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HomeMy WebLinkAbout0368 PRINCE HINCKLEY ROAD - Health 368 Prince Hinckley Road Centerville F/R A = 171 175 TOWN OF BARNSTABLE .C- LOCAf`iON��$L,82P�� f�'Z�l�cs y RP SEWAGE # /ZS— VII;LAGE'„`�F/�/E V I LL�7 ASSESSOR'S MAP & LOT 1'7 'INSTALLER'S NAME&PHONE NO. A 1 G CAN(fO SEPTIC TANK CAPACITY t�t /d738 j LEACHING FACILITY: (type)C2- 60C) �I � / (size) 62S xis/XCA ' NO.OF BEDROOMS c 3 BUILDER OR OWNER ���Tf7 PERMIT.DATE: t:` COMPLIANCE DATE: 'r Separation Distance Between the: ,Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet. Y Pnyate Water Supply Well and Leaching Facility (If any wells exist'' , on site,or within 200`feet of leaching facility) -Feet' Edge of Weiland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r 63 1 1 ,� No. Fee if ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.>' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPYication for Mi000ar *potem Cougtructiou Permit Application for a Permit to Construct( . )Repair( �ade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No.368 ���� 12,1C c/Y Owner's NNalne,Address and Tel.No. Assessor's Map/Parcel Z17r C61L� Installer's Name,Address,aA I& , Designer's Name,Address and Tel.No. CANCO '— ObvN6A) 350 Main Street W. Yarmouth, MA 02673 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 �a gallons per day. Calculated daily flow _ 3 O gallons. Plan Date '/a • Number of sheets ! Revision Date /ice Title �- / — �t✓.4A c Size of Septic Tank /O-lh� in/i✓✓ccy Type of S.A.S. S_0 y '1 Description of Soil iC 1� 14,,7 Nature of Repairs or Alterations(Answer when applicable) :1�� P/*", 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' ed,Dn,y ti Bo o Health. Signed 0' Date Application Approved by Date Application Disapproved for a following reasons Permit No. Date Issued ` Fee e. THE COMMONWEALTH OFWASSACHUSETTS t Entered in computer: "+ PUBLIC HEALTH DIVISION -TOWN-OfARNSTABLES MASSACHUSETTS Yes (pprication for Pi5pogar *p5tem Construction permit Application for a Permit to Construct( , )Repair( t,4epgrade( )Abandon( ) O Complete System ❑Individual Components ;F le Y O Location Address or Lot No. 'Z�B ��: It, 2 Owner's Name,Address and Tel.No. Assessor's Map/Parcel fAi Jl-e Installer's Name,Address,and Tel No Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ��S gallons per day. Calculated daily flow 33 U gallons. Plan Date 3' �� ' `/ Number of sheets Revision Date "V/�} Title gc Ilj Size of'Septic Tank /DUv Type of S.A.S. .5 D 6 'f Description"of Soil ��� /� Y► I . - 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 issu d by this1Bo o Health. Signed(— 1 \ l 0' ,,,� ��A", Date Application Approved by ,'ls�Y , f Date Application Disapproved for the following reasons r - W V Permit No. /� �i--> Date Issued —(— — --- -- ----- — — THE COMMONWEALTH OF MASSACHUSETTS >/ ,l,,, BARNSTABLE, MASSACHUSETTS Zertificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( �graded( ) Abandoned( ) r/1:::)A)r O at Ice Y a been constructed in accordance with the provis'ogs of Title 5 and the for Disposal System Construction Permit No.' �I dated Installer (�N aj Designer -1 1 dry o The issuance of this permit shall not be construed as a guarantee that the system,w41 function as designed. Date /2,�?u Inspector ------1—=-------- No. f /� �j% Fee �a v i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS 30igpo5al *patent Con.5truction 3permit Permission is hereby granted to Co truct( )Repair( UU grade( Abandon System located at C e �7`»cG�/G 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:C70truhtion mu t b e c mpleted within three years of the date of this lm it. _ Date: Approved by V r i TOWN OF BARNSTABLE fc— LOCAnON _f /� AP, SEWAGE # IO YII: �ti ��� ASSESSOR'S MAP & LOT I _ INSTALLER'S NAME&PHONE NO: SEPTIC TANK CAPACITY eX rs-rl Idal r LEACHING FACILITY: (type) g,,���/ (size}�� X! x NO.OF BEDROOMS BUILDER OR OWNER ®T COMPLIANCE DATE: PERMTTpATE: Separation Distance:,Between the: Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet .. Private Wat 1.er 1.Supply Well and Leaching Facility (If any wells exist" Feet