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HomeMy WebLinkAbout0122 POINT OF PINES AVENUE - Health 122 Point Of Pines Avenue Centerville A = 230 063 No. 42101/3 ORA 10%0 0 0 0 0 s ._.. Commonwealth of Massachusetts g _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is Centerville MA 02601 12/08/09 required for every _ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When fi A General Information onn the the ut forms computer, U use only the tab 1. Inspector: key to move your cursor-do not Carmen E Shay use the return Name of Inspector key. Shay Environmental Services, Inc. 160Q-6 Company Name 185 Ashumet Road Company Address etun Mashpee MA 02649 City/Town State Zip Code 508-539-7966 3080 Telephone Number License Number F 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';i'nspection. Tie inspection was performed based on my training and experience in the proper function ana'inaintenance of cn--site sewage disposal systems. I am a DEP approved system inspector pursuant=to Sectio6715.340 of Title 5 (310 CMR 15.000). The system: ` G_ s x� ® Passes ❑ Conditionally Passes ❑ Fails -a UJ ❑ Needs Further Evaluation by the Local Approving Authority CryRM �s ;.��.e E. 12/08/09 SF?Ay_ v, Inspector's ature Date The system inspector shall submit a copy of this inspection report to the;Q rr,Q`.V ty (Board of Health or DEP) within 30 days of completing this inspection. If the system rs'a+s�&Re 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. �v 122 Point of Pines Road,M Mills-2•03108 Title 5 Official Inspection Form:Subsurface Sew Disposal SystMe 1 of 15 r Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a; Y #122 Point of Pines Road Property Address Roger Berman _ Owner Owner's Name information is Centerville MA 02601 12/08/09 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: No liquid in SAS, pump chamber and alarms functioning properly 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 122 Point of Pines Road,M Mills-2•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is required for every Centerville MA 02601 12/08/09 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. 122 Point of Pines Road,M Mills-2•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is Centerville MA 02601 12/08/09 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 ❑ ® 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. 122 Point of Pines Road,M Mills-2•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \a #122 Point of Pines Road Property Address Roger Berman _ Owner Owner's Name information is Centerville MA 02601 12/08/09 required for every _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. 122 Point of Pines Road,M Mills-2•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is Centerville MA 02601 12/08/09 _ required for every page. City/Town 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)] 122 Point of Pines Road,M Mills-2-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a- #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is required for every Centerville MA 02601 12/08/09 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Sept. 2009 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: Last date of occupancy/use: Date Other(describe): 122 Point of Pines Road,M Mills-2•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is required for every Centerville MA 02601 12/08/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as Part of the inspection? El E 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): Approximate age of all components, date installed (if known) and source of information: January, 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No 122 Point of Pines Road,M Mills-2-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments eP #122 Point of Pines Road Property Address Roger Berman _ Owner Owner's Name information is Centerville MA 02601 12/08/09 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 30" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): Depth below grade: 12 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 10' x 5' x 5' Sludge depth: 40" below inlet Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 1/4" Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 122 Point of Pines Road,M Mills-2-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is required for every Centerville MA 02601 12/08/09 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.): Inlet and outlet tee present and in good condition. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 122 Point of Pines Road,M Mills-2•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is required for every Centerville MA 02601 12/08/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Equal with all two outlet inverts. 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.): No evidence of leak or cracks, no riser present. D-Box is 30 inches below grade Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ® Yes ❑ No 122 Point of Pines Road,M Mills-2•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is required for every Centerville MA 02601 12/08/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump appeared in good condition as did floats. No evidence of leaks or cracks or carryover. Alarms operational and cycled pump to ensure in good working order Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 45' x 16' x 1' ❑ 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.): SAS fuctioning properly, no evidence of any liquid around SAS. Located inspection port and opened. No liquid in SAS 122 Point of Pines Road,M Mills-2-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is required for every Centerville MA 02601 12/08/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 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.)-. 122 Point of Pines Road,M Mills-2•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 | � / Commonwealth of Massachusetts ��^��U �� Official � Inspection Form � Title M����� ���������� U���� ��N~07k� N �U �� ���� � �m� �wm � �— n �~ v��u ����*��~ n��nm ��mnnn Subsurface Sewage Disposal System Form Not for Voluntary Assessments #122 Point ofPines Road Property Address Ro e Berman owon, ---���ame-------------'--- --'-----'-- ` - Owner's information is required for every Centerville �Yu�_-- 826 12/08/09_—' _- page City/Town State Zip Code Date o/Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties Vout least two permanent reference landmarks orbenchmarks. Locate all wells within 100feet. Locate where public water supply enters the building. Do t Gil 122 Point of Pines Road,M Mills-2-03108 Title 5 Official Inspection Form:Subsurface Se�age Disposal System-Page 14 of 15 ` | z ^ Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments #122 Point of Pines Road Property Address Roger Berman Owner Owner's Name information is Centerville MA 02601 12/08/09 required for every _._ page. City/Town 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: No GWI @ 5' below sas per perc test data 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: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Obtained design plan and observed adjacent pond elevation. Obtained perc test information and elevations from plan. 122 Point of Pines Road,M Mills-2•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 COMMONWEALTH OF MASSACHUSETTS Z W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r d DEPARTMENT OF ENVIRONMENTAL PROTECTION �qM Sve v` TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: #122 Point of Pines Centerville,MA Owner's Name: Roger Berman Owner's Address: 179 South Street,Suite 300 Boston,MA 02111 V' Date of Inspection: 1/08/08 Name of Inspector: (please print) Mr.Carmen E. Shay Company Name: Shav Environmental Services,Inc. Mailing Address: 185 Ashumet Road Mashyee,MA 02649 Telephone Number: (508)-539-7966 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information r orted'' below is true,accurate and complete as of the time of the inspection.The inspection was performedlbased oy training and experience in the proper function and maintenance of on site sewage disposal systems am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3.10 CMR 15.000). The systcr►: P- >. —I � XX Passes f# rTn Conditionally Passes ee urther Evaluation by the Local Approving Autho ity ry Inspector's Signature: Date: 1/08/08 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. Notes and Comments No evidence of backup noted in D-Box. Opened inspection port and found no evidence of ponding, or saturated soil. ****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 I i Page 2 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #122 Point of Pines Centerville,MA Owner: Rop_er Berman Date of Inspection: 01/08/08 