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HomeMy WebLinkAbout0035 POWERS DRIVE - Health 3-5 Powers Drive Centerville... P A _ 167 022 i T Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22, 2009 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 filling out A. General Information forms the computer, r,use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not use the return Name of Inspector key. Ready Rooter, Inc. Company Name r� PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 re"p! City/Town State Zip Code 508-888-2805 S112843 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 0 .1 �--� ~y '. ® : October 23, 2009 =1 Inspector's Signature Date jE�; The system inspector shall submit a copy of this inspection report to the Approving ALMorlty oard. of Health or DEP)within 30 days of completing this inspection. If the system f s a sham sysrai or has a design flow of 10,000 gpd or greater, the inspector and the system owher shall sabmitwe report to the appropriate regional office of the DEP. The original should be sent to the*stemr%wner 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. 35powersdr•03/08 Title 5 Official Inspection Form:Subsurfac ewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22 2009 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: High water usage during summer months due to irrigation. B) System Conditionally Passes: ❑ One or more system components as described in Vthef' onditional Pass" section need to be replaced or repaired. The system, upon completiothe replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in e ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 ears old"' or the septic tank (whether metal or not) is structurally unsound, exhibits sub ntial infiltration or exfiltration or tank failure is imminent. System will pass inspection if th existing tank is replaced with a complying septic tank as approved by the Board of He *A metal septic tank will ss inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicatin that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or hig static water level in the distribution box due to broken or obstructed pipe(s) or due to a brok , settled or uneven distribution box. System will pass inspection if(with approval of Board of alth): ❑ broken pipe(s) are replaced ❑ obstruction is removed 35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts u W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22, 2009 every page. Cityrrown 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 pumZmore times a year due to broken or obstructed pipe(s). The system will pass inspectioal of the Board of Health): ❑ broken pipe(s) are❑ obstruction is rem 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 marine which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface ater ❑ Cesspool or privy is within 50 feet of a bor ering vegetated wetland or a salt marsh 2. System will fail unless the Board of Hea (and Public Water Supplier, if any) determines that the system is functionin in a manner that protects the public health, safety and environment: ❑ The system has a septic tank d soil absorption system (SAS) and the SAS is within 100 feet of a surface waters ply or tributary to a surface water supply. ❑ The system has a septic t and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a sept' tank and SAS and the SAS is within 50 feet of a private water supply well. 35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22 2009 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 le 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 analysi , performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence o ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fail a 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. 