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0036 POWDERHORN WAY - Health (2)
36 POWDERHORNE CIRCLE, CENTERV. A=190-008 llll �� UPC 12534 ' No.2-1_53_ HASTINGS,MN N j� o. �V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARN-STABLE, MASSACHUSETTS Yes 01pplitatlon for Disposal 6pstem Construction i3Prmit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3(a PMJb, 9 140 119, q Own��e,Add/�r-�ess,,�and Tel.No. Assessor's Map/Parcel 1910_ Ov(� (1 I I a hk,� P+�s - iN`wtc �► Installer's Name, Nkddrcss,and Tel.No. 5 DV 6r3 f`f Designer's Name,A dress,and Tel.No. �� 6ew)e 155 (�l¢n9 kArrl,r r_S Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Z No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 4 IVO gpd Design flow provided y gpd Plan Date ca® 0'VA f dl 9016 Number of sheets Revision Date 0/ft Title PrO PySeA S01+G gg*r,4�Z_ Size of Septic Tank 1 SOO Type of S.A.S. L-_Aa%&,vS, C.L wLV4_> S Description of SoilF - Nature of Repairs or Alterations(Answer when applicable) - 37NS�A L, JW "CWwL C .-_sC 3 cod b-lwx Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o He lth. -- Signe Date 3 g'? l(O Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ' �/ '"-� 9® Date Issued ----------- ---- ---------- --------- - - -- --- - � ..,,,p 1 1. j/rLJ �O D No. . v _ O _ Fee �D . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BAR STABLE, MASSACHUSETTS Yes j 2ppYication for M18p08aY *pstem Construction 3perTnit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 13(* p ( _," noDr,ij W#-N Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 19®- Oct f`5 Installer's Name ddres�s,and Tel.No. 5 Oil 6c'-�1 43 D signer's Name,A dress,and Tel.No. 7�q 4J t s6N .&—N= P(]. l0� .93 S /4arr iN�oN A.$ Ya c r i ". o;,C. ;rS 2O SO- L^^j-f. MV-.6►N M-I/$ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) jOther Type of Building �j 1�L. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 4 Or 0 gpd Design flow provided i gpd t Plan Date *a0 AlArC.A `am 1(o Number of sheets Revision Date Title PrO P0<0,J SO'I t kpki,Z_ 1 Si ze of Septic Tank 50o Type of S.A.S. �C.W rj 5 YP S. �� r Description of Soil IM GCE cl I Nature of Repairs or Alterations(Answer when applicable) ZNS4 A L NCB) C-� ►^�� C�yq J,a,{�S �,3 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board a lth. Signed �/Date c7 g 11 3.Application Approved by Date Application Disapproved by Date for the following reasons ii Permit No. (J/ kj G 9 Date Issued ------------- THE COMMONWEALTH OF MASSACHUSETTS i BARNSTABLE,MASSACHUSETTS certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( �) Abandoned( )by W tNUN 1%• SP-Ad lA %O 3� at 3 LV1 Taw dwV 401r N has been constructed in accordance with the provisions of Title 5 and then_for Disposal System Construction Permit No�c/& !` � (dated 3 /c z�� Installer W t N s6t4 A - S�4 rJ� Designer RArr,tNsy DN #bedrooms Approved design flow/' Ad q gpd The issuance of his ermit shall not be construed as a guarantee that the system will ction as designed! Dated Inspector V A No. �0 � b _G�G -------------------------------Fee-----�-0------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposar 6pstem Const union pPrmlt Permission is hereby granted to Construct( ) Repair(fit,) Upgrade( ) Abandon( ) System located at 36 t t ►J W''1 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with i Title 5 and the following local provisions or special conditions. Provided:Construction musVbe comp eted/within three years of the date of this pe it. Date -3 /- ,�/O Approved by� Town of Barnstable P# . 