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: r .,, 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #122 Point of Pines Centerville,MA Owner: RoEer Berman Date of Inspection: 01/08/08 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #122 Point of Pines Centerville,MA Owner: Roger Berman Date of Inspection: 01/08/08 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX 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—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #122 Point of Pines Centerville,MA Owner: Roger Berman Date of Inspection: 01/08/08 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks XX _ Has the system received normal flows in the previous two week period'? XX Have large volumes of water been introduced to the system recently or as part of this inspection`? XX Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up XX _ Was the site inspected for signs of break out XX _ Were all system components,excluding the SAS, located on site? XX _ 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? XX _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no XX _ Existing information.For example,a plan at the Board of Health. XX 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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #122 Point of Pines Centerville,MA Owner: Royer Berman Date of Inspection: 01/08/08 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 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)): Sump pump(yes or no): No Last date of occupancy: Currently Unoccupied 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): GENERAL INFORMATION Pumping Records Source of information: None on File Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX 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: January 2002-per Board of Health&Owner Records Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #122 Point of Pines Centerville,MA Owner: Roger Berman Date of Inspection: 01/08/08 BUILDING SEWER(locate on site plan) Depth below grade: 48" Materials of construction: XX cast iron XX 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: 12"— Material of construction: XX 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: 5' deep x 5'wide by 10' long (1500 gallon) Sludge depth: 4. 75' Distance from top of sludge to bottom of outlet tee or baffle: 3.00' Scum thickness: 3/4" Scum Laver Noted Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Structural integrity of tank was ok. No evidence of cracks, leaks or water infiltration/exfiltration 4" PVC Tee present and in good condition. Outlet Tee also in good condition. Liquid level equal with outlet invert. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass___polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): r .,..,. 7 I Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #122 Point of Pines Centerville,MA Owner: Roger Berman Date of Inspection: 01/08/08 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/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: Present (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No evidence of solids carryover or back-up. D-box structurally sound. PUMP CHAMBER: XX (locate on site plan) Pumps in working order(yes or no): Yes Alarms in working order(yes or no): Yes_ Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Pump appeared in good condition as did floats. No evidence of leaks or cracks or carryover. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #122 Point of Pines Centerville,MA Owner: Roger Berman Date of Inspection: 01/08/08 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: leaching trenches,number, length:_ XX leaching fields,number, dimensions: 16'wide by 45 feet long, 1' deep 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.): No evidence of hydraulic failure, ponding damp soil or stressed vegetation Opened Inspection port from top of field and noted no evidence of ponding or liquid in stone area. SAS is 1.5 feet to top 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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): r .