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HomeMy WebLinkAbout0009 PINE TREE DRIVE - Health 9 Pine Tree Drive (Centerville) A=208 47 F UPC 12534 No.2-153LOR HASTINGS,MN I TOWN OF BARNSTABLE LOCATION ��., �'eE SEWAGE # VILLAGE �" Q Xl �)l�� ASSESSOR'S IVCAP�& LOTS INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY //�IQ 0 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 1 BUILDER OR OWNER PERMITDATE: 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 A'AF Aq 15 AB a, AC 3�c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. Citylrown 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. General Information I on the computer, /, I use only the tab 1. Inspector: CUB U key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. Di Buono Sewer and Drain Company � Company Name 8 Johns Path Company Address Yarmouth ma 02664 Citylrown State Zip Code 508-364-9587 Si13522 Telephone Number License Number B. Certification 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 DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority E 8/13/2014 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. � d I t5ins•3113 Title 5 Official Inspectio o .Subsurface Sewage Disposal System• age 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) 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: This system contains a 1000 gallon concrete septic tank. Both inlet and outlet pvc Tee's are in place. A concrete distribution box that is at normal working level and does not show signs of decay at this time. The SAS is made up of two 500 gallon chambers B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. Citylrown State Zip Code Date of Inspection B. Certification (coot.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 El Y 0 N ND :below (Explain ) ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Pine tree Dr M Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. Cityrrown State Zip Code Date of Inspection C. Checklist 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? ® ❑ 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)) D. System Information 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): 352.98 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is Ma 02632 8/8/14 required for every Centerville page. Cityfrown State Zip Code Date of Inspection D. System Information Description: This system contains a 1000 gallon concrete septic tank. Both inlet and outlet pvc Tee's are in place. A concrete distribution box that is at normal working level and does not show signs of decay at this time. The SAS is made up of two 500 gallon chambers 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readin s, if available last 2 ears usage d 2012 134,000 g ( y g (gp )) 2013123,000 Detail: Average is 365 GPD over two years. " Irrigation system" Sump pump? ❑ Yes ❑ No Last date of occupancy: Date 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Currently Occupied Date Other(describe below): General Information Pumping Records: Source of information: Last pumped 2011 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 2 Concrete 500 gallon Chambers t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System was upgraded in 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments(on condition of joints, venting, evidence of leakage, etc.): Vented through the roof Septic Tank(locate on site plan): Depth below grade: 1ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 Gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No allon Dimensions: 1000 g i Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 18 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 28" 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.): Tank was pumped in 2011 Levels are normal, Tees are in place. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was pumped in 2011 liquid levels are normal. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level, solid 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.): D Box is level and in good working order and shows no signs of leaking or decay. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Concrete Chambers Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Field is leaching properly. No signs of break out or pondin . Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 9 Pine tree Dr Property Address Kathrine Andrew Owner information is Owner's Name required for every Centerville Ma 02632 8/8/14 page. City/Town Zi Code P Date of Inspection D. System Information (cont.) State Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of hydrualic failure Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 50 Ai ' !" a� 0 ' w c pat �j 36 4o Any exist cast iron or f n 5. Maximum 31 29 facility to m� a a 41 7.M4 1119 h y k�0 x y^. - x I L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4M 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 14+ft' 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: 2/29/2007 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: plan on file dated feb 291"2007 Shows over 8 ft seperation between Adj GW and bottom of leaching ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on fie shows bottom of Chambers at elevation 107. and Adj ground water at 98.1 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Pine tree Dr Property Address Kathrine Andrew Owner Owner's Name information is required for every Centerville Ma 02632 8/8/14 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i TOWN OF B iARNSTABLE LOCATION v�,t ;; Cc�v�eW J��IE' SEWAGE# „1M7.132 F VILLAGE e- ASSESSOR'S MAP&PARCEL -10 9-0".1,7®00 j INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 10C)'O tN LEACHING FACILITY:(type). G (size) NO. OF BEDROOMS -3 OWNER PERMIT DATE: COMPLIANCE DATE: �d Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility SA k(!6' 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 