1)partment of Regulatory Services S Public Health Division Date �' F MASs. 039. �e$ 200 Main Street,Hyannis MA 02601 Date Scheduled W Time Fee Pd. �k/G Soil Suitability Assessment for Sewage Disposal Performed By: `� `�^� � � �✓ti UY[^. Z , Witnessed By: - V ' le I OCATI( N& CEIVEI ALE FOR1V lTION Location Address 3 { Owner's Name 6r Address !Z f�-e "�o 4—,s /�. �,/� Y�•"� ©Z(o 7-3 Assessor's Map/Parcel: D Engineer's Name C> a✓�r"S��"��•S' NEW CONSTRUCTION REPAIR ✓ Telephone# 7 9 —Z 3 r'7 e-1 Land Use Y - Slopes(9a) 8 " Surface Stones D Distances from: Open Water Body 4114 ft Possible Wet Area ft Drinking Water Well ft Drainage Way ;>101 ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) P Parent material(geologic) Depth to Bedrock > 3 o o t Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater /y DET R lII1 TATI N 1 SEAS.ONA .I Y W TEKTA Method Used Depth Observed standing in obs.hole: In. Depth to soil mottles: in, Depth to weeping from side of obs.hole: in. Groundwater Adjustment_ fR• Index Well# Reading Date: Index Well level Adj.factor Adj,Groundwater?level T I�ET CI LA`f lJl\, l EST tQ. �� Tillie: Observation 0� Hole# Time at 9" Depth of Perc 76-pl Time at 6" Start Pre-soak Time @ �`f D d Time(9"-6") End Pre-soak 6- 10 _ Rate Min./Inch. Z Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-------- ***If percolation percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning.Q:\SEPTIC\PERCFORM.DOC /D 0� (` DEEP OBSERVATION HOLE LOG Hole# / Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel ® / L S /4 y l y/2 tiff c / eO-cfA—d z.5-y6 / '0 4-0 A.,- If DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other . Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel A L- S l G�� Y/Z- 4,0 ZS-/Zd Ai,G 7, 62✓t If'%c�e DEEP'OTISERVATTON H:QT;E LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel DEEVOUSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, o Gr 1 i Flood Insurance Rate Map: / Above 500 year flood boundary No_ Yes,_✓._ Within 500 year boundary No_ Yes Within 100 year flood boundary No— 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? yZIJ If not,what is the depth of naturally occurring pervious material? Certification l � I certify that on l /zq� (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 trai in ex ensexperience escribed in 310 CMR 15.017. Signature �/ Date 3 " IK Q:\SEPTICVERCFORM.DOC I Town of Barnstable Regulatory Services « Richard V. Scali,Interim Director « Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 14 /S 16 Sewage Permit# Assessor's Map\Parcel 0 00g i Designer: t'r(�.�J5, HP.e'tr i N4-(P 6 Installer: t 5�9rJ 5 Address: 01 Le,�. (Ze fff C,m Address: 0. ox a3 S Mo f Ems M,ir1 ,W.Oa.6gr `l Ne"ISA—A. VOICT K, 0aol-- o a3s On 3 a8 au i 10 O,1js6ri fa. S6P PA,,ias issued a permit to install a (date) (installer) septic system at 3C 04-de.rt'w', 0 6-u-77'e-valk based on a design drawn by (addres (sue. '. ara i {�►, �5� dated '70 A44/t 20/6 (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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (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. Strip out (if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance-with the terms of the IAA approval letters (if applicable) o� GLEN �G (Installer's Signature) ERIC oHARRINGTON No.1070 (Designer Signature) (Affix �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. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc Town of Barnstable Barnstable .� Regulatory Services Department A MANST"M 059. Public Health Division • �A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 5005 August 18, 2015 Katherine M. Toomey %Fannie Mae PO Box 650043 Dallas, TX .75265-0043 RE: 36 PowderHorn Way, Centerville MA ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 36 PowderHorn, Centerville,MA was last inspected on August 15,2015,by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF E BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future Ev1\36 PowderHorn Way Cent aug 20B.doc - �'°� Town of Barnstable i Y + BA.NnABLL Regulatory Services Department rfp MA'S a Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE 1 YEAR DEADLINE CRITERIA Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc /Y0 m-OdR Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..�� 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information is required for every Centerville MA 02632 6-15-15 page. City/Town State Zip Code Date of Inspection I:,i t�,iNt 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 ng out forms A. General information on l the computer, _1H OF 14.4ssp���� use only the tab 1. Inspector: ����`� •'9���% key to move your p `��?