HomeMy WebLinkAbout0062 PRINCE HINCKLEY ROAD - Health 62 Prince Hinckley Road
Centerville
A= 172-175
r
-L.O;CATION SEWAGE PE_R-IIT NO.
VILLAGE ?D.
[NSTA LLER'S NAME & ADDRESS
BUILDER OR OWNER
C_.f_Al TI!5'X 014A IC
DATE PERMIT. ISSUED
DATE COMPLIANCE ISSUED _�_��°
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No......................... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD .. ' HEA 06
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... oF...... .. ,�..
Applirtttiun -fur Uhipwial Worko Tonstrurtiun Vrruift
Application is hereby'made for Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
systi --a&------ ---- -- .
Locatto ress Lot No.
.... -• ...... ... . ---.... •................................ ............... --....•-•------••-...........................
Address
a ...... am....._ ...•-••-•••-••------------------------------- .........................................40....................................................
Installer Address
Q Type of Building Size Lao/Z,0_410i�5q. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) GarXage Grinder ( iW®
a, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures ----------------------------- -------------------- -------------------------=
W Design Flow............................................gallons per pet-son per day. Total daily flow----------------------------------------....gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter----____----- Depth------------
x Disposal Trench—No..................... Width.................... Total Length-----_-_---_-.___--- Total leaching area--------------------sq. ft.
Seepage Pit No--_----------------- Diameter_---___._________--_ Depth' belo inlet-__-________..-_--- Total leaching area----.-..------____sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by------------------------------------------------ ------------------------- Date-_--------------------------------
W
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..-.-_-.-----.--.--. -
fi, Test Pit No. 2................minutes per inch Depth of Test Pit-----------.-------- Depth to ground water.--_-----_.-------:-_
w' ------------- ---- --- -----.---• - -
__ .__._G
. v 0_
�Description So
--
,
�.U . •
W
U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------.-..--._ --.---
--- ----------------------- ---------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewa e Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned ther agrees not to place the system
operation until a Certificate of Compliance has bee d by th rd of alth.
f'
Da
Application Approved By-------- ----------- -- .. -- -- •-_ llJ- - --------------- --- 9.7.-77
Date
Application Disapproved for the following reasons:----•---------------------------•---•-------••-•-----••-•--------------•-----•-------------•-------------------
----------------------•-.....------------............----------------------------------------•---------•-------------------...-- -----------------------------------------------------------------------
Date
PermitNo........................................................ Issued........................................................
Date
' — T
C7J)
No......................... Fimic ..yam...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_. . _ __.. ... .._ ...-....--.OF................................... -....
Appliration -for Mipoiia1 Works Tongtrurtion Vamit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
---------------------------•---------------.....----•--------------------------------•-•------•--- ---------...----•----•----•-•--••---••••-•---------•-•---••-••----•-•---------.._......------•---
Location-Address or Lot No.
..--•.............................................•-----...-•------
Owner Address
W
Installer Address
UType of Building Size Lot_____________•_.---_____-___Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons..-------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures ----------------------------------------------------------------------------
W Design Flow-------------------------------------------_gallons per person per day. Total daily flow--------------------------------------------gallons.
P4 Septic Tcuik—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth----------_---
Disposal Trench—No-____________________ Width-------------------- Total Length-------------------- Total leaching area-_-__.__..__--.-___-sq. ft. r
Seepage Pit No--------------------- Diameter.................... Depth belo inlet_-.____________----- Total leaching area-------.----------sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) Q;- 'P, //* - �_/ ,/— 7 G
a Percolation Test Results Performed by................... ----------•-------•------------------------------•---- Date--••-------------------•--------------
Test Pit No. I.........._-----minutes per inch Depth of Test Pit_------------------ Depth to ground water-----------------...----
f=, Test Pit No. 2----------------minutes per inch Depth of Test Pit-____-.--- _________ Depth to ground water-_..-._.-_____-__-------
W ----------------- _ .
Descri�tion f Soil - " 4`'� U-�.j,, l—_ '.-7
G
jl
ff I/ r"
Ql = w
W
x
U Nature of Repairs or Alterations—Answer when applicable._.----------------------------------------------------------------------_-------------------_..
