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Home My WebLink About0543 PRINCE HINCKLEY ROAD - Health 543 PRINCE HINKLEY RD., CNTRV. A= f Commonwealth of Massachusetts R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VIA 543 Prince Hinckley Rd. M Property Address IV Davies<John &Debra Owner Owner's Name information Centerville, ✓ Ma. 02632 8/30/2016 a required for every s page. Cityrrowm State Zip Code Date of Inspection r%2 Inspection results must be submitted on this form.Inspection forms may not be altered in aM way. Please see completeness checklist at the end of the form. Important When A. Genera! Information filling out forms on the computer, v use only the tab 1 Inspector key to move your cursor-do not Raymond Dumas use the return Name of Inspector key_ Dumas Landscape Const. ffi Company Name 564 Old Stage Rd. Company Address Centerville Ma. 02632 City/Town State 508-778-0249 S1437 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CIMR.15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority w 4 8/30/2016 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 ie 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 or 17 I Commonwealth.of Massachusetts t kv- Title 5 Official Inspection r r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 543 Prince Hinckley Rd. Property Address Davies<John& Debra Owner Owner's Name information is requited for every Centerville, Ma_ 02632 8/30/2016 page. CW rown State Zip Code Date of Inspection B. Certification (coot.) 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 CiiilR 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. Check the box for"yes" "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspedan Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts PA Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 543 Prince Hinckley Rd. Property Address — Davies<John&Debra Owner Owner's Name information is required for every Centerville, Ma. 02632 8/30/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpsialarms are repaired. B) System Conditionally Passes (coat.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 543 Prince Hinckley Rd. Property Address Davies<John &Debra Owner Owner's Name information is required for very Centerville, Ma. 02632 8/30/2016 e page. Cityrrown State Zip Code Date of Inspection B. Certification (cons.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within -100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes` or"No"to each of the following for all inspections: Yes No ❑ 0 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 t5ins•3113 Title 5 Official tnspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts A Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6443 Prince Hinckley Rd. Property Address Davies<John &Debra Owner Owner's Name Inforrnation is requireci for eve Centerville, Ma. 02632 8130/2016 page. h Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a-DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to comect 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`fires"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 543 Prince Hinckley Rd. Property Address Davies<John &Debra Owner Owner's(dame information is required for every Centerville, Ma. 02632 8/30/2016 page_ Citylrown 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? } ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Idle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of MasaachuaeUs Ia Title 5 Official Inspection or Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments v 543 Prince Hinckley Rd. Property Address Davies<John&Debra Owner Owner's Name required on a Centerville Ma. 02632 8/30/2016 required for every page_ Cityfrown State Zip Code Date of Inspection D. System Information Description: i 000 gallon tnk, D=box and 1 leach pit Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2015 28000 gallons 2014 22000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Occupied now Date Commercialllndustrial Flow Conditions: Type of Establishment: — Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fort Subsurface Sewage Disposal System Form Not for Voluntary Assessments ® 543 Prince Hinckley Rd. Property Address Davies<John&Debra owner Owner's Name information is required for every Centerville, Ma. 02632 8130/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 9/2015 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1000 gallons How was quantity pumped determined? estimate Reason for pumping: Maintanance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): 1000 gallon septic tank, d-box and 1 leach pit on record at B.O.H. t5ins-3113 Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 543 Prince Hinckley Rd. Property Address Davies<John &Debra Owner Owner's Name r fO��a� Centerville, Ma. 02632 8/30/2016 per_ every Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System installed 9/12/85 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 35 inches below top of foundation feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: Town water comes in front of house feet Comments(on condition of joints,venting, evidence of leakage, etc.): all good Septic Tank(locate on site plan): Depth below grade: 12 inches below grade feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) if tank is metal, fist age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: none t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusett Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •M' 543 Prince Hinckley Rd. Property Address Davies<John &Debra Owner Owner's Name information is required for every Centerville, Ma. 02632 8/30/2016 page_ Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle all water Scum thickness none Distance from top of scum to top of outlet tee or baffle none Distance from bottom of scum to bottom of outlet tee or baffle none How were dimensions determined? dip stick ruler Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): not needed Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•W 3 TrUe 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Foy Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 543 Prince Hinckley Rd. Property Address Davies<John&Debra Owner Owner's(dame information is required for every Centerville Ma. 02632 8/30/2016 page_ Citylrown 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.): PVC tees look good Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Fonw Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 543 Prince Hinckley Rd. Properly Address Davies<John& Debra Owner Owner's Name information is required for every Centerville, Ma. 02632 8/30/2016 page_ Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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 inspected with camera looks good and liquid at level Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: Inspected with camera water level was 2.5 ft. below pipe and stain line 3 ft below pipe t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Tine 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . .V 543 Prince Hinckley Rd. Property Address Davies<John &Debra Owner owner's Name information is required for every Centerville, Ma. 02632 8/30/2016 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) 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: Precast Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): All good Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusefts kiTitle 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 543 Prince Hinckley Pd. Property Address Davies<John &Debra Owner Owner's Name informAon is required for every Centerville, Ma. 02632 8/3012016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): all good Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 543 Prince Hinckley Rd. Property Address Davies<John&Debra Owner Owner's Name information is required for every Centerville, Ma. 02632 8130/2016 page. Citylfown State Zip Code Date of Inspedion D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately c t5ins-3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 543 Prince Hinckley Rd. Property Address Davies<John &Debra Owner Owner's Name efO° required for every Centerville, Ma. 02632 8/30/2016 page, Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Greater than 14 ft Estimated depth to high ground water. 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: 12/19/84 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As per plan at Board of Health ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Records at Board of Health Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ms•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachuseft Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 543 Prince Hinckley Rd. Property Address Davies<John& Debra Owner Owners Name y��rr o Is Centerville, Ma. 02632 8/30/2016 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 TdIe.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ssessing As-Built Cards http:// w.townaf sta7ble.us/ sessin&/HMdlisplay.asp?mappar... L CATION S-EWAGE PERMIT 00. via ea _ �i_iat `4 HiQycZKtr f �f.✓T�r-��°°�t� 4j INSTALLER'S NAME i ADDRESS � K- f1cCK2) • . i3A;�rS BUILDER OR OWNER �_ l,�ditr - Sflt�cJ G DATE PERMIT ISSUED `/WA,y DATE COMPLIANCE ISSUED y � i 3� Sri , Of 1 8/29/16 8:18 AM r RECEIVED im 1 4 2000 TOWN OF BLE HEALTH DEPT. COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A l CERTIFICATION Property Address: 543 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Z'C Name of Owner ROBERT STEMLER Address of Owner: 643 PRINCE HINKLEY RD CENTERVILLE,MA 02632 Date of Inspection: 6/17100 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 508-664-7270 CERTIFICATION STATEMENT a� L cj I certify that I have personally inspected the sewage disposal system at this address and that the information reported belo w sNttue,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: f �" �► X Passes _ Conditionally Passes z r ,r _ Needs Further Evaluation y the Local Approving Authority oow _ Fails *41-�'' 000 w Inspector's Signature: Date:6/17/00 The System Inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of V;�1n completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate?regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined In Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not Imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life" THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. RECOMMEND RAISING COVER TO LEACH PIT revised 9/2198 Pagel of 11 c ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 543 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Name of Owner ROBERT STEMLER Date of Inspection: 5/17100 INSPECTION