• JA M E S ••'yR1 cursor-do not James D.Sears use the return — ' key. Name of Inspector I� CapewideEnterprises,LLC *�• o o _ II Company Name s^�� FRTir <5 .z t� � 153 Commercial Street �����ist iN SPGAL �� Company Address few Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 8-15-15 spector'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. Vs t5ins•3l13 Title 5 Official Inspection Form Subsurface Sewage Disposal Sy M Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "( 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information required for every Centerville MA 02632 8-15-15 page. Cityfrown 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: Failed-Leaching. The system is a 1500 Gal Tank D Box and five chambers. 13) 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 ❑ NO(Explain below): t5ins-3113 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 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information required for every Centerville MA 02632 8-15-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 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 36 PowderHom Way Property Address Fannie Mae Owner Owner's Name information is Centervitle MA M32 8-15-15 required for every page. Cityrrown 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 fleet 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 Q 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in csepe+et is less than 6" below invert or available volume is less than Y2 day flow F1,9 /1AIC 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 M 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information required for every Centerville MA 02632 8-15-15 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 faits. 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 foffowing, 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information required for every Centerville MA 02632 8-15-15 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 unacceptabJe)1310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form U1WSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information required for every CenteMlle MA 02632 8-15-15 page. Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.Tank D Box and five chambers. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2013-155,000Gal g ( Y g (gpd))' 2014-139,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA 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 Fond: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 �< 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information required for every Centerville AAA 02632 8-15-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 07 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): t5ins•3113 Tille 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 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information is Centerville MA 02632 8-15-15 required for every 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: 1998 Permit # 98 -521. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2' 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.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 14" 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: 1500 Gal. Precast H-10 Sludge depth: 3" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information required for every Centerville MA 02632 8-15-15 page. Cityrrown 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 27" Scum thickness 3" 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 15" How were dimensions determined? Asbuiit-Tape Sludge Judge 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 at working level. Tank and covers at 14"below grade. In and outlet tee's. Tank shows signs of being over full. Solid's on top of both tee's. 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 r 36 PowderHorn Way Property Address Fannie Mae Owner owner's Name information required for every Centervilte MA 02632 8-15-15 page. Cityrrown 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.): 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•3113 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 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information required for every Centerville MA 02632 8-15-15 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is ITxIT-2' below grade wl2 lines out. Box is loaded w/solids. Box shows sign's of being over full. 