„� 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: #122 Point of Pines Centerville,MA Owner: Roger Berman Date of Inspection: 01/08/08 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. i I t � � O " 6� ~i• —�.V i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #122 Point of Pines Centerville,MA Owner: Roger Berman Date of Inspection: 01/08/08 SITE EXAM Slope Surface water -None Check cellar -Yes Shallow wells—None Estimated depth to ground water 7.5 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: XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Observed from site conditions relative to the site and nearby Pond Front Also checked with Quadrangle of USGS Map. 5' Separation from water table to bottom of SAS from system install info. Refer to plan and adjustment to groundwater on file at Board of Health Office dated October 25,2000 by Down Cape Engineering. v' -No. `7 O Fee V U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mopozal bpe;tem Construction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.42 J �o'°�'T ���I'�'c�ti!' Owner's Name,Address and Tel.No. Assessor's Map/Parcel ,2 Installer's Name,Address,and Tel.No. 0 .70.7 Designer's Name,Address and Tel.No. 40&A6 v eA,0"F 9 3 /,--' ,rr, ,��.�,4. 6r r Se r Type of Building: Dwelling No.of Bedrooms X Lot Size sq.ft. Garbage Grinder( ) Other 'I�pe of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow I— gallons per day. Calculated daily flow s—® gallons. Plan Date Number of sheets / Revision Date Title Size of Septic Tank r'5-11'0,.9AZ �pea�p�G,fir•a,� 'c e o .A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) G ENGINEER 1446TIN SITINGlbiSIA N - LIATION IN STR SYSTE / Date last inspected: ACCORDAN P 1 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y this Board of Health. Signed o Date 00� Application Approved by 4', Date /I—&—U/ Application Disapproved for tKe following reasons Permit No. elU 0 1 — 7 ZU Date Issued TOWN OF BARNSTABLE.. LOCATION �°i"'r �'�iw!'J SEWAGE #-21-� 'J9 VILLAGE ASSESSOR'S MAP & LOT��� �d INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)-e J.ogWrd (size)��-»'X/6.-r A 9 " NO. OF BEDROOMS S' 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 I C . I `46 o . -e E.- atl No. U — ( U Fee V U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rpprication for 0i5poeaf bp! tem Construction Permit Application for a Permit to,Construct Repair( )Upgrade( )Abandon.( ) ❑Complete System ❑Individual Components F , Location Address or Lot No./.z �v�tiJ v/ /w.c``J Owner's Name,Address and Tel.No. Assessor's Map/Parcel , f 1," t aF t~ F { Installer's Name,Address,and Tel.-No. 77J'•0747•7 Designer's Name,Address and Tel.No. d o.p.v t.q f'f �+i•�,iwE�"orir�, i�c , Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow S's'� gallons per day. Calculated daily flow r`to gallons: Plan Date Number of sheets / Revision Date Title 4 Size of Septic Tank /s--ao�p�,l /ocaiK• �•�p ype oZ.A.S. / — '•�'�—.za J'T.D /++F!177'o�2J' Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ' Agreement: L 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 y this CBoard�of Health. g Signed Date Application Approved by M'• Date /?- r Applicati6h,D spproved for tKe following reasons } Permit No. -2-U 0 / - 7 V Date Issued THE COMMONWEALTH OF MASSACHUSETTS ��r�y 1 olu�ox s BARNSTABLE, MASSACHUSETT,S Certificate of Compliance' THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(,y Repaired( )Upgraded( ) Abandoned( )by 4_/h+ G E'4oF40r at ,3 s /"ye'�, Di` ��/�'Ef. G Gs✓T� -trays been constructe in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - i` b dated 0 ,Installer L,' i-- G CA6o16*0000'z' Designer The issuance of this/perm.it hall not be construed as a guarantee that the system ill function as designedf Date �( Inspector `% — �--• �`-- C� t: r1�y r /)r' a No.20 — 7y Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1wigposW *pMem Construction Permit Permission is hereby granted to Construct(X)Repair( )Upgrade( )Abandon( ) System located at O�ZS- /"Q'"X' •ff �'��'�`r G c�-MT• 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:Construc ion must be completed within three years of the date of this pt. Date: 1 0 Approved by �/`� `'' TOWN OF BARNSTABLE LGCATION \2� SEWAGE# ©Ot -`+48 'a'rILLAGE ASSE5"S -?WS MAP&PARCEL �30 INSTALLERS NAME&PHONE NO. LQ�rjt S,� }5 010LJ SEPTIC TANK CAPACITY i�bo q a\ �c,nk ! icon Q-Ck_ `� C' � LEACHING FACILITY: (type) e\A (size) NO.OF BEDROOMS OWNER42c- PERMIT DATE: \'� " \ - p\ COMPLIANCE DATE: a� p� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1 .No ►l Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) IQ/ty Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leach7facility) 1 2+0 1 Feet FURNISHED BY Rom° S, 'Y __ ,-.. , � � ' � t��—� aq ��� � � , � w .y �Yy �� '�� r t ,s t�� iy� 3� i gyp. . a ' 1 , r, f i I1 1 �� 4" y) � � � 1 r �� � � � � l TOWN OF BARNSTABLE LC'CAT10N .42J /o° l�'Y SEWAGE #-2-0�Ov $4'0 VII:LAGE ASSESSOR'S MAP & LOT.