SUMMARY: Check A, B, C, or D: V. A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If'not determined",explain why not. nla The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 1]!d Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced nta The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed +F t revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 543 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Name of Owner ROBERT STEMLER Date of Inspection: 6117100 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: i , 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance pia (approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 543 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Name of Owner ROBERT STEMLER Date of Inspection: 6/17/00 D. SYSTEM FAILS: You must Indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is Identified below.The Board of.Health should be contacted to determine what will be necessary to correct the failure. Yes No - X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. - X Liquid depth In cesspool is less than 6"below invert or available volume is less than 1/2 day flow, - X Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Q. - X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. - X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. - X Any portion of a cesspool or privy is within 50 feet of a private water supply well, - X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. W il E. LARGE SYSTEM FAILS: r h 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No - X the system is within 400 feet of a surface drinking water supply - X the system Is within 200 feet of a tributary to a surface drinking water supply - X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. I a t va revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 543 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Name of Owner: ROBERT STEMLER Date of Inspection: 6/17/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X - Pumping information was provided by the owner,occupant,or Board of Health. X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A. X - The facility or dwelling was Inspected for signs of sewage back-up. X - The system does not receive non-sanitary or industrial waste flow. X - The site was inspected for signs of breakout. X - All system components,excluding the Soil Absorption System,have been located on the site. X - The septic tank manholes were uncovered,opened,and the interior of the septic tank was Inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X - Existing information,For example,Plan at B4O,H, X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. zit revised 9098 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C_ SYSTEM INFORMATION Property Address: 543 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Name of Owner ROBERT STEMLER Date of Inspection: 6/17/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:2 Garbage grinder(yes or no):YES Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: 1994 System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS APPROXIMATELY 10 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no). NO '7.. revised 9/2198 Page 6 of 11' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 643 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Name of Owner ROBERT STEMLER Date of Inspection: 6/17100 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast Iron _ 40 Pvc X other(explain) Distance from private water supply well or suction line: n/a Diameter: 4" Comments: (condition of joints,venting,evidence of leakage,etc.) THE SYSTEM HAS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10—' Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 31" 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: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n/a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 643 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Name of Owner ROBERT STEMLER Date of Inspection: 5/17/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,Inspection) (locate on site plan) Depth below grade: nla Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallonstday Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage Into or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.SYSTEM SHOWS NO SIGNS OF FAILURE. PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 543 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Name of Owner ROBERT STEMLER Date of Inspection: 6117100 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)LEACH PIT leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.RECOMMEND RAISING COVER TO LEACH PIT. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to Inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 543 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Name of Owner ROBERT STEMLER Date of Inspection: 6/17/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) �V A 4 Q q all p 51 y PA �c 3a revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 543 PRINCE HINKLEY RD CENTERVILLE, MA 02632 Name of Owner ROBERT STEMLER Date of Inspection: 6/17100 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET revised 9/2/98 Page 11 of 11 TOWN 9F BARNSTABLE LATI013 � 1 SEWAGE # VILLAGE ' -Q, SSESSOR'S MAP &`L�T INSTALLER'S NAME&PHONE NO. �Z SEPTIC TANK CAPACIT-Y: LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCEr DATE: Separation Distance Between the: Cv� 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 QcC k D D � LUJI D Aq 4 AB 331 � (,H 9A 3� � �96 BD a, L� OUC A T I0"N - S'.E W AGE PE R M I T NO. INSTALLER'S NAME A ADDRESS e,UILDE R OR OWNER DATE PERMIT ISSUED Z , DAT E COMPLIANCE ISSUED z ��. �� . � ��I �,.3 � �-'� ;�� 3�:� ,� � L • r Xl.No.