- - --------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
'✓fJSigne -
Date
Application Approved By----- --- -------- -- ----"-���f!� -----------1 �7--77
Date
Application Disapproved for the following reasons-------------_---------- ------------ -------------------------------------------•-•-•-.-------------------
---------•---•--••----•---•------•------------------••-----------••-------••••-•---•-----•--------•---•--•-----•---------•---------------------------- -------------------------------------------------
Date
PermitNo.----................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Zr4,tn.................0 F.......... �f . ......................
Trrtif iratr of 0,11utpliartrr
THIS S T CE IFY, That the Individual Sewage Disposal System constructed ( �or Repaired ( )
by-- -------- - - - --------- j
. ------------
l i 11
G ;
has been installed in accordance with the provis_10TVtT.Aeae XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No,✓y._---/_�'--------_......___----- dated.._/'. __ -.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE `�l 7 7 Inspector - C_
P /'--•••-----------•-•--•--•------•--------•--.
THE COMMONWEALTH OF MASSACHUSETTS
gi7 BOARD F HEALTH
No.-------- ----••--•• FEE....
..f
i� >a ttt k � , rtion Vrrmit
Permission is hereby granted_______
!/ V ------ .-
to Constrict�( ) or Rgir ( ) an I d' idual Swage �jis�p�sal &stemat No �'� Vi e�l ! Q �-/� ----------------/-.--�= ----- -
Street 7 _ 7 —7
as shown on the application for Disposal Works Con ruction P riit No. ___.__________.__! tted.... ___________________________________
v�
�. -----------------------
DATE. "� Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy '
Owner information is Owner's Name /
required for every Centerville V MA 02632 6/29/20
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. Please see completeness checklist at the end of the form.
A. Inspector Information
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
00
6/29/20
Inspect o i e 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: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.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
�. ,9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner Owner's Name
information is
required for every Centerville MA 02632 6/29/20
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 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:
r
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
t
c� Commonwealth of Massachusetts
�. ,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner information is Owner's Name
required for every Centerville MA 02632 6/29/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
I '
Commonwealth of Massachusetts
,IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner information is Owner's Name
required for every Centerville MA 02632 6/29/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
1 ,
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner Owner's Name
information is
required for every Centerville MA 02632 6/29/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 Y2 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
ii� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner information is Owner's Name
required for every Centerville MA 02632 6/29/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
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)]
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner Owner's Name
information is
required for every Centerville MA 02632 6/29/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Description:
Engineered plan on file at BOH
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�. ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner Owner's Name
information is
required for every Centerville MA 02632 6/29/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Pumped 2018 per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
I. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�o
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner Owner's Name
information is
required for every Centerville MA 02632 6/29/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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:
Original septic tank, new d-box and chambers 2008 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner Owner's Name
information is
required for every Centerville MA 02632 6/29/20
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
H-10 septic tank appears to be structurally sound, covers raised to 6"of grade
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
Sludge depth: $
>12' '
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness Trace-1/2"
Distance from top of scum to top of outlet tee or baffle
>2"
�2
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
►p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner Owner's Name
information is
required for every Centerville MA 02632 6/29/20
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner Owner's Name
information is
required for every Centerville MA 02632 6/29/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
11
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.):
H-10 D-box appears to be structurally sound, it is 2'6" below grade, cover raised to 12" of grade, no
adverse conditions observed
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner information is Owner's Name
required for every Centerville MA 02632 6/29/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner Owners Name
information is
required for every Centerville MA 02632 6/29/20
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Chambers were video inspected and are damp at this time, no indication of past hydraulic failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner information is Owner's Name
required for every Centerville MA 02632 6/29/20
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner information is Owner's Name
required for every Centerville MA 02632 6/29/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cost.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc•rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
TOWN OF BARNSSTABLE p
LOCATION (O�'Pr t tx.L'"to cV LL: ! SKID SEWAGE# Oog
viLLAGE to(nP Tt ikV t L ASSESSOR'S MAP&LOT r
INSTALLER'S NAME&PHONE NO. 6t�, �&JLT, . S(R'
SEPTICTANKCAPACTTY E KtST!�5 10DOIAt
LEACHING FACILTtY:(type) ^5 �� lrJ�� (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER %L 6rcd StF C trl,ey
PERMIT DATE: COwLIANCEDAL.
