy��''� �f ;f�j`r y�,0i e3 f' �nstaller d �` �r/ j/ wry /r�,`t��,�� .l��p��at..... f..___C_.. E./c} ✓ .._. dCa a _ . ...:- 6?y - ,{.d./_. A _________________________________'mt`F__Lr4la _S!� ._. has been installed in accordance with the provisions of TITLE $o T e State Sanitary Code as described in the application for Disposal Works Construction Permit No......... s. L THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. i DATE............................................odk�w.................. Inspector........ a ; THE COMMONWEALTH OF MASSACHUSETTS BOARD, OF. HEALTH -., L �., .............OF...... `. "� ............................. No...... __.9.... FEE. ..... io�ros l o k$ Tono tutionjamit, Permission is hereby granted...-- �-------.._/ ! ,1 /....... to Constrt tt,( ) or�tepair dividual wage isposvystemi �.., /rStreet _...._. as shown on the application for Disposal Works Construction P t N/o.. ................... Dated-----:.................................... -=i••..............•------._...---------------......--------•-----.....----•- Board of health DATE. /D,..... ...... ........ FORM 1255 A. M. SULKIN, INC., BOSTON 1 TOWN OF BARNSTABLE LOCATION t'I'7 5 11 e- �!)tr-e-'�- SEWAGE VILLAGE l' !tAIV C ASSESSOR'S MAP & LOT Z-Z 1 - INR'S NAME&PHONE NO. 't r' Qn�a 1 yZ f 7 7 SEPTIC TANK CAPACITY 95J LEACHING FACILITY: (type) Z. (size) h NO. OF BEDROOMS _ i BUILDER OR< R '^ `T0,60v— / PERmrrDATE:. C DATE: Ili/OS� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any weUs exist r 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 �r 32, ZcO 1v ——98—— EXISTING CONTOUR x 100.98 EXISTING SPOT GRADE N Long Pond —W EXISTING WATER SVC. —G EXISTING GAS SVC. H.-W.— OVERHEAD WIRES TEST PIT > J > C BENCHMARK o` ce LEGEND y115 > Main St o m a = Pine Street o � rn c Ae" Y LOCUS MAP BENCHMARK-1 NOT TO SCALE MAGNETIC NAIL SET EL.=40.00 PINE R �-/ 40.22 S-i L 40,09 39.82 E1 SIDEWALKCBdh EDGE OF PAVEMENT 39,21 PK .SET — e-— 40.00; :; SIDEWALK 38,54 -19,14 :`...5 3' U.P. 38.64 39,61 38.75' M L T1 LOT CPI 39,16 p Yr i 39,12 co .94 37 ►� a 3 x 8.74:.::::,`.;' c�3 38.95 / x 38.85 VENT R 5—� o POP S.A.r-1 �� n ^� O 38.81 :PAVED DRIVEWAY,. 39.05 x 8,95 N p I 39,12;' / h 38.12:`::;` .` x 38.97 O� /Q 0 ��PC\ PORCH iEXISTING 38.73 x / x 8.73/��i0� HOUSE(#475) T.O.F.—39.75f1 38.72 / 38.34 PATI / 3915 l / -37168.-. 37, 7 8.4 WALK O / _ EXISTING SEPTIC TANK-,, INV.(OUT)=35.Of(VERIFY) l EXISTING I I I / b'5 x jGARAGE -TP_2��V 7.88 / I I /37,89 �►' / 1 I 1�TP- I r I L TS �� , / 2 & 9 0 >1 BENCHMARK-2 � 16,135 tSF - EL.=39.15 O CORNER/BOTT. STEP 1 I 1 3 7.68 LOT 90 x 36�VI �I EXISTING LEACH TRENCHES TO BE ABANDONED 35.3 OF Mass PARCEL ID: 228-106 o� PETER T. yG� PROPOSED SEPTIC SYSTEM UPGRADE PLAN McENTEE CIVIL N 475 PINE STREET, CENTERVILLE, MA No. 35109 Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 °OWNER OF RECOR RfGISTEEngineering Y�� b SCALE DRAWN JOB. NO. D ,SS/ � WOOD, DANIEL Engineering Works, Inc. 1"=20' P.T.M. 285-17 32 FEDERAL EAGLE ROAD [ 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. DUXBURY, MA 02332 l 1 l 0 (508) 477-5313 1/23/18 P.T.M. 1 Of 2 NOTE: TO PREVENT BREAKOUT, FINAL GRADE SHALL NOT BE AT, OR BELOW, EL.=34.5 FOR A DISTANCE OF 15' FROM THE EDGE SEPTIC TANK PROPOSED D-BOX OF THE PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE PROPOSED S.A.S. INSTALL RISER & COVER OVER EACH CHAMBER AND T.O.F.=39.75f SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT F.G. EL.=38.8t F.G. EL.-38.5t F.G. EL.=38.8t F.G. EL.