35powersdr-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22 2009 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 0 feet of a surface drinking water supply ❑ ❑ the system is wit ' 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is I ated in a nitrogen sensitive area (Interim Wellhead Protection Area—IWP or a mapped Zone II of a public water supply well If you have answered "yes"to a question in Section E the system is considered a significant threat, or answered "yes" in Section above the large system has failed. The owner or operator of any large system considered a signific nt threat under Section E or failed under Section D shall upgrade the system in accordance with 10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is Millis MA 02054 October 22 2009 required for , every page. Cityr'rown 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)] 35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22 2009 every 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 GPD 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 Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 2007=410 GPD 2008= 370 GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: Oct. 19, 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 le 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is Millis MA 02054 October 22, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No records found for new system 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): Approximate age of all components, date installed (if known) and source of information: System installed Oct. 8, 2002. As-built and engineered plans on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No 35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2'8" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2' Depth below grade: 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: 1 V X 5'X 4.5' 1500 Gallons Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness V. Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape measure and dip tube. 35powersdr•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22 2009 every 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 PVC tees in place. Liquid level at outlet invert. Recommend maintenance pumping of seasonal home every 4-5 years. Risers bring covers within 6" of grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal /Co] ss ❑ 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 pumpedection (locate g g ( p p ) (oc a on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ ❑ polyethylene ❑ other(explain): JA 35powersdr•03l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: /swWitches, Design Flow: ay Alarm present: ❑ No Alarm level: rking order: ❑ Yes ❑ No Date of last pumping: Comments (condition of alarm a *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 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.): One inlet, 3 outlets w/speed levelers. Equal flow. No solids carryover. No sign of high water staining over outlet invers. Riser brings cover within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22, 2009 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5-500 gal ea w/ 4 stone ❑ 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.): Chambers located not excavated, 5' below grade. Hand probing over and around SAS found no ponding or sign of past hydraulic failure. 35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is Millis MA 02054 October 22 2009 required for , every page. CityTrown 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, s' ns 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 f hydraulic failure, level of ponding, condition of vegetation, etc.): 35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is required for Millis MA 02054 October 22 2009 every page. City(Town State Zip Code Date of Inspection D. System Information (cont.) 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. 1 I \ ®�;...c.tea`\\ �. '..0 h• �'�' I pT..�r�Av I \ I_ t O : �icil 3 a , 6 k` 5" w Q)4j - � a L35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Powers Drive Centerville, MA 02632 Property Address Dr. Damien Dupuy 148 Orchard Street Owner Owner's Name information is Millis MA 02054 October 22, 2009 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: >5 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: October 2, 2002 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Test hole for new system found no ground water 5' below base on SAS. Accessed local ground water countours and topo mapping. 35powersdr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 EJ'k 27104 P 3275 .;7747 02-04-2o13 & 03 0 22P NOW, THEREFORE, Bartl tt.FalmilytTrustlsbeth M. ewa . Trustees, (owner's name} does hereby place the _ - -. fo(lowin9 restriction on his.abave-referenced land in accordance with his eStFI a: L �f rush the f Land and be binding upon all.successors in title;. ' �i i�,i 1. 1 35 Powers Drive, Centerville, MA J! 72ow�4l ,. may have constructed Niall upon & El bethlot a house {Mtnin irfo snore than 'Ft tl� ��.