BYA-ml 0ori I l F-T, 4-v3 03 3 4321G`` _ .19 r LI637f f No. �LW7 I3 •r '` w, Fee �U / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for MisspooY bpgtem COtt.5truction Permit Application for a Permit to Construct( ) Repair(A) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. C( � Owner's Name,Address,and Tel.No. / 1 N r Assessor's Map/Parcel U Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. L 01-YO 5oa-Ll'70-q6l�, ocqN) �0j Type of Building: Dwelling No.of Bedrooms 'J Lot Size 277,5­ sq. ft. Garbage Grinder ( ) Other Type of Building o ous.e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided `w ��+Cl gpd Plan Date Number of sheets Revision Date Title 1 t �Size of Septic Tank o��CfS-�IN C Type of S.A.S. 3 xZ Description of Soil Nature of Repairs or Alterations(Answer when applicable) (QX0l0 s•A S 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 th• o d of ealth. Signed Date Application Approved by ti.1� Date &15Vd-7 Application Disapproved by: Date for the following reasons Permit No. 1,47 —I 3-2- Date Issued G '7 No- 2oo? -13,z - Fee 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpplication for Mi5poal bp!ftem Construction Vermit Application for a Permirto Construct Repair(;k) Upgrade Abandon 0 Complete System �Individual Components Location Address or Lot No. +I r-,e Owner's Name,Address,and Tel.No. Assessor's Map/Parcel --) r Aoc)ieu) 20(6/69:r 00 Installer's Name,Address,and Tel.NO. Designer's Name,Address and Tel.No. cA\l 00,\) 000 ya Type of Building: Dwelling No.of Bedrooms Lot Size ' 775_ - sq. .ft. Garbage Grinder Other Type of Building No.of Persons Showers Cafeteria Other Fixtures Design Flow(min.required) gpd Design flow provided C( gpd Plan, Date Number of sheets Revision Date Title Size of Septic Tank I(, IF---"r,[S'i I N C Type of S.A.S. P b Description of Soil Nature of Repairs or Alterations(Answer when applicable) <,-AS 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-135-alrd of,.Nealth. Signed Date Application Approved by Date &AI-d 7 Application Disapproved by: Date for the following reasons Permit No. Date Issued / d { ——————————————— —— - -— - ——I —————————————-- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On- Sewage Disposal System Constructed Repaired ( Y) Upgraded Abandoned by -q-1a S -\_J�C) j P,-) at qr -11 t Q)e e5t,-A-to(\?N))*P has been constructed in accordance with the provisions of Title 5 and the,for Disposal System Construction Permit No. dated y7 Installer'!)6,x\(, 1 —A— ow P,-3 Designer AM-1 ory"� bedrooms Y-) Approved design-flow C) gpd 4 ­X The issuance of this permit shall not be construed as a guarantee that the system will function as des'gn,ed. Date cv)� 5 Inspector --------------- ---------- - ----------------- No. 2rjo-7 — ID Fee /00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Difspoal �p.5tem Con5tructi'on-V ermit Permission is hereby granted to Construct Repair (Y. ) Upgrade ( ) Abandon System located at P'#\)P Tj (-r NQr r1-N)+C-0A rcp 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: Constr-iiction must be completed within three years of the date of this permit. Date /1-7 Approved by va �j Town of Barnstable' VE r rt Regulatory Services � r Thomas F.Geiler,Director yn(.�nxsr Br Public Health Division + 7 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer c&Designer Certification Form Date: Sewage Permit# Assessor's Map\Parcel -24 9 <Z 7-1 Designer: /IJ[ `L� rJy—d'-V � Installer: DU��? S �/�-d?.Pi!✓ Address: 32-0 6,/zllZ- P Address: �/aX OZ 6-3Z On 7 �Oyc-e4S Af2 W was issued a permit to install a (date) (installer) septic system at based on a design drawn by (address) don/ m/ , �. S, dated 9 e (designer) 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. 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. y�OFSs4o AW tiN ( aller's Signature) VONHONE v # S /STEP� gNI T Afk' (Designer's Signature) (Affix Designers Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANKYOU. Q:Health/Septic/Designer Certification Form 3-26704.doc I _ Town of Barnstable. P#_-4 Department of Regulatory Services Public Health Division Date tbsy �e$ 200 Main Street.Hyannis MA 02601 Date Scheduled r ;' Time Fee Pd. roil Suitability Assessment for Sewage Disposal Performed By S.. Witnessed By. LOCATION&GENERAL INFORMATION , Location Address'. 71-ee Ownec'sName Address 616-3y ,Z 7 En neces 0 Name :AssessoesMap/P4rce1: 1Q� I 4w4v 'NEW CONSTRU�14 REPAIR Telephone# (') 7-4—,Oe 0 Land Use /�� � / Slopes(9'0) 4� Surface Stones /7� Distances from: Open Water Body,, ft Possible Wee Area ft Drinking Water Well ft _ ft Drainage Way ft. Property Line Q _ft Other i 1 SKETCH:($treet name,dimensiotis'of lot,exact locations of test holes&perc tests,locate wetlands in.proxitnity to holes) 71-e e 1G-/r�P` Ib -=-- -- - - A - r . p i • Parent material(gecilogic) 67-fQ 6i Depth to Bedrock �Q v vQG�Ps �_----- ... I ' W in Prom Pit Pace Depth to Groundwakdr: Standt�Water to Hole:' �P g Estimated Seasonal Thigh Groundwater D TERlvmv TION O 'S ASO�AL HIC]E HAT It TALE M; Method Used. v.��?{� Depth Clb,;e :ed sta^.d mg.nobs.hole: �r in. Depth to S011 motties:_-- �i Depth toiweeping from side of obs.hole in. Groundwntr Ad unttnent ��c___ Index Well# W Reading Date r- Index ell level Adj.factor �AdJc•Orounswnterin'v 1. PERCOLATI(3N. Date 3/ 'thee 4 c tr CD Observation / ( Time at 911: A(V /0 `Hole# Time at VDepth of Pere L n Time(9"•6Start Pre-soak Time.@ /End Pre-soak 9 - hate MinJlnch '. ' Site Suitability Assc$ nt: Site Passed Site Failed Additional Testing Needed(Y/N) original:.Public Heath Division Observatiori Hole Data To Be Completed on Back----- ***If percola ibn testis to be conducted within 100' of wetland,yo Dmustfirst notify the Barnstable Cbl nervation Division at least one(1)wedk prior to beginning- ' DEEP OBSERVATION..HOLK,LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure;Stones,Boulders. onsiiiinc %Gravel /l1.4 f6 , . . A10 ©ysetsl Mk DEEP OBSERVATION HOLE,LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Molding (Structure,Stones,Boaiders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, o Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color $oll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. 