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility, Feet
Private Water Supply well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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pq_�$1
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner information is Owner's Name
required for every Centerville MA 02632 6/29/20
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: >132"
I
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: 2008 NGW 132"
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
4' seperation per 2008 compliance
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping shows the site at 58'msl and nearby surface water at 30'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�e
62 Prince Hinckley Rd.
Property Address
Mehedy
Owner information is Owner's Name
required for every Centerville MA 02632 6/29/20
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
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Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
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. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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 Evaluatio by the Local Approving Authority
12-10-12
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. I
t5ins-11/10 ~,Title 5 Official Insp 'o orm:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c�M 62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
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:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11/10 Tide 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
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 ❑ R ❑ 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 a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10=12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**. .
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
r'
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
El ® 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 Y2 day flow
t5ins•11/10 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
°qM 62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
. been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
. Commonwealth of Massachusetts _
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 12-2012
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
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: Not since new in 2008
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2008
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Savage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.) t
Septic Tank(cont.) 1
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle Err
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage.
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•11/10 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
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
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.):
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-11/10 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
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
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.):
Good condition with water at working level and no sign of back-up.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers in good condition and empty at inspection with no visible stain lines.
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-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
page. City/Town 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
page. City/Town State Zip Code bate of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
�3ckc
- o D
[3 G
EE�o 61
-4
A -G - 7-3".9 - 53 `6
t5ins-11/10 Title 5 Official Inspection Form:Subsurface image Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
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:
Original design documents show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Prince Hinckley Rd
Property Address
Steve Shelley
Owner Owner's Name
information is required for every Centerville MA 02632 12-10-12
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-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Town of BaY-nstable r#
Department of Regulatory Services 91
' secs, •
Public Health Division Date 10
Mssa%61 e$ poo Main Street•,Hy#nnis MA 02601
!Fp µl,'l � •�
f � �Time- � Fee Pd. •
Date Scheduled •
Foil Suitability Assessment for Sewage Di osar Q
jw" M. ''V"��/�; Witnessed By:
Performed By: —/---i
LOCATION &{'GENERAL INFORMATION
LoeationAddress .(p2 {�(T�1f�G� NIrJCKLEY Rpgcfl; Owner's Name WIL-LFKE� SHAY
C,E n1TFKv iLl.- ►Vt, �2 p�llJ F4�NUu-EY R�.
Address G El jrr-XVI LLE Mp11 02(.3
Assessor's Map/P;lrcel: 1?214 'Vj I Engineer's Name DA Rye l,' A4, WYEK
�• (sue)�a=ate
NEW CONSTRUd,"20N REPAIR Telephone#
Land Use /� �UY Slopes.(R'o) 5- Surface Stones .
Distances from: Open Water Body ft Possible Wee Area 246ft Drinking Water Well ��S V ft
Drainage Way ft. Property Line > !U ft Other
' ft
i
SKETCH:($treet name,dimensious%f lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
m u� r-) ' 6S PIZ-U 1°U5 4 5 /7E-
4t7 � gg
=, CJ I
C"i i
. i
i
`.I
i
. 1
1 .
F
Parent material(gcdibgic I a-a- j mb."46-4 I Depth td Bedrock
Depth to Groundwater. Standing Water in Hole:' A//6— . Weeping from Pit Face
Estimated Seasonal high Groundwater 4411f— —
DI 'ERMIN�TION FOR SEASO� AL HIGH WATER TA1�LE
Method Used:
!
In
Depth d in. Depth to Solt Mottlgs:
bserved standing�in obs.hole: i in. pioundwatet AdJumttnent �•
Depth tolweeping from side of obs.hole , Adj.factor,,,_4. A4(Jrvundwater V--41,.,._.
Index Well# Reading Date index Well level
PERCOLATIbN TEST Date 9 3 Time
Observation Time at 9"
Hole#
Time at 6" .- ------
Depth of Pere
Time(911•6) ----- —
Start Pre-soak Time.@
l t6 I
End Presoak ! '
Rate Min./lnch
Site Suitability Assessment: Site Passed
�C Site Failed Additional Testing Needed(Y/N)
Original:.Public xalth Division Observation Hole Data To Be Completed on Back. -- --
***If percola�fbn testis to be conducted within 100' of wetland,,younmwnt.firstootify the
'Ray."c+aihiP. rod servation Division at least one(1)wedk prior to beg $
DEEP OBSERVATION HOLE LOG Hole# I
Depth from Soil Horizon Soil Texture Soil Color Soil Other
.Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders.
