HomeMy WebLinkAbout0055 RAINBOW DRIVE - Health 55 Rainbow Drive '
Centerville F/R
A = 188 147
No. 4210 1/3 ORA
Pendaflex'
10%
(i)
Commonwealth of Massachusetts
Title 5 ,Official Inspection Form
Subsurface S Iwage Disposal System Form-Not for Voluntary Assessments
55 Rainbow Drive,Centerville, MA
Property Address
R.W. and Clare iendon
Owner Owner's Name
information is ,
required for Centervill MA 02632 12/03/2008
} every page. City/Town I State Zip Code Date of Inspection
Inspection resu ts must be submitted on this form.Inspection forms may not be altered in any
way.Pl"se see completeness checklist at the end of the form.
i
Whenrfilli 9 out A. General Information
forms onthe I ! 'S( . . �7
computer,
r,use 1. Inspector:
only the tab key
to move your Reid C. Ellis
cursor-do not Name'of inspector
use the return
key. Ellis Brothers Const.
Company Name
23 Enterprise Road, P.O.Box 59
Company Address
�� Yarmouth Port, MA 02675
t NOW Cityrrdwn State Zip Code
508-362-6237 S121891
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( CMR 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
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 61 er shall submit-!Ihe
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. --0 -
cn
****This report only describes conditions at the time of inspection and under ry >:
the conditions of use
at that time This inspection does not address how the system will perform in the fut&a under
the same or different conditions of use.
Lfl ltij pg
t5ins-Owe Title 5 Offiaal ftpecfiw Form Suluurface Sewage Disposal System-Page 1 or 17
t
c °
Commonwealth of Massachusetts
Title 5i Official Inspection Form
Subsurface Sewa a Disposal stem Form-Not for Voluntary Assessments
� 9 P System ry
55 Rainbow Drive, Centerville, MA
Property Address
R.W. and Clare Hendon
Owner Owner's Name
information is required for Centervill MA 02632 12/03/2008
every page. Citylrown state Zip Code Date of Inspection
B..Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: Z
jo1 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 descri ed in the"Conditional Pass"section need to be
replaced or repaired.The system, upon cor ipletion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", °no"or"not determin (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 infiltra don or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is repla with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is tructurally 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 bc low):
l
t5ins•09= -r&5 Ofri W ksPechm Form:Sub t Sewage Disposal System-Pao 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I
55 Rainbow Drive, Centerville, MA
Property Address
R.W. and Clare Hendon
Owner Owner's Name
information is required for Centervill MA 02632 12/03/2008 every page. Citylrown statelf Zip Code Date of Inspection
B. Certification (cunt.)
J
B) System Conditionally Passes(cunt.):
❑ Observation of sewage backup or break o it 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 f Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or repl ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than times a year due to broken or obstructed pipe(s).The
system:will pass inspection if(with appro fal of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
x'/X
V/
C) Further Evaluation is Required by the it
d of Health:
❑ Conditions exist which require further evan by the Board of Health in order to determine if
the system is failing to protect public healfety or the environment
1. System will pass unless Board of Hdetermines in accordance with 310 CMR
15.303(1)(b)that the system is not functi ping in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet c f a surface water
❑ ;Cesspool or privy is within 50 feet if a bordering vegetated wetland or a salt marsh
t5ins.09/08
Tifb 5 Official 6upedion Fomr.Subsurface Sewage disposal System.page 3 of 17
Commonwealth of Massachusetts
Title 5Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
i
55 Rainbow Drive, Centerville, MA
Property Address
R.W. and Clare Hendon
Owner Owner's Name
information is
required for Centervill MA 02632 12/03/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.) Al#
2. System will fail unless the Board of H Ith(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 so I absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributa 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 t e 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, erformed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of an imonia nitrogen and nitrate nitrogen is equal to or
less than 5`;ppm, provided that no other failure cr teria 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 V
ElBackup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Me Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El 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
i
than %day flow
t5ins•09/0(3 i Tme 5 Official hspeMon Forth:Subs flm sewage Disposal system'Pepe 4 of 17
Commonwealth of Massachusetts
Title 51 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Rainbow Drive, Centerville, MA
Property Address
R.W. and Clare Hendon
Owner Owners Name
information is required for Centervill MA 02632 12/03/2008
every page. cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Boa of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system a 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"n "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 nitroge 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 the system is considered a significant threat,
or answered."yes"in Section D above the large syste 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.
!Sins-09M Title 6 OW=W kW8CbM Fomr St bwf"Sewage DISposal System-Pape 5 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Rainbow Drive, Centerville, MA
Property Address!
R.W. and Clare Hendon
Owner Owner's Name
information is required for Centervill MA 02632 12/03/2008
every page. C4 rown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
❑ Pumpinginformation was provided b the owner, occu ant or Boar f p y p d o 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?
E] 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?
El Was the site inspected for signs of break out?
El Were all system components,excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the i �terior of the tank
inspected for the condition of the baffles or tees, material of ccinstructtion,
dimensions,depth of liquid, depth of sludge and depth of scum?
0 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: l
Existing information. For example, a plan at the Board of Health.
El 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): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
1011
t5ins•09108 Title 5 OfBdal Inspection Form:Subsurfaos Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
-- Title 5` Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Rainbow Drive, Centerville, MA
Property Address'
R.W. and Clare Hendon
Owner Owner's Name
information is required fior Centervill MA 02632 12/03/2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: —
Does residence have a garbage grinder? � ❑ Yes
Is laundry on,a separate sewage system?[if yes separate inspection required] ❑ Yes 7190
Laundry system inspected? ❑ Yes
Seasonal use? ❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
off' 33k- l--
Sump pump?