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•3/13 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 36 PowderHom Way Property Address Fannie Mae Owner Owner's Name information required for every Centerville MA 02632 8-15-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is five infiltrators wWstone. Chambers are W below grade leaching is failed. Beside and around inlet line black wet sand.Water level over inlet. Need to replace leaching. 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 �<a 36 PowderHorn Way Property Address Fannie Mae Owner owner's Name information Centerville MA 02632 8-15-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 36 PowderHom Way Property Address Fannie Mae Owner Owner's Name information required for every Centerville MA M32 8-15-15 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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: ED hand-sketch in the area below ❑ drawing attached separately B-A A -3`' 33 r t 5-3 t5ins-3113 Title 5 Official bupection Form:Subsurface Sewage Disposal System-Page 15 of 17 r ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name information required for every Centerville MA 02632 8-15-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells �fl Estimated depth to high ground water: 3 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: 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: Per BOH file 30'G.W.. Bottom of chambers 4'-4". Bottom of chambers at 26'above G.W.. 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 36 PowderHorn Way Property Address Fannie Mae Owner Owner's Name informationis required for every Centerville MA 02632 8-15-15 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 TOWN OF BARNSTABLE LOCATION 3(o POWDER14ON4 Wf I SEWAGE# -VILLAGE LENTERMILLE ASSESSOR'S MAP&PARCEL S(-19Q -Moo INSTALLER'S NAME&PHONE NO. Win smart SrEADMAW- 508-19Da1*1 SEPTIC TANK CAPACITY 0 500 G A LLbN EX e 5 e 5 T I N G LEACHING FACILITY. (type) 3— 5300 CALLOW NO. OF BEDROOMS PERMIT DATE: COMPLIANCE DATE: Separation Distance Between :: Q Vep Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility G42DOhl®i1VaT eet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) NIAFeet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching iliG ) NL4 Feet FURNISHED BY �`` BACK DECK- ` �o I5� Cri4LLbN fi ' EXISISi1NG $�pf1C TfNVfL O I ��� AI ,3 Sao l3l �� 2 o s ►U 30 . -5oU a2 a , ti33� 1�3 3836 �owdec�vr�n ; : ° 20 LEACW 95 -S33 05 C"&Rs LIS O No. THE COMMONWEALT F MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for Migpo5ar *pgtem Construction Permit Application is hereby made for a Permit to Construct( or Repair( )a� n On-site Sewage Disposal System at: Location Address�epr ot No. F O % wner's Name,Address and Tel.No. 6 PV.C/ �haul., C. to 176 - 6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. A, S' 136�, Type of Building: Dwelling No.of Bedrooms Garbage Grinder U✓� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) /t �/i k 6/is 6-4.4d [.S'o 40 S-r- y s3,, e Al. L y4,4 t,e 7T,f o p o gr 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 of to place the system in operation until a Certifi- cate of Compliance has been i sued b -oard ealth. Sign Date !< Application Approved by Application Disapproved for the following reasons 411, Permit No. � °� ` Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS i i Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(. )on by AAA t H eo ,d S for G`- :u M / p ev'Jt; Ao 1 has been constructed in accorda ce with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: 1. i 1 1174 Q No. Fee �,.✓�'�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migonl *patent Congtruction Permit Permission is hereby granted to A' to construct(/�)repair( )anon-site Sewage System located t 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. All construction must be completed within two years of the date below. Date: Approved b4e44 ry ''r"'1 No. ~ P Fee ge THE COMMONWEAL OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS } 01pphrattou for ;Dtgpozat *pgtem Congtructtou Permit Application is hereby made for a Permit to Construct( or Repair(')an On-site Sewage Disposal System at: Location Address�sor of No. Owner's Name,Address and Tel.No. 3G d� Afd•v 2[' /r L .