Consistency.%Gravel
- Lo Cb ►0��4
pt' 't g Lam+L4
s'-72." C o 6l
72"-ram' c 2a s Y (Ol
DEEP OBSERVATION HOLE LOG Hole#
Depih:from Soil Horizon Soil Texture Soil Color 'Soil Other
Surface(in.) (USDA) (Munsell).. Mottling (Structure,Stones,Boulders.
Consistent %Gravel)
dui 1; • p oYr-4/ A
o rcC1
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent %Gravel)—
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders.
Con iste
Flood Insurance Rate Man: v
Above 500 year flood boundary No_ Yes __
Within 500 year boundary No X Yes
Within 160 year flood boundary No k 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? Y6
If not,what is the depth of naturally occurring pervious material? ,
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described in 3,10 CMR 15.017.
Signature Date l U�
Q:WPTICTERCFORM.DOC
TOWN OF BARN1'T I✓E
#or•-,I C e c /e SEWAGE #
1$1s:,LAGE C=G`t �er U , Ile ASSESSOR'S NEAP & LOT
NSTAL.I.ER:S NAME&PHONE NO.
;EPVC TANK CAPACITY `D-�
,EACHING FACILITY: (type) C.- G•�• �S (size) d S
10,OF BEDTlOOMS_,�w-
f A
WILDER OIL OWNS R
a
'ERMITDATE:-----c. __.-, COMPLIANCE DATE:
�eparaeion Distance Between the:
Aaximum Adjusted Groundwater Table to the Bottom of Leaching Facility ee e
Yavate Water Supply'WoU and Leaching Facility (if miy wells exist
on site or within 200 feet of leaching facility) __._ _- feet
,Age of Wedand and Beaching Facility(if any wetlands e '
within 300 fer t of ac1iing facili ) D
L-- . .
Lo ,
0
A-C- a5 '
A - - 6F 19- 5-4o
° G - 73,F
I TOWN OF BARNSTABLE 2 ``
LOCATION C09' et N k0 64,W j �0 SEWAGE# 3 1 0Q
VILLAGE n(50 115 RV l UU— ASSESSOR'S MAP&LOT 1
INSTALLER'S NAME&PHONE NO.�)►�, Lam. So Ov- rI� �O'8(56
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) kx e k S (size) �5
NO.OF BEDROOMS w�
BUILDER OR OWNER J y L fired S R t5 0—
-/ �I
PERMIT DATE: - S COMPLIANCE DATE: f U b
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
09
LO
�{ 5
No. U r L t a. Fee ! U0
�� �-
� r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIpprtcattou for Dtgogal �§pq;tem Con5tructton Vermtt
Application for a Permit to Construct(,) epair Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No.♦ {l�+�GQ. IT t AC,��j'81j Owner's Name,Address,and Tel.No. {' E 51A-& v-I
Assessor's Map/Parcel 17Z +-- 01)// 5 (42 N�ACk (N 67011147q/47
Installer's Na A r Tel.No. �t Q}4�l 4M6�C'p Designer's Name,Address and Tel.No.�'2� ►+"
rv(�44 t
3So rHt,a 5 fi W /o3v 0-14 wt F-0.%04 q% £. 5c,J.O✓ Ick
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 16'%3 L{ TA sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons L, Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 1 O gpd Design flow provided gpd
Plan Date 1 1)e/o-6 Number of sheets 'Z Revision Date
Title
Size of Septic Tank f oUtl !9g90-t. _Type of S.A.S. 1--*-%'CA!nn j (�•'�-
DescriptionofSoil tr.O4✓t. T.t ct WtseA S ,.of
Nature of Repairs or Alterations(Answer when applicable) (y 54t i-W!o (Z j�C(il�Cvt/l L t 4c,�e G4u.t..6"
14.10 w•4VN W all 2:o(QS utt (bop ( hl�..t I7(3.3 !�►�Q
L-c4 c�►.�.,,� �,`e�� �,S`' I 1'3'to Y Z '
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 t ' Boar of Health.