❑ Yes No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions: /
Type of Establishment
Design flow,(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 syst m? ❑ Yes ❑ No
F
Water mete readings, if available:
tsw•09108 Title 5 oRiaad Form:Subsurface Barrage Disposer System•Page 7 of 17
r
Commonwealth of Massachusetts
Title 51 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Rainbow Drive, Centerville, MA
Property Address 1,
R.W. and Clare Hendon
Owner Owner's Name
information is required for Centervill MA 02632 12/03/2008
every page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
Aj,+-5At 4-
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type o 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)
0 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):
t5irts-09108 } Title 5 Officud try Fomr:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface S�wage Disposal System Form-Not for Voluntary Assessments
55 Rainbow Drive, Centerville, MA
Property Address
R.W. and Clare Hendon
Owner Owner's Name
information is
required for Centervill MA 02632 12/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed(if known)and source of information:
g��4.f �'�� L —off o-7- 6�s'
Were sewage odors detected when arriving at the site? ❑ Yes [ No
Building Sewer(locate on site plan):
s�
Depth below grade: feet
Material of construction:
❑cast iron V40PVC ❑other(explain):
Distance from private water supply well or suction tine: .
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
�Lsv Al s /W
Septic Tank(locate on site plan):
Depth below grade:
feet
:te�nof construction:
concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain)
/I'fs
tank is metal, list age: years age confimed by a rtificate of Comp lance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
Wins•09/08
TrW 5 otaaaf hW8ct0n.F0rFTL s see o system•Page 9 or 17
Commonwealth of Maasachuaetts
Title 5Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Rainbow Drive, Centerville, MA
Property Address
R.W. and Clare Hendon
Owner Owner's Name
information is
regain for Centervill MA 02632 12/03/2008
every page. City/rown State Tip Code Date of Inspection
D. System. Information (cunt.)
Septic Tarok(cunt)
30``
Distance from top of sludge to bottom of outlet tee or baffle —s
' Scum thickness
I Distance from top of scum to top of outlet tee or baffle
0
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid el ' as related to qutlet invert, evidence of leakage, tc.):
-p i ot� i ,a• ry is 11�C �
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑ berglass ❑ polyethylene ❑other(explain):
i
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of ot get tee or baffle
Date of lastpumping: Date
t5ins•09= ( Title 5 otTrdat hR*MM FGM SWuufaoe SM99 Uls MW System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 55 Rainbow Drive,Centerville, MA
Property Address
R.W. and Clare Hendon f
Owner Owner's Name
information is Centervill MA 02632 i 12/03/2008
required Cityrrown Shafie Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations, in t and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, eviden of leakage,etc.):
i
Tight or Holding Tank(tank must be pum at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑ berglass ❑polyethylene ❑other(explain):
I
Dimensions:
i
Capacity: gallons
i
Design Flow: gallons per day
i
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
i
Date of last pumping: Date
Comments(condition of alarm and float switc es,etc.):
i
l
i
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Title 5 official hSpea=Fam[SubsWfiXW Sewage Disposal System•Page 11 of 17
t5ins•0SW
Commonwealth of Massachusetts
L IVUTitle 5 Official Inspection Forml
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Rainbow Drive, Centerville, MA
Property Address
R.W. and Clare Hendon i
Owner Owner's Name
information is required for Centervill MA 02632 12/03/2008
every page. Cityrrown 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 Iv 1'a �'R
i 67
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any
evidfce of leakage into or out of box, etc.):
1" k ze'4+ a2-a""e t A✓o CQ J/4t. :
Pump Chamber(locate on site plan): AIM
Pumps in working order. ❑ Yes ❑ No
Alarms in working order. ❑ Yes ❑ No
Comments(note condition of pump chamber, cor dition of pumps and appurtenances, etc.):
j
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located,explain why: r
c e?l,
i
t5ins.aeon True 5 official hwecWn Form:Subsurface Smage Disposal system•Page 12 of 17
Commonwealth of Massachusetts
Title 5' Official Inspection Form
Subsurface S7go Disposal System Form-Not for Voluntary Assessments
55 Rainbow Centerville, AAA
Property Address
R.W. and Clare Hendon .
Owner Owners Name
information is requited for Centervill MA 02632 12/03/2008
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Type:
❑ leaching pits number
leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/altemative system
Type/name of technology:
Comments°(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation,etc.):
�, s�`� ��t �" ram,✓ , �ne� � �
.v
17
alfA ia�.L�i�L .�Dl - /L.�ilArdA/s y� �✓�l` iyf�.S�A ►
Cesspools(cesspool must be pumped as p6rt of inspection)(locate on site plan):
Number and configuration
Depth—top.of liquid to inlet invert
Depth of solids layer
Depth of sc!m layer
Dimensionsi of cesspool
Materials of1construction
1
Indication of groundwater inflow ❑ Yes ❑ No
Mina-09W l Title 5 WOW tnspectian Fam:SWWfffaee Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5' Official Inspection Form
Subsurface S{wage Disposal System Form-Not for Voluntary Assessments
i
55 Rainbow Drive, Centerville, MA
Property Address
R.W. and Clare Hendon
Owner Owner's Name
required for
is Centervill MA 02632 12/03/2008
required for
every page. Ci rown state Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydr lic failure, level of ponding, condition of vegetation,
etc.):
i
Privy(locate on site plan): A4
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydrau lic failure, level of ponding, condition of vegetation,
etc.)
t5ins•09/08 Title 5/xfidal hupection Form:Subsinface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 ;Official Inspection Form
Subsurface Sej"ge Disposal System Form-Not for Voluntary Assessments
ii
55 Rainbow Drive, Centerville, MA
Property Address
R.W. and Clare Hendon
Owner Owner's Name
equired forte Centervill MA 02632 12/03/2008
every page. Cityrrown State Zip Code Date of Inspection
D. System ;Information (cunt.)
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
wh re public water supply enters the building.Check one of the boxes below:
hand-sketch in the area below � 4
❑ drawing attached separately
so �
i
A16
40.
fill14
t 4�
<) : • C
.a-v
Y IV
&-r dwa/i,d* AM/1
ev �lA
t5ins-pgipg Tdie 5 Otfidet won Fom[Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Seyrage Disposal System Form-Not for Voluntary Assessments
55 Rainbow Drive, Centerville, MA
Property Address I
R.W. and Clare Hendon
Owner Owner's Name
information is MA 02632 12/03/2008
required for Centervill
C rrown state Zip Code pate of Inspection
every page. �y
D. System Onformation (cunt.)
Site Exam: f!$�/
❑ Check Slope
❑ Surface;water 4AIgr Awls
❑ Check cellar 49�a leUAf t^
4 /
❑ Shallowwells //jj4
6 �� a
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
.9, 03
If checked, date of design plan reviewed: pate
❑ !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:
ltplAl
You must describe how you established the high ground water elevation:
-;;V/�VO4 A
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
tgns.09M t Title 5 offidw trrpeMw Fow Subs wlew sewage D*9W System-Page 16 of 17
e
w Commonwealth.of Massachusetts
Title 5 Official Inspection Form!