�T� .-vl2G �kr2F,a.+ f1.ai�,�I' 7z, en i e- /0 r I Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. i S' f 26 Type of Building: Dwelling No.of Bedrooms- Garbage Grinder(/L"-f Other Type of Building No. of Persons Showers( ) Cafeteria Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. • Plan Date. Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) if f.J f G " 1 r.0 40 S 4, r/1 4 ro 4 5- ley/ 'Si ,4. .d al.d�. ,. l Y 4/ 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 an of to place the system in operation until a Certifi- cate of Compliance has been issued by this-Board of-Health. Sign d!'� �r f Date , /�. � Application Approved by _ Application Disapproved for the following reasons - Permit No.% " ( Date Issued t� 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) 1�y,►� /-9GLC HA^"3 hereby certify that the application for disposal works construction permit signed by me dated F ° concerning the property located at 345 11 A'e)02,✓ C,✓e c 4e meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • �ere no private wells within 150 feet of the proposed septic system • ere is no increase in flow and/or change in use proposed • re are no variances requested or needed. • e proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 4 B)Observed Groundwater Table Elevation(according to Health Division well map). SIGNED : DATE: LICENS SEP SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert I 1 t ��a A, r i J LZ �7� r `ri l .p a5 TOWN OF BARNSTABLE LOCATION 3` w.9 Y SEWAGE # mil'7-S:/ VIL.LAGEC% L/lle- ASSESSOR'S MAP & LOT 42D - 00� INSTALLER'S NAME&PHONE NO.,*"'2Qc y<-. g r SEPTIC TANK CAPACITY I soo G,9//vim✓ LEACHING FACILITY: (type) 17,?A7 ait l' (size) NO. OF BEDROOMS BUILDER OR OWNER �t o��E �2<1C�✓ PERMTTDATE: COMPLIANCE DATE: '_C/8 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) u_-- Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C TOWN OF BARNSTABLE LOCATION je �����=Q�a�"� `vim Y SEWAGE # 2L VILLAGE C oLTr_'",Z v%�� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 7 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) S ��`i��2s�T o�r (size) NO.OF BEDROOMS _ BUILDER OR OWNER (EZO'ZGsf r e z 4e y PERMIT DATE: —��� COMPLIANCE DATE: 8 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 3 � 5/ .✓r> l?4,4To25 va Commonwealth of Massachusetts: Executive Office of Environmental AffairsP Department of Environmental Protection William F.Weld Governor Trudy Coxe :w Secretary,EOEA { David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION �' � Property Address: cv- O'C'd-(1r �e,v`' )�� ddress of Owner: Date of Inspection: �� , -�-t� j�� (If different) Name of Inspector! d� Fho5�-fitm �Company Name, Ad ress and elep er: CERTIFICATION STATEMENT 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 sewa a disposal systems. The system: Passes . r Conditionally Passes Needs Further Evaluation By the Local Approving Authority Faeacopy Inspector's Si ure: Date: f " �The System Inspector shallthis in pection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent t(-• !ne system owner and copies sem to the buyer, if applicable and the appro�ing authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTE PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair"i P passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, 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 conforming septic tank as approved by the Board of Health_. (revised 8125195) One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 Co.*Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A nn CERTIFICATION (continued) Property Address:';:30e p�t�;Yer�'fN Cei%T" Owner: 5��tiV ear Date of Inspection: III SYSTEM CONDITIONALLY PASSES (continued) 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 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 C) FURTHER EVALUATION 15 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 HEATH AND SAFETY AND HE ENVIRONMENT: IS :OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC _ 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 APPROPRIATE) DETERMINES THAT, THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE EN\'IRONINAENT: lhP wmem hat. a Septic tanK anu sciii ausurpliun System an6 iS williiu 'INICCI iu & s4"a1G 'JvalCi SliilNi'�' Oi trlbuid �' t0 d surface water supply. _ The system ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The systen, hes a septic tank and soil absorption system and 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• DI SYSTEM FAILS: / I have determined that the system violates one or more of the following failure criteria as defined 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. _ Backup of sewage into facility or system component due to an over 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. 2 (revised 8/15/95) •A . j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �j /CERTIFICATION (continued) Property Addr ss:c.ad "=�— Owner: � V ev,,� Date of Inspection: Dl SYSTEM FAILS"(continued): 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design floe+, of system is 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: 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 suppiy well' The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. r (revised 6/15/95) 3 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Ad ress: S( Owner: Date of Inspection: Check if thefollowing have been done: V✓/Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates ring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _A built plans have been.obtained and examined. Note if they are not available with N/A. e facility or dwelling was inspected for .signs of sewage back-up.g g P �T-e system does not receive non-sanitary or industrial waste flow � The site was inspected for signs of P g breakout. ZAsystem components, excluding the Soil Absorption System, have been located on the site. TTh'`�The septic tank p manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or t s, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. T e size and location of the Soil stem Absorption S n P y o the site has been determined based on existing information or proximated by non-intrusive methods. The faciiit) G..,dPr ;r, ' occupants, if ddteren! from owner; were provided with information on the proper maintenance of Sub- Surface Disposal System. .rit (revised s/is/95; 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Ad ress: Owner: SL eW Date of Inspection,,� 3 �j FLOW CONDITIONS RESIDENTIAL: `, Design flow-.- 77v allo Number of bedrooms: Number of current residents: ' Garbage grinder(yes or no):.iY Laundry connected to system yes or no)� Seasonal use (yes or no): f Water meter readings, if available: 1`J 0 �" .Last date of occupancy: ���I"�— COMMERCIAUINDUSTRIAL• Type of establishment: Design flow:__gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information:* ) System pumped as part of inspection: (yes or no)_ 1f yes, volume pumped. gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system _�/Ovever cesspool Orflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any). Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) 5 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Ad ress: �U��Y� l�►c1v ��t.tiT Owner: �� � +� Date of Inspection: R 13 SEPTIC TANK:/ / (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP_other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: 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.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom M frttm M bottnrrm of oti!le! tee or battle. 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.) . 