Signe Date
Application Approved by Date — 2-405
Application Disapproved.by: Date
for the following reasons
Permit No. z6o o ,i Date Issued b-----------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(ferttftcate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) ed ( ) Upgraded ( )
Abandoned( )by bl,AL Wc�'�-slL. D•.J J A %, o.xZK)e—
at & PA.`^G 4— 14-L,4!c K I-44 1Ryt has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 20- 00' dated Ck ' 2. '''40ot5
Installer31-J4. Uw4cA RJA,A%4L Designer ` - V v. tm,4 �t YL
#bedrooms 4 ILA,-*- Approved desi w gpd
The issuance of this perm,i 1 of c nstruous a guarantee that the system wi 1 u,Acf . designed. 0
Date Inspector
`Fee V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIppYtcatton for Migogar ,!�)pgtet Cottgtrurttou permit
Application for a Permit to Construct O 6pai�) Upgrade Abandon O ❑ Complete System ❑Individual Components
Location Address or Lot No.,,a �i2.�t It Owner
l /""� 's Name,Address,and Tel.No. �
Assessor's Map/Parcel �
Installer's N m , ddreV,,appd Tel.No la Lv''+��� @ 15&-W-b Designer's Name,Address and Tel.No.1rL'"4t�'',510
J1,0 k/k,vLv,,-t v .S-
Type of Building:
Dwelling No.of Bedrooms .? Lot Size 1 S 41.3 1-1 1,5 sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons R Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) I O gpd Design flow provided gpd
Plan Date °/ o`6 Number of sheets 1�1 Revision Date
Title
Size of Septic Tank 1 000 C!tell 0-t Type of S.A.S.
Description of Soil LA CA 5<< Uf
Nature of Repairs or Alterations(Answer when applicable) V1 5 e �W o -2 CD
Gvk, +4 c� ic�vr_ r,�t1��
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 his Boa of Health. �
Signe �� x-7 �U/tJw� Date
Application Approved by G Date 2 41 0 S
Application Disapproved by: � Date
for the following reasons y
Permit No. Date Issued t
—————————— -- ————— —=------------ ---- �- _ —
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance»--
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( )--Repaired)( ) Upgraded ( )
Abandoned( )by DI i� /l 1?j yf2 q; C-
at(,P I i>+2-' \G +- OR CA has been constr ted in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �Z6 01,;- ' dated �� '�O�
Installer5)I J k LJ 4-r- Z- D-,J"`k 1 -fi A r t Designer G V2 yt t'1-
#bedrooms Approved design-flow (1 f A_ gpd 41
The issuanep.-of this erm' sshaI not.b guarantee construe ds a that the system ald functi., nh—ass dlessi named. fI V
Date p V) �f// Inspector //�f�✓�/I I fry /'1 l cif. t ( �� i�, ,�
ivo. Fee I G C.)
THE COMMONWEALTH OF MASSACHUSETTS �D
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
lwtgoal iip.5tem Con5tructton Permit
Permission is hereby granted to Construct ( ) ®Rek ( ) Upgrade ( ) AbandonSystem located at (O-Z 4'� Y A liC. (
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 this p Emit.
Date ! ' �' GU Approved by a
Town of Barnstable
Regulatory#Sei-vicbs
Thomas xF Geiler,Director
Public Health Division
Thomas McKean,Director
200 Maui Street,Hyannis,MA02601
Office: 508-862-4644 Fax: 508-790-6304
Installer c& Designer Certification Fonan
Date: 10 - 10- OS Sewage Permit# 2P"'6 '31.j Assessor's Map\Parcel 17 2- 7
Designee0-- r t� _ <'`� Installer: J> y �loJ�l�-r S f G
Address. A),) '°'' ��� �� 1 nL ll Address: � I/vwt yJ �(' . 4N�'�9 ''� 02,693 .
On �'i • 7_ `1 - d q was issued a permit to install a
(date) (install r)
septic system at - based on a design drawn by
(address
dated
(designer)
I certify that the septic system referenced above was installed substantially
according to the design, which may include minor approved changes such as
lateral relocation of the distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes
(i.e.greater than 10' lateral relocation of the SAS or any vertical relocation of any
mponent of the eptic system)but in accordance with State &Local
egulat' evisio d as-built by d ' follow.