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Rainbow Drive, Centerville, MA
Property Address
R.W. and Clare Hendon
Owner owners Name
information is required for Centervill MA 02632 12/03/2008
every page. CityRown State Zip Code Date of Inspection
E. Report Completeness Checklist
12�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
Title 5 OMOW hffipeam FOM Subsurteoe Sewage Disposed System-Page 17 of 17
t5ins•09M
t
5
COMMONWEALTH OF MASSACHUSETTS
z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
+ d DEPARTMENT OF ENVIRONMENTAL PROTECTION
o,
�qM 5�0v BALED INSPECTION
/� WE MAIN M
/�`� WEST YARMOUTH,MA
508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 188 PAR 147
Property Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner's Name: PERSONETTE, ROBERT
Owners Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Date of Inspection AUGUST 22,2003
Name of Inspector:(please print) JAMES D. SEARS FRECEIVED
P 0 5 2001
Company Name: A& B Canco
Mailing Address: 350 Main Street TOWN OF BARNSTABLE
West Yarmouth,MA 02673 HEALTH DEPT.
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the infonmatiori reported
below is'frue',accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
tZ
Inspector's Signature: Date: - —o
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd
or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.
The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner: PERSONETTE,ROBERT
Date of Inspection: AUGUST 22,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: N/A
1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner: PERSONETTE,ROBERT
Date of Inspection: AUGUST 22,2003
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to detennine if the system is
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to detennine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner: PERSONETTE,ROBERT
Date of Inspection: AUGUST 22,2003
D. System Failure Criteria applicable to all systems: ./
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in pit is less than 6"below invert or available volume is less than''/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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone I of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
YES (Yes/No)The system fails. I have detennined 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 detennine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone 11 of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner: PERSONETTE,ROBERT
Date of Inspection: AUGUST 22,2003
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
J Pumping infonmation 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 nonnal flows in the previous two week period?
J Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes,uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
✓ Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
✓ Existing information. 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 CM 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner: PERSON ETTE,ROBERT
Date of Inspection: AUGUST 22,2003
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CM R 15.203(for example: 110 gpd x#of bedrooms: 440
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of infonnation: TANK PUMPED AFTER INSPECTION
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
AROUND 17 YEARS AGO.
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner: PERSONETTE,ROBERT
Date of Inspection: AUGUST 22,2003
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): If
Depth below grade:
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: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions detennined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL. INLET TEE,OUTLET BAFFLE. INLET COVER AT 12"
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner: PERSONETTE,ROBERT
Date of Inspection: AUGUST 22,2003
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alann 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: OVER
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
DISTRIBUTION BOX IS 4'6"BELOW GRADE. LOCATED ON SITE. DID NOT OPEN AS PIT IS FULL AND
SYSTEM FAILED.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 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: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner: PERSONETTE,ROBERT
Date of Inspection: AUGUST 22,2003
SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
./ leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT IS 5' BELOW GRADE WITH COVER AT 36".PIT IS
FULL OVER INLET. LEACHING NOT WORKING AND NEEDS TO BE REPLACED.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner: PERSONETTE, ROBERT
Date of Inspection: AUGUST 22,2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Title 5 Inspection Form 6/15/2000 10
Page 1 1 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 55 RAINBOW DRIVE
CENTERVILLE,MA 02632
Owner: PERSONETTE,ROBERT
Date of Inspection: AUGUST 22,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 1 7> feet
Please indicate(check)all methods used to determine the high ground water elevation:
./ Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
TEST HOLE OFF PAST REPORT. BOTTOM OF PIT 10' BELOW GRADE T ABOVE TEST HOLE.
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Title 5 Inspection Form 6/15/2000 11
TOWN OF BARNSTABLE
LOCATION SS 2a_4Ow Laryw SEWAGE#�—
VILLAGE Cenorr y ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. j i��S�p�C�� F /1 l 4 1P6�S C�h
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
y . Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
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TOWN OF BARNSTABLE
LOCATION 55 RAINBOW DRIVE , CENTERVIl, vAGE# 2003-603
vII.LAGE E N T E R V I L L E ASSESSOR'S MAP& L0118 8 / 14 7
INSTALLER'S NAME&PHONE N0. LLIS BROTHERS CONST . 508-362-6237
SEPTIC TANK CAPACITY O t3 n
LEACHING FACILITY: (ty l)0 1 I (size)
NO.OF BEDROOMS
BUELDEROROWNER ROBERT PERSONETTE
PERMUDATE: O L IJil 6) 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
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TOWN OF BARNSTABLE
LOCATION �� i SEWAGE #
VILLAG 02%l ASSESZSMAP &LOT f y7�G—
NAME&PHONE NO �
SEPTIC TANK CAPACITY / i:- ) Gam / L3'Pn�.GT 5 &Y,
LEACHING FACILITY: (type) �'� .��i, (size)
NO.OF BEDROOMS-
/-,,
BUILDER OR�0"ER -e//QL2j-
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist )
on site or within 200 feet of leaching facility) / Feet
Edge of Wetland and Leaching Facility(If any wetlands exist n/
within 300 feet of leaching fa ' ) / Feet
Furnished by�&,,^ ��) ,, _ S'IT"zna7i✓✓l. /C �//t{��`
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No. �kd V • Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYicatfon for Migogar *pztem Conotruction Permit
Application for a Permit to Construct( . )Repair(V)Upgrade( )Abandon( ) 0 Complete System O Individual Components
Location Address or Lot No. /,5- c.eyi Owner's Name,Address and Tel.No.
Assessor'sMap/Pazcel �17
Installer's Name Address,and Tel.No. / Designer's Name,Address and Tel.No.