�}o 40 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Q6,0X LEACHING FACILITY: (type -0 (size) NO. OF BEDROOMS S' BUILDER OR OWNER 4A. !aV^' VA.v PERMITDATE: COMPLIANCE DATE: /"y21__&X 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 of 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 corl''''" (Of� to 47 A6' s�'6� : TOWN OF BARNSTABLE LOCATION ��`� bcr� � icy _ SEWAGE # AWi r is VILAGE �P�C1 cr�1�1-� ASSESSOR'S MAP & LOT `J4 INSTALLER'S NAME&PHONE NO._- ��t1n L�hp - � O -o-- SEPTIC TANK CAPACITY 1 SM Gc,A \ 01,4,wl-n3 if" LEACHING FACILITY:.-(type) L CIXNkr- (size)--av-I-t )C NO.OF BEDROOMS_ BUILDER OR OWNER PERMITDATE: \-,;L " ^b I COMPLIANCE DATE: I P,5 10D- 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 ac ' c' (If any wetlands exist within 300 fee Feet Furnished by f g Okr w I i. 47 r i� I TOWN OF BARNSTABLE LOCATION /�J /0�'i"'r c�"�/.vE'J SEWAGE �p se® i VILLAGE GG'rT. ASSESSOR'S MAP & LOT.:?Yv �? INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY/1'`00.9Ae, I LEACHING FACILITY: (type)-e<2�4*4' -,47,!r6 (size) loy_r A 9 " NO. OF BEDROOMS S' BUILDER OR OWNER 4,OoP 40%4•A'A?AA' PERMITDATE: COMPLIANCE DATE: i 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) t A I" Feet Furnished by i 'bG I •ar - 0 4, A� 6 M '- o LO T 10N EW A G E PERMIT NO. VILLAGE IN TA LLE 'S NAME & ADDRESS GQ B U1,LDE R OR OWNER DA T E PERMIT ISS U-E D /lh /7.� DATE COMPLIANCE ISSUED /!�-q/7-7 � PAP Py� 7� . No.. ..... ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 11_........ f'� _...... .......OF.../... .." �'P'`........... .................................................. Appliratiun -fur 43topood Works Tonotrurtinn Vrrniit VZ Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: , / ocation-Address or Lot No. O ner ddress / W 'a i v� S L CQ� Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of BuiLddng ---------------------------- No. of persons___________________________• Showers ( ) — Cafeteria ( ) a' Other fixtures W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width........-....... Diameter................ Depth____-___._.... x 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 ( ) aPercolation Test Results Performed by------------------------------------------------------------------------- Date.-------- ------------------------.. a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.--___--_._--__-- rXq Test Pit No. 21................minutes per inch Depth of Test Pit---- Depth to ground water__._..-..-_---.-____---. n+ --------------------------------------------------------------- ----------••-•••--••-•-••-----------........................................................ 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ x U ----- W ----------- ------------- --------------------------- ••-•------- ----------•- --- p< ��' -- ---- ---------------- ture of Repairs or Alterations—Answe when a licabl ,� _�.i`'j.......... ........... . -- -- -------- A reement: G 'h. e �/ {,✓ �vs e /o e de 'g t9/m the aforedescribed Individual Sewage Disposal System in accor , ce with the provisionsY�e Article NI of the ttate Sanitary. Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by the board of health. `" Ggned. . ••... ® re Application Approved By............ . , -" Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ------------------------------ -------------------------------------------------------------------------------------•-----......•--•--•------•-----------•••••-•------------.....--------- Date PermitNo......................................................... Issued........................................................ Date f 7 No.. toe ............. .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ...._OF....r t' '°:....'.':........ .............................................. Application -for DigVviial Workii Ptuitrurtion Prrmit Application is hereby made for a Permit to Construct (' ) or Repair ( } an Individual Sewage Disposal System at ----------•--- ---•--- ----- -••- •----- ••-•---- ......