ZN OF kAS
Sq
D REN cyGN
(InstallePt r
No. 1140
SgNiTAR1Pa v�
1
(Designer's Signature) (Affix'Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION.CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.THANK YOU.
Q:Health/Septic/Designer Certification Form 3-26-04.doc
LEGEND d
_ A' t r eaQ
S I Maslh
PROPOSED CONTOUR � Rar_-°U as'r /n r f t afr
44
® PROPOSED SPOT GRADE fep~` j ,Ln 11` fw
r �j
98 -- EXISTING CONTOUR
(A)
+ 96.52 EXISTING SPOT GRADE
W— EXISTING WATER SERVICE ' fba f/ � tj <`
TEST PIT ' as t f 1 tea, 'S§�'
p i
fc
/ \ '5 9 \ /?
BENCH MARK
\ LOCUS MAP N.T.S.
PAINT SPOT ON
BULKHEAD CORNER �F
ELEVATION = 59. 53
GENERAL NOTES:
� EAP.NSTABLE GIS DATUM
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER.
\`wf ( I \ 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
OF LLOCALERULES AND EGULATIONS.STATE ENVIRONMENTAL ODE, TITLE V, AND ANY APPLICABLE
\ 1 `•.\ 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
O� \ _�v �/� ,/ \•� 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
\58 FROM THOSE ENGINEER BEFORE WN HEREON CONSTRUUCTIONALL BE REPORTED TO THE DESIGN
CONTINUES.
5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
j i �� O= / I \ `• THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
=o i ; \.\ HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
i / O O�,��. I I \_.\ 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
Q r l
TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
LOT 116
/0 ��7 I � I i" 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
�. AREA = 15934 S f CONSTRUCTION.
\ I 10. EXISTING LEACHING PIT TO BE PUMPED, CRUSHED AND REMOVED.
11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION
A 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY
yti i I AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY
58 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING.
14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING.
OF �s� r / `'�� / %/ 15. ALL PIPING TO BE 4" SCH 40 ® 1/8-/FT (UNLESS SPECIFIED)
�` y�DA E M 9�y✓, / i/ 16. SOIL CONDITIONS IN THIS AREA MAY VARY FROM THOSE FOUND DURING
R \ �. �' ; i i• SOIL EVALUATION.
� Existing chpit
1j N 1 0 \, (Note 10)
6/S1E�`
PROPOSED SEPTIC SYSTEM UPGRADE PLAN
+1. 62 PRINCE HINCKLEY ROAD, CENTERVILLE, MA
MAP. 172 Prepared for: Bluewoter Septic
�. i '
Engineering by: Surveying by: SCALE DRAWN JOB. NO.
SURVEY REFERENCE:
I LOT.'175 DARRENM.MEYER,R.S. Eco-Tecb Environmental 1" = 20' DMM
PLAN OF LAND BY CHARLES N. SAVERY, PLS DEEDS 48 83 PO BOX981 508 364-0894
DEED PA GE.-
1 EASTS4NDWICH,MA02537 DATE CHECKED SHEET NO.
DATED: SEPTEMBER 3, 1974 1.
508-M2-2= 09/10/08 DMM 1 of 2
r
TOP
FOUNDATION "NOTE: ALL COVERS TO BE MARKED WITH MAGNETIC TAPE
(Existing)
= 59.67 F.G.EL: 58.5 F.G.EL: 58.5 F.G. EL: 58.0 FINISH GRADE=58.0
:A MAINTAIN 2% MIN SLOPE OVER LEACHING AREA MAX. COVER OVER LEACHING = 3.0 FT.
COVERS TO WITHIN 6 OF GRADE _:
2" OF 3/8" DOUBLE 3/4" - 1-1/2" DOUBLE
►� �• WASHED STONE WASHED STONE
4" SCH 40 PVCk 4" SCH 40 PVC
®®®®- O ®®®®
(MIN.) 10"1 14" ® S= 1% (MIN.) s S= 1% (MIN.) ®®®®®®®®®®®
TEE'S ARE TO BE ®®®®®®®®®®®
A 2 EFF. DEPTH ®®®®®®®®®®®
Y 4" SCH 40 PVC INV.55.80
INV.56.59
I NV.55.60 4' 2 X 8.5' 4'
GAS PROPOSED DB-3
EXISTING OUTLET BAFFLE EFFECTIVE LENGTH = 25'
« •. ... . H-10 DISTRIBUTION BOX
INV. 5 6.8 4 EXISTING 1,000 GALLON SEPTIC TANK INV. ELEV.= 55.0
GAS BAFFLE TO BE INSTALLED ON NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING BREAKOUT
OUTLET TEE AS MANUFACTURED BY PIPE INVERTS PRIOR TO CONSTRUCTION ELEV.= 55.5
2) D-BOX SHALL BE SET LEVEL AND TRUE TO TOP CONC. ELEV.= 55.5
TUF-TITE, ZABEL, .OR EQUAL GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.= 55.0 ®® o ®®
INCH CRUSHED STONE BASE, AS SPECIFIED IN ®®®li3®®EM .