Z 3 [?.✓t".�-. ae- lLcl , q,��.. off-; �iwA. �b ��
Type of Building:
Dwelling No.of Bedrooms Lot Size C�Z 0 77 sq.ft. Garbage Grinder
Other Type of Building /moo,, No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ° gallons per day. Calculated daily flow Z/7 gallons.
Plan Date /v 2 — Cl 3 Number of sheets / Revision Date
Title �141 1Zf-*9 Lla ;A j% /�VJ /JAts D lri S S`/LA/�t/douJ 04'.
Size of Septic Tank �9A�- Type of S.A.S. 3 —OL> l��/✓ C'/��N� -te,
Description of Soil, C2� �.1 1 -Ji 4N
Nature of Repairs or Alterations(Answer when applicable) �� ✓�� L�
Date last inspected:
Agreement:
The undersigned agrees to ensure cons ction and main enance of the afore described on-site sewage disposal system
in accordance with th rovisions o itle 5 the Environme Code and not to place the system in operation until a Certifi-
cate of Compliance has bees_ y this Board of Heal
Signed Date �Z — g O3
Application Approved by Date -U
Application Disapproved for Me following rea ons
Permit No. 000 3- 0_3 Date Issued ti 0
l No. �n"iD 007 Fee U
TH51COMMONWEALTH OF MASSACHUSETTS Entered in computer:
` ! Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
ZIpprtcation for Mtgooar *p!ftem Cori5tructton Permit
Application for a Permit to Construct( . )Repair( V)Upgrade( )Abandon( ) El Complete System O Individual Components
-Location Address or Lot No. dOwner's Name,Address and Tel.No.
fill
Assessor'sMap/Pazcel go 7 5/I/ri e S5 /liDi.vS�kJ �2/✓� Geiv7G*�'/�l- YID?
Installer's Name;Address,and Tel.No. Designer's Name,Address and Tel.No.
4-. 41-
Type of Building:
Dwelling No.of Bedrooms Lot Size 0 7,7sq.ft. Garbage Grinder( �
Otheri Type of Building r No.of Persons Showers( ) Cafeteria( )
Other Fixtures
1
Design Flows gallons per day. Calculated daily flow `f 7 gallons.
Plan Date V-1 z ' - ' 3 Number of sheets / Revision Date
Title e, �-e� c b���.ef %ti,rf
Size of Septic Tank 7//7 Type of!!S��.A.S. �441
Description of Soil �� dGC- oC�C� D6i/ c_aC�/�Oi ciN /
Nature of Repairs or Alterations(Answer when applicable) /✓�w �y G �/w
'.a
r
Date last inspected:
Agreement:
The undersigned agrees to ensure the--construction action and mainttf nance of the afore described on-site sewage disposal system,
111 in accordance with the provisions of T-ittlle 5:of the Environmen Code and not to place the system in operation until a Certifi-
cate of Compliance has been s�s ed-by Board of Health
v�
Signed I � Date �'
r.
Application Approved by Date
Application Disapproved for Ne following reasons
Permit No. a Oo 3` U 3 Date Issued f 2-
U
- �-- ————————----------------- --- - _THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance /
THIS IS TO CERTIFY, ✓that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by
at 5t ✓LA 12 o a f�I✓ Le, /'X A has been constructed in ccordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 6v3-6u3 dated l 070
Installer CA/z C"N f. Designer__ �i 13 AQ 4-
The issuance d this p fit shall not be construed as a guarantee that the sys em will f�nction as esi ned. n
Date t Inspector
--------------------------.-------- ——— - . .
No. 2 0 o? -6 o 3 Fee ,5 0:r
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
0topool bpaewm Co.notruction Permit
Permission is hereby granted to Construct( )Repair()Upgrade( )Abandon( )
System located at SS /�/J/,s/yfvGc, !�2�F/� ",f��j/�� �yJ�O •
S r�/Z-CAS 6-ti r/ 's G- -
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Con on must be completed within three years of the date of •e�rcgi�.
Date:_ �a/ 7/J Approved by - '� �
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TOWN OF BARNSTABLE C
LOCATION 55 RAINBOW DRIVE , CENTERVT1 AGE #.2003-603
C,RTE 188 f147
VII,LAGE ASSESSOR'S MAP&LOT
LLIS BROTHERS CONST . 508-362-6237
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (ty U (size)
NO.OF BEDROOMS
BUILDEROROWNER ROBERT PERSONETTE
PERMTF>DATE: /-910: COMPLIANCE DATE: aloy
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 Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
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APR 1 2 1996 �
BORTOLOTTI CONSTRUCTION,INC. aeeurnraetg
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 C WMEPT
508-711-9399 508428-8926 FAX: 508428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ° _a
PART A
CERTIFICATION
Property Address: �+. 1 i /lid
Date of Inspection: -oe Inspector's Name: t
Owner's Name and Address: C'
CERTIFICATION STATEMENTe
I certify that I have personally.inspected the sewage disposal system at this address and'that the informa-
tion reported below,is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposalVftems. The System:
Passes 4
Conditionally Passes
Needs Further Evgluation By the Local Aproving Authority
Fails
Inspector's Signature: ate:
The System Inspector shall submit a py of this inspection report to the Approving authority,within thir-
ty(30)days of completing this,inspection.`' If the system is'a shared.system of 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.
INSPECTION MMARY•
r
A)SYST m PASSES:
✓✓ I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or
exfiltration,.or tank failure is imminent. The system will pass inspection ifthe existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup 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):
-1-
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping in more than four times a year due to broken or obstructed pipe(s).
The system will Pass inspection ( pp if with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed_
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 THAT THE
SYSTEM IS,NOTYUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND 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 WELL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNEkTHAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100,Feet.to,a,surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with'a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private ,
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50;
Feet or more from a private water supply well,unless a well water analysis for colifonn
'1 organic compounds indicates that the well is free from,pollution from
bacteria and volatile o g po
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. .
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
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.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). -Number of times pumped
-2-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a 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 I 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. 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.
E)LARGE SYSTEM FAILS:
The following'criteria apply to a large system in addition to the criteria above:
The design flow of a system is 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:
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.
The owner or operator,of any such system shall bring the system and facility into full compliance with'the
groundwater treatment program'requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
_Pumping information was requested of the owner,occupant,and Board of Health.