_•--•- ----------------------------------- 'fir 0 cation-Address or Lot No. C - -_'-►w _---•--- --------------- ---- ---'--------"5---cam--�----- er + f f ,ems • ...� � Installer Address UType of Building Size Lot__ ________________________Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) per-, Other—.Type of. Building -_______________ p Showers ( ) — Cafeteria ( ) ----------- No. of ersons---------------------------- a' Other fixtures W Design Flow _________________________gallons per person per day. Total daily flow--------------------------------------------gallons. PSeptic T:.nk—Liquid capacity------------gallons Length---------------- Width................ Diameter................ Depth................ xDisposal 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 ( ) aPercolation Test Results Performed bY-------- ---------------•-----------------------------•--------------- Date---------------------------------------- Test Pit No. 1----------------minutes per inch Depth of West Pit...______-________-, Depth to ground water...._._--__._____-.--. - w. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__.-.._--______.____-_ ------------------- ------•---------------------•-•-•-•----•-----•---------•--••••-----•-;-•--•-••- ••••-•----•---------•-•---- ...... ---•--•------- ODescription of Soil------- ----------- -------- ---------------- -••••••••••-------•------•-••-----••--••-••--------------- ---------------------------------------- ----------------- U ----- ------ -------------------- =•-••••••------- V —Nature of Repairs or Iterations—Answe when alicabl :�''" ____...- ► Agreement: + + "0'" ! .004"Zi w nde r t m 0 the aforedescribed Individual Sewage Disposal System in accor e with the provisions o�"g r�XI the State SanitaryCode—The undersigned further agrees not to lace the system in g g P Y operation until a Certificate of Compliance has been issue by the board of health. gned_. _--- _l__-'_ ti4' --•--,_____ ... � Dw, e Application Approved By Date Application Disapproved for the following reasons:---•------------------------------------------------------------------------------------------------------------ y -----_---____--•-•-••------=----=------------•-------__----•----•----_•--•---------•---•-•••-------------.•••--•---••----•------•-------------------------•-•----•-----------------•----••-•------------- Date PermitNo-------------------------------------------------------- :Issued.......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t+br+3 !...............:0 F.. ,a» ,.'y�.................................................... Apr#ifir�#le gf f�IIm�ii�tnrr T4.z.C.. IS TO CERTIFY, ; hat tie Indav'iidijal Sewage Dis sal System co Jstructed ) Repaired by .._ ' _I�'..-. , Via' e. r,.......................__ � '�+�-�,��'y""�,� ��► At • ----•----------------Installer ............................................... has been installed in accordance with the provisions 'of i of ' he State Sanitary Coe as d scribed in the application for Disposal Works Construction Permit No._ ____: O_, .......... dated.....,6-- _ ". _ ------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION,'15ATISFACTORY. k "' DATE-------------------------------------------------------•••----•----•------•--• Inspector------------------------------ -------------•--------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF�...9.4 ...��r„n►............... ........•-•------------....... , .- FEE_..ly --•------•-•---- r,. Permission,is. hereby, granted____ _. ._ �`!'. ___ �- -__-_------�``"' to Cons ct ( ) Repair an n vidual/9 w ge Dis osa S stem I -------�-`'!x'b: -- "' ----- - ------ -------- ---- ----------- 4.0 Street as shown on-the application for Disposal Works Construction P r Noe-- _-_ ____ Dated_`-�"'//�*` '' + _____________ r�, k* 7.7 Board of He DATE-- • .•................. ---------------------- ........................... .... ^ J 4 FORM 1255 HOBBS & WARREN. INC.. PUBLISHERSJ. ••CJi//{'/'/ /�O '- v S • r lea' yr SYSTEM PROFILE TOP FNDN. AT EL, 41.5' TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) �❑40 ACCESS COVER (WATERTIGHT) TO A.H. OJALA, PE OAK cotes MINIMUM ,75' OF COVER OVER PRECAST / WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 44.0' ENGINEER: � a A ,• a s ' A� FOR FIRST 2�L 2" DOUBLE WASHED PEASTONE WITNESS: DONNA MIORANDI, IRS i' AKE DR. 3$.0 iJ �" r 3' MAX., 18" MIN. 9 14 (PROP) PROPOSED 1500 0 �/ H-20 STD. DATE: / /2000 x rr GALLON SEPTIC 37•0' 9 �`" 7EC INFILTRATORS 42.0' < 2 MIN/INCH a 37.2 PERC. RATE = TANK (H- 10 ) GAS 41.62' MIN BA'i 41.79' ` CLASS I SOILS P# v ( 2 % SLOPE) �,6" CRUSHED STONE OR MECHANICAL a GREAT MARSH RD. COMPACTION. (15,221 (21) 0.58' ,. " 41.0' Qr`� DEPTH OF FLOW 4 (�X SLOPE) TEE SIZES: VEG TATED WETLAND 3/4" TO 1 1/2 DOUBLE WASHED STONE INLET DEPTH Q 10" 176t SF) ELEV. p" OUTLET DEPTH ..14" --�.