01 F Flood Insurance Rate Map: Above 500 year neod bo nslary No Yes _✓ Within 500 year boundary No / Yes Within 100 year flood boundary No J Yes Depth of Naturally 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 Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in-a.10 CMR 15.017. Signature Date 74 Q:4SEPTIMERCFORM.DOC COMMONWEALTH OF MASSACHUSET fS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMEENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02109(61-7)2920$00 P.O.Box 2119 TeaTidaeL Ma. (508)5646813 TRUDY CO3CE Secretary ARGEO PAUL CELLUCCI DAVID S.STRUMS Oovemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A PI►ta Il/211/ CERTIFICATION Property Address: 9 PINE ST. CENTERVILLE MAP 208 PAR 027 L 47 Name of Owner MARY DORAN Address of Owner: 142 COMMERCIAL ST.#406 ROSTON MA.02109 Date of Inspection: 9/12199 Name of inspector.(Please Print)JOMN GRACI I am a DEP approved system Inspector pursuant to Seedon 15.340 of Tide 5(310 CMR 15.000) Company Name: n/a Mailing Address. n/a Telephone Number, n/a 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 Inspection.The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system. X Passes The Inpection Is based on criteria defined in Tide V Conditionally Passes code 310 CMR 15.303,My findings are of how the system is _ Needs Furtheisystem y the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not imply any warranty or guarantee of the longgevily of the septic system and any of Its components useful life. Inspector's Signature: Date:2/13/99 The System Inspector shall of this inspection report to the Approving Authority(Board of Health or DEP)wtthin thitom d UUs inRY tom)days of pia ng spection,I a shared system or has a design flow of 10,0W gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN MAINTAINING EVERY TWO YEARS.RECOMMEND NOT DRIVING OVER THE THE D-SOX AND LEACH PIT. revised 9/2198 Page 1 of 11 Z0 39Vd ELb606L809 L£:60 T00Z/9Z/90 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 0 PINE ST.CENTERVILLE MAP 209 PAR 027 L 47 Owner MARY DORAN Date of Inspection:811249 INSPECTION SUMMAi2Y: Check A, B, C, or O: A. SYSTEM PASSES: t have not found any information which indicates that any of the failure Conditions described In 310 CMR 15.303 exist.Any failure criteria not evaluated are Indicated below. COMMENTS: System passes Title V Inspection B SYSTEM CONDITIONALLY PASSES: n(11 tine or more system COmponents as described in the'Conditional Pass*Section need to be reps or repaired.The system,upon Completion of the replacement or repair,as approved by the Board of Health,wiil pass. Indicate yes,no,or not determined(Y.N,or ND).Describe basis of determination in all instances.If"cat determined',explain why W. n& The septic lank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)indicating that the lank was inmiled within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,Shows substantial Infiltration or exfiltration.or tank failure is imminent.The system will pass Inspection if the efing septic tank is replaced with a complying septic tank as approved by the hoard of Health. n1a Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health), broken pipes)are replaced obstruction is removed distribution box Is levelled or replaced WA The System requited pumping more than four times a year due to broken or obstructed pipe(s),The system wilt pass inspection If(with approval of the Board of Health)_ broken pipes)are replaced obstruction is removed revised 912M Page 2 of 11 60 39Vd £Lb606L809 4£:60 Z00Z/SZ/90 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFIC4TION(continued) Property Address: s PINE ST.CENTERVILLE MAP 108 PAR OZ7 L 47 Owner: MARY DORAN Date of Inspection:8/1Z/S9 C. FURTHER EVALUATION 1S REQUIRED 18Y THE BOARD OF HEALTH: Conditions e)dst which require further evaluation by the Board of Health In order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 18.303(1)(h)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT TAE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - Cesspool or privy Is within 50 feet of 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 SUPPUER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - The system has a septic tank and&ad absorption system(SA47 and the SAS is wAhln 100 feet of a sutfaoe water supply or tributary to a surface water supply. - The system has a septic Unk and soil absorption system and the SAS Is within a Zone I of a public water supply well. - The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The System has a septic tank and soil absorption system and the SAS I$leas than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for collform 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.Method used to determine distance nfa(appro)imation not valid). 