_None of the system components have been pumped for atleast 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.
_ILAs-built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_;The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
r/AU system components,excluding the Soil Absorption System,have been located on site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees,material of construction,dimensions,depth of liquid,
depth of sludge,depth of scum. ,
I" he size and location of the.Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
t a,.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
_L/The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RYSIDENTI
Design Flow: gallons Number of Bedrooms: Nun bec of Current Residents:����u� ,
Garbage Grinder:&
a Laundry Connected To System: Seasonal Use: ye.S
Water Meter Readings,if availab e:
Last Date of Occupancy: _ B�QS
O M .R . AIJIND ST IALo//
Type of Establishment:
Design Flow: aallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informatio :` /?71�� zT� -IJ1112
System Pumped as part of inspection:-! If yes,volume pumped: gallons
Reason for pumping:
TYP F SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
ROXIMATE AGE of all omponents,date installed(if nown)and source of information:
LI
Sewage odors detected when arriving at the site:
y
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: Material of Construction: ✓ concrete metal FRP - Other
(explain)
Dimisions ,S'Xl o ', Sludge Depth:�,7�/ Scum Thickness: 0,0 e
Distance from top of sludge to bottom of outlet tee or battle: 3,441
Distance from bottom of scum to bottom of outlet tee or baffle: 14/D'17-e
Comments:.(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert,structural inte rity,evidence of leakage,etc.)-;L' o6 e w 1140
e,
/ �-�abl
ids bof
GREASE TRAP:
Depth Below Grade: Material of Construction: concrete_metal_FRP Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
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.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Mate nal of Construction:_concrete_metal FRP Other(explain)
Dimensions: Capacity: gallons Design Flow: gallonstday
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float-switches,etc.);
DISTRIBUTION BOX: "
Depth of liquid level above outlet invert: uG/` i�?"►/��
Comments: (note' vet and distrib lion i�al,evidence a of solids carryover,evidence of leakage intg
or out of box,etc. •��O Az,, �� 9, Cdv�
PUMP CHAMBER:A�
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS): !/
(Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits,number: Leaching chambers,number: Leaching galleries,number: '
Leaching trenches, number,length:
Leaching fields,number,dimensions:
Overflow cesspool;number:
Comments: (note condition of soil,signs of hydraulic failure level of ponding,condition of vegetation,
-/i V-
CESSPOOLS: 1� �/
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(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6-
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued).
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references,landmarks or benchmarks.
Locate all wells within 100 Feet.
J
DEPTH TO GROUNDWATER:
Depth to groundwater: /7 ' Feet f
Method of Determination Of Appro 'mation:
-7-
L'O C A'T ION SEWAGE PERMIT NO.
VILLAGE /T F, 15S
06INSTA LLER'S NAME" ADDRESS
r U 1 L D E R OR ::OW-WE R
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED i7 ��
1_.
"l
6-7
e,O'
..............................
No........... ... ...
THE COMMONWEALTH OF MASSACHUSETTS
�OARD OF HEAL-rLj
I r ....O F................
_--_-----_---
ApV irtaffon for Disposal Works Tnnstrnr#ion Vamit
eApplication
is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
.. ...... .........a oc pn..--A-ddress . �
. ...... l ..........................................................r r
pL ............................. ...
71
ow..; Address
1 -
----------------
Installer A dre / -
Q Type of Building Size Lot----.. ... .__._Sq. feet
aDwelling—No. of Bedrooms...................................Expansion Attic ( ) Garbage Grinder ( )
p� Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures .................. ......
W Design Flow........................................ gallons per person per day. Total daily flow........................... 5- ..._-_...gallons.
WSeptic Tank—Liquid capacity.J. . gallons Length-_--___-____-_- Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...-----------------sq. ft.
Seepage Pit No----_-------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed b .... ............... Date•-----. 1 —
aTest Pit No. l.. minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2 2�` minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ----------------------------••••---•--•----•--•-----------••------.----
0 Description of Soil.................................................�. �� ---...---•--------•---•-----------------•--•--------•-------.............---
x
------------------- ---------•--•---------------••------......------------------------......._..------------. ---- ---------------------------, T, ` ..------------••-•--•-------
U ture of Re a' Alterations— er when applicable.__ _____ __ �. 1Yf-N ..__. �12
Agreement: CST L C (u 1r� /N Gv62f !!y��
The undersigned agrees to install the foredescribed Indivi ual Sewage Disposal System in accordance with
the provisions of LIT" 5 f the State Sanitary Code— The undersigned further agrees not to place the system in
operati" until a Certificat of Compliance has bee4f�
dby the board of 1
` ;. Si_ ned---- --- -• . --....---------------- -- . -.......
- -
Application Approved y--- ---•- :...- .........:...... -•-••-....--. . ����....•....
ate
Application Disapproved for the following reasons:------••----••----•--------•---•-------•--------------•....--------•------•-------- .....---------..._..
--•........---•--------------•--------------•----•---......-------------------•----......-------------------•-•-------•---•---------•-•••-•----•-•------•----•-•••-----•-------------------------------
Date
Permit No... Issued________________________
_ --- Date
.r
No•__��'�2�-10 ____------- FEs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratilan for Bispoii tl Works Tomitrurtinn Vernfit
Application is hereby made for a Permit to Construct ( )%or Repairs ) an Individual Sewage Disposal
System at:
- ....._ ` _c.. =`.. .............
Locat"on-Address or Lot No.
Ownez� Addres
a '. l .e.�'�/ -•--------------�--- -'=L� � '-"�------...------------..........
Installe Adore
d Type of Building � Size Lot..�f�0�� q
S feet
Dwelling—No. of Bedrooms..............-3.......................Expansion Attic ( ) Garbage Grinder ( )
'4
p-1 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P-1 Other fixtures ---------------------------•-••. .
d ...................
.........
W Design Flow......................................... ..gallons per person per day. Total daily flow.......................... ....gallons.
W4 Septic Tank—Liquid capacity_!_)a .gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.........._......... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet....._.............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank (� ) _ _-
~' Percolation Test Results Performed by...._.._`...�.�?���...�! .� ...................... Date.......V/ :�/� .........
