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HomeMy WebLinkAbout0523 PRINCE HINCKLEY ROAD - Health 523 Prince Hinckley Road Centerville A= 170-216 s� - TOWN OF BARNSnT,A�BLE ie LOCATION Pr �c� I NC�c�py 1'�i SEWAGE # o VILLAGE cs�-� °r ,�,'CCP ASSESSOR'S MAP & LOT I?© LI 6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY tt?0 LEACHING FACILITY: (type) pt t+ (size) NO. OF BEDROOMS BUILDER OR OWNER � W��N PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6C®—Tees, �So,ArqnY;(I;7 L PIT H •� 30 o-eox LOCATIONS._ A B SEPTIC22 1 33.5 f L 22.5 f t TANK o 2 36.5 f L 119 f t . a 3 41 ft 16.5 ft a EXISTING A DWELLING # 523 WATER LINE : PRINCE HINCKLEY RO /� D NOT TO SCALE, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is Centerville MA 02632 September 10, 2007 required for /� every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer, use 1. Inspector: f, only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name rae 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addressFand 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 ma;itatienance(of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of: Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails "' ❑ Needs Further Evaluation by the Local Approving Authority September 10, 2007 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. t5-2755.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is P required for Centerville MA 02632 September 10, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2755.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is /�required for Centerville MA 02632 September 10, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-2755.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 i Commonwealth of Massachusetts ft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is Centerville MA 02632 September 10, 2007 required for P every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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. t5-2755.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is September 10, 2007 Centerville MA 02632 Se required for p every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2755.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is p required for Centerville MA 02632 September 10, 2007 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5-2755.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is p required for Centerville MA 02632 September 10, 2007 every page. City/Town State Zip Code Date of Inspection 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 gpd Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 103 gpd(30 mo) g ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: February 2006Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2755.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is P required for Centerville MA 02632 September 10, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 22+years. Certificate of Compliance issued 4112185(Board of Health permit#85-70) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2755.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is September 10, 2007 Centerville MA 02632 Se required for p every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Design Plan t5-2755.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is p required for Centerville MA 02632 September 10, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): t5-2755.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is September 10, 2007 Centerville MA 02632 Se required for P every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2755.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is required for /�Centerville MA 02632 September 10, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. t5-2755.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is P required for Centerville MA 02632 September 10, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2755.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is p required for Centerville MA 02632 September 10, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. LE"PIT THO 9❑ D-BOX LOCATIONS A B SEPTIC 22 1 33.5 f t 22.5 f t TANK o 2 36.5 f t 119 f E 3 41 FL 16.5 ft El EXISTING A DWELLING # 523 WATER LINE PRINCE HINCKLEY RO /� D NOT TO SCALE t5-2755.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 523 Prince Hinckley Road Property Address Robert Sawyer Owner Owner's Name information is p required for Centerville MA 02632 September 10, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 15+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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 15 feet above groundwater table. t5-2755.