� bedrooms. (owns * agrees that this shall be-permanent deed restriction ) Trustees, Bartlettt.:Family .Trust affecting Lot 3 loMted on 35 Powers -Drive, Centerville, being shown on the plan recorded in Plan Book 186 Paged 75 and Or on Land Court Plan Niall M. Bartlett & Elsbet M. For title of Bartlett• Family Trust y See Me folloviring-deed $odic 24126': , Page,25.2 • Or Land Court Certificate of Title Number Executed as a s. fed instrument 3 / day of Q N 2 0 i. er's signature Owner's sig Owner's signature f' - �� iTz e K� 4 C?LArmbs r © ss . 20 l3. # I I Them pe onaU a Y ,pPPar the above,named LL. M• , E= known to me to be.the Persorw#ho exe6utad;th6 for ` oin 'Instrument and acknowledged 9 the same.to be free ct and deed,.befor rate, r P'ubfic my-p9mi tss#on <• 1 g x t • �" f 35. POIOCRS VRWtV " c4ZViu,� M e � tA 1 k tT ILI C� �,XtSfi1 N�- env u�, ,l A so 1YY A M d X15TI/ 35 �Ow�KS PKiVE CENTE2VIU.E, MA B�D�o�1 no S a uD FLOoK �RDP�Eb TOWN OF BARNSTABLE LOCATION SEWAGE# { ASSESSOR'S MAP&PARCEL (6 7 s INSTALLERS NAME&PHONE NO�1� ti•4-r.. �ti�.r�—r— %7/-- SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ,-`<zir� Qft�♦ (size)NO.OF BEDROOMS OWNER ,r-, �y PERMIT DATE: 1§ � J©a. COMPLIANCE DATE: C5 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 �..� �g �,c ��J"I ��♦ CCU;b lr- i d�� ! C5< � 3 I . clr�-3j /J Z �p� TOWN OF BARNSTABLE L LOCATION °� � ���y�= � a2J U SEWAGE #P C VILLAGE- �L. ; Cl ii� I% MAP & LOT INSTALLER'S NAME&PHONE NO. %�i -✓ �� %�il�GaG - �i y�1i� ` SEPTIC TANK CAPACITY LEACHING FACILITY: (type)5 -�f--) (size) NO. OF BEDROOMS BUILDER OR OWNER A0 %J t PERMITDATE: 10 O 2 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 Aq C TOWX qQ BARNSTABLE 1-rX-A i 1ON J Ol w� �� �� SEWAGE # -IL',,AGE l � � � ASSESSOR'S MAP & L10Y­(-�lZ"L4" INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS 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 e L � cl �RT 4 v •I 146 � Sb � t3� n �/�/ No. _/��—77 L Fee: ®�VA�/ .,r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' es( PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for i�poml *patent Con.5truction Permit Application for a Permit to Construct - )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 6 Owner's Name,Address and Tel.No. Assessor's MapTarcel �I iCrz JJ 1 I6-7 192, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 0/a",1 CAL 939 /- '" , , �SSI,C�A�-l�'E �i�C��--�f�7 DitJa .lklC • Sod-3G - � 4 Type of Building: Dwelling No.of Bedrooms Lot Size - - g�sq.ft. Garbage Grinder( ) Other Type of Building .01" No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 5 5 ® gallons per day. Calculated daily flow 6 6 12 gallons. Plan Date ;�z . a .2 V Q ;2, Number of sheets t Revision Date Title � -<, — f _4— ._ . S ej^ , Size of Septic Tank I S o ® Type of S.A.S. Description of Soil ,,� , Q ems.¢, "3, 3 ' Nature of Repairs or Alterations(Answer when pplicable) 411 Z21"W.�Z' .9 /9 . —fi— -eeQZ34 10, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Ab4A, Date o d _ Application Approved by Au_ Date Id Application Disapproved for the following reasons Permit No. Do 2—yq4 Date Issued U tl No. o(W.? ! �` ''` 1 • _,. Fee/Ad Entered in computer: THE COMMONWEALTH-OF MASSACHUSETTS 1, ;Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS., J 0(pplication pont *pgtent /onztruction Permit Application for a Permit to Construct( )Repair( -)Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. Owner's�Name, Address and Tel.No. Assessor's Map/Parcel /6-7 Installer's Name,Address,and Tel.No. De'signer's Name,Address and Tel.No. G0mu.--ate .� 9 3 9 /N'Lati•. A S U r/P 410 C & XC',4--i`A-�G/_/1 11---kic . fop- 36 a - ! .s g l 1 Type of Building: Dwelling , No. of Bedrooms Lot Size 070 sq.ft. Garbage Grinder '• Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 5 5 gallons per day. Calculated daily flow 5 5 ,7 gallons. Plan Date /i Tn Q ;Z ber of sheets t Revision Date Title G�j, Size of Septic Tank S O Tyne of S.A.S. 5i Saes J:�Z CL .Jw __ , Description of,Soff G o -3© �.�c i, -?-3, 3 Nature of Repairs or Alterations(Answer when Applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Foard of Health. Signed ,�2_ Date � 3 a O _ Application Approved by S Date /ab o d Application Disapproved for the following reasons Permit No. OU t✓y Date Issued ()3- ----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance r. THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by at 3 has been constructed in accordance with the provis n Title 5 and for Disposal System Construction Permit No pGo2-1/1// dated Installer r~"'��^— Designer a4 The issuance of ' ge t shall not be construed as a guarantee that the s to , wil function a s•• tied-.