3 (revised 8/15/95) 6 i - I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Ad ess: LY6 f�Cj�y,; �✓ :—n Owner: Date of Inspection: TIGHT OR HOLDING TANK:/ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity:—gal Ions Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (Locate on site plan) Depth of liquid level above outlet invert: Comments: (note ii levei and distribuow, eyu6, ev idence of sulid: carr)o�er, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) t (revised 1/15/95) 7 I - y SUBSURFAC E SEWAG E DISPO SAL SYSTEM INSPECTION FORM PART C SYSTEM INFO �j RMATION (continued) Property Owner: I Ad S�ress: .AV ec Date of Inspection: _0a_* SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of veg ion,etc.) Nor L-- C UcV� �10c-• CESSPOOLS: (locate on site plan) 7 Number and configuration'_ «��� -(�Je�.iu.C/ Depth-top of liquid to inlet.inven: c3'/d Depth of solids layer: 1/ Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of ground%+ate . NFd inflow (cesspool must be pumped as part of inspection) Ctf - 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.) (revised 8/25/95) B t 1 9s ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Add(ess: S(Q Otar �+r 41�3'rt�J �'se yaiC vt�11 Owner: "r-6V Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER d �� Depth to groundwater: ✓� feet method of determination or approximation: � TYJw`- 0 C 'S5 Q (revised 6/15/95) 9 a , 4 F r I > I a��1 s�`���•�fly " � '� � ! --------------- — � I n - I 3x 8 rs�ax• a 117 I� I i I 1 ` I i I I I I SCALEA t/G „�y ,rt APPROVED BY: DRAWN B� DATE' ?�/ REVISED DRAWING NUMBER e I � Z G. (a) l �fis e-- /v j,,y s Li c.os�f a kSCAIE:��l/ APPROVED BY: DRAWN BY �7 DAT REVISED DRAWING NUM ER _ e 1 I T _ ' I 1 ; { vv /-� c Y i , , 1 e SCALE: / APPROVED 8Y: [REVISED AWN BY l/ `L✓' � DATLba /7 XY DRAWING NUMpER E:� f II 1 SCALE/ APPROVEDBY: DRAWN BY /7 / - DAL , REVISED. ILL _ DRAWING NUMBER , I I' 1344 l j I � slo i Li - L � I f ---- 1 i l a� l< 'I 1 i SMOKE DETECTORS REVIEWED IrZaPORTA a s -- UPGRADE REQUiRE /�g//S, ST..g. I C,' G`OOr REQiJIU._3 THE UPGRADING OF 1 B3TI►8t�le Bldg.Deb A BOIL I ' DEPT. DATE `. �u Z D 11 r~OR} FOR THE ENTIFIE i iLl� �Fq- ++ ^ -� ONE OR MOPE SLEEPING A} AS,ViH A 0DED C;4 0RE TE0. I FippYaVed by NOTc: A 5E?ARATE PEP Ml IS-REI,JIRc7 FOR THE perttu FIRE DEPARTMENT DATE INSTALLATION 4F ,9,!0 E DETECTORS-THE FLECTilm BOTH SIGNATURES ARE REQUIRED FOR PERMITTING F'-;:R JT `Z T&VISFY THE F.iCS.I!Pl-WEflT. Z�)e.7� 4tr CA SCALE: /I , APPROVED BY: DRAWN BY 9 DATE: � , REVISED 4 fi. 11 a Is T, q alit �, DRAWING NUMBER B.M.= 100.00' ASSUMED ON CORD 17R OF ��°�s S ATE N CONCRETE STOOP AT FRONT ENTRANCE ..GENERAL NOTES 1. ADDRESS: #36 POWDERHORN WAY, CENTERVILLE SITE PLAN 2. ASSESSOR'S NUMBER: MAP '30 PARCEL 008 .Noy 4. TOPOGRAPHIC INFORM LOT WAS COMPILED FROM AN ON THE e�rOtr SCALE: 1 " = 20' GROUND INSTRUMENT SURVEY. Q0\$ CONTOUR INTERVAL=1 5. TOWN WATER IS PROVIDED TO THE SITE & SURROUNDING PROPERTIES. Oa 6. REFERENCE PLAN: PLAN BOOK 204 PAGE 117 O DRIVE 7. UNDERGROUND UTILITIES LOCATED IN ACCORDANCE WITH DIGSAFE #43 TOMAHAWK8. NO WETLANDS OR POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS. 9. SEPTIC SYSTEM LOCATION DEPICTED PER AS-BUILT PLAN ON FILE AT BOH. 0 #20 BUCKSKIN PATH 190-018 10. THIS PLAN SHALL BE USED FOR THE SEPTIC INSTALLATION ONLY. SX 190-019 Proposed SAS town water Provide 3-500 gal H-20 chambers town water with 4' of stone all around. Stk w/ t k Masonic .00 j Lad . .. ROUTE - 28 c-O-MM 11 5 O X 98.24' Lodge FD ' T.H. #1 G. » ::. ................... „CENTERVILLE > .....::.:::. H. 2 10 C3 L4 LOCUS 11_ -10 ® ® ® ® ® ® ® NO SCALE <:: J N 4, 4' Design Calculations Number of Bedrooms: 4 Equivalent to 440 Gal./Day ���5 X - SE�'TION o ::>:> N -� Garbage Disposal: Not allowed with this design ° .:.:.<:<':: m .- Septic Tank Capacity Required: 1,500 gallons observ� lon .,•:•.•::n p O Septic Tank Capacity Provided: 1,500 gallons Existing por t Leaching Capacity Required: 440 Gal./Day 0 98.93 x 8.64 Application Rate for <2 min./inch = 0.74 gal/sq. ft. o c deck N Proposed Leaching Structure: 1-32'x13'x2' Leaching Trench Bottom Leaching Area Provided = 416 Sq.Ft. o 99.53 o z N .� o Side Leaching Area Provided = 180 sq. ft. CD D OD is o Total Leaching Area Provided 596 sq. ft. o m Leaching Capacity Provided =596 s ft X 0.74 al s ft.=441 d. _ o = g p y q 9 / q r___--9 P EXISTING garage o N /,.DWELLINGi° 00 slab at grade z CUNSTRUCTION NOTES First FI elev.=101.22 / � D 1. Contractor is responsible for Digsafe notification 99 37. n0. 