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable y��pFtHE tOk�On Regulatory Services Thomas F. Geiler,Director BAMMBLE, V$ 16_19. �•� Public Health Division .OjED��p Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report;this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS iA DEPARTMENT OF ENVIRONMENTAL PROTECTION 5 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 523 Prince Hinckley Road Centerville. MA 02632 Owner's Name: Michael Maguire ? Owner's Address: 122 McNeil Circle Hopkinton. MA 01748 Date of Inspection: August 30, 2005 Name of Inspector: (Please Print) Janes M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 Telephone Number: (508)862-9400 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 4Needer Evaluation by the Local Approving Authority Inspector's Signature: Date: September 7 2005 The system inspector shall sub 't copn report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions,at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 523 Prince Hinckley Road Centerville, MA Owner: Michael Maguire Date of Inspection: August 30. 2005 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 523 Prince Hinckley Road Centerville, MA Owner: Michael Maguire Date of Inspection: August 30, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 523 Prince Hinckley Road Centerville. MA Owner: Michael Ma-zuire Date of Inspection: August 30, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facilitycomponent or system p onent due to overloaded or clogged S ✓ Discharge gg AS or cesspool ar a or ondin of effluent to the u g P S 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 '/z 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. ✓ An portion of y p cesspool or privy is within 100 feet of a surface water supply or tributary t pp y ry o 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 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 523 Prince Hinckley Road Centerville, M.4 Owner: Michael Maguire Date of Inspection: August 30, 2005 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: Yes No ✓ _ Existing infonnation. 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)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 523 Prince Hinckley Road Centerville, MA Owner: Michael Maguire Date of Inspection: August 30, 2005 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: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years.usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown C OMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ------gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes.or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable 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 a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 4112185-Per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 I Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 523 Prince Hinckley Road Centerville. MA T Owner: Michael Maguire Date of Inspection: August 30, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Commnents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: _ 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 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: 523 Prince Hinckley Road Centerville, MA Owner: Michael Maguire Date of Inspection: August 30, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 523 Prince Hinckley Road Centerville, MA Owner: Michael Maguire Date of Inspection: August 30, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6'x 6'(1000 gal.) 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.): The leach pit was dry and clean. No scum line was present The cover was 32"inches below grade The bottom to grade was 9'. CESSPOOLS: None (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: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Continents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 i • Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 523 Prince Hinckley Road Centerville. MA Owner: _ Michael Maguire Date of Inspection: August 30. 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ACk a 0 Q LO � 3y �. a ell 3a 3 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 523 Prince Hinckley Road Centerville, MA Owner: Michael Maguire Date of Inspection: August 30, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- 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: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours ma sue_ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 25'+/ to Around water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 TOWN OF BSTABLE G LOCATION 5�3 ���nU. �IA U c SEWAGE # a S �1eLLAGE lint��,►Ih . ASSESSOR'S MAP &LOT a'« INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY U 0 p LEACHING FACILITY: (type) (0 xG (size) /0 0 0 NO.OF BEDROOMS 3 BUILDER OR OWNER IMAGU 1 tt_ PERMITDATE: COMPLIANCE DATE: 4` Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 f6et of leaching facility) , Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leachin facility) Feet Furnished by r U i oii d. f3AU1c M 1 O Q 3 a ell 3a L"-0 ,r. ATION SEWAC _E `PERMIT NO. PILLAGE '`�INSTA LLER'S NAME & ADDRESS �. M tC B U I L D E R OR OWNER DATE PERMIT ISSUED IUD,-TE COMPLIANCE ISSUED �� _ �3- t. , r� 11 F 71 9 1 � • Yo1, r •r No.255 Fins....THE COMMONWEALTH OF MASSACHUSETTS 3 BOARD OF HEALTH r✓ .1 .................OF.......... CcwV� s �0 ......................... ApplirFatiou for Uispao al Works C outitrur#inn Pjamit Application is hereby made for a Permit to Construct (f) or Repair ( ) an Individual Sewage Disposal System at: � - ... ...._ ... . ....