^ � # BORDERING LAND SUBJECT TO _ A 44.0' ROUTE 28 #7 •3�� f FLOODING (ELEV. 35.0') SL WEQUAQUET �3 4��, / 7 - 6 10YR 3/2" LOCATION MAP NO SCALE LAKE .. 36� B g2 LS & ASSESSORS MAP 230 PARCEL 63 ENCHMARK WOOD of i CONCRETE BOUND BOT. TH EL. 34.0' GRAVEL ZONING DISTRICT: RD-1 ELEV = 36,38' 30" 1OYR 4/6 41.5 YARD SETBACKS: FRONT = 30' SAND � Q• CONCRETE COVER ALARM AND CONTROL PANEL SIDE = 10' / TO BE INSTALLED INSIDE .� BEAC R�� P� P PUMPXCHAMBER (REMOVE BOTH BUILDING. ALARM TO BE ON ",OR FILL WITH CLEAN SAND INV. IN .9�' c REAR = lot ) SEPARATE CIRCUIT FROM PUMP --.y 2^ p�S��PtPE TO Q'BOx PROP. BLUESTONE WALK I000 GA+. H-to si _ IN / ,,;•. / 800 GA , VEEP HOLE PERC PLAN REF. — 124 91 3 EDGE OF ` E� ALARM ON BACK to PC / & 12.. 87 FLOAT SWITCH RESERVE HECK VALVE SAND SETTMGS PUMP ON COMPACT FLOOD ZONE: C 0 FLAG ` PROP. DECK (11.6' x 6') 4' WORKING RANGE' I` PQE `� ZOELLER 'WASTEMATE' M/C SAND & POLE SG 4' SUBMERSIBLE MODEL M202 I/Z HP PUMP 'DECK PROP. ADD'N W 2ND STORY PUMP OFF 4• SYSTEM CDR EQUAL) GRAVEL k C` .' 1�` V COMPACTION PUMPSTONE OR oc7o� PUMP CHAMBER 1OYR 5/8 EXISTING _ PROP. REBUILD OF MIDDLE (NOT To SCALE) \ HOUSE a� SECTION OF DWELLING PR P. SECOND STORY 2� 30" MAP L TF=41.5' ; . �:. , - a RE-BUILD FOUNDATION (CRAWLSPACE) 120" 34 0' PROP. SECOND STORY cj moo, `o. NOTE: OLD GAS LINE IN THIc NO WATER ENCOUNTERED NOTES: AREA (HIT DURING TEST HOLE) e �, �;y• SF-PTIC DESIGN: (GARBAGE DISPOSER IS.. 'JT ALLOWED ) 1. DATUM IS BASED ON WEQUAQUET LAKE DATUM SY1 TEM f co o � DESIGN FLOW: 5 BEDROOMS ( 110 GPD) = 550 GPD 2, MUNICIPAL WATER IS - EXISTING 'C,,-G,� P� A ! �. .._—�.1.: F_ A - 550 GPD DESIGN FLOW _ _ _ - 3: MINIMUM PIPE PITCH TO BE 1 /�;" PER FOOT. PROP. VENT - -- __..___-_- - . EXIST. CONC PATIO TG BE I TO?ORocKS- �� a MET .- 5E:PTIC TANK: 550 GPD ( 2 ) = 1100 4. DESIGN LOADING FOR ALL PRECAST UNI r 5 TO BE t1- 11 �" REPLACED BY DECK 1 BOT SHINGLE 5 �� Ul ELEVa39.43' 5. PIPE JOINTS TO BE MADE WATERTIGHT. w. USE A 1504 GALLON SEPTIC TANK LEACHING: AA = 550/.75 = 733.3 SF 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.ENVIRONMENTAL CODE TITLE V. �o N/A 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT of, RR�E o SIDES: TO Bt USED FOR ANY OTHER PURPOSE. BOTTOM: 44.75 x 16.5 (.75) = 553 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. TOTAL: 738 S.F. 553 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT LANDSCAPE TIE C) ST E DRIVE/P RKIN �s, USE 44.75' x 16.5' LEACH FIELD OF 3 ROWS OF (7) H720• INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED RET, -- FROM BOARD OF HEALTH. WALL r- STANDARD INFILTRATORS WITH 2' STONE BETWEEN 10. PUMP & .REMOVE (OR FILL W/CLEAN SAND) EXISTING SEPTIC SYSTEMS ROWS AND 0.5' AT ENDS BENCHMIkRK T \ l CONCRETE BM AD r, � � i .. � r r �� 'p• ,\ ELEV = 45.47' * UNKNOWN LOCATION AND INVERT OF EXIT SEWER LINE. ADJUST AS NECESSARY TO �� �� v f���' ,'� LEGEND TITLE T T� �j c T � PL a� PROVIDE GRAVITY FLOW TO SEPTIC TANK ' ,\ ( f 1 . Q�-� I 1 % �.+.L GUY EX T. L ACH l �I00.0 PROPOSED SPOT ELEVATION of WIRE RHODYs FI D o . 1122 POINT OF PINES \', , L� �✓ �,� •1 OOX0 EXISTING SPOT ;ELEVATION G IN THE TOWN OF: g PYOLE r Y �� , 100 PROPOSED CONTOUR o ( CENTERVILLE ) BARNST A B L E OVERHEAD CAN $� TO COTTAGE 0 OVERHEAD ) . 100 PREPARED EXISTING CONTOUR PREP FOR: 4'1 AND ABUTTINc`s\!I �I �f �� a��, �,oF �� O ROGER BERMAN HOUSES 20 0 20 40 60 J \� BOARD OF HEALTH MA SCALE: 1" 20' DATE: OCTOBER 25, 2000 APPROVED DATE — REV. 1/08/01 (IVW) STONE \ REV. 3/18/01 (DIM) `.\DRIVE `.\ ; oil 508-362-4541 REV. 8/1/0I (DECKS. DIM) ` .` �� t �• fox 508 362-9880 ' A - � I /O OF F. `,p OF k4 OXJUNC �����P ARNE HAcyG °r�� A HNE 4C� PORTION of down cape englneering, Inc. o OJALA �, LA `' UTILITY CIVIL o No. 348 4 LOT B3 �� ``� �/ POLE OVERHEAD TO HOUSE CIVIL ENGINEERS 0. 30792 wPP. 12 G -87 LAND SURVEYORS �o FfcI TEa .�....,- DB 54 .4 PG .277 DB 8922 PG 332 ; 00--211 939 main st. yarmouth, ma 02675 ARNE H. OJALA, P.E., P.L.S. DATE