310 CMR 15.221(2) ®®®®®®®
3) REPLACE EXISTING 1,000 GALL014 SEPTIC ®®®®®®
0= 53. ®®®®®®®
TANK WITH 1500 GALLON SEPTIC TANK BOTTOM EL. 4' S FT. 4'
IF FAILED, DAMAGED, OR UNDERSIZED.
4) INSTALL INLET & OUTLET TEES AS REQUIRED ,
SEPARATION 6.0 FT. EFFECTIVE WIDTH = 13
SEPTIC SYSTEM PROFILE BOTTOM OF TESTHOLE EL: 47.0 _ SOIL ABSORPTION SYSTEM (SECTION)
(500 GALLON LEACH CHAMBER (H-10) LOADING)
N.T.S.
SOIL LOGS DESIGN CRITERIA
NUMBER OF BEDROOMS: 3 BEDROOM
DATE: SEPTEMBER 3, 2008 SOIL TEXTURAL CLASS: CLASS I
SOIL EVALUATOR: DARREN MEYER, R.S., CSE DESIGN PERCOLATION RATE: <2 MIN/IN
WITNESS: DONNA MIORANDI DAILY FLOW: 110 G.P.D.
HEALTH AGENT DESIGN FLOW: 330 G.P.D.
Depth s SEPTIC TANK (VOL..REQUIRED): 330 gpd x 2 = 660 gpd (USE EXIST. 1,OOOG SEPTIC TANK)
Elev. TH- 1 Depth Elev. TH-2 De
--e- GARBAGE GRINDER: NO (not designed for garbage grinder)
58.0 0" 57.87 0"
A LOAMY SAND A LOAMY SAND LEACHING AREA REQUIRED: 330 gpd/0.74 = 445.94 S.F.
10YR 4/1 10YR 4/1 USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS (H-10 LOADING)
57.17 B 10" 57.04 B 10" ,
WITH 4 FT. ON ALL SIDES: 25 L x 13 W x 2 D
LOAMY SAND LOAMY SAND
tOYR 5/8 10YR 5/8 BOTTOM AREA: 25 X 13 = 325 SF
55.09 35" 55.04 34" SIDE AREA: (25 + 13) X 2 X 2 = 152 SF
Cl C1 TOTAL SQUARE FEET PROVIDED = 477 vs. 445.94 REQ'D
LOAMY SAND LOAMY SAND
10YR 6/6 10YR 6/6 DESIGN FLOW PROVIDED: 0.74(477 S.F.) = 352.98 G.P.D. vs. req'd 330 GPD
52.0 C1 72" 52.29 C1 67" �Q~�� of Algssq�y� PROPOSED SEPTIC SYSTEM UPGRADE PLAN
2ED. SAN.5Y 6/4 PERC053.0 2.5Y6/4D D M E R 62 PRINCE HINCKLEY ROAD, CENTERVILLE, MA
�
No. 1140 Prepared for: Bluewater Septic
C/SjQ Engineering by: Surveying by: SCALE DRAWN JOB. N0.
47.0 132" 47.87 120" tom' DARRENM.MEYER,R.S. Eco-Tech Ehvironmenta N.T.S. DMM
PERC RATE <2 MIN IN. ( -Cl- HORIZON) PERC RATE <2 MIN IN. (-Cl- HORIZON �NITAR�p EASTSAPO BOX er (sDe) 364-oe9a
/ / (" ) EASTSANOWICN,MA02537 DATE CHECKED SHEEP N0.
NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED .d� ,D$ 508-362-2922 09/10/08 DMM 2 Of 2