� ----. . ........................................ Loca .... '._.......�...............t......-Address i�, .._...._�......�.�.._..�._ �1A.y.V.4..�._.....�....,_. !1. Lo_t...No. ........L-Cow.. .... ................... Addnes Installer Address Type of Building Size Lot.. S feet U YP g r� t................ q. U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures ------------------------------------- - W Design Flow..... ..............................gallons per person per day. Total daily flow............ .. ..................gallons. WSeptic Tank—Liquid capacity.tgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length---------....i...... Total leaching area....................sq. ft. Seepage Pit No........I--.----__ Diameter......10-_---__ Depth below inlet....... Total leaching area .......sq. ft. Z Other Distribution box (J) Dosing tank ( ) `-' Percolation Test Results Performed byJN..W_kQ 2.".fm�$C4,_______________ Date....'®."_1�?_"ev----- ,,..a Test Pit No. 1__.L�'._..minutes per inch Depth of Test Pit-----0._....... Depth to ground water_._. '................ f3, Test Pit No. 2---- ._minutes per inch Depth of Test Pit..... ;,Y........ Depth to ground water...`................ Description of Soil d �*-----'T�P�.r7�.�d�1��L-.y � �-� M��"..v���®........................ x `�"Ru x -------------------------- ----------------------------------------------------------------------------------------------------------•------•---•---•-------•-•---•••-•-•-•-••---•--•--••••-•--•-------- V 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate off% m liance has bee * uWbytho of health. Signed Gl�' / �--........... Da Application Approved BY -�... J/ ��� Application Disapproved for the following reasons:-------•---------------------------------------------------------------------------------- Da e----••-----•-- .....................••-•--•---------••-•••••••-•----•--•-••••-•--•----••-----•-•-•.........•-•-•---•••-----•-•--•-•--•••••••••-•••••-•-••••-•--•--••••••------•-------- ------------------------------- Date PermitNo......................................................... Issued....................................................... Date w THE COMMONWEALTH �OF MASSACHUSETTS BOARD OF�., HEALTH . --- -----------OF........... ✓lc.V h S _- ...... Appliratiou for Bi_gpasal Workii Toutitrurtion ramit Application is hereby made for a Permit to Construct (/ or Repair ( ) an Individual Sewage Disposal t System at: �f ._ ................................................... - ... ................. ................. . :-........................................ •• Location-Address or Lot No. ............. ........ T.. 23 .... ---.-.1-!:!. .................................................. —Owner v Addres / _• --------- ................................ Installer Address d Type of Building Size Lot--- ._Sq. feet Dwelling—No. of Bedrooms.__..._..._.13..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) Otherfi tures ......................... --••---•--•-••--••-•••---•-------••••••----•---•--•-----•-•--.....•••-•--••-•-•-•-----•--•--••-•-•-•••--••----••-------•.... .! J. _ W Design Flow___._.___7_______________________________gallons per person per day. Total daily flow...........5';�7!e..................gallons. WSeptic Tank—Liquid capacity.k allons Length________________ Width....._.^___..... Diameter..............._ Depth................ x Disposal Trench—No..................... Width.................... Total Len gth.............._----- Total leaching area....................sq. ft. Seepage Pit No.........I Diameter....... ----- Depth below inlet___--__C........ Total leaching area ______sq. ft. Z Other Distribution box (✓) Dosing tank ( ) Percolation Test Results Performed by_f�&J._IA.JA,Zt.+J-i_G-... _�` �................. Date....�.�_'_��_p :...... Test Pit No. I---- _.minutes per inch Depth of Test Pit_._._4?.?......... Depth to ground water.... ................. GC4 Test Pit No. 2____4_2--__minutes per inch Depth of Test Pit................. Depth to ground water____-............... a ............................. -•--•-•-----••-••---•-••••-------...--•••.............•--...........__......----.....--•-•-•--•-•----•---....--•----•--------- O Description of Soil------. 7- ------ L 5 ice!-C ----------------------- v --- W 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 TITi1 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation u>ntJil a Certificate fb" of Compliance has been,issued by theoqrd of health. % -- T t Signed.......I I. r s-'t a r � "'".