36 I and protection of all underground utilities and pipes. Q 9.01' X 2. The septic tank and distribution box shall be set level on 6�� of 3/4 -11/2 stone. X �9.44 0, JJIL EVALUATION 3. Backfidi should be clean sand or gravel with no B.' �) ::::::::.....:::::::::::::::. -- - _ stones ovc. _ I n s.ze. z� U. I�Ji . :::::::::::. :::::::::::::::::. Date of SOIL EVALUAIIJN: March 16, e.016 ' Evaluation Performed E' Glen E. Harrington, R.S. 4. This systel Is subject to Inspection during Installation 99 v I Y 9 , Excavator: John Graci to Glen E. Harrington, R.S. o : ::::::::::: Percolation Rate:< 2 nipi, 24 gals applied during presoak 5. The contractor shall install this system in accordance 3 ;.::;:;.;;;•:;;•;; Witness: David W. Stanton, R.S., BOH Agent with Title V. of the Massachusetts Environmental Code. Li > I and local Board of Health Regulations. .:. .':.'.':.':. L :.'. .'::::.. Q X 98.96' ° Test Hole Test Hole 6. If, during installation the contractor encounters any ..... .......... ............ : ::::::::::: < :`.<: : : : I No. 1 No. 2 soil conritions or site conditions that are different r ; ? : : : : i o_ ti DEPTH SOILS ELEV. DEPTH SOILS ELEV. from those shown on the soil log or in the design, LOT 42 :;..? : : :::� : ' o ss.5' o ss.4' PERK TEST 14975 o # the installer shall halt installation and immediately notify AREA= 16 780_ s ft ::;. ::::::: -} sq.ft A A DEPTH: 36"-54" Glen E. Harrington, R.S. loamy sandloamy sandBEGIN SOAK: 00:00 g 1OYR4/2 " 110YR4/2 END SOAK: 06:30 7. No vehicle or heavy machinery shall drive over the 10" 8 TIME: 6 MIN. 30 SEC.= UNABLE TO SOAK, ' USE <2 MPI FOR DESIGN PURPOSES FOR CLASS 1 SOIL septic System unless noted as H-20 septic components. 11 5'00 Jam mBwsan loamy 98.57 27" 1oYR5 s s7.25' 25" 1oYR5 s s7.32' 8. Install Tuf-Tite gas baffles or equal on septic tank outlet tee. hydrants --X 97.59' 36" 9. All piping shall be SCH 40 PVC. t p .:::.::::.: . . .: .:. 8 proposed SAS. gel. pole c1 C1 PERK 10. No wells are located within 150 of p -76 - ----- - �edge of pavement me aniline me amine 54 11. Install a 4 dia. SCH 40 PVC vent with carbon filter, as shown. Maintain vent for the life of the soil absorption system. 126 89.0' 120" 89.4' 2.� 7/2 2.5Y 7/2 12. Remove leachate contaminated soil from existing SAS and replace " �6 WAY /��/ No Observed Ground Wa�,er with fill according to 310 CMR 15.255. n 0 W D E �-I O V V / � I 13. The Contractor shall notify the Board of Health and the Designer r Soil Evaluation Certification at least 24 hours in advance to inspect and certify the system. I certify that on October, 1995, 1 have passed the soil evaluator examination approved by the DEP and that the analysis was performed by me consistent with the required training, expertise and experience described ;n 310 CMR 15.017. PROPOSED SEPTIC SYSTEM REPAIR PREPARED FOR { GLEN E. HARRIN TON, R.S. GRArl SEPTIC INSPECTIONS, LLC . AT Existing Dwelling SYSTEM PROFILE #36 POWDERHORN WAY First n. = 101.22' Not to Scale 3 HOLE H-20 (CENTERVILLE) BARNSTABLE DIST. BOX Provide 4" dia. observation port Existing Grade = 99.4' Finished grade over system=-2% slope away Existing Grade = 99.5't to 3" of grade Septic tank covers must be D-Box cover shall be OWNER: AMANDA & OSHANE BROWN CELLAR pcover in. 2"-1/8"-1/2" Double-Washed Stone WALL S = 0.02/FT ' within 6" of finished grade within 6' of finished grade thin 6"Hof rfin shed shall e 9 LEGEND ' 9 or eo-textile filter cloth - " S=0.01'/FT To of Peastone Elay.=96.8't �- Approximate location PREPARED BY: Level for 2' S=o.01 ft/ft gas line �•(k$OF, 14' EXISTING Invert Elev.=96.32' A roximate location 1,500 GAL. 12' - w pp ` Glen E. Harrington, R.S. 21' 3 � G � ® ® water lineUL SEPTIC TANK P=96.53' 24" -18- Existin contour j Leda Rose Lane H-10 = I C3 o 1--3 ® g Bottom of Leach Install Gas Baffle 32' Facility Elev.=94.32' EA Ex.1,500 gal. H-10 loading ;� i ? a rStO n s Mills, MA 02 648 Inv. elev.=97.07' or a ual P=96.70' septic tank I: 774-238-1813 3/4"-1%" Double-Washed Stone 5' Min. 1 6" -0F 3/4"-11/2".STONE Existing SAS to be EMAIL: gharr880hotmail.com LEACHING CHAMBERS Bottom of Test D El pumped $c filled � , .,. 6" OF 3 4"-11/2" STONE f� �., ' / Hole #2 Elev.=8s.o' ' 20 DRAWN' BY: GEH DATE: 20 MAR 2016 DATUM: ASSUMED FILE: Graci36Pwdrhrn SHEET 1 OF 1