Test Pit No. 1_yyl�_ _�.......minutes per inch Depth of Test Pit.................... Depth to ground water........................
f=1 Test Pit No. 2),..,..........minutes per inch Depth of Test Pit.................... Depth to ground water---__._____..-_.••.-_-_-
-------------------------------------•---- ......------• ................... .........................................................
DDescription of Soil ..................... -----------•-----------------------••--------------------------•---------•---
x
W = -------------
UNature of Repairs..or Alterations-Answer when applicable_- �._.. ==_� _- (11�,�......................f -T....(.. _r.`
1.1�1�- - C��v ► ' ' �-------.- '� zCu-
LC
Agreement:
The undersigned agrees to install the hforedescribed Individual Sewage Disposal System in accordance with
the rovisi,o s of TITLE of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate/of Compliance has been issued by the board----o a th. ��
� � .
iL��i�"
Ad /Signed_ _ J
A lication Approved By............ ............................................—.........
......../ . ..................
e
Date
Application Disapproved for the following reasons:...................................M...... -----•------ ............--.............................
..................•-•------•-•-•-•-----•-----------------------•---•----••----.._....---...------------M---•-------------------------------------------------------------------..........--------------
Permit No. .......................................... Date
Issued.----------------------------. Date
Date
+y. THE COMMONWEALTH OF MASSACHUSETT\\S� >
BOARD OF FffEALTH
a................/ ...OF........................ ...CiZ'?' .........��...............
Trrtif iratr of Tomphattre
THIS IS TO CERT Y, Tat the Jndividoal Sewage Disposal System constructed ,(Y) or Repaired ( )
-------------------------------------------------------------------------------
Installexj
at.. �/CJT/ = ���?7� - . cam------------- C911--- -
has been installed in accordance with the provisions of TI'i'L_r. j_of The State Sanitary Cod . as described in the
application for Disposal Works Construction Permit No....... ..... dated__..... ...=� �.:.------...........
_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUE® AS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. .......... fF '{y��....------•.......:................... inspector....... _....� r. _
THE COMMONWEALTH OF MASSACHUSETTS / 1A-lu Gc
i BOARD OF HEALTH V "'r
`^ _ .....O R....................................................................................
No.'-:'( ...1' FEE.._....::..
Disposal Workii Tn utnutuan rrmit
Permission is hereby granted.....ty r--- --�• -----Vas fear=---- --------------------------------------------------------------------
to Constr ict ( ) or Repair ( ) an Indivi"ual Sewage Disposal Sys em
at No.... �. 1 = �`� �_r,o,�,,,✓! �'-.=t: -�r ., i�� �
Street
as shown on the application for Disposal Works Construction Permit No^_!_..r< ..... Dated.._ ___._Ral ..................
_ ----••-------------------------•-------------------------.............................................
11_ -7 Board of Health
DATE--------•-••-- A� ...............
t-
FORM 1288•,Hoeas a WARREN, INC., PUBLISHERS
r 7�,41/v23 0 W
0 5.70 /34o C �4 y
ok
N
`� ,.�r �� g•
jr, °` o, � � 5.• `2y _ , Ind '�/"��,/�e/,� �j�/.per
rlf ^ r � `�7. .0 ��a J'1. Yr �•-J .�/'t%`• '""' C/I•-�.�1'v •�
771,
\ ;V r� R E°SE/Q v E
A c A 4*
,'J, W/D 7r l
7s6 7-7F , � ` - N°T�
57,
/
vqn
r �
OF
LEGEND ., s e• .
XISTING $POT ELEVATION.'
XISTING CONTOUR—.... p -• E' '�ECISTE�`b@� . CERTIFIED PLOT PLAN
INISHED SPOT ELEVATI,.ON �v�- /s RA „v,3aw D2,vE
INISHE® CONTOUR :�.0 -•
/:x h/TFk V/L L E
J YrE: The location of An, kihg urdQtg:'nlan .,s.lkra,:e
9Yis, or other �itili:t#,�s shoMm o ..: this�lan is, -� 0 �-
nato only as deteruiined fro 'record and/or verbal ��, �t•�•� MASS*
ifor:mation. ,The contr*ct9v`, responsible `for:thp `7r 1
5rlication of the existing` Ipeaticns in `the field 9CAi.E� 1 t1 ��1 DATETDRE .
DGE Eitl EROIY� cur
1dT I CERTIFY THAT THE PROPOSED
�OISTERg R �ISTEREO s d� b
;..CIVIL aA Ji � NO BUILDING SHOWN ON THIS PLAN
�LA1N1� _ CO'Nf�®RMS TO THE ZONING LAWS
DR.,BY I :,.A„�,..
^�. OF BARNSTABLE MA
7 i MAIN 3'TREE1''° , t , C1� .�Y� '
M YA W N I Si 14 A.
SHEET•.:. Of � ATE REG.
SURVEYOR
r a - Y .r "ZO FT. . /'•/A/. t {VOTE :::dF NER it .t7 SEPTIC,TANk: O Q ^'
- -
. . . . . -.LE, -Pik" A/rF" .?RF.._Tiyi9 , ..../2~BELO1'V-:
/d P7:%H/w0. �J,4AOE�Al 24�D/A�7 ETER C•aNORE.TE CO .:
•Q'PYG` p/Pr SNAGL &,F B/POUG/lT 7-06igAO.�.�itiN EXTRA
CONG.�CTB M/Adr. PITCH /1E.4Vy CAST /RO/� GOYER SHALL C3E USED >.