-' ,. Application Approved BY .. ------------------------•- ---- �Da�`, Application Disapproved for the following reasons---------------------------------------------------------------•-------•----•••---••--- ------•-•----•-•_--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , )r ..........0 F.....i?/.,,: 7 1V ....................... uprrtifiratr of Toutpltana THIS �S sT0 C IFY, That the Individual Sewage Disposal,,,System constructed (--,/or Repaired ( ) by ............f s �� :._'' 1� sl r 4f 7 > t 9_s - °__________ ____________�, -____- 1 _...� I 11 1..........., •-••---•-• .........E �• • _ at has been installed in accordance with the provisions of TIT� S of The Stare Sanitary Cod/9� as described in the application for Disposal Works Construction Permit No..-.... __7,E>........ dated------ _ /�f`� ................. THE ISSYANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEId 1 L FUNCTION SATISFACTORY. DATE....... ..._r...��. ................................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD -.OF HEALTH_,...._ � .. ........OF..../, .. ......... No..... _� �"p FEE........................ Permission is hereby granted '� ®=r J = L� - = --�- 1' ............. to Construct (2<) o`r Repair ( ,•' an Individual Sewadea Disposal System 4 at No.............- --r------ .. .. Street as shown on the application for Disposal Works Construction Permit No .1....... Dated...... '............... DATE................................................................................ Board of Health FORM 1255 HOSES & WARREN. INC., PUBLISHERS S • SITE PLAN SHEET I OF 2 ` SCALE: I Zo' •Sa is f,. Iava c.,A. sEil C.Ta0V-- IPA- s Sl•4 ;`STD. �rz�z.;�.,' Go r�IL 1 •� CU !o S i a OF AfAlp of, 4 AIILLIAM M. " o WARWICK No. 19771 e e� FOR. REGISTERED LAND SURVEYOR ZONE -G G i `J i L i_.t:: PLAN REF. DATE BENCH MARK DATUM J&i5t5il UNI =-p WM. M. WARWICK 8 ASSOC. , INC. DOMESTIC WATER SOURCE �AJ ti'A.T ►CL BOX 801 - NORTH FALMOUTH FLOOD ZONE L`62N)- A A.ZAw-d � C=Il MASS. 02556 (617) 563 -2638 ; r LEACHING BASIN SECT/ON NOT TO SCALE Shame 2 �f Z R ' 24"C.1.MH COVER EA a RTH FILL 8RICK AND MORTAR COURSES AS RFO'D TO BRlm. I �. _ COVER TO GRADE �,. _ 8'FLOW L lNE l •• l I INLET' L _ _— :_ :: 2"- /g 7-0/ WASHED P£ASTONE FREE OF IRONS, PIPE FINS AND DUST IN PLACE • ; / •. y 414" To l%2 WASHED CRUSHED STONE FREE OF 6 OPENING WITH 4/g IRONS, FINES AND DUST IN PLACE 7 OUTER DIAMETER AND /3/4" INSIDE DIAMETER 1. CONCRETE TO BE 4000 PSI 28 DAYS r . <2. REINFORCED WITH 6"x 6" NO. 6 GA. W.W.M. _ 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR GREATER DEPTH REQUIREMENTS 4'0" Z s o" 4. NUMBER OF PITS REQUIRED v^' MIN I EFFECTIVE DIAMETER NOTE: EXCAVATE TO ELEVATION ?* to OR (NOT To EXCEED 3 T1MES EFFECTIVE DEPTH) LOWER AS REQUIRED TO. REMOVE ALL WATER TABLE - LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN TYPICAL PROF/LE GRAVEL TO DESIGNED GRADE. 18"STD. LT. WGT. C./.MH COVER b2.� '•. 51•Gi 54•'� 51.(o 4"C.I.PIPE 4'B/T.f/BER PIPE OUTLET LEVEL FLOW LINE TIGHT JOINT DWELLING T_ •• TO FIRST JOINT --;--•4-;. ,-,-;:.:_• �I9•(00 ,v 1I' p O O 1 4 U �O A l C.I. TEE7>3 � ifOoO �Oa 01 II 44•S �.Z9 S70. PRECAST CONC. ��tj 0/ST. BOX TO BE ' � 1 O 00 O 0 1 100GAL.SEPTIC TANK:,' 11 000 0 0 0 1 I I . INSTALLED ON LEVEL, 1 000 00 0) STABLE BASE 0 000 00 0 1 —�-,\S£PT/C TANK TO BE i 1 000 00 1 1. I • INSTALL 0 ON CEvt4, f 1001 O 0 1 1 STABLE BASE. i i 1 0 0 0 0 0 0 0 i11000 G011 � � A H/NG 8A•,� if 1 0 Q O I 0 0 0 1 , BASE TO SE LEVEL 1 o O O 01 1 ALE 1� 42.10 I SOIL AND PERC. DATA PERC. RATE ' �Z MIN. /IN. 0„ TEST PIT NO. P 3/og4� TEST PIT NO. ToP/Sl>P.Shv lL ToP�SLJ05 11- TEST BY :. J2fZUGr:::: WITNESSED BY: LotJ 6ltF4=49Iz2 SAtiD M1GD: .rvD I P->&8 ct I-Z TCZAL� C�E'AVEJ; TEST PIT GR. EL.t-L-02 el_ 51' -nz�G� G'IZPu1�L DATE: io- 4(p--64 I� . 3�.Z 13' et_- 4 IJOta.•I?�uluD�,uLI�jZ NOC�R-UUtJf�,t7.4TIFIZ OES/GN DATA GENERAL NOTES 'BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL — SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL.32!'_5GPD• PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK I000 GAL, ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE SIDEWALL AREAZ's GAL./SQ.FT. MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA 1•d GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY 1 , 1977. LEACHING REQUIRED 179•I SQ.FT.. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL LEACHING AREA OF HEALTH, I Z L? :SQ.FT. ',,.AT -COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPEC-IO.N. 6 PITCH ALL SEWER LINES I/al / FT. UNLESS INDICATED OTHERWISE. �jH"0 ! St A DISPOSA L SYS TEM I o' MARTIN yG � 4 vj M 237 i1241 4P P Q 4 ► )C- e l-1 t IJ L lL L,E. r i2_o A LD ; 3417�Q — ---r y i,�rJYi✓(��/ 4L-L.. MA ��. , SCALE AS INDICATED DATE WM. M. WARWICK & ASSOC., INC. ®OX 801 - NORTH FAL M04JTH MASS. 02556 - (6/7l 5 63 -2638 i PROFESSIONAL ENGINEER