--- Date t vI Inspector J �' --------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migozar *pztem Conotruction Permit Permission is hereby granted to C,oystruct Repair(� )Upgrade( )Abandon System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of pe f � Date: Approved byS- TOWNr OF BARNSTABLE LOCATION SEWAGE # —��` f VILLAGE ILjASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �w—'��� A�"�i (size) NO.OF BEDROOMS -�L BUILDER OR OWNER J 2 t U PERMITDATE: 10 U 2 COMPLIANCE DATE: Io du2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) .Edge of Wetland and Leaching Facility(If any wetlands exist _- Feet within 300 feet of leaching facility) Furnished by o Q � t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION p J a TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE DISPOSAL SYSTEM FORM ; PART A .:: ` CERTIFICATION Property Address: 35 POWERS DR CENTERVILLE,MA 02632 Owner's Name: MARION DAUWER -, Owner's Address: 20 SHADY LANE NEEDHAM MA.02492 � rS �R Date of Inspection: 10/29/01 Name of Inspector: (please print) JOHN GRACI �C�Q�� JS R Company Name: SEPTIC INSPECTIONSs1`�u ��; Mailing Address: <'. P.O. BOX 2119 TEATICKET,MA.02536 1QQ� Telephone Number: 508-564-6813 FAX 508-564-7270 10O D LSH CERTIFICATION STATEMENT HEA , 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: x; X Passes " _ Conditionally Passes _ Needs Further uation by the Local Approving Authority Fails Inspector's Signature: Date: 10/29/01 The system inspector shall submit Inolf py of this inspection report to the Approving Authority(Board of Health or DEP)within }"A 30 days of completing this inspect the s stem is a shared s stem or has a desi n flow of 10,000 d or reater,the Y P g PY Y g gp g ,r 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. r ,� Jl eyy 7 Notes and Comments THE SYSTEM PASSES TITLE V INSPECTION.THE SYSTEM CONSISTS OF TWO BLOCK CESSPOOLS-BOTH '" ' EMPTY AT TIME OF INSPECTION.THE,SYSTEM IS NOT TITLE V-HOW EVER MEETS PASSING CRITERIA AS PER TITLE V CODE. t' �♦art ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This r r' inspection does not address how the system will perform in the future under the same or different conditions of use. f �' x r Tit1P 5 TmnPrtinn Form h/150000 1 `,aF.••,." Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) M fiA?�'eY_ Property Address: 35 POWERS DR CENTERVILLE,MA 02632 Owner: MARION DAUWER Date of Inspection: 10/29/01 ' � Nx,'!0. 9 xr"ra Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D 5 A. System Passes: ; ¢ X 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: . THE SYSTEM PASSES TITLE V INSPECTION.THE SYSTEM CONSISTS OF TWO BLOCK CESSPOOLS- BOTH EMPTY AT TIME OF INSPECTION.THE SYSTEM IS NOT TITLE V-HOWEVER MEETS PASSING CRITERIA AS PER TITLE V CODE. B. System Conditionally Passes: 4 s"` _ 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.', i Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. n/a 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 , < ` : 4 that the tank is less than 20 years old is available. ,tk^ �, ND explain: n/a t n/a 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 offf Health): _ Broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: n/a k # n/a 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: n/a 7 F d � i f x Page 3 of 11 at OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) �`�° Property Address: 35 POWERS DR CENTERVILLE,MA 02632 Owner: MARION DAUWER Date of Inspection: 10/29/01 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 '-��'�Y not functioning in a manner which'will protect public health,safety and the environment: f;'I` _ Cesspool or privy is within 50 feet of a surface water , 4 1 _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh s i I. Y 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the t system is functioning in a manner that protects the public health safety and environment: ' Y g P P � Y _ 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 t'aWand 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 tosdetermine distance n/a "This system passes if the well wafer 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 y` t of the analysis must be attached to this form. '• ,J,'j 4r� p 4 Jk� al�t*f ' 3. Other: 'a d�a 3 afi y I d, F, l Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r'w CERTIFICATION(continued) 7 Property Address: 35 POWERS DR CENTERVILLE,MA 02632 ;:,r" a Owner: MARION DAUWER Date of Inspection: 10/29/01 4 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: r•: Yes No +` x X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspools t�,4u X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow € ,. X Required pumping more than 4 times in the last year NnT due to clogged or obstructed pipe(s).Number of times .f ,. pumped n1a. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 1' X Any portion of a cesspool or,privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. `'''j+'4, _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with i t no acceptable water quality analysis. This system asses if the well water analysis,performed at a DEP P q h' Y � Y P Y +P certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free °'} ,t from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or ,ra less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] New �i (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 IN C f necessary to correct the failure. ' 4 E. Large Systems: C iy 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 f ( g PP Y g Y ) yes no X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply . X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone 11 of a public water supply well s If you have answered"yes" to auiyS 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. Ilk t T 7 Il; d I Page 5 of 11 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST t ': Property Address: 35 POWERS OR CENTERVILLE,MA 02632 Owner: MARION DAUWER Date of Inspection: 10/29/01 `..`a +' Check if the following have been done.You must indicate"yes"or"no"as to each of the following: �'.. Yes No r{ti X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? t; X Has the system received normal flows in the previous two week period? _ X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) :;r , X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? r X _ Were the septic tank manh°oles uncovered,opened,and the interior of the tank inspected for the condition of the + baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance � r of subsurface sewage disposal systems? �L+ The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of&failure criteria related to Part C is at issue approximation of distance is y�t ' unacceptable)[310 CMR 15.302(3)(b)] '' 9?"g X: ar ^� Ti t ;*. F�. ITS� F a. t `i , 5 1 . Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION Property Address: 35 POWERS DR CENTERVILLE,MA 02632 Owner: MARION DAUWER t. Date of Inspection: 10/29/01 , � . .t FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 7 Number of bedrooms(actual): 7 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 770 d Number of current residents: 0Y Does residence have a garbage grinder es or no):NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] a �' Laundry system inspected(yes or no): NO ,,kxr Seasonal use:(yes or no): YES t Water meter readings, if available(last 2 years usage(gpd)): n/a « ; Sump Pump(Yes or no):NO 1 < � Last date of occupancy: n/a AA , k ' COMMERCIALANDUSTRIAL � h Type of establishment: n/a Design flow(based on 310 CN14 1'5 203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO " '� . Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: n/a . 9 Last date of occupancy/use: n/a OTHER(describe): n/a Yll GENERAL INFORMATION Pumping Records l �k Source of information: n/a , t Was system pumped as part of the inspection(yes or no):NO . If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a ';_ to � ; Reason for pumping: n/a TYPE OF SYSTEM ` X Septic tank,distribution box,soil'absorption system Single cesspool _Overflow cesspool , a _Privy n , ' _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): n/a Approximate age of all components,date'installed(if known)and source of information: 1965 FROM OWNER/AND REATOR Were sewage odors detected when arriving at the site(yes or no):NO ,. F b 9 - R� 1 Page 7 of 11 k y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' b SYSTEM INFORMATION(continued) Property Address: 35 POWERS DR CENTERVILLE,MA 02632 '' ' Owner: MARION DAUWER Date of Inspection: 10/29/01 Y. BUILDING SEWER(locate on.site plan) t ,- ;_ F 4 Depth below grade:36" Materials of construction:_cast iron _40 PVC Xother(explain): ORANGEBURG Distance from private water supply well or suction line: n/a s, Comments(on condition of joints,venting,evidence of leakage,etc.): gypsy ': TOWN WATER . SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions:6'X 6' BLOCK EMPTY" ��; si ti' Sludge depth: n/a Distance from top of sludge to bottom of outlet tee or baffle: n/as � Scum thickness: n/a " Distance from top of scum to top of outlet tee or baffle: n/a 1? �; Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED f Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related. 