Y on site.or thin 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If.any wetlands exist Feet within 300 feet of leaching facility) Furnished by i - r rr i Town of Barnstable °&j"E Tyo Regulatory Services Thomas F.Geiler,Director BAMSrABM Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: May 12, 200+ Designer: bk(z(zeq Installer: f Address: . F,®° 1301C C.7 t Address: F, - o2-Ss7 , gym lm( On 3 U l 6q;AJ60 was issued a permit to install a (dat ) (installer) septic system at `368 P;tln10E AA-Q based on a design drawn by (address) �1'kR(�q IV,. M,F_', E=K dated 3//-Z/Oy. / (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved-changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. o=y u/ DARR ,2 o M. li RAJ (Installer's Signature) 4` o.YE,40 1 TS V S�NITARIP� (Designer's Signature) (Affix Designer's Stamp Here) 0 PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIE. BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form 1 FhLED INSPECTION i Cv COMMONWEALTH OF MASSACHUSETTS z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED oqM 5�6 v` 350 MAIN STREET WEST YARMOUTH,MA NOV 1 8 2003 508-775-2800 TOVN,'N OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 171 PAR 175 Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner's Name: BOOTH,MARTHA Owner's Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Date of Inspection OCTOBER 30,2003 Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco Mailing.Address: 350 Main Street West Yannouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 Needs Further Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: �Q 3 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 tot he buyer,if applicable,and the approving authority. p Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner: BOOTH,MARTHA Date of Inspection: OCTOBER 30,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/A _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner: BOOTH,MARTHA Date of Inspection: OCTOBER 30,2003 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to detenmine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 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 public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner: BOOTH,MARTHA Date of Inspection: OCTOBER 30,2003 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 pit 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone I of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner: BOOTH,MARTHA Date of Inspection: OCTOBER 30,2003 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)has been determined based on: Yes No ✓ Existing infonmation. For example,a plan at the Board of Health. ✓ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner: BOOTH,MARTHA Date of Inspection: OCTOBER 30,2003 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 2003 Was system pumped as part of the inspection(yes or no): 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) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: INSTALLED 1984 PERMIT#84-624 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner: BOOTH,MART14A Date of Inspection: OCTOBER 30,2003 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 12" Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 16" Material of construction: concrete metal fiberglass polyethylene other(explain) Itank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 1" Distance from top of sludge to the bottom of outlet tee or baffle: 29" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: ASBUILT AND 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.): MAIN TANK AT WORKING LEVEL.TANK AND COVERS AT 16".INLET TEE,OUTLET BAFFLE.BAFFLE NOT IN BEST OF SHAPE.NO SIGN OF LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner: BOOTH,MARTHA Date of Inspection: OCTOBER 30,2003 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alann and float switches,etc.): DISTRIBUTION BOX: ./ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: N/A 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.,): DISTRIBUTION BOX LOCATED ON SITE,DID NOT OPEN AS LEACHING 1S FAILED.BOX IS 2' BELOW GRADE. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): V Title 5 Inspection Form 6/15/2000 8 1 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner: BOOTH,MARTHA Date of Inspection: OCTOBER 30,2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ./ leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT IS 45"BELOW GRADE WITH COVER AT 2'.WATER LEVEL AND STAIN LINE IN PIT IS HIGH.PIT NOT LEACHING.LEACHING IS FAILED. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner: BOOTH,MARTHA Date of Inspection: OCTOBER 30,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. � BAR O Title 5 Inspection Form 6/15/2000 10 I Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 368 PRINCE HINCKLEY ROAD CENTERVILLE,MA 02632 Owner: BOOTH,MARTHA Date of Inspection: OCTOBER 30,2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: USGS AIW 230 WELL /0 to Title 5 Inspection Form 6/15/2000 11 Rd wo", 16N SEWAGE E PE RMIT NO. 30 U VILLAGE I N S T A LLER'S NAME A ADDRESS F -,(, .r`" a a . 10 L D E R OR OWNER cAt&,,-.., -e4�� DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED ��j' 0 do' No. ��'.. Zl..... Fmc.. ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF..........................................----------..--------------............._..------ Appliratiou for Biipnial Works Tonstrnr#iun Urrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at• , .. r.ea.............................. ........ '3 ' . .• ----"•'',---• ' .... Locator ddress t No` .. ............ ................. .. .. ._. ..........................-- ...... .. ... . . wner Address W ••.......... . . . .................................................... Installer Address Type of Building Size Lot....... ._ ....Sq. feet U Dwelling—No. of Bedrooms.................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building No. of persons............................ Showers Q, YP g ------•--•-•----.-••.-•-•--- P ( ) — Cafeteria ( ) a' Othe —12 d ---------------••-•---••--.•----••...•--••-•----'-•-•-•--•-•---------•-•-.__-----------......---•--•--•--.........-----.-- W Design Flow.......... .....�......... . _gallons per person per day. Total daily flow__-_-.._------ ..��.._..._...gallons. WSeptic Tank—Liquid capacity]. lons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width...........:........ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..._ .-_ meter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.............................................................•----•-•----• Date.................._..................... a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------------------•-•-•--.........-..................--•-•----•--••....................................................-•-...... 0 Description of Soil....................................................................................................................................................._...........---•-... x U -----•-----------••-••----•-•-------•--•-----'---------------•----............-•-•....••--•-•-•-••--•••--•---'..............-•••-••...--•--•-•-'---••-........---•--•....---'--......•----••--•-••..... w x -•-••---------------- ------------------------------------------------................................----'••••-•••••-•-----'---•••---••••-•-------•-•---•--••....................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... . . . ..................... Agreement: undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the r •isio s of TIT 5 of e State Sanitary Code—The undersigned further agrees not to place the system in er on C cate ompliance has been iss ed by the board of li th. (/ te pl' ation Approved BY-----..... .... .........-••.........................'--'--..........................._......•• -•--- .. •-- .. ........... Date lieation Disapproved for he ollowing reasons-................................................................................................................ .........-•---•--------•---------------------------••--•-•-•.......