--- -• ---- 4 ;� . Fps. ......................... THE COMMONWEALTH OF MASSACHUSETTS t BOAR® OF HEALTH .. Tc96^_. ................OF.... 3PcQ- P� L,I� Appliration for Diapos al Workii Tongtrurtion rrntit Application is hereby made for a Permit to Construct (V� or Repair ( ) an Individual Sewage Disposal System at 2z r2 IJ ►-F I etc_- (� �/ ,L ..:.--•- -•.............�--------..-....-•---•---------------.---------------------- ........ -------------- ------ M Ac / L Location-address ( or Lot No. -�' ....... ................................-•-------f---- �I•--• ....2 �.1 .1� S !.V�.&.................................. Owner dress Type Installer Address � q T e of BuildingSize Lot........G...i...............S . feet U Dwelling—No. of Bedrooms........2................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures<11 ------------------------------------------------------------------------------•--------------------------------------------------- W Design Flow............!r........................gallons per person per day. Total daily flow__-_-�J. ....................... WSeptic Tank—Liquid capacity.-I.-W.gallons Length._-J-_�. .... Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area______.:..........._sq. ft. Seepage Pit No..........I......... Diameter_..__��-------- Depth below inlet....... -...._... Total leaching area �.�..sq. ft. Z Other Distribution box (✓) Dosing tank ( ) Percolation Test Results Performed L..................... Date..... Test Pit No. 14_.2-_-____minutes per inch Depth of Test Pit...... s........ Depth to ground water.. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_..................... O ..........................................................................t---------....................................................................... Description of Soil................ zf 5''�fl�°t L"1 Z �' �j L.-f x ----------------- -- 1 ......---....---------••••--- v .....•-••-•--•-•-•••--•--•••------•--••.....------•---•--••----•-----••-••....---.`f.'...\. .�. M ED i v M s.Qrr j D W ----------------------------------------------------------------------------------- --------------•------------------------......---------------------------------------------------------------....... 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 of Compliance has 4 e ssu b t oard of health. --� Application Approved By............ Date Application Disapproved for the following reasons------------------------•-------------------------------------------------------------------••--•----•........._ ...................... -----........ ----------------- •--------------------------- .....------ ------ ----- •--•--------------•---------------------------------------•--------------------------•---- Date PermitNo......................................................... Issued-------•-----------------------••-----•--...------•.... Date No...... :.. _> `4 FEE.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �01..� ,J...............OF..... nl.S.Yft__.L C. ...------------------..------ Appliratinn. for Disposal Works Tnmitruriinn tIrrutit Application is hereby made for a Permit to Construct (1/ or Repair ( ) an Individual Sewage Disposal System at: MA,, . Location•Add,ess a l� J J�. �. 'J'�9d v----•-----•�!-l--�-..`.1!. � Afor .......•^.----`--- — l -LU_) ---••-•`-0 I., .......... .......1....�.-.-......... ... -...... ` �- •- .o t 'ANlo .�.................................. es Ow ( d l . ' " . , 1! � ' ------------------------------- -----•------...0_ .H. Installer Address U Type of Building Size Lot......1.6_+.I 1........Sq. feet Dwelling—No. of Bedrooms___.....�J.................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P-1 Other fixtures W Design Flow............. .......................gallons per person per day. Total daily flow...... ........................gallons. WSeptic Tank—Liquid capacity..WYZgallons Length__f��* .D.... Width................ Diameter-----........... Depth..._............ x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No-----------)___--- Diameter..____1� DePtz below inlet ._______ Total leaching Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by._!_�lc,1 (_K►.__✓h. _G?L..................... Date----- --"-__� ,aa Test Pit No. l.� '......minutes per inch Depth of Test Pit......i 4.._._... Depth to ground water--^1 w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •----------------------------------=------------------------- •-----•--••-=--------.....------ .•--......................................................... O Description of Soil................ .. J GI.]� L. f 7-•=_ 1 L f W ................................................................................`�-"...� `�................ -�-D......M------s-'-�-'v.....------...............-............. x -•---------•-------------- ------------------------------------------------------------•---------------------------------------------------- ........................................................... U Nature of Repairs or Alterations—Answer when applicable.