4 , to outlet invert,evidence of leakage,etc.): MAIN CESSPOOL AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND.EMPTY AT THE f TIME OF INSPECTION.RECOMMEND PUMPING EVERY YEAR TO MAINTAIN USEFULL LIFE. , ° GREASE TRAP:_(locate on site plan) RSY+i Depth below grade: n/a °4 Material of construction: concrete metal fiberglass polyethylene_other(explain): n/a — — — Dimensions: n/a ,, Scum thickness: n/akr." ` Distance from top of scum to top of outlet tee or baffle: n/a �� Distance from bottom of scum to bottom of outlet tee or baffle: n/a i Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related a to outlet invert,evidence of leakage,etc.): N A ' n/a # 4 ;. s •,,. rt r; , �a�T Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS p ° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C " SYSTEM INFORMATION(continued) Property Address: 35 POWERS DR CENTERVILLE,MA 02632 t` Owner: MARION DAUWER Date of Inspection: 10/29/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a � v Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a # 34 { Dimensions: n/a Capacity: n/a gallons w' ` Design Flow: n/a gallons/day 41, Alarm present(yes or no): N/AF ` Alarm level:N/A Alarm in working order(yes or no):NO Date of last pumping: n/a fitk� g' Comments(condition of alarm and float switches,etc.): n/a a :. DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) ' Depth of liquid level above outlet invert: n/a i 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-DISTRIBUTION BOX ,a «� r PUMP CHAMBER:_(locate on site plan) Fr r> s Pumps in working order(yes or no):NO S Alarms in working order(yes or no):NO k °` Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a � ik ,g " A . 3 t, 9 i t f, Y Page 9 of 11 ;. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS " N". SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C { SYSTEM INFORMATION(continued) ` Property Address: 35 POWERS DR CENTERVILLE,MA 02632 Owner: MARION DAUWER Date of Inspection: 10/29/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) " If SAS not located explain why: n/a Type z n/a leaching pits, number: 0 ' n/a leaching chambers, number: nla n/a leaching galleries, number: n/a y ` n/a leaching trenches, number, length: n/a n/a leaching fields, number: nla :. 6' X 6' BLOCK CESSPOOL overflow cesspool, number. f.. n/a innovative/alternative system Type/name of technology: n/a w Comments note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc. : THE OVERFLOW CESSPOOL IS STRUCTURALLY SOUND AND WAS EMPTY AT TIME OF INSPECTION. c SYSTEM SHOWS NO SIGNS OF FAILURE. GPD'S FOR SYSTEM WILL BASED ON EXISTING BEDROOMS X �' 110-IF SYSTEM FAILS-IT WILL NEED TO BE BROUGHT UP TO TITLE V STANDARDS FOR 7 BEDROOMS ' ^a.t+1 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a t; Depth—top of liquid to inlet invert: n/a Depth'of solids layer: n/a t � $ Depth of scum layer: n/a Dimensions of cesspool: n/a '` Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): t ' ',; n/a •e;.z, , PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a .. F �>" Depth of solids: n/a I Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc.): g y P g g � i n/a �y e m i s �Y: r Page 10 of 11 i, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C ,;;;;. SYSTEM INFORMATION(continued) Property Address: 35 POWERS DR CENTERVILLE,MA 02632 Owner: MARION DAUWER ..,:�• Date of Inspection: 10/29/01 . 