••-•.........................................._.................................................................................... :.. Date PermitNo......................................................... Issued.............-......................................... Date L No........................ FI�a.. ...�:?................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. ....... . . ............OF......................................... Appliratiun for Diiipuuttl Workii Toniiitrurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: {� �J .._......••. _ 4°° f e to r." - " ,f- / c: t ! L� Locatwn Address o¢Lot No .................. f r r. !... =x- .....................-- ..............---•--. ............................. Owner Ad W dress Installer Address � Type of Building ,� Size Lot_...�c.................Sq. feet aDwelling—No. of Bedrooms........... _________________________EExpansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOthe�rfixtures,,,,,c............. ...•--•------------•--.....---....---•----•-••-•-........---•-...........•--......_.....---------•-.....---....--•-••................ n Flow "`' _ '�,r lons. W g -�_.`7................gallons per person per day. Total daily flow__._......_.__. �-_am...- gal 1x Septic Tank—Liquid capacity#.�—,-r.'"Gallons Length................ Width................ Diameter................ Depth._......._...... Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area................... Seepage Pit No.... .._.._�' '. I eter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --••----•-•--•-----•............................•------.........._........--------•--•-•----._....._........--•-•-•---------••-••••-........_............--- 0 Description of Soil........................................................................................................................................................................ x U •----- w --------------- ---------------------•----------------------------------------------------------------------------------------...---------------------------------------------------------............. U Nature of Repairs or Alterations—Answer when applicable....___......................................................................................... ---------------------------------••------------•-------------------•--•-...-•-••...•-•..... Agreement: undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the r is s of 'PT-5 of e State Sanitary Code—The undersigned further agrees not to place the system in er on �C cate ompliance has been issued by the board of h Ith. Vie, ., �, ` fL lr r ned ._�n...............•--•••a ...e"-e ..... .....t.......0 7` r /* < to pl' at on Approved By--------- -•-•- -------------------•------•----•-••------•----•--•--------•-•-••-•-••-----...... dam'' �> e lication Disapproved f o th following reasons:••--------------------------------------•--•--------•----•---•-------------••--•--------------------............ ----------•---------•----------------•---•---•-----------•--•------------•-•------------•••-•-----•••-------.........---•------------•------------•-•------------•--•----------•--••---•----•••.._...••. Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF ..................................... Trrtifiratr of Tomplianrr TWS IS TO CERTIFY, That the Individual Sewage Disposal System constructed �or Repaired ( ) by .............................................% = r l- --------- - / Installer i at----------.. •----•-•----. ••:........... ............ -------------------•-----•......----------- has been installed in accordance with the)p�visions of TITLE 5 of The State Sanitary Cod was d ribed in the application for Disposal Works Constrckion Permit No.�'!:.—. . ................ dated_- .____�/�... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE S AGUARANTE HAT THE SYSTEM WILL,I JN I SATISFACTORY. DATE.......2...................� ..............................