3) OTHER n revised 912198 Page 3 of 11 b0 39Vd £Lb606Lt30S L£t60 100Z/5Z/90 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cotdinued) Property Address:8 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8112199 0. SYSTEM FAILS: You must Indicate ether°Yes"or"No'to each of the following: I have determined that one or more of the following failure conditions wdsl as described In 310 CMR 15.303.The basis for this determination is Identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into faclilty or system component due to an 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 lose than 6"below invert or avallable volume is less than 1/2 day flow, i X Required pumping more than 4 times.In the Fast year NOT due to clogged or obstructed.pipe(s). f Number of times pumped a&. !I X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a 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 prhry is within a Zone I of a public well. X Any portion of a cesspool or privy 18 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.If the well has been analyzed to be acceptable,attach copy of well water analyals for coliform bacteria,volatile organic ompounds. ammonia nitrogen.and nitrate nitrogen. X The liquid level in the SAS is over the[rived pipe,Is In Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yee"or"No"to each of the following: The following critaft apply to large systems In addition to the criteria above: _ Tttis system serves a facility with a design noway of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the f011owIng conditions exlst: Yes No X the system is within 400 feet of a surface drlm&q water supply X the system is within 200 feet of a tributary to a eurfece drinking water supply X the system Is located in a nitrogen aensitive area(Interim Wellhead Protection Area-IWPA)ors mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9096 Page 4 of 11 i 90 39V8 CLb606L809 L6:60 Z00Z/SZ/90 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 PINE ST.CENTERVILLE MAP 209 PAR 027 L 47 Owner: MARY DORAN Date of Inspec ion:8/12199 Cheek H the following have been done:You must indicate either"Yes'or'No as to each of the follow ng: Yes No X Pumping information was provided by the owner,occupant,or Board of Heath. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced Into the system recently or as part of this Inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-Sanitary or Industrial waste flaw. X The site was inspected for signs of breakout, X All system components,excluding the Sal Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the Septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scorn.The size and location of he Sal Absorption System on the site has been determined based on: X Existing Information,For example,Plan at B4O,H, X Determined in the field Of any of the failure criteria related to Part C IS at issue,appro)dmatlon of distance IS unacceptable) X The facli ty owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface()tsposal Systems. revised 9/2/98 Page 5 of t i 90 39Vd ELb606L809 LE:60 T00Z/SZ/90 r SUSSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 PINE ST.CENTERVILLE MAP 209 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:3112199 FLOW CONDITIONS REQIDENTIAL Design flow.-=g.p.dibeddroom Number of bedrooms(design): s -- Number of bedrooms(actuaq:I Total DESIGN flow. = Number of current residents:2 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): No if yea,separate inspection required Laundry system inspected(yes or no):-Na Seasonal use(yes or no):-YES Water meter readings,If available(last two year's usage(gpd): n/A Sump Pump(yes or no): NO Last date of occupancy. n/A CAM FR A nN 1S3[aIAL Type of establishment: n/a Design flow. nia go(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no): )!lQ Industrial Waste Holding Tank present:(yes or no): KQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.If available:n(A Last date of occupancy: n/a OTHER: (Describe) tt/a Last date of occupancy: nfa GENERAL INFORMATION PUMPING RECORDS and source of information: nfa System pumped as part of inspection:(yes or noy NQ If yes,Volume pumped x& gallons Reason for pumping: WA TYPE OF SYSTEM X Septic tank/dlstribuilon boWsof absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,If any) I/A Technology etc:Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: tits APPROXIMATE AGE of all components,date Installed(if known)and source of information: THE SYSTEM 14 APPROXIMATELY 1S YEARS Ot 0 Sewage odors detected when arriving at the site:.(yes or no) NO revised 9098 Page 6 of 11 L0 39dd ELV60GL809 L6:60 Z00Z/SZ/90 r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prope►ty Address:9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:9M2199 13UILDING SEWER: (Locate on aite plan) Depth below grade: Z� Material of conswdlon:_ cast Iron X 40 PvC _ other(explain) Distance from private water supply well or suction fine: TOWN Diameter: WA Comments: (condition of joints,venting,evidence of leakage,etc,) nlA SEPTIC TANK: X (locate on site plan) Depth below grade: 2 Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) all If tank Is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): SO Dimensions: L 8'8"H 6'7"W 4'io" Sludge depth: A: Distance from top of sludge to bottom of outlet tee or baffle: M Scum thicimess: Distance from lop of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet lee or baffle: 15_ How dimensions were determined: MPAst1SEQ Comments: (reoommendat(on for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage. etc.) SEPTIC TANK ftjj"COMPO GREASE TRAP: (locate on site plan) Depth glow grade: Marl of constriction:_concrete_ metal_ Fiberglass _ Potyethylene_other(explain) de Dimensions: WA Scum thickness: a& Distance from top of scum to top of outlet tee or baffle:-WA Distance from bottom of scum to bottom of outlet tee or baffle nta Date of last pumping: nk Comments: (recommendation for pumping.condition of Win and outlet tees or baffles,depth of liquid level in relation to outlet Invert,structural integrity,evidence of leakage, etc.) revised s rll88 Page?of 11 80 39Vd £Lb606L809 L£:60 Z00Z/SZ/90 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMA710N(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 200 PAR 027 L 47 Owner. MARY DORAN Date of inspection:8112199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prier to,or at time of,inspection) (locate on sae plan) Depth below grade: JI& Materiel of construction:_ concrete_ metal_ Flbergiass _Polyethylene` other(explain) OIA Dimensions: Wa Capacity: Wit 90ons Design flow. WA