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. �j'". J L•,xr I ri,.: y. V�f O µl a F is N. Y h p. R AA yye d g+ M1 �n Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) Property Address: 35 POWERS DR CENTERVILLE,MA 02632 Owner: MARION DAUWER Date of Inspection: 10/29/01 t. pear. SITE EXAM _Slope _Surface water _Check cellar Shallow wells '.s''`` Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: , NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a F YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,�installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED FROM AUGER-NO WATER AT 12'-BOTTOM OF PIT AT 9' 6" cry 5 �ry t . t• to Fx ' } g 1. x f r R,f... 11 ` " F 30' �V: 8-4" DECK V\ :�`. ro eE ALwr.TF4 5"� .": � JY� i•�\ \ sR"`a—> \ \ \\ \ 5 �H.w NLo '' \ ,10._6. \ \ \ 1 MUD ROOM c' gi i i LAV SS COMPUTER NETWORK IJ CABLE/SATELLITE N 3 ^ 22.500" / IIR DOOR BELUCKIME 3'-10—" �-- 5 4'-2" Hzi4' OPENER 1 f\(LRMER �ORC " ��\• -F� • m FLOORRIC OUTLET�WITN LONER ❑ ❑ ❑ FIRST FLOOR PLAN ' FLUORESCENT SECOND FLOOR PLAN SUSPENDED LIGHT S SWITCH S'-118 oo ELECTRIC DOOR OPENER SWITCH 3' 3' 6'-38" Sc CEILING LIGHT FIXTURE O JUNCTION BOX CEILING MOUNTED(RECESSED) J POLE MOUNTED LIGHT FIXTURE RECESSED LIGHT FIXTURE RECESSED HALOGEN CEILING LIGHT 1C! THERMOSTAT O" -ram WALL MOUNTED JUNCTION BOX(RECESSED) WALLMOUNTEDUGHTFU(RIRE WATT HOUR METER EYEBALL SPOT 1J- �/ \\ FLOOD LIGHT \ < TELEPHONE OUTLET 110 V OUTLET GROUND FAULT 220 V OUTLET ' J SPECIAL PURPOSE OUTI.-(WITH DESIGNATION) SOW DISH WASHER GC SHALL FURNISH d INSTALL F FAN LV LOW VOLTAGE AIR TO AIR EXCHANGE SYSTEM. HID NOT IN CONTRACT t/1 GC SHALL FURNISH Al INSTALL \ PT LIGHT FRAMED AREAS. S( NTB NOT SCALE A PS PULL SWITCH WP WEATHERPROOF C � � EWO ELECTRIC WINDOW OPENER •l WINE STORAGE J ANDERSON .Rl.00w K,wRmnX�R Al T. \ L"� GENERAL NOTESp�Is��� oATWeX 'R -1 PmIATFFaIN1Fa ROCKPORT POST AND BEAM BASEMENT PLAN THIS DRAWING CAN NOT BE P.O.BOX 353.ROCKPORT,MAINS O4856 REPRODUCED IN WHOLE Oft (207)230 8562(888)285 8562 IN PART WITHOUT THE - WRITTEN CONSENTOF ROCKPORT POST d BEAM. DATE OCT 2.02 DUPUY SCALE 1/4'=1' RESIDENCE BY JOHN DYER DWG OF TOP FNDN, AT EL. 26.3' SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SCALE) ARNE H. OJALA PE /25 Pt ACCESS COVER (WATERTIGHT) TO ENGINE1rR•. MINIMUM .75' OF COVER OVER PRECAST WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 25 7' WITNESS: DAVID STANTON 2' DOUBLE WASHED PEASTONE 9 19 Q2 �- RUN PIPE LEVEL DATE: ! ' 23PERC. RATE - < 2 MIN/INCH W FOR FIRST 2' 3 MAX. (PROP) PROPOSEDI 0 o GALLON SEPTI7cl - L11 22.7 RIVER ROAD 22.50' CLASS I SOILS P# a 22.75 TANK (H- 10 GAS � 0 E� C-1 C3 O CJ O m E=] '' . ` BAFFLE 22.17 000c> 22.0 a 21.85' 0 0 Cl M M M C❑ m 10 �' °� ( MI % SLOPE) y E3CDEDd 0 C❑ © COm �� m� �6' CRUSHED STONE OR MF_`CHANICAL c Q?5� 2' F 0 [� [� [] [J [� Q C� �0 19.�5' 1:P ELEV,., I COMPACTION. (15,221 (23) .. ___ o 0� 25.8 r�, / DEPTH OF FLOW = 4 1 1 3/4" TO 1 1/2' DOUBLE WASHED STONE A �"'m LOCUS ( .. % SLOPE) ( % SLOPE) a TEE SIZES+ INLET DEPTH = 10" LS OUTLET DEPTH = 14" 12" 1pYR 4/4 LOCATION MAP NTS FOUNDATION- 23' SEPTIC TANK 33' D' BOX 21' LEACHING B ASSESSORS MAP 167 PARCEL 22 FACILITY 6.05 LS ZONING DISTRICT, RD-1 30" 10YR 5/6 23.3' YARD SETBACKS. FRONT = 30' SIDE = 10' REAR - 10' 35.v 13.8' C PERC M/F FLOOD ZONE: C \ CONTRACTOR SHALL CONFIRM BUILDING SETBACK 2.5Y 6/6 REQUIREMENTS PRIOR TO ANY CONSTRUCTION \ �32.0 + 33.4/ \1 BENCH MARK - TOP OF CONC. BOUND 33- \ 30.o ELEVATION = 29.2' 144 13.8 + NO WATER ENCOUNTERED NOTES: -I-.W 04 y,1 �.- 2-" I 2 .2 _ ASSUMED _I - `SEPTIC DESIGN (GARBAGE DISPOSER IS N(�� ALLOWEfL > 1, DATUM IS 1 ESIGN FLOW; 5 BEDROOMS (J1.0_ GPD) - 550 GPD 2, MUNICIPAL WATER IS FXII�TINr 7. � � O D USE A 550 GPD DESIGN FLOW 3. DESiIFGN LOADING! IF❑R I u B'L i/8s i,Ek r IJLJ l . W ALL PRECAST UNNITS TO BE AASHQ0. 2y,. _ _ - . ..__- --_ ._. ---•�' .�� � `SEPTIC TANK; 550 GPD ( 2_) 1100 y -_._ 5, PIPE � JOINTS TO BE MADE WATERTIGHT - 86.5 �' "' �tf> USE A 1500 GALLON SEPTIC TANK 2 .27.3 -_ �._.. . 26.3 ---- 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS, x a. ,o v� � LEACHING: ENVIRONMENTAL CODE TITLE V 26 _ _ _ Wa p/y �r� µ 2(�47.5 + 10.83) 2 (.74) - 172 7. THI i PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT + 26.` 7 /+� s \ `� 5 SIDES T❑ E USED FOR ANY 07HER PURPOSE. + 3 2� �, i / 32' 47.5 x 10.83 (.74) - 380 8, PIPF: FOR SEPTIC SYSTEM TO SCH, 40-4" PVC. 24 P �,�/ I Z 21.8 ROTT❑M ' SAPID' + 23.2 J 5.8 / j/i x 2 . p TOTAL; 747 S.F. 552 GPD 9. CUIPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT r �1 G .I N IN:>PECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED H �� ; G/,I +/ USE (-5) 500 GAL. LEACHING CHAMBERS (ACME OR FR]M BOARD OF HEALTH. + 25.6 _ + �J/ EQUAL) WITH 3' STONE AT SIDES AND 2.5' AT ENDS 10, PUM 9, REMOVE EXISTING SEPTIC SYSTEM 1 - / 17.9 -- r o PATIO 23,5 _ 24 \� EXIST._ c�5 DWELL. ` �g6.2 / r,i - DECK i ,� ; � ,S EMEND 263 d) PL TITLE 5 SITE AN ��: PROPOSED SPOT ELEVATION 17 35 POWERS DRIVE 100x0 EXISTING SF'I�T ELEVATION p.x- l� `y �� IN THI:_= TOWN OF: �� , `� 00 79 �� s PROPOSED CONTOUR ( CENTERVILLE) BARNSTABLE �� 11 6 10 0 EXISTING C❑N T O U R PREPARED FOR: D A M I A N D U P U Y -- 10.6 + 16. 