=39.0t VENT MAINTAIN 2% SLOPE OVER S.A.S. L = 70' _ 5 ® S=1% (MIN.) ® S=1% (MIN.) 4•'SCH40 PVC 4"SCH40 PVC 2- LAYER OF 1/8" TO 1/2" 6" DOUBLE WASHED STONE to"I " 6 eaaSaaa R APPROVED FILTER FABRIC) 14" aB®BBBa EXISTING 48' LIQUID aaaaaaa _3/4" TO 1-1/2- DOUBLE LEVEL WASHED STONE ADD INV.=34.27 PROPOSED 4' 4.8' oil (() GAS BAFFLE INV.=35.Ot D BOX INV.=34.10 EFFECTIVE WIDTH = 12.8' . .... . ... . . . • ,.. (FIELD VERIFY) 3 OUTLETS INV.=34.00 FISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN H-20 RATED NOTES: TOP CONC. ELEV.=35.1 t 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPES & BREAKOUT ELEV.=34.50 INVERTS EXITING HOUSE, PRIOR TO INSTALLATION. INV. ELEV.=34.00 aaaaa - aaataaaataaaa 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE aaaaaaaaaaa ON A MECHANICALLY COMPACTED SIX INCH CRUSHED BOTTOM ELEV.=32.00 4' 2 x 8.5' = 17.0' 4' STONE BASE, AS SPECIFIED 310 CMR 15.405(2). 4' OF NATURALLY OCCURRING 3) INSTALL INLET & OUTLET TEES AS REQUIRED. PERVIOUS MATERIAL EFFECTIVE LENGTH = 25.0' 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 5' (MIN.) ABOVE G.W. AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. LEACHING SYSTEM SECTION BOTTOM OF TEST PIT, EL.=26.9 SEPTIC SYSTEM PROFILE SOIL LOG DATE: NOVEMBER 13, 2017 (REF#15,526) GENERAL. NOTES: SOIL EVALUATOR: PETER McENTEE PE WITNESS: DONALD DESMARAIS R.S. HEALTH AGENT 1 CHANGES THIS THE DESIGN B ENGINEER.APPROVED BY THE LOCAL BOARD OF HEALTH AND ELEV. TP-1 DEPTH ELEv. TP-2 DEPTH 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 37.9 A 0" 38.0 A 0" OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: LOAMY SAND LOAMY SAND -310 CMR 10YR 4/2 10YR 4/2 15.405(1)(b): 37.4 e g•• 37.5 e g^ 1) A 3' variance to the 3' maximum cover requirement, for up to 6' of max. cover. S.A.S. shall be H-20 and vented. LOAMY SAND LOAMY SAND -- - - 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 35.9 24" 35.8 10YR 5/8 C 26" TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE C 10YR 5/8 DESIGN ENGINEER. PERC 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 28"/46" FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. MED. SAND MED. SAND 2.5Y 6/4 2.5Y 6/4 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 26.9 132" 27.0 1 132" 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. PERC RATE <2 MIN/IN. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS NO GROUNDWATER ENCOUNTERED AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. '( 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND EXISTING PORCH NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. HOUSE(1475) 14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC TO.F.=39.75f SYSTEM COMPONENTS NOT SHOWN ON THE PLAN DESIGN CRITERIA 0 NUMBER OF BEDROOMS: 3 BEDROOMSNo SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) DESIGN PERCOLATION RATE: <2 MIN/IN 559 DAILY FLOW: 330 GPD T ---- DESIGN FLOW: 330 GPD -00 GARBAGE GRINDER: NO-not allowed with design N PR S.A.S. LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF I .74 GPD/SF 25' SEPTIC LAYOUT EXISTING SEPTIC TANK: 1500 GALLON CAPACITY PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-20 RATED USE 2-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 475 PINE STREET, CENTERVILLE, MA SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO. TOTAL AREA:........................................................... 471.2 S.F. Engineering Works, Inc. N.T.S. P.T.M. 285-17 DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 1/23/18 P.T.M. 2 Of 2