-------------------------------------------------------------------_........................... ---------------------•----------•----------•--------------•--•--------•---------•--•----......:------•-----•----------------------•-------------- ...................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to.place the system in operation until a Certificate of Compliance has bgt� issued by�th, oard of health. k.Sign "k.. 1_... !�`�!-'ti-- 1 jo -- 1--- /_ at --- Application Approved By----•-----•-.-••---. .... a... -•-----•----•---------------•-•-..... Date Application Disapproved for the following reasons:_. ...........................................................................•._...._....._...._.__._ ...........................................................-....................................-----••--•--.._.._-•--------------------------•------....•----•--•--------------•----------•-••-------- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS �--- BOAJIJW OF HEAj,,1H �...... �rr�ifirtt#r ,af f�tt3n�rli�anrr THIS W CpERTI hat the In ;idual Sewa isposa],Sygem constructed ( or Repaired ( ) by............. ,�-gD '.. ---- --------------------- -�- --- Installer at ,/ '' , L f has been installed in acco.dance with the rovis>o1�s of I of to Sar�itwr ode as uescribed in:the application for Disposal Works Construction Permit No._____. `'r � .. d-ated-____.._-.-.-_----_-_---------------------•- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �-- 1-/ / / DATE.................f•-•,C-•.1 `S Inspector----1_ ----•------------------------••----•------...........-•--•--•-••--- THE COMMONWEALTH OF MASSACHUSETTS BOARD Q F HEALTH - ./. ............OF............ f- No..._._... FEE........................ i �rla1 orkii ('11nntrinn rrntit Permission is hereby granted..... ---/-�1... --------------•------•---------------•-------...-----•-•------•--•---..........•_.... to Construct ( �-Repair ( ) an fuchyidual. r sisal SysteR > as shown on the application for Disposal Works Construction Permit jo -?___A��bated.._._ _T_ .. ./_.l. .--• -•----•--------------------------------...................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS' ` v .,, SI TE PL A nJ sHEEr / OF 2 ' SCALE: /„ Z�;, f9 R EG.A-=,-r GONG _ �-rw Ae-6k , �i,t► t nj A6 4b x 1 ;i Ian 4AL.. �-.0 Ip `t5xo ?S z9 k4 WILLIAM M. tam &wmnIeel p�> _�� REGISTERED LAND SURVEYOR FOR -- �-- L.►..�a..t/� L.-oT zr7-4j Prz I r.rGe N t►�G 1.E Y t�D, ZONE - Git�1TF-2:v ! l.l. PLAN REF. DATE _ 1-2-/ 1-2 BENCH MARK DATUM A' SE'IJNAEa WM, M. WARWICK 8 ASSOC. , INC. DOMESTIC WATER SOURCE BOX BOl — NORTH FAL MDUTN FLOOD ZONE - N t)t4 MASS. 02556 - (6/7) 563 -26 3B s I z LEACkNG 3ASIN SECTION NOT TO.SCALE Sheell z e f z 24 C.L MY COVER E E� ARTN FILL BRICK AND MORTAR COURSES AS REOD• TO BRING _.,• y_ — COVER TO GRADE q /NLE +B FGOW Z/NE , �. 2"-�g"TO WASHED PEASTONE FREE OF IRONS, PIPE '•'• FINES AND DUST /N PLACE OPEN/NC W/TH 4,k8" /4 r0 l!12 WASHED CRUSHED STONE •FREE OF OUTER DIAMETER IRONS, FINES AND DUST /N PLACE AND /3/4„INS/DE + . DIAMETER 1. CONCRETE TO BE 4000 PSI 28 DAYS t ; 2. REINFORCED WITH 6"x 6° NO. 6 GA. W W.M. 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR GREATER DEPTH REQUIREMENTS -6,0„ -I--Z' ---� 4. NUMBER OF PITS REQUIRED e- J m MIN" F,. l o NOTE: EXCAVATE TO ELEVATION 3Z.0 OR EFFECTIVE DIAMETER l (Nor ro ExcFED i TIMES EFFECTIVE DEPrH) LOWER AS REQUIRED TO REMOVE ALL • WArFR TABLE - LOAM AND CLAY BENEATH PIT. .REPLACE EXCAVATED MATERIAL WITH CLEAN TYPICAL PROFILE GRAVEL TO DESIGNED GRADE. GL-EL.s}$.v . /B"SrO. LT. WGr. C.I.MN COVER 47.0 4"c.I.PIPE 4"8/r,FIBER PIPE r/GHr JOINT OUTLET LEVEL DWEL L ING FLOW L/NF O TO FIRST JOIN r -- /4„ 00 1 Io�00 1 0.IZ c./. TEE 4 Z"& 4z•3� 110 00 1 1 11100 00 11 11 �9 5 iz-gz T.`srD. PRECAST CONC. �Z.53 /S Box ro BE ' l 1 0 00 .0 0 0 1 1 1 , __ qz.v jQQQGAL.SEPTIC TAN INSTALLED ON LEVEL, 11 1 1 o O 00 0 1 1 1 STABLE BASE 11 1 0 0 0 00 0 I 1 t11p00 00111 \BEPT/C TANK TO Be 11 1 000 00 1 1 t INSTALL D OWLEVEL, 1 it 100100 1.11 STABLE BASE. 1 it 000 0 0 I I 1 , • 11p00 G 0 1 1 „ ' LEACHING BASIN I t 0 p 0 0 0 0 I , BASE TO BE LEVEL 1 1 8 0 1 1 , i g L e V SOIL AND PERC. DATA PERC. RATE MIN. /IN. TEST-PIT N0. 19-3&Vgs : TEST PIT NO. 2 0 O TEST BY :" 4 '6t Ll 2-f 5 a,v WITNESSED, BY: D TEST.PIT GR. EL. ` c tpxr_j 7 DATE: l o- LCo DESIGN DATA GENERAL NOTES BEDROOMS 3 NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL t4e11J i . SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL 33OGPD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK ►oaP GAL. ALL .SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIDEWALL AREA?.LGAL./SQ.FT, MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA l-d GALAG.FT. SANITARY SEWAGE, EFFECTIVE ON JULY 1 , 1977. LEACHING REQUIRED I�9'1 SQ.FT., ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL LEACHING AREA OF HEALTH. AT •COMPLETION.OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES ` 1/4' / FT. UNLESS INDICATED .OTHERWISE. F � SEWAGE D/SPOSA L SYS TEM ' moo`' MRRTIN �• , .A f 223417 Lo'[" Z Zej �rz t ICJ LE !-�1 LK lk� 2 o A r Le:.tJ T C_r.V I,u.Ic Nt ASS 5 SCALE 4S. IND/CArED DATE- i� 11YM. N. WARWICK B ASSOC., INC. " BOX 80I - NORTH FA moo rs MASS. 02556 - (6I7) 5 63 2638 PROFESSIONAL ENGINEER