gallons/day Alarm present: UQ Alarm level:j2IgL Marro in working order:Yes,_No—: DQ Date of previous pumping: IYd Comments: (condition of Inlet tee,condition of afarm and float switches,etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID I_EVEL WRH BOTTOM OF PIF Comments: (r► o If level and distribution Is equal,evidence of solids carryover,evidence of leakage Into or out of box,etc.) RFGOMMFND NOT DRIVING OVER D 3OX PUMP CHAMBER: 00 (locate on site plan) Pumps in waiting order:(Yea or No): NO Alarms In working order(Yes or No): lam. Comments: (note condition of pump Chamber,condition of pumps and apputtenences.etc.) Wit revised 9098 Page 8 or i t 60 39Vd £Lb606L809 L£:60 Z00Z/SZ/90 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:SM2199 $OIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible:excavation not required,location may be appr&Amated by non-intrusive methods) If not located,explain: nia Type: leaching pits,number. ONF PIT leaches chambers,number., -n& leaching galleries,number. W& leaching benches,number,length: p(a Maching fields,number,dimensions: n& overflow cesspool,number: nia Alternative system: p(a Name of Technology: -I& Comments: (note corndltitn of soh,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc,) THF,LEACH PIT APPEARS TO BE FJMCTIONING PROPERLY SYSTEM SNOWS Ne aIGNS OF FAILURE-RECOMMIFISID NOT ORWING OVER e CESSPOOLS: _ (locate on site plan) Number and configuration: jtU Depth-top of liquid to inlet invert: pia Depth of solids layer zi& Depth of scum layer. a(a Dimensions of cesspool: p(A Materials of construction: Indication of groundwater: a& Ingm(cesspool must be pumped as part of Inspection)m& Comments: (note condition of soli,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: (locate on site plan) Materials of construction:pia Dimensions:n1a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) pia revised 9098 Page 9 of i I 01 39dd £LP606L809 L£:60 T00Z/SZ/90 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of inspection:8112NO SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at"St two permanent rererence landmarks or benchmarks locate all wells within 100'(Locate where public water supply manes into house) n/a f peck e o � 44 AVIL Ac p 8A �� 3e6 revised 9/2f98 Page 10 of 11 11 39Vd £Lb606L80S L£:60 ti00Z/5Z/90 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOIRMATION(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY OORAN Date of Inspection:81W99 NRCS Report name; MIA Soil Type: n1a Typical depth to groundwater: nta USGS Date website visited: 0fa Observation Wells checked: NO Groundwater depth:Shallow_ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you establishm the High Groundwater Elevdon.(Must be completed) uses MAPS AND CHARTS revised 9/2/98 Page 11 of 11 ZI 39Vd ELb606L80S LE:60 I00Z/SZ/90 e flK From Cii1hMno Andrew F ftem Including carer l Z w� Rol cc: O L4vwd Par Rw sw O ph. conment []pj. Ropy 0 PWW"Rocyclo 4 TO 3E)Vd ELb606L80S LE:60 T00Z/SZ/90 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 9 PINE ST. CENTERVILLE MAP 208 PAR 027 L 47 Name of Owner MARY DORAN Address of Owner: 142 COMMERCIAL ST.#406 BOSTON MA.02109 s Date of Inspection: 8/12199 r B Name of Inspector:('Please Print)JOHN GRACI ` �}n 44X1 I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) " 7 Fo LC l� 9 Company Name: n/a '0A 49 Mailing Address: n/a "�� �Vs��o 9 Telephone Number: n/a 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection Is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is Needs Further Evalu on y the Local Approving Authority performing at the time of the inspection.My inspection does Fails not imply any warranty or guarantee of the Ionggevity of the septic system and any of its components useful life. Inspector's Signature: Date:8/13/99 The System Inspector shall s bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If he 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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN MAINTAINING EVERY TWO YEARS.RECOMMEND NOT DRIVING OVER THE THE D-BOX AND LEACH PIT. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8/12/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nta 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced nta The system required pumping more than four 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 revised 9/2198 Page 2 of 11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8/12/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance nia- (approximation not valid). 3) OTHER n revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8/12/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an 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 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8/12/99 Check if the following have been done:You must indicate either"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. None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth,of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) ]t 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8/12/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-Q g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):X Total DESIGN flow: IQ Number of current residents:2 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): MQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NQ Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) nLa Last date of occupancy: xi& GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nLa_ gallons Reason for pumping: nk 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS APPROXIMATELY 15 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no) NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8/12/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 2LE Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) n1a SEPTIC TANK: X (locate on site plan) Depth below