•, �"L' 9 mod. COVERS �B'PE.p E7 /F/lV DR/VEJ•VA Y ,..,
IN
Co ✓ER CLEAN S'A/VO w
.. . . . . . &A CA L L
3 L1,9010 LEVEL
t �_'
.. ''
•r• • " � 2 LAYEPON
s s/ev.or7VW '
' SEPTIC tANK DIST• •':�-� �:, • `., • • • • 1 .• • a jYASHED 57nNE
j = 2
r �� •� .+ . 1 �IEfPECT/VL 1 • • r. 3
i / 1 OEPTI+I . �:• • .• lyASXEl� STOrYE
s �ti /'/3_ �r' Gb r /--�-...'_ ► s. 1 • • • • • • • ► PREC�IST,SEEPAGE '
l/N/if.•RT EiL�i/i4T/D.VS p/T c:�P.�c�T 49 v G!'��-✓O�y • •� • • • ..• • • • a 1 t . P/T OR EAU/V, i
EL. �7 o i
iNYERT.SIT �//ILDr/VG jr c 3 • G D//�M.
z /Z SFBUL�9TI
0I�
5� ISLET`$EPT�C :7A*VX F TA
CC,,�E
Po O�ITLET.SEPT/G:TANIC --
/NLrfT OJSTR/8!/T/ON 4Zc,b F� SECT/ON.OF GRO[!NO 1�TElt 7A, 4%L r
O p/ /BiIT'/ON'BO�Y' L --
INLET LEACRING /"/T- /.o fT SEyt/AGE GlSPATAL SY.�TL�/�9 TA.QULATlGN
L EACHIMa '•J®/T
{- - TCALE : %s' _'/=O' OIIIEN.S/ON A '�- xT,
® SIGN CRITERIADLAf.E/vs/a/v $ FT.
NL/MSER OF BEDROA/yS J OlMENS/ON• C g Fr;
G,-4'R ,�.�v/sPos.�c uw/r °�„� .SOIL LOG
TOTAL E1T/MATE® FLOhY 3 3 V GAG.�DAY SOIL TEST At/ $o/L 7.EST2 S�/L TEST
NUMBER OF LEACNM/G P/T=_
PATE OF SO/L TEST •�S�L
SIDE LrACH/NG PER air /S SQ. IrT.
90TT0/►4 L�agClf/NG PER PIT' // 3 S4• FT. _ RESULTS i'v/T/VESSED dY S'FON R JA CUI`i.
i L�;,q M f'ERCOcAT/ON RATE/. CES !rJ/N11NCM
TOTAL L.EACN/NG AREA SQ- f 7; s�, �- r.L I-ERCO4A7-/ON RATE N.IINCH
RESERVEL AC-N/NGAREA, 7- 4 SQ. FT. 3 � � • Z..D
P—,/-7 0, ..
-07
ROMERT M� CANT C R ✓ /4 L E
ALEEr,, \; Z -
1 a UX
6.
( P•iuciSc
\,�ri1�_ - EL.OREDGE GMAER/NYG CV IA'C. •
�'A, E C •76.,5. _ 7/Z-.MAIN ST. , A"YANNiS MAS-T
EEL NAC)TO!!Nv &-v,4TER !E/VCOIJ/NTEREO el-As"T:MGK✓C-AS
r [;
8 s I z6 PREDr/V3zL GRO UN7 Lv. TEE JOB MO.- S
Est°
r-
i
President:
Member of:
ROBERT BRUCE ELDREDGE,R.L.S. CAPE COD SOCIETY OF PROFESSIONAL
ENGINEERS AND LAND SURVEYORS
ELDREDGE ENGINEERING MASS.ASSOC.OF LAND SURVEYORS
Associates: AND CIVIL ENGINEERS-
ALBERT A.MORSE,P.E.,R.L.S. COMPANY, INC. AMERICAN CONGRESS ON
PHILIP WEINBERG,P.E.,R.L.S. SURVEYING AND MAPPING
[J
/ �J AMERICAN SOCIETY FOR
-R-9LsEE2EQ -R-3 LStE%Ed TESTING AND MATERIALS
j.
1'ancf 712 MAIN STREET
cSttzvE ozs �n LnEEzs HYANNIS,MASS.02601
TEL.(617)775-2244
Town of Barnstable W
Boar f Health d o eah t
367 Main Street
Hyannis, Ma. 02601 April 8, 1986
RE: Lot 15, Rainbow Drive - Centerville (Nickulas #.85126 ) .
Gentlemen:
The sewerage system was inspected, on April 4, 1986 and appears
to be in compliance with the design plans dated 10/31 /85 except
for the following:
The leaching pit was installed at the location marked on
the plan "100% reserve" , which is located about 85 feet from the
isolated wetland. As noted on the original plan, a Board of Health
variance is required from the 100 foot minimum setback requirement.
Since the State Title V Sanitary Code requires only a minimum of
50 feet, I have no objection to the approval of the variance by
the Board of Health.
Sincerely,
Y
ELDREDGE ENGI EERING CO. , INC.
Robert B. Eldredge
cc: Nickulas
RBE/lld
S` .
S
A
APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
LOCATION NO.
VILLAGE DATE 3///4/ 4'
APPLICANT MS EJ E7 FEE`�LS' _
ADDRESS S_Q P a N 3' TELEPHONE NO. (Non.-refundable)
ENGINEER TELEPHONE NO.
DATE SCHE U ED f 4/� _ �_4 W
(Applicant' s signature
.-. . . . . . aoe000 . o .00000 . . . . . . . 000 . o . . . . . . . . o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ® . . . . . . . . .