17 - -17 + !/- 30 0 40 60 90 BOARD OF HEALTH + 12.17 -.�-.�_--. L=32.32' R=21.70' MA SCALE: 1" = 30' DATE; SEPTEMBER 21, 2002 LOT 3A APPROVED DATE 20,888t SQ. FT, 0.48f ACRES off 508-362-4541 fox 508 362-9880 Is• -,� pub",�.�-' WELL down cape engineering, inc. �*/ ARNE-, yt ' ARNE: H. G� � H. J NOTE: SEWAGE EJECTOR PUMP WILL BE REQUIRED FOR OJALAALA n ' EXIST. BATHROOM IN BASEMENT CIVIL ENGINEERS Q CIVIL o.30792 y 26. LAND SURVEYORS �' FC TER` NAL a '� 7ay/�. .., 02- 302 939 vain st, yarmouth, mo 02675 - --�-- ��- - H. OJALA, P.E., P.L.S. DATE TOP FNDN, AT EL. 26.3' SYSTEM PROFILE TEST HOLE LOGS . , ACCESS COVER TO WITHIN 6' OF FIN, GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) TO ENGINEER ARNE H. OJALA, PE /25'± MINIMUM ,75' OF COVER OVER PRECAST WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 25 7' DAV{D STANTON WITNESS 2' DOUBLE WASHED PEASTONE 19 02 I_ RUN PIPE LEVEL DATE l / _ 23, La FOR FIRST 2' 3 MAX. < 2 MIN INCH(PROP) PERC. RATE = l r2 50' 22.7' CLASS -_ I SOILS P#ILL a,,lEa aoAo22.75' IAS22.Or LjC.7E� CO O 0r--1 IiAPPLE22.17' �"" n 21,85' E3Q � 0 Cl mmmG71,� " o MIN 17-7117OED0 C7 m0E-1 ED m� p ( 2 % SLOPE) �_6' CRUSHED STONE OR MECHANICAL �g 2' 0 E1 ED CJ Il EO Q FTO 19.85' Q ELEV,, COMPACTION. (15,221 (23 ©� 0" 25.8 s, / DEPTH OF FLOW = 4' ( 1 % SLOPE) ( 1 % SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED_ SIONE A � � ��o LOCUS TEE SIZES INLET DEPTH = 10" LS OUTLET DEPTH = 114 12" 1OYR 4/4 LOCATION MAP NTS FOUNDATION- 23' SEPTIC TANK 33' D' BOX 21' LEACHING B ASSESSORS MAP 167 PARCEL 22 FACILITY 6.05 LS ZONING DISTRICT, RD-1 30„ 10YR 5/6 23.3' YARD SETBACKS! FRONT = 30 r SIDE = 10' REAR = 10' 35.v 13.8' C PERC M/F FLOOD ZONE. C \ CONTRACTOR SHALL CONFIRM BUILDING SETBACK 2.5Y 6/6 REQUIREMENTS PRIOR TO ANY CONSTRUCTION \ �32.0 BENCH MARK - TOP OF CONC. BOUND 3 - \ ELEVATION = 29.2' 144>r 13.8, \ + 30.o NO WATER ENCOUNTERED.4 NOTES . _ - ASSUMED /' /\ o LPTIC DESIGN: (GARBAGE DISPOSER IS ) 1, DATUM IS :31 s / �,� � =' ._L�t.C)T A LL CLEFL . O ,?ESIGN FLOW; 5 BEDROOMS C 110 GPO) Y 550 GPD 2, MUNICIPAL WATER IS EXISTING Q� USE A 550 GPO DESIGN FLOW` 3.' MiNii`vii M' P '' 'Pl it H l 0 bL- 3ph 3Q 0 fg � EPTTC T < ANK; 550 7�0 GPD < 2 _ 1100 Imo- 0, 4, DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO ) _- -- 5. PIPE JOINTS TO BE MADE WATERTIGHT. 265 �` CJ� USE A 1500 GALLON SEPTIC TANK 27.3 __.,_ , �_ - �O 26.3 0 ��, .,a ----- 6, CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS, �\ W" o. -10 -7 LEACHING: ENVIRONMENTAL CODE TITLE V. ' cr �,.� _ 2(47.5 + 10.83) 2 (.74) = 172 7, THIN PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT ;� j a- \ Ct` "' G SIDES: + 26.` -- " �j a5?b s TOE USED FOR ANY OTHER PURPOSE, + .3 3 2 `1r 47.5 x 10.83 (.74 380 24- `h 2 ;;j 2 _21.g 3OTTOM. �- = 8. PIPE- FOR SEPTIC SYSTEM TO SCH, 40-4" PVC. + 23.2 5.s 'i �� 2 9. CMPONENTS NOT TO BE BACKF-ILLED OR CONCEALED WITHOUT � . r \a TOTAL; 747 S.F. 552 GPI7 rj �1 G �� � IN`>PECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED /� Q - - cy) + 25.6 USE 5 500 GAL. LEACHING CHAMBERS ACME OR - FRM BOARD OF HEALTH. - 2 A ! ( a EQUAL) WITH 3' STONE AT SIDES AND 2.5' AT ENDS 10. PUM'' 9, REMOVE EXISTING SEPTIC SYSTEM Px TIO 0 2 + 2 3.5 _ EXIST. 24 DWELL. �.�c i• / � __._�- TF = 26.3' 20 , 4 2� \/ j 22- TITLE 5 SITE PLAN PROPOSED SPOT ELEVATION 974 13.0 35 POWERS DRIVE 100x0 EXISTING SOOT ELEVATION � O/t,9/ \�F ��,� IN THE TOWN OF: ------ r - I T� S/ tt 1 _ 00 PROPOSED CONTOUR ► ( CENTERVILLE) BARNSTABLE 116 EXISTING CONTOUR 10.6 11 100 PREPARED FOR: DAMIAN DUPUY -17 7;7 // 40 60 90 Y3 i IJ BOARD OF HEALTH „APPROVED DATE MA SCALE: 1" = 30' DATE; SEPTEMBER 21, 2002 LOT 3A R=21.70' 20,888t SQ. FT, 0.48t ACRES off 508-362-4541 fax 508 362-9980 ��N (1 F �4SGr �P�\tl Of WELL down cape engineering, incIC�,rA ��y �� Ri�ENE HNOTE: SEWAGE EJECTOR PUMP WILL BE REQUIRED FOR JALAie7LA ' EXIST. BATHROOM IN BASEMENT C I\/I L ENGINEERS e1vILU 2LAND SURVEYORS ,o • 34792� TERM , ac . y �/ 939 vain st, yarmouth, ya 02675 ay�- , 02 -302 H. OJALA, P.E., P.L.S. DATF