grade: 2 Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO nLa Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: ZE Scum thickness:3 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 1E How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass Polyethylene_other(explain) nLa Dimensions: Wit Scum thickness: nta Distance from top of scum to top of outlet tee or baffle:iVa Distance from bottom of scum to bottom of outlet tee or baffle Wa Date of last pumping: Wit Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nLa revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8/12/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nla Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) ills Dimensions: Wa Capacity: nla gallons Design flow: Wa gallons/day Alarm present: NQ Alarm level:_nla_ Alarm in working order:Yes—No—: NO Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DIA DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) RECOMMEND NOT DRIVING OVER D-BOX PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8112/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: ONE PIT leaching chambers,number: _nLa leaching galleries,number: jtLa leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: Wa Alternative system: n& Name of Technology: j3& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY,SYSTEM SHOWS NO SIGNS OF FAILURE RECOMMEND NOT DRIVING OVER PIT CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: Wa Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)Dia Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:n& Depth of solids: nL& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8/12/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a I Deck q c is o) AV 1� �c ay revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 PINE ST.CENTERVILLE MAP 208 PAR 027 L 47 Owner: MARY DORAN Date of Inspection:8/12/99 NRCS Report name: n/a Soil Type: nta Typical depth to groundwater: Wa USGS Date website visited: Wa Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records Checked local excavators,installers XUsed USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 ASSESSORS MAP NO. 208 PARCEL 27 LOCATION SEWAGE PERMIT NO. .LOT 41A PINE TREE DRIVE - 86-746 VILLAGE CENTERVILLE, MA INSTALLERS NAME & ADDRESS B.C.K. 97 TOWN BROOK ROAD WEST YARMOUTH, MA 02673 BUILDER OR OWNER BOND REALTY DATE PERMIT ISSUED: 7/28/86 DATE COMPLIANCE ISSUED: 9/10/86 M1 .J Ge 3 ',� ASSESSORS MAP NO: .2O9 2_77 No.�.:`I..Li !® �'�t�tGEt. f�d0.. Fji$. `�.. THE COMMONWEALTH OF MASSACHUSETTS r---BOARD OF HEALTH 1...T'._.0..............OF....................................................................... + Appliration for Elhiposal Workii Tonatrnrtinn thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: a......p h t / r e ti 1-v e ..... ...... ...................... . q-•-----.....--••-----..._................................_. ...... PCB 4/N R L /VP/A/dr lT1 0 r t No Owner .Address Installer Address Type of Building Size Lot....9._77-3_..._...Sq. feet 3 ,.., Dwelling—No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( ) C14 Other—Type of Building ....... .... No, of persons............................ Showers (2) — Cafeteria ( ) a'' Other fixtures ..... ........................... W Design Flow.................. . � . gallons per person per day. Total daily flow....... ...._....._.._gallons. g �g P P P Y Y 04 Septic Tank—Liquid capacity_V.9..gallons Length................ Width................ Diameter---------------- Depth................ W Disposal Trench—No. .................... Width_TT, ....... Total Total Length.._..._ _ Total leaching area.__--._.____-_______sq. ft. Seepage Pit No............:........ D• eter........ 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............"iftiinutes per inch Depth of Test Pit.................... Depth to ground water........................ GG r.. -------••-• ............... . 0 Description of Soil....... 7.... W UNature of Repairs or Alterations—Answer when applicable.........................................................:..:.................................. ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system i operation until a Certificate of Compliance has been issued by the board of health. ---9. Application Approved By................ .-•-••-•---•-•-••....__-•--- ...............................................•••--•---•--•....•-----....._•-•---•----- ...... D.. .--.T...- --------------------------------------Date Application Disapproved for the following reasons:..................................................... .---.-_-.•_•.. -••---------------------•---•----•----------•---.....----•-----•------...-------•-•-----•--•-•------------••--•-•-...........•-••--••••--•-••-•---••••--••-•--•-•••-••••-••----••-•---•••••••...._------ ICZZZ PermitNo. ............. Issued_........................................................au Date —W--_--- ------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..-77 ....................................... Apphratiun for Uiipuod Works Tonstrurtion Prrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �- Location-Ad ss or Lot No. . •-------------------- •------------ - . ................ ....-.......... ....... --....._..._................._------_-- . .. .. .. C "V 6 Address a ._....•-- ....................... . .....Installer Address ••••• Type of Building Size Lot............................5q• feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------------------------------•-•-•-••------••----•-•-----•-•••----•--•-•••••••......•-•--------•......•--•--•-----•. Design Flow.................. �........gallons per person per day. Total daily flow.......' 25, ---------------gallons. Septic'Tank—Liquid ca.pacity../.vRgallons Length................ Width................ Diameter............... Depth................ x Disposal Trench—No..................... Width.................... Total Length...... ...... Total leaching area...................sq. ft. 3 Seepage Pit No-------_----------- Di eter.........�... Depth below inlet-------- ....... Total leaching area..................sq. ft. Z Other Distribution box ( l.� Dosing tank ( ) � Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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........................ 1:4 -•--•---••---•••••......•..............•. •......••....--•-•...........-•-•-••••.....--_....•......................................................... D Description of Soil..........-_ � •--•-••--•--••---•----••--•---•--•--••--•-.......-•-•--•••••---...-•---•-•.......................•-•••--•-•••--••-•----•---•---•••--•--•----••• . ..........---••••--••-•••••.....•-•-•••••----_---... ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------••--•--.........••••....••••-- U Nature of Repairs or Alterations—Answer when applicable..........................................................................._.............._..... ... ... ..........•--•-•-•-••••••..........._....•••••--•-------•----••---•••---•-•-•-•----••---•••-•-••-•......--•••-•-•-----••-------••---••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.I 5 of the State Sanitary Code— The undersigned further agrees not to lace the system i ' operation until a Certificate of Compliance has been issued by the board of health. ate . ---------------------- -----------------------••------------------•--------------- ••••---_------------ a e Application Approved �!l,1�- - D / -- ............ Date Application Disapproved for the following reasons:..........................................................................................................--- ......-•-•----------•--------•------------------------------------•--......'.......------------------------•---...----••---....._...--•-----•-•--•-•••-••-•-•.......-•-•----••......._......••........._ Date PermitNo..�--•• ---------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t ..........................................OF..................................................................................... (Intifutt#r of Tout rlittnrr THIS IS Thl�hatt ,1— Wividual Sewage Disposal System constructed or Repaired by-------------------• •-----------.•------- � -----•------.---------•---•--------- -------•---------------••-•----__-_-.---.-_------.----.---------..--••----_-•--•- ----•••- Installer at........... ....'With . 5 of Tl�e take Sanitar C lddescri ed in the '1 C.Oapplication for Disposal Works Construction Permit 4 ..........._ •.........._.....__. dated.--.�:. _1..�...V_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIONSATISf�ACTORY. i y, DATE..----=--••-•------•------•r ... --- ............ Inspector........... ....... =:_.._..........._.. ...................... THE COMMONWEALTH OF MASSACHUSETTS r--(f BOARD OF HEALTH OF..................` ��L._......... No� .. � .......................................... Fzz..........k...�..., — �iu�ru d Vor wilnuiruu#iun f ami# Permissionis hereby granted.... •-- -------------......•---..G..-----........------•--.....................................--•--................____ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at�1�1o. _.r. ..... 1 `Q 1......................................... ................ ........... ........ ........... v<. i U L/( ..._.-•-.-`�•1( <.. ...�.....str � ji `-fir i t L— -1/ /..... -'` as shown on the application for Disposal Works Construction Permit Nc;:.::_ ,.._ `Dated....� ? q,........ G `� Board of Health DATE. .....!............................... i FORM 1255 A. M. SULKIN, INC., BOSTON i DESIGN:DATA t--A(ar STRUCTURE SttiC't r Fdtin\t V DWFI � DESIGN FLOW� r3Og t,A /NO c- a� ���x � YLS�rvr�ptl�_ SOIr_PIPs S SEPTIC TANK U--E IOCGZ� a / � LEACHING RATES SIDE AREA z-S GPD/SF /��.'`Q/� ��� � rE�•go 5 LD SQL \ BOTTOM AREA LZ)GPO/SF LEACHING FACILITY /\p ell, SIS�t= dp��: 7_XR x(„tC�1� I.-So L c y , 6 D1�clI�S. FS�ST. Sr?�/�"TTX C Z = \1 5 e5T?��NGJ \ �'� Llti� <ISo X �_. S, .P13YC 1•C7 = y6B PC> i � 6•. o PLAN REFERENCE [ ,::e- I7-.L12 _ ti QJ1G4 a t.M2\� ASSESSORS LOT NO.t &&r-I $ L.CELZ�1 _Fx 1ST\IVG cFCG> S v / ./ a� NOTE- _ 'r0 0e= a at�IDor.lEa. �Q �/f 1. ALL MATERIALS AND CONSTRUCTION METHODS TO CONFORM WITH COMM. OF MASS. TITLE 3L tl ENVIRONMENTAL CODE DRAIN FROM KITCHEN. /O / S io. �•• ofMgsr ?. L-cr-r o \c= QDAVID y 2,�j. T(> L I t,,A C. rrA—=Inf�l r,Hbkl{�. oTHU9J6 L.�, EXISTIT�II SEPTIC' SYSTFI�/� - `�9 ,VJ � ,e F VEC� Tb PSG �S3f�r�l�f�1`IEi�. ! T6� O E>C I S-T 1\-1 G C FL a D c --50 PLAN. �. Ex\STIt-Ac SO1l_P1PG PPC7PO.�E� SOIL PIPE SCALE 1"_�' TEST PIT NO. TEST PIT NO. _ i SS ELEV. . A-I'1:Co ELEV. iA M SOIL OBSERVATION PITS P-59I O DATE OF TEST 19 8 Czv Ike _ ENGINEER Er r 15 TO i' - C ory rvE T To' B.O.H.AGENT. Nn.lvc�c t_E1c�!-\'rOt�f ex ST IL PIP —.9cisT. G_RtaaE_ EXCAVATOR 1K7S H g HOE �cIN ABOV — — — — —— — PERC RATE IN NO._ATS'FT.�GZ MIN./IN. L19.S} �AS SH � 3 � T.P. a yy TA•9 1.11C e I000 RISER c �gsO1l_ 1--OT I'hi, Plr:iETRrr-=-=lE:;>Rwr= -IS.S PTIG LI 5.1 po p D ME..D. `• No ��rG £ GcznvE� ELLIS & THULIN, INC. LH.S o C/ `o° LAND SURVEYORS EAST SANDWICH,CIVIL ENGINEERS 10' Z9' 8.5' , o 0 0 ° qo.5' �, ��r H MEo. 2 EP,d.\FR ' y.9� stallo PROPOsr=n PL o-r PL�.tJ,SCALE Hoe- \"=b'vEe:i'_s' SECTION THRU SEPTIC SYSTEM IZ rJ4�c1A.T>=2 S. Lft_ ZS {�BC� •0Y: L-�T _ y I ASSESSOR'S MAP: 208 GENERAL NOTES: FeV'0a6S OCU PARCEL: 27-1 `{ N 1. VERTICAL DATUM: Assumed rD � REFERENCE: L.C.C. 124221 � 2. MUNICIPAL WATER tS AVAILABLE. T t, ? FLOOD ZONE: C Town of Barnstable 3. SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT SYSTEM #2500010015 C (8/19/82) UNLESS OTHERWISE NOTED. 0 �� 4. ALL PRECAST UNITS TO CONFORM TO o (N �. AASHTO: H-10 g FU��er. 5. PIPE PITCH-1/4" PER FOOT UNLESS OTHERWISE NOTED. � (V Skunkne ROda 6. ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE WITH MA tt Road o �j ENVIR. CODE(TITLE V)AND LOCAL REGULATIONS. Q. + 7. CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO U LOCUS MAP N.T.S. A _i CONSTRUCTION. PINE TREE DRIVE 107,75 108.77 109,23 Edge of pak4 e`er 110,53 110 99 O .�: p112.64 ' r �HOFMq JP/580/1 �10' N 89°06`00" E _ _- zs' q �3 1. 4 110,4a -` 845 5.46' 112,83 1'3,65.s o VONHONE y CB/DH/FN1 i 1/1 112.03 1 9s 114 y v 9�#106P�a i Existing Tank IN 58 s ois cti a - I H to remain N s` \ � 4 N 111,79 X 5,38 f T cA,�\ 7 - } 00 13,22 ( 114,35 +© s6, �'S rn ���P�zHOf,ugSs�cy Q ►v SD �, I �° TERRY Gs O 1 114.6- .' t. F` Lot 48 _ * ANN S C Full r O Na 3$72R 1WARNE 3` 5 Fnd. 29' #9 0 � `111.13 -- 4:9. _ : Deck— TOF=117.20 (Main) 116, o .•`•-ll. ,i, ��:>: (Assumed) , 3 /��f�7 o - '� 11 20' Crawl Space Woo NOTE: Pump and -�n I --- ti1�` X 115,47 w o o backfill failed w W ' ".TOF=117.31 m o �13,8 t ( 116,64 NOTE: This plan is to be used for septic leach it. Removal p ' 1 114,6- 115,56 pd a of contaminated 112,97' X 2ro ,yo system purposes only and is not to be 3 24,01' soils within 5' of v �'= X �°� considered a property line survey. proposed leach •�>—, :113. Lot 47115;17 , X 5� X 11 ,24 facility is required. Raved 9116.54 7751 S.F. 11'S,74 ' °� ' : ",•r_ 9 PINE TREE DRIVE, CENTERVILLE, MA O :�Drive . ;_.:Map 208 `' r� , / 117,01 Parcel 27- r ��! N ): ;o ade LEGEND: VH PREPARED FOR: Z N ?^ / i�69 2830117,27 PROPOSED CONTOUR associates Douglas Brown 414 115.2 � S SEPTIC SYSTEM DESIGNS and � / ) �/ gg PROPOSED SPOT GRADE 116,33 —40 - EXISTING CONTOUR 320CotuitRoad S. Catherine Andrew Sandwich,MA 02563 Lot 42 — 30.23"— EXISTING SPOT GRADE 508.833.UXI 9 Pine Tree Drive BENCHMARK SET: TEST PIT Centerville, MA 02632 W. Left corner brick step EXISTING WATER SERVICE SUNS)"Terry A. Warner.P.L.S. EL. 117.03 (ASSUMED) 22 Long Road E3-3,• Xr WORK LIMIT LINE Harwich, w►D2dw DATE REVISED SCALE SHEET NO. Scale: 1"= 20' (50$) e32-8309 03/18/07 1" = 20' 1 of 2 q s . Provide Riser over D-box NOTE:All components to be marked with NOTE:To prevent breakout,final grade T.O.F.(Full) to within 6"of final grade magnetic tape or similar prior to final cover. of EL. 109.5 to be carried out a EL. 117.2 ! minimum 15'beyond edge of leach F.G.EL: 114.5-116.5± F.G. EL: 113.7± facility. Existing F.G. EL: 113.0± Maintain Min.2°!°slope over leach facility to prevent ponding F.G.EL: 112.0 113.5± EXISTING Install risers w/covers over inlet and Min.2"of 1/8"-3/4"Washed Stone or Geotextile Fabric Inspection Port within 6"to grade EL. 112.78 outlet to within 6"of final grade - 3/4"-11/2" Double Washed Stone 4"SCH 40 PVrinsta�ll _ " L-12 L=15' @S=15°/a(2°E 4 SCH 40 PVC 4"SCH 40 PVC Top of Peastone or Geotextile Fabric EL 109.5 @S=59'o(1%MIN) ° a®® ® 24 Eff.Depth 6 @S=3.3%(0.5/oMIN) a®aaaB®EL. 110.28 EL. 109.5' a®a®a®a 7 0 Gas Baffle EL. 109.67 { EL. 109.0 EL. 110.53 PROPOSED DB-3 Use 2 500 Gallon Precast Chambers -91 5-999 H-10 DISTRIBUTION BOX (H-10)with Double Washed Stone 5.8 8.9 .1 Ift NOTE:Contractor to confirm (Install PVC Inlet&Outlet Tees) SEPTIC SYSTEM PROFILE 4'Ends,4'Sides minimum 1000 gal.septic tank. EXISTING 1000 GALLON (25'x 13'x 2') Replace with min.1500 gal.tank if H-10 SEPTIC TANK Bottom of fH 1 undersized or damaged. N.T.S. m of (Adjusted Groundwater Calculated EL.98.1) SOIL LOG SEPTIC SETBACKS ADDITIONAL NOTES 1. Contractor to confim soil suitability prior to installation. Contact BOH in the event of SOIL EVALUATOR: AMY VON HONE,R.S. varying soils from original soil test. DESIGN CRITERIA INSPECTOR: DONNA MORANDI, BARNSTABLE BOH DATE: MARCH 16,2007 11:00 AM 2. Failed leach pit to be pumped and backfilled per Title V specifications.All Number of Bedrooms: Existing 3 Bedrooms PERCOLATION RATE: <2 MIN/INCH PERMIT#11631 contaminated soils to be removed within 5'of proposed leach facility. Soil Type: Class I *Test Hole 2 Waived by Health Agent 0 3- Water line to be sleeved at any sewerline crossings and within 10'of any septic Design Percolation Rate: <2 min/Inch TH - 1 components,as needed, per Water Department requirements. Dally Flow: 330 G.P.D. EL.112.2 Design Flow: 330 G.P.D.(Min.Required) 49, 36 4. Any existing orangeburg pipe to be replaced with Sch. 40 PVC pipe back to existing Sandy Loam Cast iron or PVC pipe. Garbage Grinder: No 10YR3/2 101, 111.37 29' 5. Maximum 3'of cover to be maintained over teach facility. Regrade area over leach Leaching Area Required: (330)/0.74=445.94 S.F. B facility to maintain maximum cover. Sandy Loam 31` Septic Tank Required: 1000 Gallon (Existing) 10YR4/4 109.7 0 FLOOR PLAN Use 2-500 Gallon Precast Chambers with Double Washed Stone: 3o' C1 (H-10)4`on Ends, 4'on Sides: 25'x 13'x 2' Coarse Sand N.T.S. Sidewall Area: 2(25'+13')2'=152.0 S.F. Pere 2.5Y5/6 Bottom Area: 25'x 13'=325.0 S.F. @ ,OA a*9 Family/Library Total Area: 477.0 S.F. 48"Bott `l 1j Room Design Flow Provided: 0.74(477.0 S.F.)=352.98 G.P.D. 2p OQZ Bath 132" Bottom ofTH-1 101.2 9 PINE TREE DRIVE, CENTERVILLE, MA VH ` Bred 1 2nd Floor PREPARED FOR: Douglas Brown 169" Ad'.Water 981 Kitchen associates g SEPTIC SYSTEM DESIGNS a n d 216" 94.2 PERC RATE:<2 MIN/IN.(Cl Horizon):<9"@ 10:00 minutes 1st Floor Bed 2 320 Cotult Road S. Catherine Andrew Bed 3 Sandwtch,MA02563 No Groundwater Observed in TH-1 : Use Groundwater Data from Barnstable Groundwater Contour Map 508.833.0041 9 Pine Tree Drive MIW-29, Feb.2007,Zone C(8.6),Adj=3.9%Observed Water @ EL.94.2/Adjusted Water @ EL.98.1 Centerville, MA 02632 Surveying by: I,Amy L.von Hone,R.S.,hereby certify that I am currently approved by the DEP pursuant to Bath Terry A. Wamer.P.L.S. 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been 22 lAng Rood performed by me consistent with the requirements of 310 CMR 15.017. 1 further certify that H(508) 2 o2ea5 DATE REVISED SCALE SHEET NO. I have successfully passed the Soil Evaluator's Exam on November,2004. (5De) 432-6sos 03/18/07 1" = 20' 2 of 2