•-••--••... Inspector -------•-•-•-•---•-••-----•------------------------------------------••-•--------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4 j. .................. .......................OF..................................................................................... N ......................... FEe.!................... Rupo�,�l orku �onutrnrtion rrntit Permission is hereby granted.l---•'=.L e.:.....................:...:. to Construct ( ) or Rq4 r ( ) an �I-n�yr�ivaI Seri%age Disposal System --r" ✓ , 1 . �- Z at No °" ` _, Street as shown on the application for Disposal Works C nstruction P- ' No..................... Dated.......................................... ...... .......•----•--••........----•-------.....-----•-•-------•..._.........•--•------•-. DATE.............../`:.o�I.....--•--------------------------.....--------- Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON �a1►� GLG- FAMII-Y - ;3 BCUROOM Y � WO "GARBAGES DAlLN( F�-0W z II•Q A 3 = . 730G.P. R 5EPTIG TAQK = 330x15�% 5 ��1 0%5Po5AL PIT V6I~ 1000 GAL, r s.F x 2.5 3?5 G.Po T REA 4 5 S.F x 1• o f -7oTQ.1-. -Tc:,TAL. LEA►LY FLOV4 33o G,Po. .�5 + PLOP F 263' 1 it , PE2COLA.TIC)N RATE ] 1"IN ZMIN oP--La55� o tN Of ��s ,?%`;N of M, r 6xT 2162RICHARD AeeA OAVIO 1� A. t �• THULIN �+ _ p BAXTER i No. 29976 'No.24048 p GjVll.ti� ( 157.7Z �Q s?��`yb`�' APp�Fs�lstf���`��`' 30I 4,Vo RJR ONAI + i s I $u TEST P4 fG = Sj= TOP FNU - joou ! 5✓R„SvjL. DjST• INY. 56P��� $i•Y ( � Z 1 �poo ItJY, DuxL TgNK —/O y ' f .. 63 ! s' ? SA/Ja�/ LE liCLl ��. 3 G,j�y P iT I N Y. INV. WIT u a $3•Z 53►� /z 7 WASKGD4-7 1 5Ta lyE 410 I� CER.TIFIEP PLoT PLAN _ s j Sava P _ L O Z A-T 1 o N CEt,fWz-vl L-4-6 lImo. NO SCALE Scp.LE Il T�ATE G'Zo-$d i-ot3 13 REF E P-E N C E '. _R i I: cE RT►FY -THAT Tµa Fotlh W rlc/A 5NOµ(N GOMPL`(5 WITH "CH S I DELIN rc LdT � i 1' A► P SET5AC 2.6Q�IR.EMENT� o''IIF '�µE- PL�11.1 F02 ,4LA>> +� -Ta W N o F S , LOCATED WITNI T►-1C G INS• \-000 PLn.IN �Tt� MAY 13119nd- D AT i✓ 1. I < BAXTEQ.e P.I`(E r "TuI PLv.t.I 1 `.1 WaT ob AN e>STE2VILLE- 5 luS-I-RuMENT Su2v>✓`( Frn1-F,SET.S No'T C3E u5ED"TO COE-TER!^1WE NT ALhLP ti` �MAU • - CCC '•Y v ASSESSORS MAP : NOTES: i�11 TEST HOLE LOGS PARCEL : 0'� 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUATOR : mel�ra �/" C�� THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF DaD 44 A FLOOD ZONE : �lv(� I� rid.•r1Fa—d� lePftWd " S1 &`6 / a WITNESS : 6�lt�T- 1Ja ? „' BAU'3f P—J- - BOARD OF HEALTH REGULATIONS. tl_ REFERENCE : E)V- 474'� DATE : M�CU Uv' _ 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, P O� PERCOLATION RATE :_WG. '�Ms f� SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO a INSTALLATION. 8 °E'S p � d� TH- 1 �tj,1(� TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION a p Did L<JAM �� ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE DETERMINATION. ,u) + ° N l 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS aD SPECIFIED OTHERWISE) LOCAT I ON MAP(N 15) 5) THE DESIGN OF TI iS SYSTEM DOES NOT ALLOW FOR THE USE OF A E GARBAGE DISPOSAL. �tJtf ,S SN 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) 2 T r- � MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON /4. '' A BASE OF 6"OF CRUSHED STONE. eX15PAl6 1 e1�ciq p 77-0 t3c. PomP. '.,:C tvifrE P . a l� �e. ���N.O-vvrJ Pp.`vw .c� SEPTIC SYSTEM DESIGN q, NQ WLI 7L/1-ti FLOW ESTIMATE lo) f�0 V,prr�/�1�.�� ��o___�'1���D�P✓(.��✓- � �tJ�11!�_ 3 BEDR001-0 AT 00 GAL/DAY/BEDROOM - 330 GAL/DAY ' SEPTIC TANK E�(r 330 GAL/DAY x 2 DAYS . 00 sn AY ` 6GAL USE If 000 GALLON SEPTIC TANI6 • CX/S-pN ( '1 SOIL ABSORPTION SYSTEM SE 60 GIvu.oA) P 6 rL)T jr--- t1 o W14 , Sr)Qt ot,,, 51of'-5 (15�L.x l3 tyx 2'D� �- — w. oex,�;,kt,,• ' ® S I Dr: AREA: 4- (t 3)2 x 2_ 0, 7 Y — N -,Y 9 0 See n BOTTOM AREA: 2_° I �-' '7 Zoe SO pk - ---- - 3 5 SEPTIC SYSTEM SECTIONr1�Y . 6X eS-Pti1 eq ak50.s? E . ° 1 {,nisk pa e- t"2 C ; q7,7a GAS 47.f - _ ul � WsaIn4 611 -nc. GAL -7� o w ® � 4(�,�s � LAI 70 \ o 1! U5� SEPT I C TANK lev I'ez) , F�6-r4' 15 7tJC� t F t "ices -f W Sh�� S7 N Gib T�0 t l UM or- 7S /.to Le i®© or A RE SI TE AND SEWAGE PLAN PKI � c / �/ �,o ] LOCAT I ON : 36;£� lnl !/y�ICt. l�! l 1�. I' o. 11�s0 =1 l PREPARED FOR : Y s ��RR I� M. 9" �y�ER, R.S. scALE�.,� (7 43 �f1 STREET T DATE : 3 /,Z t' CN�ZC-�S N. Av� lNo. u S D UXBU RY, VIA 02332 PA-7Z-: SE.P7�Em,3&{Z 31) Pi DATE, HEALTH AGENT (781) 585-029 J