SOIL LOG_
SUB-DIVISION NAME DATE fGLi(�,.;.:Q �' � TIME J0: 19 F7
EXPANSION AREA: YES !/ NO_'-eo.. �, f ENGINEER"•)
TOWN WATER PRIVATE WELL x �� BOARD OF HEALTH
GtQ EXCAVATOR
SKETCH: (Stree*_ name- etc: dim sions of lot, exact location of test holes and
percolation tests, 1, cate wetlands in proximity to test holes )
• NOTES:
S j
us � \
PERCOLATION RATE: _ �3 6"
TEST HOLE NO: ELEVA O TEST HOLE NO: ?— ELEVATION:
� _ 3
4 _ 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
i 12 12
i 13
14 1"4
15 15
16 16
SUITABLE FOR SUB—SURFACE SEWAGE: ' LEACHING FIELD LEACHING PITS v
�. LEACHING TRENCHES ✓
UNSUITABLE FOR SUB—SURFACE SEWAGE. REASONS:
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ONE' ERC TEST APPLICATION
ORIGINAL: COMPLETED IN ENTIRETY BY P . E. AND RETURNED TO BOARD OF- HEALTH
COPY: RETAINED BY. APPLICANT
-
SYSTEM PROFILE TEST HOLE LOGS
TOP FNDN. = 29.18 - To SCALE)
ACCESS COVER TO WITHIN 6 NOT OF FIN. GRADE ( PROP. h1SPECTION PORT,
ACCESS COVER (WATERTIGHT) TO WITHIN 6" OF FIN, GRADE ENGINEER: LISA LYONS, RS
MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM Z WITNESS: SAM WHITE, IRS
DATE: 10/16/03 Locus
i EL 26.06' RUN PIPE LEVEL 2" DOUBLE WASHED PEASTO E
1000 FOR FIRST 2' PERC. RATE _ < 2 MIN/INCH o
EXISTING i SOILS P
GALLON SEPTIC 24.6't* CLASS9
TTANK (H- 10-)
GAS BAFFLE ('
(RE-USE) 24.0jilsad� \�� 0 0 a a 0 a o C3 L� o�
MIN 23.73' L� EOEO CJ M00E It ELEV. �� �o
5� J�e��\�� %50(l�
aar� o a oEIEaE� ,
( 2 % SLOPE) 6" CRUSHED STONE OR MECHANICAL ** 0 �0 0
COMPACTION. (15.221 [2]) ��$ 2' = 0 Q [� [] EI = '._3_ 0 21 .73 A e
DEPTH OF FLOW = 4' ( % SLOPE) ( % SLOPE) '
3 4" TO 1 1 2" DOUBLE WASHED STONE LS 9,
TEE SIZES: / /
INLET DEPTH = 10" g" 1OYR 3/2
LOCATION MAP NO SCALE
OUTLET DEPTH 14" B
, LEACH NG LS ASSESSORS MAP 188 PARCEL 147
FOUNDATION— EXIST. SEPTIC TANK `+$ D BOX 12 FACILITY
I *THE INSTALLER SHALL VERIFY THE 28„ 10YR 5/6 27.6'
LOCATIONS OF ALL UTILITIES AND ALL
8,73'
I BUILDING SEWER OUTLETS AND ELEVATIONS
PRIOR TO INSTALLING ANY PORTION OF
SEPTIC SYSTEM C NOTE: POCKET OF LS
PERC ON GARAGE SIDE OF
TEST HOLE;
MS ENCOUNTEREDEMOVE DURINGF
r�0'0 WETLAND AT EL. 13.0' EXCAVATION OR
Q8 S ENGINEER TO PERC IT
6 2.5Y 6/4
CONTRACTOP TO CONFIRM SUITABLE SOILS
AND NO WATER FOR 5' MIN, BELOW B SE OF
LOT 15 LEACHING FACILITY
21,077 SFf
12 20.0'
RAINBOW
' .,- NO WATER ENCOUNTERED
� NOTES:
e DRIVE
\ D
SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED 1, DATUM IS APPROXIMATE NGV
_ )
\ _ 2. MUNICIPAL WATER IS _EXISTING
nc cMr, �E (,tA�, 4 4 �o,.
PFpr fin• ( 110 Gpn) = GPD r "
Q, J. IVII
2$ f UG TEL USE A GPD DESIGN FLOW 4. DESIGN LOADING FOR ALL :'RECAST UNITS TO BE AASHO H-- 10
GAS K SEPTIC TAN 440 GALLONS GPD 2 = 88�
(----) 5. PIPE JOINTS TO BE MADE WATERTIGHT.
ME R
`d 7 'T EDGE OF PAVEMENT USE A 1--50Q-T GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
ENVIRONMENTAL CODE TITLE V.
LEACHING: 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
UG TE , PAVED 0"/ SIDES: PERIMETER = 90 x 2 x .74 = 137 USED FOR LOT LINE STAKING.
I UG EL C
EXISTING DRIVE � 32 ELEC PAC' BOTTOM: 418 SF (.74) = 310 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
DWELLING f �` ,� d UTILITY 9. COMPONENTS NOT T 0 BE BACKFILLED OR CONCEALED WITHOUT
TF=29.18 � i RISERS TOTAL: _ S.F. 447_ GPD
INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
2ti� -� i USE (3) 500 GAL. LEACHING CHAMBERS (ACME OR FROM BOARD OF HEALTH.
ti GAR. ELEC 1p. EQUAL WITH 4' STONE AROUND EXCEPT IN AREA SHOWN 10. LEACH PIT TO BE PUMPED AND FILLED WITH CLEAN SAND OR
SLAB
METER ; REMOVED AS NECESSARY.
1� DECK i (SEE DETAIL) 11 . WETLAND FLAGGED BY AM WILSON ASSOCIATES
PROPOSED.RE--GRAC'NG LEGEND
APPROx pc ST 100.0 PROPOSED SPOT ELEVATION TITLE .5 SITE PLAN
(R SE) .\ PATIO /
I ,�LPIT .��h 100x0 EXISTING SPOT ELEVATION OF
DBOX
goo' 55 RAINBOW DRIVE
PROP. VENT (FINAL PROPOSED CONTOUR
PLACEMENT BY CONTRACTOR 100 IN THE TOWN OF:
WITH HOMEOWNER
' 2 CONSULTATION). PROVIDE 100 EXISTING CONTOUR ( CENTERVILLE ) B A R N S T A B L E
CHARCOAL FILTER AND _
BENCHMARK BUGSCREEN PREPARED FOR:
ROBERT PERSONETTE
/ j3s NAIL IN 14" OAK
W/ 6S• ELEV = 31.66 G�,' BOARD OF HEALTH
20 0 20 40 60 Feet
MA
L APPROVED DATE
� 29.4'—
#10 SCALE:-1- a 1 = 20 DATE: OCTOBER 21, 2003
100, ' 00
I N
r off 508-362-4541
fox 506 362-98W
r
33.5'y down cape engineering, inc.
%N Of MY�,
SAS PERIMETER ARNE
DETAIL CIVIL ENGINEERS H.
LAND SURVEYORS JALp A N. Gs�
; , rn
939 main st. yarmouth, ma 02675 � :� s /9 J c�
_ 'M0 o � vG T
03---28 1 ,
ARNE H. OJ F£s .,��� S. DATE
i _